Overall and cause-specific premature mortality in epilepsy: A systematic review

Aborted sudden cardiac death in a young patient with epilepsy and the Gorlin Goltz syndrome

Epilepsy is one of the most common chronical neurological conditions affecting over 50 million people worldwide. In addition to the stigma and discrimination, individuals with epilepsy suffer from a nearly three-fold increased risk of premature death compared to the general population. Although these premature deaths occur due to multiple causes, sudden unexpected death in epilepsy (SUDEP) still challenges neurologists and clinicians dealing with individuals with epilepsy. Recently, an increased interest in cardiac outcomes related to acute seizures and chronic epilepsy resulted in the groundbreaking development of the "epileptic heart" concept, and sudden cardiac death in individuals with epilepsy, which is 4.5 times as frequent as SUDEP according to some observational data, has gained more attention. As we gather information and learn about possible comorbidities and consequences of seizures and/or chronic epilepsy, we present a clinical case of a young patient with an unusual association of epilepsy, the Gorlin Goltz syndrome, and a cardiac fibroma with Wolf-Parkinson-White (WPW), who had multiple aborted cardiac arrests. Diagnostic challenges and multiple possible causes of sudden cardiac death in this single patient report are discussed.

Cardiovascular Disease Burden, Mortality, and Sudden Death Risk in Epilepsy: A UK Biobank Study

BACKGROUND

Sudden death is the leading cause of mortality in medically refractory epilepsy. Middle-aged persons with epilepsy (PWE) are under investigated regarding their mortality risk and burden of cardiovascular disease (CVD).

METHODS

Using UK Biobank, we identified 7786 (1.6%) participants with diagnoses of epilepsy and 6,171,803 person-years of follow-up (mean 12.30 years, standard deviation 1.74); 566 patients with previous histories of stroke were excluded. The 7220 PWE comprised the study cohort with the remaining 494,676 without epilepsy as the comparator group. Prevalence of CVD was determined using validated diagnostic codes. Cox proportional hazards regression was used to assess all-cause mortality and sudden death risk.

RESULTS

Hypertension, coronary artery disease, heart failure, valvular heart disease, and congenital heart disease were more prevalent in PWE. Arrhythmias including atrial fibrillation/flutter (12.2% vs 6.9%; P < 0.01), bradyarrhythmias (7.7% vs 3.5%; P < 0.01), conduction defects (6.1% vs 2.6%; P < 0.01), and ventricular arrhythmias (2.3% vs 1.0%; P < 0.01), as well as cardiac implantable electric devices (4.6% vs 2.0%; P < 0.01) were more prevalent in PWE. PWE had higher adjusted all-cause mortality (hazard ratio [HR], 3.9; 95% confidence interval [CI], 3.01-3.39), and sudden death-specific mortality (HR, 6.65; 95% CI, 4.53-9.77); and were almost 2 years younger at death (68.1 vs 69.8; P < 0.001).

CONCLUSIONS

Middle-aged PWE have increased all-cause and sudden death-specific mortality and higher burden of CVD including arrhythmias and heart failure. Further work is required to elucidate mechanisms underlying all-cause mortality and sudden death risk in PWE of middle age, to identify prognostic biomarkers and develop preventative therapies in PWE.

Adult epilepsy

Epilepsy is a common medical condition that affects people of all ages, races, social classes, and geographical regions. Diagnosis of epilepsy remains clinical, and ancillary investigations (electroencephalography, imaging, etc) are of aid to determine the type, cause, and prognosis. Antiseizure medications represent the mainstay of epilepsy treatment: they aim to suppress seizures without adverse events, but they do not affect the underlying predisposition to generate seizures. Currently available antiseizure medications are effective in around two-thirds of patients with epilepsy. Neurosurgical resection is an effective strategy to reach seizure control in selected individuals with drug-resistant focal epilepsy. Non-pharmacological treatments such as palliative surgery (eg, corpus callosotomy), neuromodulation techniques (eg, vagus nerve stimulation), and dietary interventions represent therapeutic options for patients with drug-resistant epilepsy who are not suitable for resective brain surgery.

Variation in prognosis and treatment outcome in juvenile myoclonic epilepsy: a Biology of Juvenile Myoclonic Epilepsy Consortium proposal for a practical definition and stratified medicine classifications

Reliable definitions, classifications and prognostic models are the cornerstones of stratified medicine, but none of the current classifications systems in epilepsy address prognostic or outcome issues. Although heterogeneity is widely acknowledged within epilepsy syndromes, the significance of variation in electroclinical features, comorbidities and treatment response, as they relate to diagnostic and prognostic purposes, has not been explored. In this paper, we aim to provide an evidence-based definition of juvenile myoclonic epilepsy showing that with a predefined and limited set of mandatory features, variation in juvenile myoclonic epilepsy phenotype can be exploited for prognostic purposes. Our study is based on clinical data collected by the Biology of Juvenile Myoclonic Epilepsy Consortium augmented by literature data. We review prognosis research on mortality and seizure remission, predictors of antiseizure medication resistance and selected adverse drug events to valproate, levetiracetam and lamotrigine. Based on our analysis, a simplified set of diagnostic criteria for juvenile myoclonic epilepsy includes the following: (i) myoclonic jerks as mandatory seizure type; (ii) a circadian timing for myoclonia not mandatory for the diagnosis of juvenile myoclonic epilepsy; (iii) age of onset ranging from 6 to 40 years; (iv) generalized EEG abnormalities; and (v) intelligence conforming to population distribution. We find sufficient evidence to propose a predictive model of antiseizure medication resistance that emphasises (i) absence seizures as the strongest stratifying factor with regard to antiseizure medication resistance or seizure freedom for both sexes and (ii) sex as a major stratifying factor, revealing elevated odds of antiseizure medication resistance that correlates to self-report of catamenial and stress-related factors including sleep deprivation. In women, there are reduced odds of antiseizure medication resistance associated with EEG-measured or self-reported photosensitivity. In conclusion, by applying a simplified set of criteria to define phenotypic variations of juvenile myoclonic epilepsy, our paper proposes an evidence-based definition and prognostic stratification of juvenile myoclonic epilepsy. Further studies in existing data sets of individual patient data would be helpful to replicate our findings, and prospective studies in inception cohorts will contribute to validate them in real-world practice for juvenile myoclonic epilepsy management.

