Prevalence and patterns of anti-epileptic medication prescribing in the treatment of epilepsy in older adults with intellectual disabilities

Drug burden index of people ageing with intellectual disability and cognitive complaints attending a specialist memory service

BACKGROUND

Medications with sedative or anticholinergic properties should be prescribed with caution in those with cognitive complaints. This is particularly relevant in people ageing with an intellectual disability (ID). Higher drug burden index (DBI) scores are associated with increased frailty and falls and reduced quality of life in older people and increased risk of adverse effects (daytime somnolence, constipation) in those with ID. While previous studies have shown that the ID population has higher rates of drug burden and a higher propensity to be prescribed an antipsychotic than the general population, the degree of burden has not been assessed specifically in those with ID and cognitive complaints.

METHODS

We assessed drug burden in a cohort of sequential referrals to a national memory service for people with ID. All patients were referred for assessment of cognitive complaints (self-reported or caregiver-reported problems with memory or cognition). DBI was calculated individually for each participant, and the impact of aetiology of ID, level of ID, age, psychiatric/neurological comorbidities and diagnostic outcome on DBI scores was assessed.

RESULTS

The study population was 58.6% female with a median age of 55 years and aetiology of ID was Down syndrome (DS) in 71.3%. Consensus diagnosis was Alzheimer's dementia in 40.2%, mild cognitive impairment in 29.9% and cognitively unimpaired from baseline in 25.3%. Medication use was high with 95.4% taking medications, with a median number of medications of 4 (interquartile range 4) and a rate of polypharmacy (≥5 medications) of 51.7%. Overall, 65.5% were exposed to sedative or anticholinergic medications with 39.1% exposed to a clinically significant DBI score >1. Those with psychiatric comorbidities, non-DS aetiology or epilepsy were significantly more likely to have a DBI score >1.

CONCLUSIONS

People with ID and incipient cognitive complaints have a high level of drug burden, which concerningly exceeds that of the general population.

Neurocysticercosis and cognitive impairment among people with epilepsy in Taenia solium endemic regions of rural southern Tanzania: A hospital-based cross-sectional study in mental health clinics of selected sites in Tanzania

BACKGROUND

Epilepsy poses a significant public health problem in many parts of the world. The majority of people with epilepsy (PWE) are from low-income and middle-income countries (LMICs). Taenia solium neurocysticercosis (NCC) is estimated to cause 30% of preventable epilepsy in PWE in areas of T. solium endemicity. This study was conducted to assess the prevalence of NCC in PWE, evaluate the presence of cognitive impairment in PWE, and assess potential contributing factors.

METHODS

PWE were recruited within a mental health clinic-based cross-sectional study in rural Southern Tanzania. PWE underwent a detailed neurological examination, and a blood sample was collected for T. solium cysticercosis (CC) serology testing. Patients who were serologically positive for CC and those detected to have prominent neurological deficits apart from epilepsy were invited to receive a cerebral computed tomography (CT) examination.

RESULTS

Out of the 223 people with epilepsy (PWE) recruited, 221 underwent clinical examination. Among these, 26 (11.8 %) had cognitive impairment, and 2 had additional neurological signs or symptoms. Twenty-five of the 223 PWE (11.2 %) tested positive for CC. A total of 36 participants underwent CT scans, with 18 testing positives for CC and 18 negatives. Of the 36 who had CT scans, 8 (22.2 %) were diagnosed with NCC; 7 were CC positive, and 1 was CC negative. Multivariate logistic regression confirmed that cognitive impairment in PWE was 8.62 times higher for Kongwa participants compared to Chunya, with a statistically significant association (95 % CI: 1.75-156; P<0.037). Additionally, having an education was associated with a 91 % reduction in the odds of NCC (OR=0.09) compared to no education, which was also statistically significant (95 % CI: 0.01 to 0.33; P<0.002).

CONCLUSION

Our study found a 22.2% prevalence of neurocysticercosis (NCC) among PWE. Cognitive impairment was present in 11.8% of PWE but was not significantly associated with NCC. Socioeconomic and educational factors may play a larger role in cognitive impairment among PWE.

The relationship between clinical presentation and the nature of care in adults with intellectual disability and epilepsy - national comparative cohort study

BACKGROUND

A quarter of People with Intellectual Disabilities (PwID) have epilepsy compared with 1% of the general population. Epilepsy in PwID is a bellwether for premature mortality, multimorbidity and polypharmacy. This group depends on their care provider to give relevant information for management, especially epilepsy. There is no research on care status relationship and clinical characteristics of PwID and epilepsy.

