An update on the prevalence and incidence of epilepsy among older adults

Excess prevalence of preexisting chronic conditions in older adults with incident epilepsy

OBJECTIVE

Prior studies have examined chronic conditions in older adults with prevalent epilepsy, but rarely among those with incident epilepsy. Identifying the chronic conditions with which older adults present at epilepsy incidence assists with the evaluation of disease burden in this patient population and informs coordinated care development. The aim of this study was to identify preexisting chronic conditions with excess prevalence in older adults with incident epilepsy compared to those without.

METHODS

Using a random sample of 4 999 999 fee-for-service Medicare beneficiaries aged >65 years, we conducted a retrospective cohort study of epilepsy incidence in 2019. Non-Hispanic Black and Hispanic beneficiaries were oversampled. We identified preexisting chronic conditions from the 2016-2018 Medicare Beneficiary Summary Files and compared chronic condition prevalence between Medicare beneficiaries with and without incident epilepsy in 2019. We characterized variations in preexisting excess chronic condition prevalence by age, sex, and race/ethnicity, adjusting for the racial/ethnic oversampling.

RESULTS

We observed excess prevalence of most preexisting chronic conditions in beneficiaries with incident epilepsy (n = 20 545, weighted n = 19 631). For stroke, for example, the adjusted prevalence rate ratio (APRR) was 4.82 (99% CI:4.60, 5.04), meaning that, compared to those without epilepsy, beneficiaries with incident epilepsy in 2019 had 4.82 times the stroke prevalence. Similarly, beneficiaries with incident epilepsy had a higher prevalence rate for preexisting neurological conditions (APRR = 3.17, 99% CI = 3.08-3.27), substance use disorders (APRR = 3.00, 99% CI = 2.81-3.19), and psychiatric disorders (APRR = 1.98, 99% CI = 1.94-2.01). For most documented chronic conditions, excess prevalence among beneficiaries with incident epilepsy in 2019 was larger for younger age groups compared to older age groups, and for Hispanic beneficiaries compared to both non-Hispanic White and non-Hispanic Black beneficiaries.

SIGNIFICANCE

Compared to epilepsy-free Medicare beneficiaries, those with incident epilepsy in 2019 had a higher prevalence of most preexisting chronic conditions. Our findings highlight the importance of health promotion and prevention, multidisciplinary care, and elucidating shared pathophysiology to identify opportunities for prevention.

Dosing profiles of concurrent opioid and benzodiazepine use associated with overdose risk among US Medicare beneficiaries: group-based multi-trajectory models

BACKGROUND AND AIMS

One-third of opioid (OPI) overdose deaths involve concurrent benzodiazepine (BZD) use. Little is known about concurrent opioid and benzodiazepine use (OPI-BZD) most associated with overdose risk. We aimed to examine associations between OPI-BZD dose and duration trajectories, and subsequent OPI or BZD overdose in US Medicare.

DESIGN

Retrospective cohort study.

SETTING

US Medicare.

PARTICIPANTS

Using a 5% national Medicare data sample (2013-16) of fee-for-service beneficiaries without cancer initiating OPI prescriptions, we identified 37 879 beneficiaries (age ≥ 65 = 59.3%, female = 71.9%, white = 87.6%, having OPI overdose = 0.3%).

MEASUREMENTS

During the 6 months following OPI initiation (i.e. trajectory period), we identified OPI-BZD dose and duration patterns using group-based multi-trajectory models, based on average daily morphine milligram equivalents (MME) for OPIs and diazepam milligram equivalents (DME) for BZDs. To label dose levels in each trajectory, we defined OPI use as very low (< 25 MME), low (25-50 MME), moderate (51-90 MME), high (91-150 MME) and very high (>150 MME) dose. Similarly, we defined BZD use as very low (< 10 DME), low (10-20 DME), moderate (21-40 DME), high (41-60 DME) and very high (> 60 DME) dose. Our primary analysis was to estimate the risk of time to first hospital or emergency department visit for OPI overdose within 6 months following the trajectory period using inverse probability of treatment-weighted Cox proportional hazards models.

FINDINGS

We identified nine distinct OPI-BZD trajectories: group A: very low OPI (early discontinuation)-very low declining BZD (n = 10 598; 28.0% of the cohort); B: very low OPI (early discontinuation)-very low stable BZD (n = 4923; 13.0%); C: very low OPI (early discontinuation)-medium BZD (n = 4997; 13.2%); D: low OPI-low BZD (n = 5083; 13.4%); E: low OPI-high BZD (n = 3906; 10.3%); F: medium OPI-low BZD (n = 3948; 10.4%); G: very high OPI-high BZD (n = 1371; 3.6%); H: very high OPI-very high BZD (n = 957; 2.5%); and I: very high OPI-low BZD (n = 2096; 5.5%). Compared with group A, five trajectories (32.3% of the study cohort) were associated with increased 6-month OPI overdose risks: E: low OPI-high BZD [hazard ratio (HR) = 3.27, 95% confidence interval (CI) = 1.61-6.63]; F: medium OPI-low BZD (HR = 4.04, 95% CI = 2.06-7.95); G: very high OPI-high BZD (HR = 6.98, 95% CI = 3.11-15.64); H: very high OPI-very high BZD (HR = 4.41, 95% CI = 1.51-12.85); and I: very high OPI-low BZD (HR = 6.50, 95% CI = 3.15-13.42).