Psychogenic Nonepileptic Seizures-High Mortality Rate Is a 'Wake-Up Call'

Patients with epilepsy have an elevated mortality rate compared to the general population and now studies are showing a comparable death ratio in patients diagnosed with psychogenic nonepileptic seizures. The latter is a top differential diagnosis for epilepsy and the unexpected mortality rate in these patients underscores the importance of an accurate diagnosis. Experts have called for more studies to elucidate this finding but the explanation is already available, embedded in the existing data. To illustrate, a review of the diagnostic practice in epilepsy monitoring units, of the studies examining mortality in PNES and epilepsy patients, and of the general clinical literature on the two populations was conducted. The analysis reveals that the scalp EEG test result, which distinguishes a psychogenic from an epileptic seizure, is highly fallible; that the clinical profiles of the PNES and epilepsy patient populations are virtually identical; and that both are dying of natural and non-natural causes including sudden unexpected death associated with confirmed or suspected seizure activity. The recent data showing a similar mortality rate simply constitutes more confirmatory evidence that the PNES population consists largely of patients with drug-resistant scalp EEG-negative epileptic seizures. To reduce the morbidity and mortality in these patients, they must be given access to treatments for epilepsy.

Premature Mortality and Causes of Death Among People With Epilepsy: A Nationwide Population-Based Incident Cohort Study

BACKGROUND AND OBJECTIVES

People with epilepsy (PWE) are at risk of premature death with considerable variability according to the study population. We aimed to estimate the risk and causes of death in PWE according to age, disease severity, disease course, comorbidities, and socioeconomic status in Korea.

METHODS

We conducted a nationwide population-based retrospective cohort study using the National Health Insurance database linked with the national death register. Newly treated PWE from 2008 to 2016 who were identified by antiseizure medication (ASM) prescriptions and diagnostic codes for epilepsy/seizure were included and observed until 2017. We assessed all-cause and cause-specific crude mortality rates and standardized mortality ratios (SMRs).

RESULTS

Among 138,998 PWE, 20,095 deaths were identified, and the mean follow-up period was 4.79 years. The SMR was 2.25 in the overall group of PWE, with a higher value in the younger age group at diagnosis and a shorter time interval after diagnosis. The SMR in the monotherapy group was 1.56, while that in the group with 4 or more ASMs was 4.93. PWE without any comorbidities had an SMR of 1.61. PWE who were rural residents had a higher SMR than those who were urban residents (2.47 vs 2.03, respectively). The causes of death among PWE were cerebrovascular disease (18.9%, SMR 4.50), malignant neoplasms outside the CNS (15.7%, SMR 1.37), malignant neoplasms of the CNS (6.7%, SMR 46.95), pneumonia (6.0%, SMR 2.08), and external causes (7.2%, SMR 2.17), including suicide (2.6%, SMR 2.07). Epilepsy itself and status epilepticus accounted for 1.9% of the overall death. The excess mortality associated with pneumonia and external causes was persistently high, whereas the excess mortality associated with malignancy and cerebrovascular diseases tended to decrease with increasing time since diagnosis.

DISCUSSION

This study showed excess mortality in PWE, even in those without comorbidities and those receiving monotherapy. Regional disparities and sustained risks of deaths from external causes over 10 years imply potential points of intervention. In addition to active control of seizures, education about injury prevention, monitoring for suicidal ideation, and efforts to improve accessibility to epilepsy care are all required to reduce mortality.

Understanding Contexts and Challenges of Information Management for Epilepsy Care

Epilepsy is a common chronic neurological disease. People with epilepsy (PWE) and their caregivers face several challenges related to their epilepsy management, including quality of care, care coordination, side effects, and stigma management. The sociotechnical issues of the information management contexts and challenges for epilepsy care may be mitigated through effective information management. We conducted 4 focus groups with 5 PWE and 7 caregivers to explore how they manage epilepsy-related information and the challenges they encountered. Primary issues include challenges of finding the right information, complexities of tracking and monitoring data, and limited information sharing. We provide a framework that encompasses three attributes - individual epilepsy symptoms and health conditions, information complexity, and circumstantial constraints. We suggest future design implications to mitigate these challenges and improve epilepsy information management and care coordination.

Poo Matters! A scoping review of impact of constipation on epilepsy

BACKGROUND

Epilepsy is a common neurological disorder which frequently presents with co-morbid physical health conditions, including constipation. However, the nature of the relationship between the two conditions has not been well defined.

AIM

To quantify constipation's relationship with epilepsy and anti-seizure medication (ASM).

METHOD

A scoping review registered on PROSPERO (CRD42022320079) with suitable search terms was conducted and reported in accordance with PRISMA guidance. CINAHL, Embase, PsycInfo and MEDLINE electronic databases were searched by an information specialist. The Joanna Briggs Institute (JBI) critical appraisal tools alongside the Oxford Centre for Evidence Based Medicine (OCEBM) levels of evidence were used to assist in assessing relevance, quality, and results of the included publications.

RESULTS

Nine articles selected for inclusion in the review. The prevalence of irritable bowel syndrome (including constipation) was reported to be up to five times more frequent in people with epilepsy (PWE). Functional constipation was reported in 36% of PWE. Constipation was found to be the second most common co-morbid condition in children with epilepsy. Two studies found constipation to precede seizures. Constipation was reported as a common side effect of ASMs in PWE. Two studies rated OCEBM level 2 the remaining level 3.

CONCLUSION

Our findings suggest a higher prevalence of constipation in PWE. Co-occurring multimorbidity and resulting polypharmacy adds further complexity to the process of establishing aetiology of constipation in PWE. Potential contributory aetiological factors for constipation such as neurodevelopmental and genetic disorders, ASM side effects and the epilepsy itself require better understanding and research.

