Epilepsy and mortality: a retrospective cohort analysis with a nested case-control study identifying causes and risk factors from primary care and linkage-derived data

Mortality in patients with epilepsy: a systematic review

BACKGROUND

Epilepsy is linked to a significantly higher risk of death, yet public awareness remains low. This study aims to investigate mortality characteristics, to reduce epilepsy-related deaths and improve prevention strategies.

METHODS

This study systematically reviews mortality data in relevant literature from PubMed and Embase up until June 2024. Data quality is assessed using the Newcastle-Ottawa Scale, and analysis includes trends, regional differences, and the economic impact of premature death. Global Burden of Disease (GBD) data are used to validate trends. In addition, a review of guidelines and expert statements on sudden unexpected death in epilepsy (SUDEP) is included to explore intervention strategies and recommendations.

RESULTS

Annual mortality rates of epilepsy have gradually declined, mainly due to improvements in low-income countries, while high-income regions have experienced an upward trend. Male patients exhibit higher mortality rates than females. Age-based analysis shows that the elderly contributes most to this increase due to chronic conditions such as cardiovascular disease and pneumonia related to epilepsy. This may be a key factor contributing to the increased mortality among epilepsy patients in aging high-income regions. Accidents and suicides are more prevalent in low-income regions. The highest mortality risks occur in the early years post-diagnosis and during prolonged, uncontrolled epilepsy. SUDEP remains a leading cause of death.

CONCLUSION

This study highlights the impact of gender, region, and disease duration on epilepsy mortality. Future research should focus on elderly epilepsy patients mortality characteristics and personalized interventions for SUDEP.

Development of an International Standard Set of Outcomes and Measurement Methods for Routine Practice for Infants, Children, and Adolescents with Epilepsy: The International Consortium for Health Outcomes Measurement Consensus Recommendations

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy, and their representatives to develop minimum sets of standardized outcomes and outcome measurement methods for clinical practice. Using modified Delphi consensus methods with consecutive rounds of online voting over 12 months, a core set of outcomes and corresponding measurement tool packages to capture the outcomes were identified for infants, children, and adolescents with epilepsy. Consensus methods identified 20 core outcomes. In addition to the outcomes identified for the ICHOM Epilepsy adult standard set, behavioral, motor, and cognitive/language development outcomes were voted as essential for all infants and children with epilepsy. The proposed set of outcomes and measurement methods will facilitate the implementation of the use of patient-centered outcomes in daily practice.

Development of an International Standard Set of Outcomes and Measurement Methods for Routine Practice for Adults with Epilepsy: The International Consortium for Health Outcomes Measurement Consensus Recommendations

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. Therefore, the International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy and their representatives to develop minimum sets of standardized outcomes and outcomes measurement methods for clinical practice that support patient-clinician decision-making and quality improvement. Consensus methods identified 20 core outcomes. Measurement tools were recommended based on their evidence of strong clinical measurement properties, feasibility, and cross-cultural applicability. The essential outcomes included many non-seizure outcomes: anxiety, depression, suicidality, memory and attention, sleep quality, functional status, and the social impact of epilepsy. The proposed set will facilitate the implementation of the use of patient-centered outcomes in daily practice, ensuring holistic care. They also encourage harmonization of outcome measurement, and if widely implemented should reduce the heterogeneity of outcome measurement, accelerate comparative research, and facilitate quality improvement efforts.

Utilisation of specialist epilepsy services and antiseizure medication adherence rates in a cohort of people with epilepsy (PWE) accessing emergency care

BACKGROUND

An epilepsy-related attendance at A&E is associated an increased risk of subsequent death within 6 months. Although further work is required to provide a definitive explanation to account for these findings, in the interim it would seem reasonable that services are designed to ensure timely access and provide support at a time of greatest risk. We aim to determine the frequency of patients accessing specialist neurology services following an epilepsy-related admission/unscheduled care episode and consider ASM adherence at the point of attendance.