CONCLUSIONS

Patterns of concurrent opioid and benzodiazepine use most associated with overdose risk among fee-for-service US Medicare beneficiaries initiating opioid prescriptions include very high-dose opioid use (MME > 150), high-dose benzodiazepine use (DME > 40) or medium-dose opioid with low-dose benzodiazepine use.

Knowledge, attitudes, and practices of physiotherapists with regard to epilepsy and patients with epilepsy: A systematic scoping review

BACKGROUND

In today's healthcare systems, physiotherapists are one of the most important providers of care services to patients with disabilities including those with epilepsy. The aims of this systematic scoping review were to identify, summarize, and present narrative synthesis of qualitative evidence on knowledge, attitudes, and practices of physiotherapists toward epilepsy and patients with epilepsy.

METHODS

Primary studies were searched in Medline/PubMed, Embase, Science Direct, SpringerLink, CInAHL/EBSCO, Cochrane library, and Scopus as late as July 02, 2021. Appraisal of the methodological quality was conducted for the studies included in this systematic scoping review. Due to the heterogenous nature of the collected data, results of this study are presented as narrative synthesis.

RESULTS

A total of 11 were finally included in the qualitative synthesis. The selected studies were published in the period between 2016 and 2020. The studies included in this review had acceptable methodological quality in many of the 11 domains of the quality assessment tool. Contents of the included studies were grouped into the 11 themes and 8 subthemes. The major themes were related education/access to information, interaction with patients, witnessing seizures, barriers and promoters of adequate knowledge and attitudes, and interventions to improve knowledge and attitudes.

CONCLUSION

Currently, high-quality interventional studies are needed to improve knowledge, attitudes, and practices of physiotherapists with regard to epilepsy and patients with epilepsy. Future studies are still needed to investigate if improving knowledge, attitudes, and practices of physiotherapists with regard to epilepsy and patients with epilepsy can improve health-related outcomes of the patients.

Researching on the compliance of epilepsy patients of the Phenobarbital Epilepsy Management Project in a rural area of China: A retrospective study

ABSTRACT

The aim of this study was to explore the compliance of epilepsy patients in the Phenobarbital Epilepsy Management Project in a rural area of China and its influencing factors, so as to provide the basis for further strategies.A retrospective study researching on the compliance of epilepsy patients in the Phenobarbital Epilepsy Management Project of Rural China was conducted. The Nan County, Hunan Province as a typical rural China was selected as the study site. We collected the compliance and other relative factors from 2017 to 2019 though the Phenobarbital Epilepsy Management Project data system.The good compliance patients in the Phenobarbital Epilepsy Management Project in a rural area of China were 98.99% (393/397); only 4 cases had poor compliance. The factors affecting the compliance of epilepsy patients were "adverse reactions of digestive tract symptoms," "how the patient felt physically, mentally, or working and learning ability during this period," and "the ratio of the attack to the previous one."The rate of good compliance among the epilepsy patients in the Phenobarbital Epilepsy Management Project in a rural area of China was high. More attention to education, patients' psychology, and the curative effect of family members may improve the compliance of patients with epilepsy further.

Exploring the prevalence and profile of epilepsy across Europe using a standard retrospective chart review: Challenges and opportunities

OBJECTIVE

This study aimed to determine the prevalence of epilepsy in four European countries (Austria, Denmark, Ireland, and Romania) employing a standard methodology. The study was conducted under the auspices of ESBACE (European Study on the Burden and Care of Epilepsy).

METHODS

All hospitals and general practitioners serving a region of at least 50 000 persons in each country were asked to identify patients living in the region who had a diagnosis of epilepsy or experienced a single unprovoked seizure. Medical records were accessed, where available, to complete a standardized case report form. Data were sought on seizure frequency, seizure type, investigations, etiology, comorbidities, and use of antiseizure medication. Cases were validated in each country, and the degree of certainty was graded as definite, probable, or suspect cases.

RESULTS

From a total population of 237 757 in the four countries, 1988 (.8%) patients were identified as potential cases of epilepsy. Due to legal and ethical issues in the individual countries, medical records were available for only 1208 patients, and among these, 113 had insufficient clinical information. The remaining 1095 cases were classified as either definite (n = 706, 64.5%), probable (n = 191, 17.4%), suspect (n = 153, 14.0%), or not epilepsy (n = 45, 4.1%).

