The management of epilepsy in children: the role of the clinical nurse specialist

The epilepsy specialist nurse: A mixed-methods case study on the role and activities

PURPOSE

To describe the role and activities of epilepsy specialist nurses (ESNs) operating as a team in the setting of a hospital specialising in the diagnosis and management of seizure disorders.

METHODS

We conducted a descriptive mixed-methods embedded single case study. We recruited 9 ESNs, 14 of their professional colleagues and 9 'key informants' to analyse their perceptions of the role and activities of ESNs. We collected data through interviews, questionnaires, observations, and documentation. The study was conducted at the Filadelfia Epilepsy Hospital, Denmark.

RESULTS

The team of ESNs offers holistic care to patients and their caregivers regarding the clinical, social, and emotional aspects of epilepsy. The ESNs are integrated in a multidisciplinary team and promote collaboration among the team members. ESNs also contribute to organisational aspects and perform research activities.

CONCLUSION

A structured group of ESNs can operate effectively and extensively in a specialised hospital setting. Our findings contribute to clarifying the description of the ESN's role, and provide an example of how ESNs can be incorporated into a hospital's organisational structure.

The challenge of paediatric epilepsy nursing: An interview with Mrs. Jenny O'Brien, paediatric epilepsy nursing specialist at the Wirral University Teaching Hospital, UK

Epilepsy in childhood is one of the most common neurological disorders encountered in paediatric clinical practice. The current treatment of paediatric epilepsy aims to improve health outcomes, as well as to manage the educational, social and psychological issues that are involved in the quality of life of paediatric patients and their parents. In this direction, in several countries, a specialized, comprehensive, multidisciplinary service has been developed, including paediatric epilepsy nursing, which constitute a key component of this service. According to Mrs. Jennifer O'Brien, one of the pioneering paediatric epilepsy nursing specialists in the UK with a significant contribution in the care of children with epilepsy in Merseyside, the mission of paediatric epilepsy nursing is to enable children with epilepsy and their families to live as normal a life as possible, to ensure that all those who care for the child are well-educated regarding the child's epilepsy and to promote the child's safety and integration into society. She notes that in the past, epilepsy was not considered as a specialty and was looked after by all paediatricians; it is recognised now that it is an incredibly complex group of conditions, which deserves to have specialist management. She believes that although modern technology is crucial in informing and educating families, face to face education and advice is still the most important method of providing support. She highlights the recent advances in genetics of paediatric neurology along with the drive for epilepsy specialists, both nursing and medical, while she estimates that over the following years, paediatric epilepsy nursing will have progressed beyond nowadays expectations.

Validity and reliability of Turkish version of the scales of perceived stigma for children with epilepsy and their parents

Purpose

This study aims to establish a Turkish version of the scales of perceived stigma amongst children with epilepsy and their parents by adopting the scales developed by Austin et al. This study also aims to analyse the scales' validity and reliability in evaluating stigma perceptions amongst the aforementioned population.

Methods

The population of this methodological study consisted of parents and 85 epileptic children between 9 and 16 years old. This population visited the paediatric neurology clinic of a hospital in Erzurum Province, Turkey, between April 2015 and January 2016. The scales of perceived stigma amongst children with epilepsy and their parents, as well as its Turkish version, were used as measuring tools. Experts were also consulted for their opinions. Meanwhile, Bartlett's test, Kaiser–Meyer–Olkin (KMO) index, exploratory factor analysis, principal component analysis, varimax rotation and scree plot test were used to determine the validity of the study. Moreover, the coefficients of Cronbach's α and Pearson's product-moment correlation were used to identify internal consistency, homogeneity and thus reliability.

Results

Evaluations and analyses indicated that the Turkish version of the child and parent scales can be used with a single dimension. The mean scores of such scales were 24.02 ± 8.47 and 15.68 ± 4.04, respectively. All item-total score correlations of the child and parent scales were found to be significant (P < 0.05). The KMO coefficient of the child scale was 0.94, whereas the chi-square value of Bartlett's test of sphericity was significant at 209.311 (P < 0.05). Moreover, the KMO coefficient of the parent scale was found to be 0.80, whereas the chi-square value of Bartlett's test of sphericity was found to be significant at 209.311 (P < 0.05). The Cronbach's α coefficients were 0.95 and 0.87 for the child and parent scales, respectively.

Conclusion

The Turkish version of the child and parent scales of perceived stigma is valid and reliable in measuring the perception of stigma amongst children with epilepsy and their parents.