METHODS

Patients were identified retrospectively via the NHS Greater Glasgow and Clyde live integrated epilepsy Dashboard following an unscheduled epilepsy-related admission or A&E attendance between 1st January 2022 and 30th June 2022. We calculated adherence to anti-seizure medication for a period of 6 months prior to admission and defined poor medication adherence as a medication possession ratio of less than 80 %. We evaluated the rate of any outpatient neurology clinic attendance in the subsequent 3, 6 and 12 months following an epilepsy-related unscheduled care episode. Additional clinical information was identified via the electronic patient records.

RESULTS

Between 1st Jan 2022 and 30th June 2022, there were 266 emergency care seizure-related attendances. The mean age at attendance was 46 years (range: 16-91). Most of PWE were males (63 %) and 37 % were females. Epilepsy classification-29.3 % had GGE, 41.7% had focal epilepsy, and in 29 % of cases the epilepsy was unclassified. Of the admissions, 107/ 266 (40.2 %) generated follow-up within 6 months of attendance. Poor medication adherence was noted in 54/266 (20.3 %). 28.2 % of cases had input from on-call neurology service during admission/ED attendance, and of those 60 % had ASM adjusted. 18 % of attendances had a background diagnosis of learning disability. One-third of attendances of PWE had a history of mental health disorder 35 % (93/266). 25 % of ED attendances noted an active history of alcohol consumption misuse or/and recreational drug use. 14 (5.5 %) of PWE died during the period of interest (12 months following the last ED visit). In 6/14 (42.3 %) death was associated with poor medication adherence.

CONCLUSION

This study demonstrates that a significant proportion of patients who experienced seizure-related admissions/ attendance did not access specialist neurology services in a timely manner. In addition, poor medication adherence remains a problem for a substantial number of people living with epilepsy. Early access to specialist services may go some way to improving care and reducing excessive mortality in PWE by allowing anti-seizure medication to be titrated and poor medication adherence to be addressed in those at greatest risk.

Specialist epilepsy service input following an epilepsy related unscheduled care episode

BACKGROUND

Emergency and unplanned epilepsy-related attendances are associated with an increased risk of subsequent death within 6 months. Although further work is required to provide a definitive explanation to account for these findings, in the interim it would seem reasonable that services are designed to ensure timely access and provide support at a time of greatest risk. We aim to determine the frequency of patients with epilepsy (PWE) accessing specialist neurology services following an epilepsy-related admission/unscheduled care episode.

METHODS

Patients were included in the cohort if they had at least 1 prescription for an anti-seizure medication and at least one epilepsy-related admission, emergency department attendance, or outpatient neurology clinic attendance between January 2011 and November 2021. We evaluated the rate of any outpatient neurology clinic attendance in the subsequent 6 months following an epilepsy related unscheduled care episode.

RESULTS

Of the 6,449 PWE included in the cohort, 4,465 were included for analysis. At the end of the follow up period less than 40% were accessing specialist services within 6 months of an episode of admission/ unscheduled care episode. Around a third (31.1%) of deaths occurred within 6 months of an epilepsy-related admission, and in the majority of cases patients were not seen by an epilepsy specialist in the period between discharge and death. The frequency of mental health comorbidity in PWE accessing unscheduled care remains very high with almost 80% having a diagnosis of either depression or anxiety.

CONCLUSION

A significant proportion of PWE are not accessing specialist services in a timely manner following an episode of unscheduled care. Such provision may potentially provide an opportunity to reduce epilepsy related mortality by altering antiseizure medication doses and considering reversible factors associated with poor outcomes in PWE, such as poor medication adherence.

Sustainability of seizure reduction and seizure control with adjunctive cenobamate: Post hoc analysis of a phase 3, open-label study

OBJECTIVE

In this post hoc analysis of a subset of patients from a long-term, open-label phase 3 study, we assessed ≥50%, ≥75%, ≥90%, and 100% seizure reduction and sustainability of these responses with cenobamate using a time-to-event analytical approach.

METHODS

Of 240 patients with uncontrolled focal seizures who had adequate seizure data available, 214 completed the 12-week titration phase and received ≥1 dose of cenobamate in the maintenance phase (max dose 400 mg/day) and were included in this post hoc analysis. Among patients who met an initial given seizure-reduction level (≥50%, ≥75%, ≥90%, or 100%), sustainability of that response was measured using a time-to-event methodology. An event was defined as the occurrence of a study visit at which the seizure frequency during the interval since the prior study visit exceeded the initially attained reduction level. Study visits during the maintenance phase occurred at 3-month intervals.