SIGNIFICANCE

Although a precise prevalence estimate could not be generated from these data, the study found a high validity of epilepsy classification among evaluated cases (95.9%). More generally, this study highlights the significant challenges facing epidemiological research methodologies that are reliant on patient consent and retrospective chart review, largely due to the introduction of data protection legislation during the study period. Documentation of the epilepsy diagnosis was, in some cases, relatively low, indicating a need for improved guidelines for assessment, follow-up, and documentation. This study highlights the need to address the concerns and requirements of recruitment sites to engage in epidemiological research.

Are medical students adequately prepared to provide quality care for patients with epilepsy? A cross-sectional study of their knowledge and attitude

OBJECTIVE

This study assessed preparedness of Palestinian medical students as future physicians to care for patients with epilepsy through assessing their knowledge and attitude.

METHODS

The current study was conducted in a cross-sectional design. A pre-validated study tool was used to collect sociodemographic and academic details of the students, test their knowledge using a 16-item test, and test their attitude using a 13-item test.

RESULTS

A total of 386 medical students completed the study tool. The median knowledge score was 75.0% (range: 62.5% to 87.5%). The median attitude score was 81.5% (range: 73.8% to 89.2%). Knowledge and attitude scores correlated positively (Spearman's rho = 0.25, p-value < 0.001). Students who were in their clinical training stage (OR = 4.22, 95% CI of 2.54 to 7.01), who had received a course/part of a course on epilepsy (OR = 2.55, 95% CI of 1.26 to 5.17), who perceived their knowledge of epilepsy as moderate (OR = 3.14, 95% CI of 1.87 to 5.28), and those who perceived their knowledge of epilepsy as high (OR = 11.91, 95% CI of 2.47 to 57.41) were more likely to score ≥ 70% in the knowledge test compared to those who were in their basic training stage, who had not received a course/part of a course on epilepsy, and who perceived their knowledge of epilepsy as low, respectively.

CONCLUSION

Findings of the current investigation may indicate that inclusion of courses on epilepsy early in the medical curriculum might promote knowledge of medical students with regard to epilepsy.

Dual-trajectories of opioid and gabapentinoid use and risk of subsequent drug overdose among Medicare beneficiaries in the United States: a retrospective cohort study

BACKGROUND AND AIMS

Little is known about opioid and gabapentinoid (OPI-GABA) use duration and dose patterns' associations with adverse outcome risks. We examined associations between OPI-GABA dose and duration trajectories and subsequent drug overdose.

DESIGN

Retrospective cohort study.

SETTING

US Medicare.

PARTICIPANTS

Using a 5% sample (2011-16), we identified 71 005 fee-for-service Medicare beneficiaries with fibromyalgia, low back pain, neuropathy and/or osteoarthritis initiating OPIs and/or GABAs [mean age ± standard deviation (SD) = 65.5 ± 14.5 years, female = 68.1%, white = 76.8%].

MEASUREMENTS

Group-based multi-trajectory models identified distinct OPI-GABA use patterns during the year of OPI and/or GABA initiation, based on weekly average standardized daily dose (i.e. OPIs = morphine milligram equivalent, GABAs = minimum effective daily dose). We estimated models with three to 12 trajectories and selected the best model based on Bayesian information criterion (BIC) and Nagin's criteria. We estimated risk of time to first drug overdose diagnosis within 12 months following the index year, adjusting for socio-demographic and health factors using inverse probability of treatment weighted multivariable Cox proportional hazards models.

FINDINGS

We identified 10 distinct trajectories (BIC = -1 176 954; OPI-only = 3, GABA-only = 3, OPI-GABA = 4). Compared with OPI-only early discontinuers (40.6% of the cohort), 1-year drug overdose risk varied by trajectory group: consistent low-dose OPI-only users [16.6%; hazard ratio (HR) = 1.47, 95% confidence interval (CI) = 1.19-1.82], consistent high-dose OPI-only users (1.8%; HR = 4.57, 95% CI = 2.99-6.98), GABA-only early discontinuers (12.5%; HR = 1.39, 95% CI = 1.09-1.77), consistent low-dose GABA-only users (11.0%; HR = 1.44, 95% CI = 1.12-1.85), consistent high-dose GABA-only users (3.1%; HR = 1.43, 95% CI = 0.94-2.17), early discontinuation of OPIs and consistent low-dose GABA users (6.9%; HR = 1.24, 95% CI = 0.90-1.69), consistent low-dose OPI-GABA users (3.4%; HR = 2.49, 95% CI = 1.76-3.52), consistent low-dose OPI and high-dose GABA users (3.2%; HR = 2.46, 95% CI = 1.71-3.53) and consistent high-dose OPI and moderate-dose GABA users (0.9%; HR = 7.22, 95% CI = 4.46-11.69).