Trends of Epilepsy-Related Mortality in South Korea

BACKGROUND AND PURPOSE

Epilepsy increases the risk of death in affected individuals of any age. We aimed to determine the mortality caused by epilepsy and its time trends in Korea.

METHODS

We obtained population and cause of death data between 1993 and 2019 from Statistics Korea. We identified death caused by epilepsy or status epilepticus. We calculated the crude mortality rate (CMR), age-specific mortality rate, age-standardized mortality rate (ASMR, corresponding to epilepsy-related deaths per 100,000 persons in the general population), and the proportional mortality (PM, corresponding to the proportion of epilepsy-related deaths among all-cause deaths).

RESULTS

In 2019, 471 deaths were caused by epilepsy (CMR=0.92), accounting for 0.16% of all deaths in that year. The age-specific mortality rate increased with age, up to 7.01% among individuals aged 80 years and older, while the PM was the highest (3.80%) among individuals aged 5-14 years, which decreased with age. Between 1993 and 2019, the CMR, ASMR, and PM peaked in 2002, and the CMR then rebounded after the trough in this trend in 2011 while the ASMR continued to decrease, and the PM became relatively stable from 2011. Starting in 2005, the age-specific mortality rate for epilepsy had an increasing tendency over time among those aged 75 years or older, and a decreasing tendency in the younger age groups.

CONCLUSIONS

A declining tendency of mortality from epilepsy was found in the overall population of Korea over recent decades. However, epilepsy is a notable cause of death in children, and epilepsy-related mortality is increasing in the elderly population.

Association Between Standardized Mortality Ratio and Utilization of Care in US Veterans With Drug-Resistant Epilepsy Compared With All US Veterans and the US General Population

Importance

Drug-resistant epilepsy (DRE) is thought to be associated with increased mortality, but larger population-based studies are lacking. Additionally, the benefit of effective management in DRE lacks evidence.

Objective

To examine the association of utilization of care with mortality in US veterans with DRE.

Design, Setting, and Participants

Observational cohort study conducted between October 1, 2013, and March 31, 2020. Mortality statistics in US veterans with DRE were compared to the US general population and all veterans within the Veterans Health Administration. Epilepsy was defined as use of 1 or more antiseizure medications (ASMs) for 30 days or longer with a seizure diagnosis or 1 inpatient or 2 outpatient encounters with an epilepsy diagnosis. DRE was defined as the use of 2 or more ASMs. Among 9.6 million US veterans, 164 435 (1.7%) had epilepsy, of whom 55 571 (33.8%) had DRE. Epilepsy and DRE were administratively identified based on criteria noted in design. Identified participants were included for analysis.

Exposures

Veterans with DRE.

Main Outcomes and Measures

Standardized mortality ratio (SMR).

Results

Among US veterans with DRE, the mean (SD) age was 58.3 (15.4) years, and 49 430 individuals (88.9%) were male. Of ethnicity data gathered, 3170 individuals (5.7%) were Hispanic or Latino, 50 599 (91.1%) were not Hispanic or Latino, 842 (1.5%) declined to answer, and 960 (1.7%) were recorded as unknown. Of race data gathered, 516 individuals (0.9%) were American Indian or Alaskan Native, 270 (0.5%) were Asian, 11 316 (20.4%) were Black or African American, 587 (1.1%) were of multiple races, 453 (0.8%) were Native Hawaiian or Pacific Islander, 39 543 (71.2%) were White, 1697 (3.1%) declined to answer, and 1189 (2.1%) were recorded as unknown. SMR was 1.50 (95% CI, 1.47-1.53) compared with the US general population and 1.56 (95% CI, 1.53-1.59) compared with all veterans. Utilization rates were 81.1% (n = 45 057) for neurology clinic evaluation, 66.4% (n = 36 905) for magnetic resonance imaging (MRI), and 49.6% (n = 27 546) for electroencephalography (EEG) testing. Only 8350 individuals (15.0%) had comprehensive epilepsy evaluations and 3357 (6.0%) had epilepsy monitoring. Multivariable analysis revealed an association between lower mortality and neurology clinic evaluation, EEG, MRI, epilepsy monitoring, and the use of more than 2 ASMs after adjusting for age and comorbidities.

Conclusions and Relevance

Mortality rates were significantly higher in US veterans with DRE compared to the general population. Better utilization of comprehensive epilepsy care, diagnostic services, and medications were each associated with reduced mortality. These findings indicate that appropriate management of DRE is critical in this population.

Sudden Unexpected Death in Epilepsy

Epilepsy is a complex neurological condition with numerous etiologies and treatment options. In a subset of these patients, sudden unexpected death can occur, and to date, there are numerous explanations as to the pathophysiological mechanisms and how to mitigate these catastrophic outcomes. Approximately 2.3 million Americans have epilepsy, and nearly 150,000 people develop the condition each year. Sudden unexpected death in epilepsy (SUDEP) accounts for 2–18% of all epilepsy-related deaths and this is equivalent to one death in 1000 person-years of diagnosed epilepsy. It is more common in young adults aged 20–45. Seizures in the past year; the absence of terminal remission in the last five years; increased seizure frequency, particularly GTCS; and nocturnal seizures are the most potent modifiable risk factors for SUDEP. Patients not receiving any antiepileptic drug therapy are at higher risk of SUDEP. Patient education on medication compliance; care plans for seizure clusters (rescue medicines); epilepsy self-management programs; and lifestyle changes to avoid seizure-triggering factors, including avoiding excessive alcohol use and sleep deprivation, should be provided by health care providers. Continued research into SUDEP will hopefully lead to effective interventions to minimize occurrences. At present, aggressive control of epilepsy and enhanced education for individuals and the public are the most effective weapons for combating SUDEP. This narrative review focuses on updated information related to SUDEP epidemiology; pathophysiology; risk factor treatment options; and finally, a discussion of important clinical studies. We seek to encourage clinicians who care for patients with epilepsy to be aggressive in controlling seizure activity and diligent in their review of risk factors and education of patients and their families about SUDEP.