How can paediatric epilepsy services best be delivered in secondary care?

OBJECTIVE

To produce practical evidence-based guidelines for the management of paediatric epilepsy in secondary care settings.

DESIGN

Question-specific systematic literature review and local service audit.

MAIN OUTCOME MEASURES

Grade of recommendation for specific management issues.

RESULTS

There is little good quality research to support many existing epilepsy guidelines for secondary care.

CONCLUSION

Practical guidelines for the provision of children's epilepsy services can be evidence influenced but until more relevant research is undertaken, not evidence based.

Systematic reviews of specialist epilepsy services

BACKGROUND

Concern has been expressed over UK epilepsy service standards but the most clinically effective model of care is unknown.

OBJECTIVE

To systematically review the current evidence on specialist epilepsy clinics compared to general neurology clinics and specialist epilepsy nurses compared to usual care.

METHODS

Medline, Psychlit, Embase, Healthplan, GEARS, BIDS ISI, UKCHHO, international HTA websites, InterTASC databases and The Cochrane Library were searched to September 1999. Any studies comparing specialist epilepsy clinics or nurses to generalist services or usual care, reporting physical health, costs or generic quality-of-life outcomes were included. Two people independently applied inclusion and exclusion criteria and extracted data independently. Randomized controlled trial (RCT) quality was assessed by Jadad score and other studies qualitatively by the likelihood of bias.

RESULTS

Findings were one RCT and two other studies on epilepsy clinics and four RCTs and a controlled trial on epilepsy nurses. Data synthesis was inappropriate. Epilepsy clinics showed no evidence of reduced seizure frequency or severity, no quality-of-life information and were more expensive. Epilepsy nurse services showed no evidence of reduced seizure frequency or severity, no effect on quality-of-life but were less expensive.

CONCLUSION

There is insufficient evidence to demonstrate the superiority of any particular care model for producing better health outcomes.

The information needs and understanding of 5-10-year old children with epilepsy, asthma or diabetes

This exploratory study compared the information needs and understanding of 25 5-10-year olds with epilepsy with those of 10 children with asthma and 10 with diabetes (of the same age range). The children were interviewed whilst attending specialist clinics by the first author and were unaware of her professional status. All the children had access to specialist nurses and their families had received literature about their condition. The interview covered five main areas: knowledge of their condition, psychological effects, medication, restrictions on lifestyle, where they obtained their information and if they had unanswered questions. The children with epilepsy had far more unanswered questions and felt excluded from discussions with doctors. They also appeared reluctant to tell their friends their diagnosis and, at such a young age, felt stigmatized by their condition. The results highlight a contrast in the understanding of children with epilepsy when compared with those with asthma or diabetes. It is proposed that if a simple biological model were used to explain epilepsy this could aid children's understanding and reduce their reluctance to disclose their diagnosis.

Improving the epilepsy service: the role of the specialist nurse

There is currently a wide variation in the level of service provided for patients with epilepsy across the UK. Evidence is becoming available to suggest that improvements in local service provision may be achieved through the intervention of a specialist nurse. Using practical examples, this article explores the roles of the epilepsy specialist nurse, and examines how they may benefit patients and improve services. Functions such as liaison, patient assessment and management, counselling, provision of information, education, and audit are considered. It is hoped that the improved co-ordination and management of epilepsy services, that is achieved through specialist nurse intervention, will lead to improved patient outcomes and increased cost-effectiveness.

Use of new antiepileptic drugs in the treatment of childhood epilepsy

The management of epilepsy in children requires careful evaluation, classification, and pharmacologic treatment. With classic antiepileptic drugs (AEDs), at least 25% of children remain refractory to appropriate therapy. The past decade has allowed the introduction of a number of newer AEDs for treatment of both adults and children with epilepsy. These include felbamate, gabapentin, lamotrigine, topiramate, tiagabine, and vigabatrin. Emerging information regarding the efficacy of these AEDs in treating childhood epilepsy syndromes suggests advantages for many patients. Limited data are available that define the optimal use of new AEDs in pediatric patients. Further research must be completed to validate the positive effects described in existing clinical trials of the new AEDs in the treatment of childhood epilepsy.

Role of vigabatrin and lamotrigine in treatment of childhood epileptic syndromes

PURPOSE

Vigabatrin (VGB) and lamotrigine (LTG) are two new antiepileptic drugs (AEDs) with different mechanisms of action for treatment of refractory epilepsies. Previous reports have indicated efficacy of both drugs in a number of epileptic syndromes.