RESULTS

Of the 214 patients analyzed, 188 (88%), 177 (83%), 160 (75%), and 145 (68%) met ≥50%, ≥75%, ≥90%, and 100% seizure-reduction responses, respectively, for at least one study visit interval during the maintenance phase. The median (95% confidence interval [CI]) time to first visit without a ≥50% seizure reduction was not reached by 30 months of follow-up (53% of patients maintained their initial ≥50% seizure reduction). Median (95% CI) time to first visit without sustaining the initial ≥75%, ≥90%, or 100% seizure reduction was 13.0 (7.5-21.9) months, 7.5 (5.4-11.6) months, and 7.0 (5.3-10.4) months, respectively. Among the 145 patients who had 100% seizure reduction during at least one study visit, 22% remained seizure-free for at least 30 months and 63% had ≤3 study visits with seizures.

SIGNIFICANCE

Adjunctive treatment with cenobamate led to sustained seizure reductions during the maintenance phase of the phase 3 safety study.

Epilepsy-related mortality during the COVID-19 pandemic: A nationwide study of routine Scottish data

OBJECTIVE

To examine whether epilepsy-related deaths increased during the COVID-19 pandemic and if the proportion with COVID-19 listed as the underlying cause is different between people experiencing epilepsy-related deaths and those experiencing deaths unrelated to epilepsy.

METHODS

This was a Scotland-wide, population-based, cross-sectional study of routinely-collected mortality data pertaining to March-August of 2020 (COVID-19 pandemic peak) compared to the corresponding periods in 2015-2019. ICD-10-coded causes of death of deceased people of any age were obtained from a national mortality registry of death certificates in order to identify those experiencing epilepsy-related deaths (coded G40-41), deaths with COVID-19 listed as a cause (coded U07.1-07.2), and deaths unrelated to epilepsy (death without G40-41 coded). The number of epilepsy-related deaths in 2020 were compared to the mean observed through 2015-2019 on an autoregressive integrated moving average (ARIMA) model (overall, men, women). Proportionate mortality and odds ratios (OR) for deaths with COVID-19 listed as the underlying cause were determined for the epilepsy-related deaths compared to deaths unrelated to epilepsy, reporting 95% confidence intervals (CIs).

RESULTS

A mean number of 164 epilepsy-related deaths occurred through March-August of 2015-2019 (of which a mean of 71 were in women and 93 in men). There were subsequently 189 epilepsy-related deaths during the pandemic March-August 2020 (89 women, 100 men). This was 25 more epilepsy-related deaths (18 women, 7 men) compared to the mean through 2015-2019. The increase in women was beyond the mean year-to-year variation seen in 2015-2019. Proportionate mortality with COVID-19 listed as the underlying cause was similar between people experiencing epilepsy-related deaths (21/189, 11.1%, CI 7.0-16.5%) and deaths unrelated to epilepsy (3,879/27,428, 14.1%, CI 13.7-14.6%), OR 0.76 (CI 0.48-1.20). Ten of 18 excess epilepsy-related deaths in women had COVID-19 listed as an additional cause.

CONCLUSIONS

There is little evidence to suggest there have been any major increases in epilepsy-related deaths in Scotland during the COVID-19 pandemic. COVID-19 is a common underlying cause of both epilepsy-related and unrelated deaths.