Sudden unexpected death in epilepsy

PURPOSE OF REVIEW

Sudden unexpected death in epilepsy (SUDEP) is a major contributor to premature mortality in people with epilepsy. This review provides an update on recent findings on the epidemiology of SUDEP, clinical risk factors and potential mechanisms.

RECENT FINDINGS

The overall risk rate of SUDEP is approximately 1 per 1000 patients per year in the general epilepsy population and that children and older adults have a similar incidence. Generalized convulsive seizures (GCS), perhaps through their effects on brainstem cardiopulmonary networks, can cause significant postictal respiratory and autonomic dysfunction though other mechanisms likely exist as well. Work in animal models of SUDEP has identified multiple neurotransmitter systems, which may be future targets for pharmacological intervention. There are also chronic functional and structural changes in autonomic function in patients who subsequently die from SUDEP suggesting that some SUDEP risk is dynamic. Modifiable risks for SUDEP include GCS seizure frequency, medication adherence and nighttime supervision.

SUMMARY

Current knowledge of SUDEP risk factors has identified multiple targets for SUDEP prevention today as we await more specific therapeutic targets that are emerging from translational research studies.

Validation of an epilepsy management smartphone application in Pakistan

Background

There is no single way to improve epilepsy care in low- and middle-income countries (LMICs). An epilepsy management aid application (app) has been described, which enables a non-physician health worker (NPHW) to communicate with an epilepsy specialist using a smartphone. In this study, we aimed to assess the validity and quality of this care system in building connections between NPHWs and specialists in Pakistan and the UK.

Methods

A NPHW in Pakistan used the app on a series of referrals and sent the app-generated summary by email to a neurologist in the UK, who replied and suggested possible management. Patients were later seen in a face-to-face (FF) manner by the UK neurologist and a local neurologist, and diagnostic accuracy and quality parameters were assessed.

Results

Over 10 months, 59 patients were recruited and 33 of them were available for FF assessment. The misdiagnosis rate of the app was 6% (2 cases). Treatment advice provided by the app was judged appropriate in 32 patients (97%). In addition, 46% of the referrals were completed within 2 h and 85% within 24 h.

Conclusions

Consistent with an earlier study, this system is a safe method to provide care for patients who cannot access neurological services in person. In addition, it has advantage of timeliness compared to FF assessment and requires less specialist time, both of which are especially important during the coronavirus disease 2019 pandemic. This system can be generalised easily, depending on the willingness of referrers and specialists to use it.

Telehealth for patients with rare epilepsies

Recent developments in technology and exigencies of the COVID-19 pandemic have spurred innovations for telehealth in patients with rare epilepsies. This review details the many ways telehealth may be used in the diagnosis and management of rare, pharmacoresistant epilepsy and documents our experience as measured by surveying caregivers of pediatric patients with epilepsy. Most components of the epilepsy evaluation, including history and examination, neuroimaging, and electroencephalogram (EEG) can be performed or reviewed remotely, assuming similar technique and quality of diagnostic studies. Seizure and epilepsy diagnosis is enhanced through the assistance of caregiver smart phone video recordings and 'ambulatory' EEG. Monitoring patient seizure frequency through paper seizure diaries is now increasingly being replaced by electronic diaries in both clinical and research settings. Electronic seizure diaries have numerous advantages such as data durability, increased accessibility, real-time availability, and easier analysis. Telehealth enhances access to specialized epilepsy care, which has been shown to reduce mortality and improve patient compliance and outcomes. Telehealth can also enable evaluation of patients with rare epilepsy in centers of excellence and enhance enrollment in clinical trials. Reducing mortality risk in patients with epilepsy can be accomplished through remote counseling and addressing psychiatric co-morbidities. Findings from surveying caregivers of children with epilepsy treated at Children's National Hospital showed that 54/56 (96.4%) found that not having to commute to the appointment positively contributed to their telemedicine experience. Overall, most respondents had a positive experience with their telemedicine visit. Almost all respondents (98%) were either 'very happy' or 'happy' with their telemedicine visit and their ability to communicate over telemedicine with the provider and either 'very likely' or 'likely' to want to use telemedicine for some future clinic visits. Telehealth in rare epilepsies is feasible and, in many ways, comparable with traditional evaluation and management.

Epilepsy-Related Mortality in Children and Young Adults in Denmark: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

Mortality is increased in epilepsy, but the important issue is that a proportion of epilepsy-related death is potentially preventable by optimized therapy and needs therefore to be identified. A new systematic classification of epilepsy-related mortality has been suggested by Devinsky et al. in 2016 to identify these preventable deaths. We applied this classification to an analysis of premature mortality in persons with epilepsy younger than 50 years.

METHODS

The study was a population-based retrospective cohort of all Danish citizens with and without epilepsy aged 1-49 years during 2007-2009. Information on all deaths was retrieved from the Danish Cause of Death Registry, autopsy reports, death certificates, and the Danish National Patient Registry. The primary cause of death in persons with epilepsy was evaluated independently by three neurologist, one neuro-pediatrician, and two cardiologists. In case of uncertainty a pathologist was consulted. All deaths were classified as either epilepsy- or not-epilepsy-related, and the underlying causes or modes of death were compared between persons with and without epilepsy.

RESULTS

During the study period 700 deaths were identified in persons with epilepsy, and 440 (62.9%) of these were epilepsy-related, hereof, 169 (38%) directly related to seizures and 181 (41%) due to an underlying neurological disease. SUDEP accounted for 80% of deaths directly related to epilepsy. Aspiration pneumonia was the cause of death in 80% of cases indirectly related to epilepsy.Compared with the background population, persons with epilepsy had a nearly four-fold increased all-cause mortality (adjusted mortality hazard ratio of 3.95 [95% CI 3.64-4.27], p<0.0001) and a higher risk of dying from various underlying causes including alcohol-related conditions (hazard ratio of 2.91 [95% CI 2.23-3.80], p<0.0001) and suicide (hazard ratio of 2.10 [95% CI 1.18-3.73], p=0.01).