CONCLUSIONS

Risk of drug overdose varied substantially among US Medicare beneficiaries on different use trajectories of opioids and gabapentinoids. High-dose opioid-only users and all consistent opioid and gabapentinoid users (regardless of doses) had more than double the risk of subsequent drug overdose compared with opioid-only early discontinuers.

Incidence and prevalence of epilepsy in the Republic of North Macedonia: Data from nationwide integrated health care platform

PURPOSE

This study aimed to evaluate the incidence and period prevalence of epilepsy in the Republic of North Macedonia, an upper-middle-income country with universal access to healthcare, based on a nationwide healthcare platform (NHP).

METHODS

NHP contains reports from all inpatient and outpatient medical encounters and procedures, and all electronic medical records are linked together with a unique patient number. We performed the analysis of the data maintained at the Macedonian Ministry of Health, concerning the five years of the study (2014 through 2018). Population and demographic data for each year were obtained from the State Statistical Office.

RESULTS

The period prevalence was 6.67 per 1,000 inhabitants. There were 6383 (46.2%) females and 7435 (53.8%) males; the gender difference was significant: 6.17 per 1,000 females and 7.16 per 1,000 males (p = 0.0000). Between 2015 and 2018 the median annual incidence of epilepsy was 68 new epilepsy patients per 100,000, with an upward trend over time. The age-specific incidence was high in childhood and adolescence, was constant (and low) in the adult years, and gradually increased in each successive age group after the age of 50 years. The greatest incidence was found in group 70-79 years of age. The incidence in childhood and adolescence tends to gradually decrease from 2015 to 2018, while it progressively increased in population over 50 years of age, which may explain a rise in overall incidence. We found a statistically significant higher incidence in males than in females, a ratio consistently being 1.2: 1.

CONCLUSION

The data from the study provides accurate findings on the prevalence and incidence of epilepsy in the upper-middle-income Southeastern European country.

Association Between Dual Trajectories of Opioid and Gabapentinoid Use and Healthcare Expenditures Among US Medicare Beneficiaries

OBJECTIVES

Little is known about relationships between opioid- and gabapentinoid-use patterns and healthcare expenditures that may be affected by pain management and risk of adverse outcomes. This study examined the association between patients' opioid and gabapentinoid prescription filling/refilling trajectories and direct medical expenditures in US Medicare.

METHODS

This cross-sectional study included a 5% national sample (2011-2016) of fee-for-service beneficiaries with fibromyalgia, low back pain, neuropathy, or osteoarthritis newly initiating opioids or gabapentinoids. Using group-based multitrajectory modeling, this study identified patients' distinct opioid and gabapentinoid (OPI-GABA) dose and duration patterns, based on standardized daily doses, within a year of initiating opioids and/or gabapentinoids. Concurrent direct medical expenditures within the same year were estimated using inverse probability of treatment weighted multivariable generalized linear regression, adjusting for sociodemographic and health status factors.

RESULTS

Among 67 827 eligible beneficiaries (mean age ± SD = 63.6 ± 14.8 years, female = 65.8%, white = 77.1%), 11 distinct trajectories were identified (3 opioid-only, 4 gabapentinoid-only, and 4 concurrent OPI-GABA trajectories). Compared with opioid-only early discontinuers ($13 830, 95% confidence interval = $13 643-14 019), gabapentinoid-only early discontinuers and consistent low-dose and moderate-dose gabapentinoid-only users were associated with 11% to 23% lower health expenditures (adjusted mean expenditure = $10 607-$11 713). Consistent low-dose opioid-only users, consistent high-dose opioid-only users, consistent low-dose OPI-GABA users, consistent low-dose opioid and high-dose gabapentinoid users, and consistent high-dose opioid and moderate-dose gabapentinoid users were associated with 14% to 106% higher healthcare expenditures (adjusted mean expenditure = $15 721-$28 464).

CONCLUSIONS

Dose and duration patterns of concurrent OPI-GABA varied substantially among fee-for-service Medicare beneficiaries. Consistent opioid-only users and all concurrent OPI-GABA users were associated with higher healthcare expenditures compared to opioid-only discontinuers.

Predictors of Mortality in Older Adults With Epilepsy: Implications for Learning Health Systems

OBJECTIVE

To determine the incidence of epilepsy and subsequent 5-year mortality among older adults, as well as characteristics associated with mortality.

METHODS

This was a retrospective cohort study of Medicare beneficiaries age 65 or above with at least 2 years enrollment before January 2009. Incident epilepsy cases were identified in 2009 using ICD-9-CM code-based algorithms; death was assessed through 2014. Cox regression models examined the association between 5-year mortality and incident epilepsy, and whether mortality differed by sociodemographic characteristics or comorbid disorders.

