The A-B neuropsychological assessment schedule (ABNAS): the relationship between patient-perceived drug related cognitive impairment and results of neuropsychological tests

Brain magnetic resonance imaging findings six months after critical COVID-19: A prospective cohort study

BACKGROUND

COVID-19 patients suffered from neurological symptoms in the acute phase. Whether this led to long-term consequences was unknown. We studied long-term brain MRI findings in ICU-treated COVID-19 patients and compared them with findings in groups with less severe acute disease.

MATERIALS AND METHODS

In this prospective cohort study, 69 ICU-treated, 46 ward-treated, and 46 home-isolated patients, as well as 53 non-COVID-19 controls, underwent brain MRI six months after acute COVID-19. Plasma neurofilament light chain (NfL), a biomarker of neuroaxonal injury, was measured simultaneously.

RESULTS

Ischaemic infarctions existed in 5.8% of ICU-treated patients. Cerebral microbleeds (CMBs) existed in 27 (39.1%) ICU-treated, 13 (28.3%) ward-treated, 8 (17.4%) home-isolated COVID-19 patients, and 12 (22.6%) non-COVID controls. Patients with CMBs were older (p < 0.001), had a higher level of plasma NfL (p = 0.003), and higher supplementary oxygen days (p < 0.001). In multivariable analysis, age (OR 1.06, 95% CI 1.02-1.09) and supplementary oxygen days (OR 1.07, 95% CI 1.02-1.13) were associated with CMBs. The ICU group showed prevalent distribution of CMBs in deep regions.

CONCLUSION

Age and supplementary oxygen days were independently associated with CMBs; COVID-19 status showed no association. Accumulation of risk factors in the ICU group may explain the higher prevalence of CMBs.

TRIAL REGISTRATION

ClinicalTrials.govNCT04864938, registered February 9, 2021.

Associations of subjective and objective cognitive functioning after COVID-19: A six-month follow-up of ICU, ward, and home-isolated patients

Background

Subjective and objective cognitive dysfunction are reported after COVID-19 but with limited data on their congruence and associations with the severity of the acute disease. The aim of this cohort study is to describe the prevalence of subjective and objective cognitive dysfunction at three and six months after COVID-19 and the associations of subjective cognitive symptoms and psychological and disease-related factors.

Methods

We assessed a cohort of 184 patients at three and six months after COVID-19: 82 patients admitted to the Intensive Care Unit (ICU), 53 admitted to regular hospital wards, and 49 isolated at home. A non-COVID control group of 53 individuals was included. Demographic and clinical data were collected. Subjective cognitive symptoms, objective cognitive impairment, and depressive and post-traumatic stress disorder (PTSD) symptoms were assessed.

Results

At six months, subjective cognitive impairment was reported by 32.3% of ICU-treated, 37.3% of ward-treated, and 33.3% of home-isolated patients and objective cognitive impairment was observed in 36.1% of ICU-treated, 34.7% of ward-treated, and 8.9% of home-isolated patients. Subjective cognitive symptoms were associated with depressive and PTSD symptoms and female sex, but not with objective cognitive assessment or hospital metrics.

Conclusions

One-third of COVID-19 patients, regardless of the acute disease severity, reported high levels of subjective cognitive dysfunction which was not associated with results from objective cognitive screening but with psychological and demographic factors. Our study stresses the importance of thorough assessment of patients reporting long-term subjective symptoms, screening for underlying mental health related factors such as PTSD or depression.

EuroQOL-5D-3L does not adequately map quality-of-life deterioration in severely affected patients with epilepsy

INTRODUCTION

The steadily increasing impact of health-related quality of life (HRQOL) on reasonable diagnostic and therapeutic decisions makes the correct mapping of HRQOL indispensable in modern epileptology. The aim of this study was to address the reliability of the often-used generic HRQOL screening questionnaire EuroQOL 5-dimension, 3-level (EQ-5D-3L) by comparing its normalized index value (calculated via the time trade-off method) and visual analog scale (VAS) to the gold standard of the extensive Quality of Life in Epilepsy Inventory (QOLIE-31). QOLIE-10 scores were compared with the extensive QOLIE-31 and EQ-5D-3L TTO.