DISCUSSION

The newly proposed classification for mortality in persons with epilepsy was useful in an unselected nationwide cohort. It helped classifying unnatural causes of death as epilepsy-related or not, and it helped identifying potentially preventable deaths. The leading causes of premature mortality in persons younger than 50 years were related to epilepsy and were thus potentially preventable by good seizure control.

Mortality among People with Epilepsy: A Retrospective Nationwide Analysis from 2016 to 2019

We estimated age-adjusted mortality and investigated the dominant causes of death as well as comorbidities among people with epilepsy (PWE) in Lithuania, a country with frequent deaths from external causes. From 2016 to 2019, the age-adjusted rate of death among PWE in Lithuania was compared with mortality data in the general population. Each year of analysis, individuals who were diagnosed with epilepsy comprised a retrospective cohort. The standardized mortality ratio (SMR) of PWE varied from 2.93 (95% CI 2.78 to 3.07) to 3.18 (95% CI 3.02 to 3.34). PWE died at least one decade earlier than expected in the general population. The dominant causes of death were cardiovascular diseases (their proportion ranged from 44.8% to 49.3%), cancer (16.7% to 21.3%) and external causes of death (8.5% to 10.9%). The proportion of the latter decreased over time (r = −0.99, p = 0.01), whereas the SMR for external causes of death remained relatively constant. Epilepsy was the underlying cause of death in 163 cases (2.6%), and noted as a condition contributing to death in 1010 cases (15.9%). Cerebrovascular and cardiological conditions and dementia were the most frequent comorbidities among PWE before their death. Epilepsy-unrelated causes of death are relevant contributors to mortality among PWE. There is a need for PWE-oriented societal interventions to reduce the frequency of external deaths beyond the trend in the general population.

Adult onset epilepsy is defined by phenotypic clusters with unique comorbidities and risks of death

OBJECTIVE

This study was undertaken to identify clusters of adult onset epilepsy with distinct comorbidities and risks of early and late death.

METHODS

This was a retrospective open cohort study that included all adults meeting a case definition for epilepsy after the Acceptable Mortality Recording date in the Health Improvement Network database for the years 2000-2012 inclusive. Unsupervised agglomerative hierarchical clustering was performed to identify unique clusters of patients based on their predicted risk of early (<4 years of epilepsy diagnosis) and late (≥4 years from diagnosis) mortality and patient-level clinical characteristics.

RESULTS

We identified 10 499 presumed incident cases of epilepsy from 11 194 182 patients. Four phenotypic clusters were identified in the early and late risk periods. Early clusters include older adults with cardiovascular disease and a high risk of death (median predicted risk = 20%, interquartile range [IQR] = 9%-31%), a group with moderate risk of death and cancer (median predicted risk = 6%, IQR = 2%-15%), a group with psychiatric disease/substance use and few somatic comorbidities (median predicted risk = 5%, IQR = 2%-9%), and one with a younger age at onset and few comorbidities (median predicted risk = 4%, IQR = 1%-11%). There was minimal movement of individuals between clusters for those surviving the early risk period. Age- and sex-standardized 3-year mortality ratios were more than sixfold higher than the general population for every cluster, even those primarily comprised of healthy younger adults.

SIGNIFICANCE

Adult onset epilepsy is marked by unique clusters of comorbid conditions and elevated risks of death that form discrete populations for targeted therapeutic interventions. These clusters remain relatively stable between the early and late mortality risk periods. Of particular interest are the clusters marked by young and otherwise healthy adults whose standardized mortality ratio is sixfold higher than general population despite few conventional risk factors for premature death.

Sudden unexpected death in epilepsy in persons younger than 50 years: A retrospective nationwide cohort study in Denmark

OBJECTIVE

Persons with epilepsy have an increased mortality including a high risk of sudden unexplained death (SUD), also referred to as sudden unexpected death in epilepsy (SUDEP). We aimed to evaluate the risk of SUDEP in comparison to other causes of death and the risk of SUD in persons with and without epilepsy.

METHODS

We undertook a retrospective population-based cohort study of all Danish citizens with and without epilepsy aged 1-49 years during 2007-2009. All deaths in the population were evaluated, and all cases of SUD identified. Primary causes of death in persons with epilepsy were evaluated independently by three neurologists and one neuropediatrician, using the unified SUDEP criteria.

RESULTS

The three most frequent causes of death in persons with epilepsy were cancer (2.38 per 1000 person-years), SUDEP (1.65 per 1000 person-years), and pneumonia (1.09 per 1000 person-years) compared with cancer (.17 per 1000 person-years), accident-related deaths (.14 per 1000 person-years), and cardiovascular disease (.09 per 1000 person-years) in persons without epilepsy. Considering definite, definite plus, and probable cases, the SUDEP incidence was .27 per 1000 person-years (95% confidence interval [CI] = .11-.64) in children aged 1-17 years and 1.21 per 1000 person-years (95% CI = .96-1.51) in adults aged 18-49 years. Adjusted for age and sex, persons with epilepsy younger than 50 years had a 10.8-fold (95% CI = 9.97-11.64, p < .0001) increased all-cause mortality and a 34.4-fold (95% CI = 23.57-50.28, p < .0001) increased risk of SUD compared with persons without epilepsy. SUDEP accounted for 23.3% of all SUD.

SIGNIFICANCE

This nationwide study of all deaths in persons with epilepsy younger than 50 years found a lower SUDEP risk in children compared with adults, and that epilepsy was a major risk factor for SUD in the background population. This underlines the importance of addressing risk factors for SUDEP to prevent premature death.