RESULTS

Among the 99,990 of 33,615,037 beneficiaries who developed epilepsy, most were White (79.7%), female (57.3%), urban (80.5%), and without Medicaid (71.3%). The 5-year mortality rate for incident epilepsy was 62.8% (62,838 deaths). In multivariable models, lower mortality was associated with female sex (adjusted hazards ratio [AHR] 0.85, 95% confidence interval [CI] 0.84-0.87), Asian race (AHR 0.82, 95% CI 0.76-0.88), and Hispanic ethnicity (AHR 0.81, 95% CI 0.76-0.84). Hazard of death increased with comorbid disease burden (per 1-point increase: AHR 1.27, 95% CI 1.26-1.27) and Medicaid coinsurance (AHR 1.17, 95% CI 1.14-1.19). Incident epilepsy was particularly associated with higher mortality when diagnosed after another neurologic condition: Parkinson disease (AHR 1.29, 95% CI 1.21-1.38), multiple sclerosis (AHR 2.13, 95% CI 1.79-2.59), dementia (AHR 1.33, 95% CI 1.31-1.36), traumatic brain injury (AHR 1.55, 95% CI 1.45-1.66), and stroke/TIA (AHR 1.20, 95% CI 1.18-1.21).

CONCLUSIONS

Newly diagnosed epilepsy is associated with high 5-year mortality among Medicare beneficiaries. Future studies that parse the interplay of effects from underlying disease, race, sex, and poverty on mortality will be critical in the design of learning health care systems to reduce premature deaths.

Effects of atorvastatin and aspirin on post-stroke epilepsy and usage of levetiracetam

OBJECTIVE

Atorvastatin and aspirin have been used in treating different forms of epilepsy. However, their effect on post-stroke epilepsy (PSE) still needs to be validated by large-scale clinical studies. In addition, their impact on the use of the antiepileptic drug levetiracetam for post-stroke epilepsy remains to be explored. Thus, the aim of this study was to further evaluate the effect of atorvastatin and aspirin on PSE and their effect on the usage of the antiepileptic drug levetiracetam in PSE patients.

METHODS

Patients, aged 65 to 85 years, with newly diagnosed post-ischemic stroke epilepsy from August 30, 2014 to August 30, 2018 were included in the study, with the exclusion of those with coexisting conditions.

RESULTS

Initially, 1321 patients were included, and 780 remained in the study at the 1-year follow-up. During the study, atorvastatin treatment with or without aspirin reduced the number of clinical epileptic episodes in PSE patients. It also reduced the dosage of levetiracetam and achieved better control of epilepsy compared to levetiracetam mono-treatment. Aspirin co-treatment with levetiracetam did not result in a significant improvement. However, the combination of aspirin with atorvastatin significantly reduced the number of seizures compared to atorvastatin treatment alone.

CONCLUSION

Atorvastatin and aspirin co-treatment with levetiracetam can reduce epilepsy in PSE patients and reduce the dosage of levetiracetam required for effective control of PSE.

Therapeutic monitoring of antiepileptic drugs: Recommendations to improve care of patients with epilepsy in the Palestinian practice

BACKGROUND

Therapeutic drug monitoring (TDM) can play a major role in optimizing pharmacotherapy of epilepsy. This study was conducted to explore views and opinions of clinicians who care for patients with epilepsy (PWE) in Palestine and to develop consensus-based recommendations with regard to importance, justification, technical, and analytical issues of TDM of antiepileptic drugs (AEDs).

METHODS

The study was conducted in three phases: (1) the published literature was thoroughly searched for an initial list of items relevant to TDM of AEDs, (2) the list was supplemented by items provided by key experts (n = 8) through semi-structured in-depth interviews, (3) views and opinions of clinicians (n = 20) on TDM of AEDs were explored, and (4) a two-round Delphi technique was followed among a panel of experts (n = 27) to develop consensus-based recommendations to guide TDM of AEDs in Palestine.

RESULTS

Consensus was achieved on items related to importance (8 items) of TDM of AEDs, clinical justifications of TDM of AEDs (19 items), guidelines for optimal TDM of AEDs (11 items), TDM of some AEDs (21 items), TDM practice (24 items), and some technical and analytical issues in TDM of AEDs (13 items).

CONCLUSION

Consensus-based recommendations that might be used in guiding TDM of AEDs in Palestine were developed. Future studies are still needed to investigate if these consensus-based recommendations can improve healthcare of PWE in Palestine.