METHODS

We conducted a retrospective analysis of a monocentric study of 184 patients with epilepsy. Bivariate Spearman correlation analysis and Fisher's r-to-z transformation were used to compare the strengths of correlations of EQ-5D-3L, QOLIE-10 and QOLIE-31 with different epilepsy-specific domains (disease severity, drug interactions, emotional well-being, stigmatization, seizure-related anxiety, cognitive impairment).

RESULTS

The different metrics of EQ-5D-3L, QOLIE-10 and QOLIE-31 showed moderate to very strong intra- and inter-metric correlations for overall HRQOL. Quality of Life in Epilepsy Inventory-31 VAS and EQ-5D-3L VAS did not show any significantly different strengths of correlations with respect to the domains studied. In contrast, the correlation strength of the normalized EQ-5D-3L index value differed significantly from the QOLIE-31 T-score for several domains, for example, for drug-related adverse events, neuropsychological deficits, symptoms of depression and seizure worry. In seizure-free patients, EQ-5D-3L VAS and EQ-5D-3L index values correlated significantly less with the domain of "cognitive impairment" than the QOLIE-31 T-score. In patients without relevant neuropsychological deficits, the strengths of correlations with the assessed domains did not differ significantly between EQ-5D-3L metrics and the QOLIE-31 T-score. The HRQOL mapping probability of QOLIE-10 was inferior to QOLIE-31 and comparable to EQ-5D-3L regarding the analyzed domains.

CONCLUSION

In contrast to the EQ-5D-3L VAS, EQ-5D-3L index values do not adequately map health-related quality of life in severely affected patients with epilepsy and therefore should not be used as screening tools. The QOLIE-31 T-score remains the gold standard for HRQOL assessment in patients with epilepsy.

Depressive and Anxiety Symptoms Are Predictors of Seizure Recurrence in Adults With Newly Diagnosed Epilepsy

Objective: To investigate whether emerging depressive and anxiety symptoms are predictors of seizure recurrence in a cohort of patients with newly diagnosed epilepsy (PWNDE) who did not have a history of psychiatric diagnosis. Methods: A cohort of 283 PWNDE were psychiatrically assessed before antiseizure medication (ASM) therapy and were followed for 12 months to assess seizure recurrence. The influence of depressive and anxiety symptoms score on seizure recurrence was assessed using univariate and multivariate binary logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was utilized. Results: A total of 283 individuals were included in final analysis, and 115 patients (40.6%) experienced seizure recurrence during follow-up. In multivariate logistic regression analysis, NDDI-E and GAD-7 score were associated with an increased risk of seizure recurrence with an adjusted OR of 1.360 (CI: 1.176-1.572; P < 0.001) and 1.101 (CI: 1.004-1.209; P = 0.041), respectively. Additionally, the adjusted OR and 95% CI of seizure recurrence for the "high NDDI-E score and high GAD-7 score" vs. "not high NDDI-E score and not high GAD-7 score" was 7.059 (3.521-14.149) (P for trend < 0.001). Conclusion: We found that an emergence of new psychiatric symptoms including depressive and anxiety symptoms were predictors of seizure recurrence in adults with newly diagnosed epilepsy who did not have psychiatric history.