AIM

Explore and compare the clinical characteristics of PwID with epilepsy across different care settings.

METHOD

A retrospective multicentre cohort study across England and Wales collected information on seizure characteristics, intellectual disability severity, neurodevelopmental/biological/psychiatric comorbidities, medication including psychotropics/anti-seizure medication, and care status. Clinical characteristics were compared across different care settings, and those aged over and younger than 40 years.

RESULTS

Of 618 adult PwID across six centres (male:female = 61%:39%), 338 (55%) received professional care whereas 258 (42%) lived with family. Significant differences between the care groups existed in intellectual disability severity (P = 0.01), autism presence (P < 0.001), challenging behaviour (P < 0.001) and comorbid physical conditions (P = 0.008). The two groups did not vary in intellectual disability severity/genetic conditions/seizure type and frequency/psychiatric disorders. The professional care cohort experienced increased polypharmacy (P < 0.001) and antipsychotic/psychotropic use (P < 0.001/P = 0.008).The over-40s cohort had lower autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) comorbidity (P < 0.001/P = 0.007), increased psychiatric comorbidity and challenging behaviour (P < 0.05), physical multimorbidity (P < 0.001), polypharmacy (P < 0.001) and antipsychotic use (P < 0.001) but reduced numbers of seizures (P = 0.007).

CONCLUSION

PwID and epilepsy over 40 years in professional care have more complex clinical characteristics, increased polypharmacy and antipsychotic prescribing but fewer seizures.

Patterns of antiseizure medications prescribing in people with intellectual disability and epilepsy: A narrative review and analysis

People with intellectual disabilities (PwID) have a bidirectional relationship with epilepsy. Nearly 25% of PwID have seizures and 30% people with epilepsy are thought to have a significant intellectual impairment. Furthermore, 70% of PwID are thought to have treatment-resistant epilepsy. In the United Kingdom, antiseizure medications (ASMs) are the second most widely prescribed psychotropic agent for PwID. However, it is unclear what the current evidence and patterns is on current prescribing of ASMs, including when and how a case is made to withdraw them. A narrative review along with an analysis of large-scale NHS Digital published data (2015-2020) on several aspects of ASM prescribing by general practices for PwID was undertaken. The review results and data analysis are consolidated and presented as 11 themes to provide a comprehensive overview of the study topic. Recent studies estimate that one-third and one-fifth of PwID are prescribed ASMs. A history of epilepsy is seen as the primary prescribing reason; however, often it is a legacy, and the indication is no longer clear. The proportion receiving ASMs continues to rise with age. This pattern of use does not correlate well with seizure onset. There are limited data on de-prescribing ASMs in PwID. The study population heterogenicity, associated polypharmacy, multimorbidity and higher sudden unexpected death in epilepsy risks are outlined. Suggestions are made from available evidence for improving prescribing practices for PwID and seizures, and key areas for further research in this complex clinical area are outlined.

Rating scales to measure adverse effects of medications in people with intellectual disability: a scoping review

Purpose

Intellectual disability (ID) is a chronic neurodevelopmental condition characterised by limitations in intelligence and adaptive skills with an onset prior to the age of 18 years. People with ID have complex healthcare needs and are more likely than the general population to experience multiple comorbidities and polypharmacy, with subsequent increased risk of adverse medication effects. The aim of this scoping review is to characterise rating scales used to measure adverse effects of medication in people with ID.

Methods

Four online databases (PsycINFO, Medline, Web of Science and OpenGrey) were searched in April 2020. Studies were assessed for inclusion against pre-specified eligibility criteria. Reference lists of included studies were hand searched. Data extraction was carried out by two independent reviewers and key findings were tabulated for consideration. Studies were assessed for quality using the Mixed Methods Appraisal Tool.

Results

The search resulted in 512 unique records, of which fifteen met the inclusion criteria. Fourteen scales were identified. All scales assessed adverse effects of psychotropics only. Of the scales, only one, the Matson Evaluation of Drug Side Effects, which focuses on psychotropic medications, was originally developed for use in a population with ID.

Conclusion

The Matson Evaluation of Drug Side Effects scale appears to be the most reliable and well-researched scale in people with ID. However, a scale which measures adverse effects across multiple medication classes would be valuable for use in this population.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00228-022-03375-2.