METHODS

We compared these new AEDs drugs to determine their respective efficacy against different types of epileptic syndrome and to develop a rational approach to their use. We reviewed the charts of 105 children, with partial and generalized epilepsies.

RESULTS

VGB was to be significantly more effective in children with partial epilepsies, and LTG was more effective in those with generalized epilepsies.

CONCLUSIONS

VGB and LTG have different therapeutic profiles. Combination treatment with the two drugs may represent rational polytherapy for patients with epilepsy resistant to treatment with either drug alone or as add-on to other AED treatment.

Zonisamide monotherapy in newly diagnosed infantile spasms

PURPOSE

We determined the short-term efficacy of zonisamide (ZNS) monotherapy in newly diagnosed patients with infantile spasms (IS).

METHODS

Eleven hospitals participated in this open, prospective trial. ZNS 3-10 mg/kg/day was administered as the second-choice drug to 11 newly diagnosed patients with IS (cryptogenic 3, symptomatic 8) who failed to respond to high-dose vitamin B6.

RESULTS

Four infants with symptomatic IS had cessation of spasms and disappearance of the hypsarrhythmia. In these responders, the spasms ceased after a few days (1-5 days) of treatment at a dose of ZNS 4-5 mg/kg/day which produced plasma ZNS concentrations ranging from 5.2 to 16.3 microg/ml (mean 9.8 microg/ml). There were two relapses (50%) 4-6 weeks after cessation of seizures, however. Relapse was predicted by effects of ZNS on EEG; the 2 infants in whom an abnormal EEG persisted had relapses, whereas the 2 whose EEG normalized remained seizure-free (follow-up 20 and 26 months). No adverse reactions were noted.

CONCLUSIONS

ZNS may be effective in the initial treatment of selected patients with IS.

Vigabatrin as first line therapy in infantile spasms: review of seven patients

OBJECTIVE

To study the efficacy of vigabatrin as initial therapy in infantile spasms.

METHODOLOGY

We reviewed seven patients with newly diagnosed infantile spasms referred to Tuen Mun Hospital, Hong Kong from 1994 to 1995. Vigabatrin was given as the initial monotherapy at therapeutic dose of 50-100 mg/kg. Efficacy was evaluated at the end of second week of treatment.

RESULTS

Significant improvement was observed in four patients, 50-75% seizure reduction in two and no response in one patient. Efficacy was noted within the first week of treatment in five of the six patients who responded. No adverse effects were observed. Vigabatrin monotherapy could be continued in five patients.

CONCLUSION

Vigabatrin could be considered as the first line treatment in infantile spasms. A period of 2 weeks may be sufficient to evaluate its efficacy.

Impairments, disabilities and handicaps in children and adolescents with epilepsy

The patterns of motor and sensory impairments, disabilities and handicap were assessed in 217 children and adolescents with epilepsy. Motor and sensory dysfunctions were found to be common even in children without major additional neurodisorders such as cerebral palsy and mental retardation. Handicap was most severe in the dimensions of physical independence and orientation and increased significantly with duration of epilepsy. It was more severe when the onset of seizures was early and when secondary generalized seizures were present. Handicap was significantly reduced after epilepsy surgery.

Managing the teenager with epilepsy: paediatric to adult care

Epilepsy starting in childhood frequently persists through adolescence and into adult life, and an onset in adolescence itself is common. The management of the teenager with epilepsy is important but often inadequate. In 1991, a specific clinic for teenagers with epilepsy was established in Liverpool to address the unique needs and concerns of this age group and, importantly, to facilitate a smooth hand-over of specialist epilepsy care from paediatric to adult services. An additional and crucial benefit of this clinic has been to provide a further, and hopefully final, screen to confirm (or refute) the diagnosis of epilepsy, to corroborate, or correctly identify, the specific epilepsy syndrome and to ensure that the most appropriate antiepileptic drug (AED) is being prescribed and when, if possible, the drug can be withdrawn. Of 120 consecutive patients referred to the teenager clinic, 12 (10%) did not have epilepsy, and 26 (22%) were being treated with an inappropriate AED. The main issues and concerns voiced by the teenagers included choices of further education and career, the possibility and risks of withdrawing anticonvulsants, driving regulations, the inheritance of epilepsy and pregnancy/contraception. This teenager clinic could serve as a model for both other 'epilepsy centres' and also for managing other chronic disorders with an onset in childhood.