One-Year Analysis of Risk Factors Associated With Cognitive Impairment in Newly Diagnosed Epilepsy in Adults

Cognitive impairment (CI) occurs in people with epilepsy, affecting their quality of life. This study aimed to identify factors associated with CI in adult patients with newly diagnosed epilepsy. Additionally, we sought to determine whether any particular cognitive function is impaired predominantly by anti-seizure medications or by other factors. We enrolled 229 patients with newly diagnosed epilepsy and 191 participants were followed up for 1 y. We used the Montreal Cognitive Assessment as a tool to quantify CI. The sub-item scores were also collected to assess whether any aspects of CI are predominantly affected by anti-seizure medication treatment. Subjective memory decline due to anti-seizure medications was also recorded. One-hundred-and-two participants (44.5%) had CI onset before anti-seizure medication treatment. Aging, low education level, stroke or brain surgery etiology, and anxious symptoms were identified as risk factors for CI before anti-seizure medications use. Brain surgery for the young, anxious status for the middle-aged, and depressive status for the elderly were risk factors for CI at different ages. The elderly PWE had worse memory than the others. PWE with TLE had worse cognition, especially in memory and naming. The overall impact of anti-seizure medications on cognition was mild. Refractory epilepsy was a predictor of cognitive decline. Subjective memory decline was predicted by high-risk treatment and by a finding of refractory epilepsy. Clarifying the risk factors for CI can help the physician to assess the probable risk of CI for each individual before the start of anti-seizure medication treatment, which may lead to better compliance.

Systematic review of subjective memory measures to inform assessing memory limitations after stroke and stroke-related aphasia

AIM

Primary aims of this systematic review were to: (1) identify the range of subjective memory measures used in the stroke and stroke-related aphasia literature and (2) critically appraise their psychometric properties as well as (3) the methodological qualities of studies that included them, (4) investigate whether such measures provide an accurate reflection of memory impairments (i.e., in comparison to norms from age-matched, neurotypical participants), (5) document the representation of individuals with stroke-related aphasia, and (6) examine the extent to which subjective memory measures correlate with objective memory measures.

METHODS

Systematic review of the literature from 1970 to June 2019 using a comprehensive range of relevant search terms in EMBASE, Medline, PsychINFO, SCOPUS, and Web of Science. Eligibility criteria were for studies to include adults who had suffered of clinical stroke, to report a subjective memory measure that was completed by the stroke survivors, to be reported in a peer-reviewed journal, and to be published in English or Dutch. Quality appraisal was carried out for the included studies as well as the subjective memory measures they employed.

RESULTS

A total of 7,077 titles or abstracts were screened, with 41 studies included in the quantitative and qualitative synthesis. Twenty-six subjective memory measures were used in the included studies. The critical appraisal of their psychometric properties and the methodological quality of the included studies revealed significant shortcomings; for example, neurotypical participants were included in only 14 of the 41 studies. When statistical comparisons were made, different outcomes arose. Only eight studies statistically compared subjective with objective memory measures.

CONCLUSIONS

This literature domain currently provides an unclear picture as to how memory limitations affect participation in stroke and stroke-related aphasia.IMPLICATIONS FOR REHABILITATIONA broad range of subjective memory measures have been used to determine stroke survivors' perceptions of their everyday memory issues.Because of psychometric weaknesses such as inadequate reliability and cross-cultural validity among subjective memory measures, there remains a need to carefully review a given measure's properties to determine if it is appropriate for use with a given stroke survivor.Stroke survivors with aphasia have been infrequently included or inadequately described in studies of subjective memory measures, and thus how these individuals perceive their everyday memory abilities requires further investigation.Although the relationship between subjective and objective memory measures has been infrequently investigated by stroke researchers, both types of measures should be considered as they likely offer complementary rather than redundant information about stroke survivors' memory abilities.

Migraine comorbidity and cognitive performance in patients with focal epilepsy

BACKGROUND

Migraine and epilepsy are comorbid conditions. While it is well known that epilepsy can have an impact on cognitive abilities, there is conflicting evidence in the literature on the relationship between migraine and cognitive function. The aim of this study was to assess whether migraine comorbidity in patients with newly diagnosed focal epilepsy is associated with cognitive dysfunction.