Nature and extent of intellectual disability nursing research in Ireland: a scoping review to inform health and health service research

OBJECTIVES

To capture the extent and nature of intellectual disability nursing publications in Ireland.

DESIGN

Scoping review using Arksey and O'Malley approach.

DATA SOURCES

Six databases (PsycINFO, CINAHL, Medline, Academic Search Complete, Scopus, Embase) were searched along with a web-based search of the eight academic institutions delivering intellectual disability nurse education in Ireland for publications indexed from the earliest available date to the 31 December 2020.

ELIGIBILITY CRITERIA

Publications by an academic, practitioner or student working in intellectual disability practice or education in Ireland relating to intellectual disability nursing, care or education.

DATA EXTRACTION AND SYNTHESIS

Data pertaining to type of paper/design, authors (academic/professional/student), year, collaboration (national/international), topic/content area and title were extracted from each paper. Data were analysed by two authors using Colorafi and Evans content analysis steps where data was tabulated, and a narrative synthesis undertaken.

RESULTS

The reporting of the review is in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and PRISMA extension for Scoping Reviews Checklist. Database and web-based searching resulting 245 articles meeting the criteria for this review. Through content analysis the 245 articles were mapped onto six themes: supporting inclusion, future planning, aspects of health, interventions, education, professional development and research, and personal and professional accounts of caring.

CONCLUSIONS

This review highlights the extent and nature of intellectual disability publications by academic, practitioner or student working in intellectual disability nursing in Ireland together with opportunities for future growth and development. From the findings it is apparent that there is an ongoing need for intellectual disability nurses to define their role across the full trajectory of health provision and to make visible their role in person-family centred support, inclusion, and contributions in health education, health promotion and health management.

Current role of carbamazepine and oxcarbazepine in the management of epilepsy

Epilepsy is one of the most common neurological disorders, affecting approximately 50 million people worldwide. Despite a dramatic increase in treatment options over the past 30 years, it still ranks fourth in the world's disease burden. There are now close to 30 antiepileptic drugs (AEDs), with more than two thirds introduced to the market after carbamazepine (CBZ) and one third after its derivative, oxcarbazepine (OXC). Following the introduction of these newer AEDs, the role of CBZ and OXC in the therapeutic armamentarium for seizure control and effective epilepsy management needs to be reviewed. The main guidelines list both CBZ and OXC as first-line options or second-line alternatives for the treatment of focal-onset epilepsy and primary generalized tonic-clonic seizures. While evidence suggests that overall AEDs have similar efficacy, some newer AEDs may be better tolerated than CBZ. In line with this, there have been changes in treatment patterns, with many variations across different countries. However, CBZ remains among the two or three most prescribed drugs for focal epilepsy in many countries, and is widely used across Europe, Africa, South America, and Asia, where it represents a good compromise between cost, availability, and effectiveness. OXC is among the first-choice options for the initial treatment of focal-onset seizures in several countries, including the US and China, where the oral suspension is commonly prescribed. This review provides guidance on the optimal use of these two drugs in clinical practice, including in children, the elderly, and in pregnancy.

Vagal Nerve Stimulation in Epilepsy: Experiences of Participants with Cognitive Deficits

INTRODUCTION

The purpose of this study was to examine patients' experiences of vagal nerve stimulation (VNS) with a special interest in patients with cognitive deficit (CD).

MATERIALS AND METHODS

An open, retrospective study was conducted on 82 patients with pharmacoresistant epilepsy, who were treated with VNS for at least 10 months. Based on the inability to live independently, they were divided into two groups: patients with cognitive deficit (CD group) and patients without cognitive deficit (non-CD group). A specially designed questionnaire was used for semi-structured interviews about patients' experiences of VNS treatment.

RESULTS

Approximately one-third described a continuous reduction of seizure frequency of 50% or more and were regarded as responders. Fewer subjects in the CD group were responders than in the non-CD group. Approximately one-third of all subjects had no positive effect of VNS treatment. More CD patients described additional improvements and the most common were milder seizures and improved alertness. The most commonly reported adverse effect was hoarseness.

DISCUSSION

VNS treatment in patients without CD had better effect on seizure frequency reduction than in patients with CD, but many patients with CD reported other benefits from the treatment.

CONCLUSION

Non-CD patients had higher seizure frequency reduction than CD patients during VNS treatment, but many CD patients described other benefits.