Mortality in Parenchymal and Subarachnoid Neurocysticercosis

Neurocysticercosis (NCC) is endemic in many parts of the world, carrying significant neurological morbidity that varies according to whether lesions are located inside the cerebral parenchyma or in extraparenchymal spaces. The latter, in particular subarachnoid NCC, is assumed to be more severe, but no controlled studies comparing mortality between types of NCC exist. The aim of this study was to compare all-cause mortality between patients with intraparenchymal NCC and those with subarachnoid NCC. Vital status and sociodemographic characteristics were evaluated in patients with intraparenchymal viable, intraparenchymal calcified, and subarachnoid NCC attending a neurological referral hospital in Lima, Perú. Survival analyses using Kaplan-Meier curves and Cox proportional regression models were carried out to compare mortality rates between groups. From 840 NCC patients followed by a median time of 82.3 months, 42 (5.0%) died, six (1.8%) in the intraparenchymal viable group, four (1.3%) in the calcified group, and 32 (16.6%) in the subarachnoid group (P < 0.001). Older age and lower education were significantly associated with mortality. The age-adjusted hazard ratio for death in the subarachnoid group was 13.6 (95% CI: 5.6-33.0, P < 0.001) compared with the intraparenchymal viable group and 10.7 (95% CI: 3.7-30.8, P < 0.001) when compared with the calcified group. We concluded that subarachnoid disease is associated with a much higher mortality in NCC.

Just In Time: Challenges and Opportunities of First Aid Care Information Sharing for Supporting Epileptic Seizure Response

There are over three million people living with epilepsy in the U.S. People with epilepsy experience multiple daily challenges such as seizures, social isolation, social stigma, experience of physical and emotional symptoms, medication side effects, cognitive and memory deficits, care coordination difficulties, and risks of sudden unexpected death. In this work, we report findings collected from 3 focus groups of 11 people with epilepsy and caregivers and 10 follow-up questionnaires. We found that these participants feel that most people do not know how to deal with seizures. To improve others' abilities to respond safely and appropriately to someone having seizures, people with epilepsy and caregivers would like to share and educate the public about their epilepsy conditions, reduce common misconceptions about seizures and prevent associated stigma, and get first aid help from the public when needed. Considering social stigma, we propose design implications of future technologies for effective delivery of appropriate first aid care information to bystanders around individuals with epilepsy when they experience a seizure.

A reappraisal of injuries and accidents in people with epilepsy

PURPOSE OF REVIEW

We review data on injuries and traffic accidents affecting people with epilepsy with emphasis on the overall risk of injuries, specific types of injuries, and risk factors.

RECENT FINDINGS

Population-based studies of incident epilepsy cohorts indicate that the risk of physical injuries in people with epilepsy in general is increased only modestly. The risk is higher in selected populations that attend epilepsy clinics or referral centers. Soft tissue injuries, dislocations, and fractures are the most common injures, whereas the greatest increase in risk is reported for more uncommon injuries such as drowning. People with epilepsy are at a two-fold to four-fold increased risk for fatal injuries. Comorbidities contribute to fatal as well as nonfatal injuries. The other major risk factor is poorly controlled major convulsive seizures (generalized as well as focal to bilateral tonic-clonic seizures). Serious transport accidents associated with increased risks for people with epilepsy include pedestrian, bicycle, as well as car accidents.

SUMMARY

Individualized information on the risk of physical injuries and accidents should be part of counseling of patients with epilepsy. Improved seizure control is likely the most effective way to reduce risks, but work place and home adjustments should also be considered.

Would people living with epilepsy benefit from palliative care?

Palliative care (PC) is an approach to the care of persons living with serious illness and their families that focuses on improving quality of life and reducing suffering by addressing complex medical symptoms, psychosocial needs, spiritual well-being, and advance care planning. While PC has traditionally been associated with hospice care for persons with cancer, there is now recognition that PC is relevant to many noncancer diagnoses, including neurologic illness, and at multiple points along the illness journey, not just end of life. Despite the recent growth of the field of neuropalliative care there has been scant attention paid to the relevance of PC principles in epilepsy or the potential for PC approaches to improve outcomes for persons living with epilepsy and their families. We believe this has been a significant oversight and that PC may provide a useful framework for addressing the many sources of suffering facing persons living with epilepsy, for engaging patients and families in challenging conversations, and to focus efforts to improve models of care for this population. In this manuscript we review areas of significant unmet needs where a PC approach may improve patient and family-centered outcomes, including complex symptom management, goals of care, advance care planning, psychosocial support for patient and family and spiritual well-being. When relevant we highlight areas where epilepsy patients may have unique PC needs compared to other patient populations and conclude with suggestions for future research, clinical, and educational efforts.

Primary care electronic medical records can be used to predict risk and identify potentially modifiable factors for early and late death in adult onset epilepsy

OBJECTIVE

To use clinically informed machine learning to derive prediction models for early and late premature death in epilepsy.

METHODS

This was a population-based primary care observational cohort study. All patients meeting a case definition for incident epilepsy in the Health Improvement Network database for inclusive years 2000-2012 were included. A modified Delphi process identified 30 potential risk factors. Outcome was early (within 4 years of epilepsy diagnosis) and late (4 years or more from diagnosis) mortality. We used regularized logistic regression, support vector machines, Gaussian naive Bayes, and random forest classifiers to predict outcomes. We assessed model calibration, discrimination, and generalizability using the Brier score, mean area under the receiver operating characteristic curve (AUC) derived from stratified fivefold cross-validation, plotted calibration curves, and extracted measures of association where possible.

RESULTS

We identified 10 499 presumed incident cases from 11 194 182 patients. All models performed comparably well following stratified fivefold cross-validation, with AUCs ranging from 0.73 to 0.81 and from 0.71 to 0.79 for early and late death, respectively. In addition to comorbid disease, social habits (alcoholism odds ratio [OR] for early death = 1.54, 95% confidence interval [CI] = 1.12-2.11 and OR for late death = 2.62, 95% CI = 1.66-4.16) and treatment patterns (OR for early death when no antiseizure medication [ASM] was prescribed at baseline = 1.33, 95% CI = 1.07-1.64 and OR for late death after receipt of enzyme-inducing ASM at baseline = 1.32, 95% CI = 1.04-1.66) were significantly associated with increased risk of premature death. Baseline ASM polytherapy (OR = 0.55, 95% CI = 0.36-0.85) was associated with reduced risk of early death.