METHODS

This is a post hoc analysis of data prospectively collected for the Human Epilepsy Project (HEP). There were 349 participants screened for migraine with the 13 questions used in the American Migraine Prevalence and Prevention (AMPP) study. Participants were also screened for depression using the Neurological Disorder Depression Inventory for Epilepsy (NDDI-E) and the Center for Epidemiologic Studies Depression Scale (CES-D) and for anxiety using the Generalized Anxiety Disorder-7 (GAD-7) scale. Cognitive performance was assessed with the Cogstate Brief Battery and Aldenkamp-Baker Neuropsychological Assessment Schedule (ABNAS).

RESULTS

About a fifth (21.2%) of patients with a new diagnosis of focal epilepsy screened positive for migraine. There were more women and less participants employed full time among the participants with comorbid migraine. They reported slightly more depressive and anxious symptoms than the participants without migraine. Migraine comorbidity was associated with ABNAS memory score (median: 2, range: 0-12, Mann Whitney U p-value: 0.015). However, migraine comorbidity was not associated with Cogstate scores nor ABNAS total scores or other ABNAS domain scores. In linear regressions, depression and anxiety scores were associated with the ABNAS memory score.

CONCLUSION

In this study, there was no association between migraine comorbidity and objective cognitive scores in patients with newly diagnosed focal epilepsy. The relationship between migraine comorbidity and subjective memory deficits seemed to be mediated by the higher prevalence of depression and anxiety symptoms in patients with epilepsy with comorbid migraine.

Affective and behavioral dysfunction under antiepileptic drugs in epilepsy: Development of a new drug-sensitive screening tool

OBJECTIVE

Behavioral problems and psychiatric symptoms are common in patients with epilepsy and have a multifactorial origin, including adverse effects of antiepileptic drugs (AEDs). In order to develop a screening tool for behavioral AED effects, the aim of this study was to identify behavioral problems and symptoms particularly sensitive to AED drug load and the presence/absence of AEDs with known negative psychotropic profiles.

METHODS

Four hundred ninety-four patients with epilepsy were evaluated who had been assessed with three self-report questionnaires on mood, personality, and behavior (Beck Depression Inventory, BDI; Neurological Disorders Depression Inventory for Epilepsy extended, NDDI-E; and Fragebogen zur Persönlichkeit bei zerebralen Erkrankungen, FPZ). Drug-sensitive items were determined via correlation analyses and entered into an exploratory factor analysis for scale construction. The resulting scales were then analyzed as a function of drug treatment.

RESULTS

Analyses revealed 30 items, which could be allocated to six behavioral domains: Emotional Lability, Depression, Aggression/Irritability, Psychosis & Suicidality, Risk- & Sensation-seeking, and Somatization. Subsequent analysis showed significant effects of the number of AEDs on behavior, as in Emotional Lability (F=2.54, p=.029), Aggression/Irritability (F=2.29, p=.046), Psychosis & Suicidality (F=2.98, p=.012), and Somatization (F=2.39, p=.038). Affective and behavioral difficulties were more prominent in those patients taking AEDs with supposedly negative psychotropic profiles. These effects were largely domain-unspecific and primarily manifested in polytherapy.

CONCLUSION

Drug-sensitive behavioral domains and items were identified which qualify for a self-report screening tool. The tool indicates impairments with a higher drug load and when administering AEDs with negative psychotropic profiles. The next steps require normalization in healthy subjects and the clinical validation of the newly developed screening tool PsyTrack along with antiepileptic drug treatment.

Adverse effects of anti-epileptics in trigeminal neuralgiform pain

BACKGROUND

Side effects of anti-epileptic drugs (AEDs) have not been adequately documented in trigeminal neuralgia and its variants. The aim of this observational cross-sectional study was to compare the A-B Neuropsychological Assessment Schedule (ABNAS), which measures cognitive side effects to the Adverse Events Profile (AEP), which looks at a broader range of side effects, and to investigate drug/dosage relationships with questionnaire scores to help determine a point at which a drug change would be indicated.