CDC-supported epilepsy surveillance and epidemiologic studies: A review of progress since 1994

To report progress, to identify gaps, and to plan epilepsy surveillance and research activities more effectively, the Centers for Disease Control and Prevention (CDC) Epilepsy Program has summarized findings from selected CDC-supported surveillance and epidemiologic studies about epilepsy from 1994 through 2019. We identified publications supported by CDC funding and publications conducted by the CDC Epilepsy Program alone or with partners. We included only epilepsy surveillance and epidemiologic studies focusing on epilepsy burden, epilepsy-related outcomes, and healthcare utilization. We describe the findings of these studies in the following order: 1)prevalence; 2)incidence; 3)epilepsy-related outcomes by selected demographic characteristics; 4)cysticercosis or neurocysticercosis (NCC); 5)traumatic brain injury (TBI); 6)comorbidity; 7)mortality; 8)access to care; 9)quality of care; and 10) cost. We have characterized these findings in relation to the scope of the first three domains of the 2012 Institute of Medicine report on epilepsy and its relevant first four recommendations. From 1994 through 2019, 76 publications on epilepsy-related epidemiologic and surveillance studies were identified. Over the past 25 years, CDC has expanded community, state, and national surveillance on epilepsy and supported epidemiologic studies by using multiple assessment methods and validated case-ascertainment criteria to identify epilepsy burden, epilepsy-related outcomes, and healthcare utilization in the general population or in population subgroups. Among identified research opportunities, studies on epilepsy incidence and risk factors, mortality, and cost are considered as important surveillance gaps. Other remaining gaps and suggested surveillance strategies are also proposed. Findings from this review may help epilepsy researchers and other stakeholders reference and prioritize future activities for epidemiologic and surveillance studies in epilepsy.

Agreement of Palestinian nursing students with recommendations to eliminate epilepsy stigma and change perception of the general public about epilepsy: A cross-sectional study

OBJECTIVE

This study was conducted to assess the degree of agreement of Palestinian nursing students with recommendations and key messages to eliminate/reduce epilepsy stigma and change perception of the general public about epilepsy and people with epilepsy (PWE).

METHODS

A cross-sectional observational study was conducted among undergraduate nursing students. The study tool was a questionnaire with 24 items which collected the sociodemographic and academic characteristics of the participants (6 items) and agreements with 18 recommendations and key messages to eliminate/reduce epilepsy stigma.

RESULTS

A total of 342 nursing students completed the questionnaire with a response rate of 68.4%. The participants agreed with the 6 recommendations to inform media, improve awareness, and educate the general public on epilepsy (agreement rates: 87.7% to 92.4%), 4 recommendations to coordinate efforts to improve awareness and educate the general public on epilepsy and PWE (agreement rates: 89.8% to 93.0%), and 8 key messages to eliminate/reduce epilepsy stigma (agreement rates: 70.2% to 93.9%). In general, female students tended to express significantly higher levels of agreement with the recommendations and key messages (p-value < 0.05).

CONCLUSION

Results of the present study highlighted the importance of involving nurses and future nurses in eliminating/reducing epilepsy stigma and changing perception of the general public about epilepsy and PWE. Further studies are to be conducted to investigate if these recommendations and messages can eliminate or significantly reduce epilepsy stigma and change perception of the general public about epilepsy and PWE.

The Prevalence and Factors Associated with Antiepileptic Drug Use in US Nursing Home Residents

BACKGROUND

Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant.

OBJECTIVE

The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine).

METHODS

We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs).

RESULTS

Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPR_{moderate/severe vs. no pain} 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR_{85+ vs. 65-74 years} 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPR_{severe vs. no impairment} 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aOR_{moderate/severe vs. no pain} 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication.

CONCLUSIONS

AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.

Crossword puzzles improve learning of Palestinian nursing students about pharmacology of epilepsy: Results of a randomized controlled study

OBJECTIVE

This study was conducted to investigate if crossword puzzles as active learning tools can improve the knowledge retention of nursing students in pharmacology of epilepsy and improve their performance in writing the correct spelling of antiepileptic drugs (AEDs).

METHODS

The present study was a randomized controlled prospective parallel study in which a control group design with pretests and posttests were used among nursing students. Students were randomly allocated to either control group (n = 114) who received routine learning or intervention group (n = 110) who received crossword puzzles. Both control and intervention groups had to complete multiple-choice question (MCQs) and spelling pretests and posttests.

RESULTS

Scores of the MCQs and spelling pretests were not statistically different (p-value > 0.05) for participants in all achievement categories in both control and intervention groups. In the intervention group, scores in the first and second MCQs and spelling posttests were significantly higher than their corresponding scores in the pretest scores for participants from the all achievement categories (p-value < 0.05) and scores of the first and second MCQs and spelling posttests were not significantly different (p-value > 0.05). Data analyses showed that there were significant normalized changes between scores of students in across all achievement categories.

CONCLUSION

Findings of this study suggested that crossword puzzles were effective in improving the learning of nursing students about the pharmacology of epilepsy and writing correct spelling of AEDs. Educators should consider using crossword puzzles as active learning tools to improve knowledge of nursing students about the pharmacology of epilepsy.