SIGNIFICANCE

Clinically informed models using routine electronic medical records can be used to predict early and late mortality in epilepsy, with moderate to high accuracy and evidence of generalizability. Medical, social, and treatment-related risk factors, such as delayed ASM prescription and baseline prescription of enzyme-inducing ASMs, were important predictors.

Collaborative scientific production of epilepsy in Latin America from 1989 to 2018: A bibliometric analysis

Socioeconomic and cultural factors coupled with an inability to control many endemic and emerging diseases have resulted in a growing incidence of epilepsy cases in Latin America. This study aimed to analyze and describe scientific research output trends in epilepsy research for the period 1989-2018. Publications were extracted from Scopus indexed journals. Bibliometric analysis was used to analyze scientific output including number of annual publications, documents, and publication characteristics. A mapping analysis using VOSviewer software visualized collaborative network analysis, co-citation analysis, and keyword co-occurrence analysis. SciVal quantitatively analyzed distribution of countries, institutions, citation counts, H-index, and research collaborative partnerships. A total of 176507 records were initially retrieved after which 5636 were analyzed. Overall, an increasing trend for publication output was observed from 19 articles in 1989 to 342 in 2018; the number of publications significantly increased over the past 20 years (p = 0.0065). The majority of publications were original articles (74.4%). Brazil had the most scientific production (55.2%), followed by Mexico (15.4%) and Argentina (10%). Extra-regional collaboration was primarily with the United States, United Kingdom, and Canada; intraregional collaboration was low. The most common area of investigation by co-occurrences was "diagnostic research" (37.2%), with studies based on electroencephalography and nuclear magnetic resonance. Epilepsy research in Latin America has seen a steady growth with significant increases over the past 20 years. Brazil, Mexico, and Argentina are the most productive countries in the field collaborating primarily with extra-regional countries of high-income.

Drug Resistance in Epilepsy: Clinical Impact, Potential Mechanisms, and New Innovative Treatment Options

Epilepsy is a chronic neurologic disorder that affects over 70 million people worldwide. Despite the availability of over 20 antiseizure drugs (ASDs) for symptomatic treatment of epileptic seizures, about one-third of patients with epilepsy have seizures refractory to pharmacotherapy. Patients with such drug-resistant epilepsy (DRE) have increased risks of premature death, injuries, psychosocial dysfunction, and a reduced quality of life, so development of more effective therapies is an urgent clinical need. However, the various types of epilepsy and seizures and the complex temporal patterns of refractoriness complicate the issue. Furthermore, the underlying mechanisms of DRE are not fully understood, though recent work has begun to shape our understanding more clearly. Experimental models of DRE offer opportunities to discover, characterize, and challenge putative mechanisms of drug resistance. Furthermore, such preclinical models are important in developing therapies that may overcome drug resistance. Here, we will review the current understanding of the molecular, genetic, and structural mechanisms of ASD resistance and discuss how to overcome this problem. Encouragingly, better elucidation of the pathophysiological mechanisms underpinning epilepsies and drug resistance by concerted preclinical and clinical efforts have recently enabled a revised approach to the development of more promising therapies, including numerous potential etiology-specific drugs (“precision medicine”) for severe pediatric (monogenetic) epilepsies and novel multitargeted ASDs for acquired partial epilepsies, suggesting that the long hoped-for breakthrough in therapy for as-yet ASD-resistant patients is a feasible goal.

Dramatic outcomes in epilepsy: depression, suicide, injuries, and mortality

In this narrative review, we will discuss some of the significant risks and dramatic consequences that are associated with epilepsy: depression, suicide, seizure-related injuries, and mortality, both in adults and in children. Considering the high prevalence of depression among people with epilepsy (PWE), routine and periodic screening of all PWE for early detection and appropriate management of depression is recommended. PWE should be screened for suicidal ideation regularly and when needed, patients should be referred for a psychiatric evaluation and treatment. When starting an antiepileptic drug (AED) or switching from one to another AED, patients should be advised to report to their treating physician any change in their mood and existence of suicidal ideation. The risk of injuries for the general epilepsy population is increased only moderately. The risk is higher in selected populations attending epilepsy clinics and referral centers. This being said, there are PWE that may suffer frequent, severe, and sometimes even life-threatening seizure-related injuries. The most obvious way to reduce risk is to strive for improved seizure control. Finally, PWE have a 2-3 times higher mortality rate than the general population. Deaths in PWE may relate to the underlying cause of epilepsy, to seizures (including sudden unexpected death in epilepsy [SUDEP] and seizure related injuries) and to status epilepticus, as well as to other conditions that do not appear directly related to epilepsy. Improving seizure control and patient education may be the most important measures to reduce epilepsy related mortality in general and SUDEP in particular.

The development of a smartphone application to help manage epilepsy in resource-limited settings

PURPOSE

Epilepsy is treatable but in low- and middle-income countries (LMICs) it goes untreated with dire consequences for people with it and their families. There are not enough available doctors to treat it so it has been suggested that non-physician health workers (NPHWs) take a role in diagnosis and management. Tools will be essential to help them. A smartphone application (app) for episode diagnosis has proved safe and effective; this paper describes an app for epilepsy management.

METHODS

Questions were devised which captured temporal characteristics of episodes, diagnosis of episodes, seizure types, and epilepsy type, together with information on previous investigations, treatment, drug reactions, and current treatment. For untreated patients a management plan was suggested. The app generated a summary which could be sent to a remote specialist for advice. The finished app was evaluated in 23 people presenting with possible epilepsy by four doctors in training and one NPHW; its summary was compared to face-to-face evaluation by a neurologist.