METHODS

One hundred five patients were recruited from a facial pain clinic, over a 10-month period. Self-complete questionnaire scores were compared between patients using different AEDs.

RESULTS

A-B Neuropsychological Assessment Schedule score correlated well with AEP indicating that cognitive side effects were a significant burden. Toxic range on the ABNAS was estimated to occur when scores were >43/72 (95% CI: 37.4-48.6). Polytherapy is weakly associated with the higher scores. Oxcarbazepine dosage was found to linearly correlate with AEP and ABNAS scores, better than carbamazepine dosage. Memory alteration was least common with lamotrigine and oxcarbazepine, and there was less association between fatigues with oxcarbazepine/pregabalin.

CONCLUSION

Anti-epileptic drugs have significant side effects. The ABNAS questionnaire is a useful tool along with the AEP to recognize and monitor AEDs' side effects and to help to adjust medications to optimal dosage.

Evaluating subjective cognitive impairment in the adult epilepsy clinic: Effects of depression, number of antiepileptic medications, and seizure frequency

OBJECTIVE

Subjective cognitive complaints are a frequent concern of patients with epilepsy. The Aldenkamp-Baker Neuropsychological Assessment Schedule (ABNAS) is a patient-reported scale validated to measure adverse cognitive effects of antiepileptic drugs (AEDs). The goals of this study were to identify predictors of patient-reported cognitive dysfunction and to assess the relationship between subjective and objective cognitive impairment.

METHODS

The Cleveland Clinic Knowledge Program Data Registry was used to identify adult patients seen in outpatient epilepsy clinic from January to May 2015 and who completed the following scales: ABNAS for subjective cognitive impairment, Patient Health Questionnaire (PHQ-9) for depression, Generalized Anxiety Disorder 7-item (GAD-7) scale, Quality of Life in Epilepsy (QOLIE-10), and EuroQOL five dimensions questionnaire (EQ-5D) for health-related quality of life. Topiramate (TPM) was considered a high-risk medication for cognitive impairment. Patients were categorized into groups based on total ABNAS score: subjective cognitive impairment (ABNAS>15; N=270) and no subjective cognitive impairment (ABNAS≤15; N=400). Multivariable logistic regression models were constructed to identify independent predictors of subjective cognitive impairment. In a subset of patients who had neuropsychological testing within 6months of completing the ABNAS (N=60), Pearson correlations and multivariable logistic regression models, controlling for number of AEDs, depression, and anxiety, assessed the relationship between subjective cognitive impairment and objective cognitive performance on measures of intelligence, attention/working memory, verbal fluency, naming, processing speed, manual dexterity, visuomotor processing, and verbal memory.

RESULTS

Forty percent of patients in the overall sample (N=270/670) reported cognitive impairment. The variables most strongly associated with subjective cognitive impairment were PHQ-9 score, number of AEDs, and seizure frequency. In the subset of patients with neuropsychological testing, ABNAS score was correlated with anxiety (r=0.44), depression (r=0.38), and attention/working memory (r=-0.31). After adjusting for depression and anxiety, patients who endorsed subjective cognitive impairment scored significantly lower on measures of nonverbal intelligence and attention/working memory, but not on other cognitive measures.

CONCLUSIONS

Subjective cognitive impairment as reported on the ABNAS is most strongly associated with depressive symptomatology, number of AEDs, and seizure frequency, but not with most objective cognitive measures. Identifying these three predictors provides a clear framework to understand and address subjective cognitive complaints in adult patients with epilepsy.

Socioeconomic Outcome and Quality of Life in Adults after Status Epilepticus: A Multicenter, Longitudinal, Matched Case-Control Analysis from Germany

Background

There is a lack of data concerning socioeconomic outcome and quality of life (QoL) in patients after status epilepticus (SE) in Germany.