Case-control study developing Scottish Epilepsy Deaths Study Score to predict epilepsy-related death

This study aimed to develop a risk prediction model for epilepsy-related death in adults. In this age- and sex-matched case-control study, we compared adults (aged ≥16 years) who had epilepsy-related death between 2009 and 2016 to living adults with epilepsy in Scotland. Cases were identified from validated administrative national datasets linked to mortality records. ICD-10 cause-of-death coding was used to define epilepsy-related death. Controls were recruited from a research database and epilepsy clinics. Clinical data from medical records were abstracted and used to undertake univariable and multivariable conditional logistic regression to develop a risk prediction model consisting of four variables chosen a priori. A weighted sum of the factors present was taken to create a risk index-the Scottish Epilepsy Deaths Study Score. Odds ratios were estimated with 95% confidence intervals (CIs). Here, 224 deceased cases (mean age 48 years, 114 male) and 224 matched living controls were compared. In univariable analysis, predictors of epilepsy-related death were recent epilepsy-related accident and emergency attendance (odds ratio 5.1, 95% CI 3.2-8.3), living in deprived areas (odds ratio 2.5, 95% CI 1.6-4.0), developmental epilepsy (odds ratio 3.1, 95% CI 1.7-5.7), raised Charlson Comorbidity Index score (odds ratio 2.5, 95% CI 1.2-5.2), alcohol abuse (odds ratio 4.4, 95% CI 2.2-9.2), absent recent neurology review (odds ratio 3.8, 95% CI 2.4-6.1) and generalized epilepsy (odds ratio 1.9, 95% CI 1.2-3.0). Scottish Epilepsy Deaths Study Score model variables were derived from the first four listed before, with Charlson Comorbidity Index ≥2 given 1 point, living in the two most deprived areas given 2 points, having an inherited or congenital aetiology or risk factor for developing epilepsy given 2 points and recent epilepsy-related accident and emergency attendance given 3 points. Compared to having a Scottish Epilepsy Deaths Study Score of 0, those with a Scottish Epilepsy Deaths Study Score of 1 remained low risk, with odds ratio 1.6 (95% CI 0.5-4.8). Those with a Scottish Epilepsy Deaths Study Score of 2-3 had moderate risk, with odds ratio 2.8 (95% CI 1.3-6.2). Those with a Scottish Epilepsy Deaths Study Score of 4-5 and 6-8 were high risk, with odds ratio 14.4 (95% CI 5.9-35.2) and 24.0 (95% CI 8.1-71.2), respectively. The Scottish Epilepsy Deaths Study Score may be a helpful tool for identifying adults at high risk of epilepsy-related death and requires external validation.

Mortality risk in adults with intellectual disabilities and epilepsy: an England and Wales case-control study

BACKGROUND

People with epilepsy (PWE) and people with intellectual disabilities (ID) both live shorter lives than the general population and both conditions increase the risk of death further. We aimed to measure associations between certain risk factors for death in PWE and ID.

METHODS

A retrospective case-control study was conducted in ten regions in England and Wales. Data were collected on PWE registered with secondary care ID and neurology services between 2017 and 2021. Prevalence rates of neurodevelopmental, psychiatric and medical diagnoses, seizure frequency, psychotropic and antiseizure medications (ASM) prescribed, and health activity (epilepsy reviews/risk assessments/care plans/compliance etc.) recorded were compared between the two groups.

RESULTS

190 PWE and ID who died were compared with 910 living controls. People who died were less likely to have had an epilepsy risk assessment but had a greater prevalence of genetic conditions, older age, poor physical health, generalized tonic-clonic seizures, polypharmacy (not ASMs) and antipsychotic use. The multivariable logistic regression for risk of epilepsy-related death identified that age over 50, medical condition prevalence, antipsychotic medication use and the lack of an epilepsy review in the last 12 months as associated with increased risk of death. Reviews by psychiatrists in ID services was associated with a 72% reduction in the odds of death compared neurology services.

CONCLUSIONS

Polypharmacy and use of antipsychotics may be associated with death but not ASMs. Greater and closer monitoring by creating capable health communities may reduce the risk of death. ID services maybe more likely to provide this holistic approach.

"Untold Distress" - How did the COVID-19 pandemic affect those who had previously experienced an epilepsy-related bereavement?

PURPOSE

This study explores the impact of the COVID-19 pandemic and lockdown on people with lived experience of sudden bereavement as a consequence of an epilepsy-related death.

METHOD

We developed an online survey with fixed choice and open-ended response formats to collect data on grief symptoms and well-being during the pandemic. A total of 275 people bereaved by epilepsy-related deaths between 1980-2020 participated in this study: with 79 participants providing free-text responses for inductive thematic analysis.