Facilitating ethical, legal, and professional deliberations to resolve dilemmas in daily healthcare practice: A case of driver with breakthrough seizures

OBJECTIVE

The present study was conducted among pharmacy students to use an 8-step systematic approach to facilitate discussions, deliberations, and decision-making on what to do when facing a dilemma of a patient with epilepsy who drives while having breakthrough seizures.

METHODS

A hypothetical case was developed using the 12-tips for developing dilemma case-based assessments in health education. A mixed method was used in this study. A serial group discussions based on the nominal group technique (NGT) method were applied. A thorough review of the literature and interviews with key experts in the domain (n = 12) were conducted to obtain pertinent data to inform discussions, deliberations, and decision-making. The analytic hierarchy process (AHP) was used to pairwise compare countervailing arguments and alternative courses of action.

RESULTS

In this study, 3 nominal groups were held, and for each 3, discussion rounds were conducted. A total of 27 panelists took part in the nominal groups. Compared with other alternative courses of action, significantly higher weight scores (p-value < 0.001) were given to the course action, "the pharmacist could counsel/educate the patient on the dangers/risks of driving while experiencing breakthrough seizures, inform the patient to refrain from driving in this period, and make a shared decision with the patient to refrain from driving in this period and inform the state authorities".

CONCLUSION

This study demonstrates that the 8-step approach when combined with the AHP can be a handy method in facilitating decision-making while addressing and resolving ethical/legal/professional dilemmas in daily healthcare practice.

Assessing knowledge and attitudes of Palestinian undergraduate nursing students toward epilepsy and patients with epilepsy: A cross-sectional study

OBJECTIVE

This study assessed knowledge and attitudes of undergraduate nursing students toward epilepsy and patients with epilepsy (PWEs). Associations between different sociodemographic and academic variables and knowledge and attitude scores were also assessed.

METHODS

The present study was conducted in a cross-sectional observational design among Palestinian undergraduate nursing students using a prevalidated and reliable questionnaire of 38 items. After collecting sociodemographic and academic characteristics, students answered a knowledge test (16 items) and attitude test (13 items).

RESULTS

The questionnaire was completed by 342 nursing students. The median knowledge score was 65.6 with an interquartile range (IQR) of 31.3, and the median attitude score was 81.5 with an IQR of 20.0. Multiple linear regression analyses showed that higher knowledge scores were predicted by being female in gender (p-value <0.05), had a course/studied about epilepsy (p-value <0.001), self-rated knowledge about epilepsy as high (p-value <0.05), and ever witnessing a PWE experiencing seizures (p-value <0.001). Higher attitude scores were predicted by self-rated knowledge about epilepsy as high (p-value <0.001), had a course/studied about epilepsy (p-value <0.05), and ever witnessed a PWE experiencing seizures (p-value <0.05).

CONCLUSION

Nursing students had moderate knowledge of epilepsy and had generally positive attitudes toward PWEs. Findings of this study highlighted knowledge gaps and areas for improvement. As knowledge scores were positively correlated with attitudes, probably, findings of this study might suggest that educational/training interventions can improve knowledge as well as positive attitudes of nursing students with regard to epilepsy and PWEs.

Epilepsy Among Elderly Medicare Beneficiaries: A Validated Approach to Identify Prevalent and Incident Epilepsy

BACKGROUND

Uncertain validity of epilepsy diagnoses within health insurance claims and other large datasets have hindered efforts to study and monitor care at the population level.

OBJECTIVES

To develop and validate prediction models using longitudinal Medicare administrative data to identify patients with actual epilepsy among those with the diagnosis.

RESEARCH DESIGN, SUBJECTS, MEASURES

We used linked electronic health records and Medicare administrative data including claims to predict epilepsy status. A neurologist reviewed electronic health record data to assess epilepsy status in a stratified random sample of Medicare beneficiaries aged 65+ years between January 2012 and December 2014. We then reconstructed the full sample using inverse probability sampling weights. We developed prediction models using longitudinal Medicare data, then in a separate sample evaluated the predictive performance of each model, for example, area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity.

RESULTS

Of 20,945 patients in the reconstructed sample, 2.1% had confirmed epilepsy. The best-performing prediction model to identify prevalent epilepsy required epilepsy diagnoses with multiple claims at least 60 days apart, and epilepsy-specific drug claims: AUROC=0.93 [95% confidence interval (CI), 0.90-0.96], and with an 80% diagnostic threshold, sensitivity=87.8% (95% CI, 80.4%-93.2%), specificity=98.4% (95% CI, 98.2%-98.5%). A similar model also performed well in predicting incident epilepsy (k=0.79; 95% CI, 0.66-0.92).

CONCLUSIONS

Prediction models using longitudinal Medicare data perform well in predicting incident and prevalent epilepsy status accurately.