RESULTS

The app was correct in 22 of 23 (96 %) patients for episode diagnosis, 2 of 2 for symptomatic seizures,18/20 (90 %) for epilepsy type and 9/10 (90 %) for treatment suggestion in untreated patients. The app took less than 15 min to complete.

CONCLUSION

The initial results suggest that this management app is a worthwhile tool to help inexpert doctors or NPHWs manage suspected epilepsy. Its accuracy is well within reported inter-observer agreement. In its present form it requires input from a remote epilepsy specialist. This combination is a potential solution to managing epilepsy in LMICs.

The postictal state - What do we know?

This narrative review provides a broad and comprehensive overview of the most important discoveries on the postictal state over the past decades as well as recent developments. After a description and definition of the postictal state, we discuss postictal sypmtoms, their clinical manifestations, and related findings. Moreover, pathophysiological advances are reviewed, followed by current treatment options.

Mortality in Epilepsy: Referral to a Specialty Center Makes a Difference

Association of Levels of Specialized Care With Risk of Premature Mortality in Patients With Epilepsy

Lowerison MW, Josephson CB, Jetté N, et al. JAMA Neurol. 2019;76:1352-1358.

Importance:

Patients with epilepsy are at an elevated risk of premature mortality. Interventions to reduce this risk are crucial.

Objective:

To determine if the level of care (non-neurologist, neurologist, or comprehensive epilepsy program) is negatively associated with the risk of premature mortality.

Design, Setting, and Participants:

In this retrospective open cohort study, all adult patients 18 years or older who met the administrative case definition for incident epilepsy in linked databases (Alberta Health Services administrative health data and the Comprehensive Calgary Epilepsy Programme Registry [CEP]) inclusive of the years 2002 to 2016 were followed up until death or loss to follow-up. The final analyses were performed on May 1, 2019.

Exposures:

Evaluation by a non-neurologist, neurologist, or epileptologist.

Main Outcomes and Measures:

The outcome was all-cause mortality. We used extended Cox models treating exposure to a neurologist or the CEP as time-varying covariates. Age, sex, socioeconomic deprivation, disease severity, and comorbid burden at index date were modeled as fixed-time coefficients.

Results:

A total 23 653 incident cases were identified (annual incidence of 89 per 100 000); the mean age (SD) at index date was 50.8 (19.1) years and 12 158 (50.3%) were women. A total of 14 099 (60%) were not exposed to specialist neurological care, 9554 (40%) received care by a neurologist, and 2054 (9%) received care in the CEP. In total, 4098 deaths (71%) occurred in the nonspecialist setting, 1481 (26%) for those seen by a neurologist, and 176 (3%) for those receiving CEP care. The standardized mortality rate was 7.2% for the entire cohort, 9.4% for those receiving nonspecialist care, 5.6% for those seen by a neurologist, and 2.8% for those seen in the CEP. The hazard ratio (HR) of mortality was lower in those receiving neurologist (HR, 0.85; 95% CI, 0.77-0.93) and CEP (HR, 0.49; 95% CI, 0.38-0.62) care. In multivariable modeling, specialist care, the age at index, and disease severity were retained in the final model of the association between specialist care and mortality.

Conclusions and Relevance:

Exposure to specialist care is associated with incremental reductions in the hazard of premature mortality. Those referred to a comprehensive epilepsy program received the greatest benefit.

Managing Epilepsy by Telemedicine in Resource-Poor Settings

Epilepsy is a common and treatable disease; in rich countries the expectation is that two-thirds of people will have their seizure episodes controlled on medication. In low- and middle-income countries (LMICs) however most people are not on treatment either because no doctors live near them or the logistics of affordable drug supply is absent. People with epilepsy then are prone to the bad effects of this disease—death, disfigurement from accidents and burns, and social problems due to the stigma with which the disease is associated. So this represents a failure of conventional face-to-face medicine. Might a telemedicine approach do better? The World Health Organization has suggested that non-physician health workers are empowered to diagnose and manage epilepsy; to do this they will need considerable medical support, which might be provided by telemedicine through the telephone, smartphone applications or a combination. This paper sets out what telemedicine does at present for people with epilepsy in LMICs and suggests how it might be developed in the future.

Epilepsy-related and other causes of mortality in people with epilepsy: A systematic review of systematic reviews

BACKGROUND

This systematic review of epilepsy mortality systematic reviews evaluates comparative risks, causes, and risk factors for all-cause mortality in people with epilepsy (PWE) to specifically establish the burden of epilepsy-related deaths.

METHODS

MEDLINE and Embase were searched from conception to 26/12/2018 for systematic reviews evaluating all-cause mortality in PWE of any age. Independent study selection, data extraction and quality assessment were performed. Deaths were separated into epilepsy-related and unrelated using a recently published classification system. Outcomes included standardized mortality ratio (SMR) and mortality rate (MR) in a primary analysis of comparative risks, causes, and risk factors for all-cause and epilepsy-related mortality. A narrative synthesis of review findings was used to present results, including from a secondary analysis of individual epilepsy-related death risk factors.

RESULTS

Six moderate or high-quality systematic reviews were included in the primary analysis, evaluating 103 observational studies. All-cause mortality remained similarly high between 1950 and present (median SMR range 2.2-3.4). Africa had the highest SMR (median 5.4, range 2.6-7.2). SMRs were also higher for children <18 years (median 7.5, range 3.1-22.4) than adults (median 2.6, range 1.3-8.7), and for epilepsy-related (median 3.8, range 0.0-82.4,) than unrelated causes (median 1.7, range 0.7-17.6). Structural brain disease conferred the greatest risk for all-cause mortality (SMR range 24.0-41.5). Common epilepsy-related causes included alcohol, drowning, pneumonia, and suicide. In secondary analysis of nine additional systematic reviews, epilepsy-related death risk factors were reported for sudden unexpected death in epilepsy (SUDEP), drowning and suicide.

CONCLUSIONS

Premature all-cause mortality remains a major problem in PWE globally, particularly in children and young adults, with most being epilepsy-related and potentially preventable. SUDEP is only one of several other common and important epilepsy-related causes of death.