RESULTS

In total, 84% of participants reported a bereavement following a sudden death of a person aged under 40, with 22% aged 19 and under. The majority (77% of participants) reported they had been thinking more about the person who died compared to before the COVID-19 outbreak and 54% had experienced more distressing flashbacks to the time of death. Additionally, 61% reported more difficulties falling asleep and staying asleep and 88% of participants reported that the outbreak and response measures had negatively impacted upon their mental health. Medication was being taken for a diagnosed mental health condition by 33% of participants at the time of the study. We categorized these negative experiences during COVID in to four main-themes - 'Family', 'Lifestyle', 'Personal Well-being' and 'Health Services and Shielding Populations'. The 'Personal Well-being' theme was inextricably linked to grief symptoms including 'reflection on the death', 're-exposure to feeling', 'grief', 'salience of sudden deaths in the media' and 'inability to commemorate anniversaries and rituals'. These findings were consistent for bereaved people irrespective of the recency of the death.

CONCLUSION

This study highlights the impact of the disruption caused by the pandemic on the grief-management of those bereaved by epilepsy-related death. Grief is not static and its management is connected to the psychosocial and formal support structures that were disrupted during the pandemic. The removal of these supports had an adverse effect upon the mental health and well-being of many bereaved. There is an urgent need for a system-wide transformation of epilepsy and mental health services to be inclusive of the needs and experiences of people impacted by sudden deaths in epilepsy and the contribution of the specialist service developed by families and clinicians to meet this gap.

Epilepsy, intellectual disability and the epilepsy care pathway: improving outcomes

The strong, life-long association between epilepsy and intellectual disability means that psychiatric teams, and the services they exist in, have a need for significant competencies in the field of epilepsy. This article addresses these competencies through the pathway of care. It will focus on those areas most relevant to psychiatric care and, when possible, explore where technology has begun to influence practice. The pathway leads from diagnosis through, in some cases, to mortality and support of the bereaved in psychiatric care. We will approach the topic through showing how the intertwining themes of information, empowerment, access to care, assessment of risk and psychological support are important. Technological advances are supporting changes in most of these areas, and psychological support, a knowledge of the needs of people with epilepsy and intellectual disability and epilepsy skills remain the foundation in the application of these advances.

Psychiatric comorbidities and all-cause mortality in epilepsy: A nationwide cohort study

Background

People with epilepsy (PWE) having comorbid psychiatric conditions may be at greater risk of death. We aimed to determine the association between psychiatric disorders and all-cause mortality among PWE after adjustment for somatic comorbidities.

Methods

Based on data from the National Health Insurance Fund, a Cox survival analysis was done within a retrospective open cohort of all PWE (≥12 years) in Lithuania between January 2014 and June 2020. Cox models comparing mortality between PWE with or without psychiatric comorbidities were adjusted for sex, age, hospitalizations, and the epilepsy-specific comorbidity index.

Results

Of 47,964 PWE (age Md = 49, IQR = 34–62 years, 60.3% male, follow-up Md = 4.4, IQR = 2.1–6.1 years), 10,290 (21.5%) died during the study. The diagnosis of any psychiatric disorder (n = 26,137, 54.5%) was associated with increased mortality when adjusted for only sex and age (HR = 1.13, 95% CI = 1.09 to 1.18). After including the epilepsy-specific comorbidity index, the number of hospitalizations and hospital days in the analysis, only self-harm (HR = 1.55, 95% CI = 1.40 to 1.71) and substance use disorders (HR = 1.39 95% CI = 1.32 to 1.47), but not any psychiatric comorbidities (HR = 0.92 95% CI = 0.88 to 0.96) were related to elevated all-cause mortality. Mood, anxiety and behavioral disorders were associated with lower odds of mortality; however, they were rarely documented.

Conclusions

Our results suggest that psychiatric comorbidities increase all-cause mortality among PWE through their association with coexisting somatic conditions as only substance use disorders and self-harm were independently related to elevated all-cause mortality. Future clinical interview-based studies should explore the relationship between mortality in epilepsy and psychiatric comorbidities while adjusting for somatic comorbidities.