Comparison of new-onset and persistent epilepsy in the elderly

BACKGROUND

Previous studies on elderly epilepsy included only patients with new-onset disease, but there are many patients who developed epilepsy earlier and aged.

AIM

We compared the characteristics of new-onset and persistent epilepsy in the elderly.

METHODS

We performed a 10-year retrospective analysis of elderly patients with epilepsy divided into two groups according to the onset of seizure: new-onset epilepsy (onset age ≥65) and persistent epilepsy (onset age<65).

RESULTS

Nearly half (78/172, 45.3%) of patients in the new-onset group presented as status epilepticus, and one-fourth of these (19/78, 24.4%) died during the initial treatment for status epilepticus. Patients in the new-onset epilepsy group presented more frequently as status epilepticus (59/153 vs 12/78, P < 0.001) and had a past history of status epilepticus (63/153 vs 20/78, P = 0.02). History of stroke (81/153 vs 30/78, P = 0.04), hypertension (83/153 vs 29/78, P = 0.01), and dyslipidemia (53/153 vs 17/78, P = 0.05) was more common in the new-onset group, but patients in the persistent group used more antiepileptic drugs (AEDs; P = 0.036) and total AED drug loads (P = 0.028).

CONCLUSIONS

Our study shows that new-onset epilepsy has a higher incidence of status epilepticus and more stroke-related risk factors but may require fewer AEDs for epilepsy control.

Medicare claims can identify post-stroke epilepsy

OBJECTIVE

There have been no validated Medicare claims-based algorithms available to identify epilepsy by discrete etiology of stroke (e.g., post-stroke epilepsy, PSE) in community-dwelling elderly individuals, despite the increasing availability of large datasets. Our objective was to validate algorithms that detect which patients have true PSE.

METHODS

We linked electronic health records (EHR) to Medicare claims from a Medicare Pioneer Accountable Care Organization (ACO) to identify PSE. A neurologist reviewed 01/2012-12/2014 EHR data from a stratified sample of Medicare patients aged 65+ years to adjudicate a reference-standard to develop an algorithm for identifying patients with PSE. Patient sampling strata included those with: A) epilepsy-related claims diagnosis (n = 534 [all]); B) no diagnosis but neurologist visit (n = 500 [randomly sampled from 4346]); C) all others (n = 500 [randomly sampled from 16,065]). We reconstructed the full sample using inverse probability sampling weights; then used half to derive algorithms and assess performance, and the remainder to confirm performance. We evaluated predictive performance across several measures, e.g., specificity, sensitivity, negative and positive predictive values (NPV, PPV). We selected our best performing algorithms based on the greatest specificity and sensitivity.

RESULTS

Of 20,943 patients in the reconstructed sample, 13.6% of patients with epilepsy had reference-standard PSE diagnosis, which represents a 3-year overall prevalence of 0.28% or 28/10,000, and a prevalence within the subpopulation with stroke of 3%. The best algorithm included three conditions: (a) at least one cerebrovascular claim AND one epilepsy-specific anticonvulsant OR (b) at least one cerebrovascular claim AND one electroencephalography claim (specificity 100.0% [95% CI 99.9%-100.0%], NPV 98.8% [98.6%-99.0%], sensitivity 20.6% [95% CI 14.6%-27.9%], PPV 86.5% [95% CI 71.2%-95.5%]).

CONCLUSION

Medicare claims can identify elderly Medicare beneficiaries with PSE with high accuracy. Future epidemiological surveillance of epilepsy could incorporate similar algorithms to accurately identify epilepsy by varying etiologies.

Close to 1 million US adults aged 55 years or older have active epilepsy-National Health Interview Survey, 2010, 2013, and 2015

Epilepsy is common in older adults because known risk factors-such as traumatic brain injury, stroke, cerebrovascular disease, neurodegenerative disorders, and neoplasms-increase with age. This study uses the most recent data from the 2010, 2013, and 2015 National Health Interview Survey (NHIS) to provide updated national estimates of epilepsy prevalence among US adults aged 55 years or older to help guide public health action. We used the following validated surveillance case definition for active epilepsy: adults with self-reported doctor-diagnosed epilepsy or seizure disorder who reported either currently taking medications to treat their epilepsy or seizure disorder or at least one seizure during the past 12 months. We estimated the prevalence of active epilepsy to be 1.4% (about 529,000) among US adults aged 55-64, 0.9% (225,000) for those aged 65-74, and 1.0% (178,000) for those aged ≥75 years. The prevalence of a history of epilepsy and active epilepsy among adults aged 55-64 years was significantly higher than the prevalence in older age groups. Collectively, close to 1 million adults aged 55 years or older reported active epilepsy. Epilepsy stakeholders should ensure that older adults with epilepsy have access to age-appropriate clinical preventive services, chronic disease self-management support, specialty care for epilepsy and other comorbidities, and appropriate community services to promote quality of life.