Patients and methods

Adult patients treated between 2011 and 2015 due to SE at the university hospitals in Frankfurt, Greifswald, and Marburg were asked to fill out a questionnaire regarding long-term outcome of at least 3 months after discharge. The SE cohort consisted of 25.9% patients with an acute symptomatic, 42% with a remote symptomatic and previous epilepsy, 22.2% with a new-onset remote symptomatic, and 9.9% with other or unknown etiology. A matched case–control analysis was applied for comparison with patients with drug refractory epilepsy and seizure remission, both not previously affected by SE.

Results

A total of 81 patients (mean age: 58.7 ± 18.0 years; 58% female) participated. A non-refractory course was present in 59.3%, while 27.2% had a refractory SE (RSE) and 13.6% had a superrefractory SE (SRSE). Before admission, a favorable modified Rankin Scale (mRS) of 0–3 was found in 82.7% (67/81), deteriorating to 38.3% (31/81) (p = 0.003) at discharge. The majority returned home [51.9% (42/81)], 32.1% entered a rehabilitation facility, while 12.3% were transferred to a nursing home and 3.7% to another hospital. The overall mRS at follow-up did not change; 61.8% (45/74) reached an mRS of 0–3. In RSE and SRSE, the proportion with a favorable mRS increased from 45.5% at discharge to 70% at follow-up, while QoL was comparable to a non-refractory SE course. Matched epilepsy controls in seizure remission were treated with a lower mean number of anticonvulsants (1.3 ± 0.7) compared to controls with drug refractory epilepsy (1.9 ± 0.8; p < 0.001) or SE (1.9 ± 1.1; p < 0.001). A major depression was found in 32.8% of patients with SE and in 36.8% of drug refractory epilepsy, but only in 20.3% of patients in seizure remission. QoL was reduced in all categories (QOLIE-31) in SE patients in comparison with patients in seizure remission, but was comparable to patients with drug refractory epilepsy.

Discussion

Patients after SE show substantial impairments in their QoL and daily life activities. However, in the long term, patients with RSE and SRSE had a relatively favorable outcome comparable to that of patients with a non-refractory SE course. This underlines the need for efficient therapeutic options in SE.

Do social functioning and symptoms improve with continuation antidepressant treatment of persistent depressive disorder? An observational study

OBJECTIVE

To determine efficacy of continued treatment with the serotonin norepinephrine reuptake inhibitor duloxetine on symptom reduction and functional improvement in outpatients with dysthymia.

METHOD

Fifty outpatients with DSM-IV-TR diagnosed dysthymia who had participated in a 10 week double-blind, placebo-controlled study of duloxetine received open treatment for three months. Nineteen duloxetine responders continued duloxetine, 24 patients initially treated with placebo started open duloxetine treatment, and 7 duloxetine non-responders were treated with desvenlafaxine or bupropion, selected by clinician choice.

RESULTS

Patients continuing duloxetine maintained symptom improvement, 84% meeting response and 63% remission criteria at week 22. Patients initially treated with placebo showed similarly high levels of response (83%) and remission (62%) at week 22, and most duloxetine non-responders subsequently responded to other antidepressants. Duloxetine-continuation patients improved modestly between weeks 10 and 22 on measures of social and cognitive functioning and temperament. Despite this improvement concurrently across several functional domains, 66.7% of patients continuing duloxetine remained in the impaired range of functioning according to the Social Adjustment Scale (SAS).

CONCLUSIONS

Continued duloxetine treatment appears to be effective in maintaining symptom response in dysthymic disorder, and has positive effects on social functioning. However, the majority of patients do not show normalization of functioning, even when controlling for remission status. Additional treatments should be considered to target residual impairments in social functioning in mood remitted patients with persistent depressive disorder.

The Portland Neurotoxicity Scale

The Portland Neurotoxicity Scale (PNS) is a brief patient-based survey of neurotoxicity complaints commonly encountered with the use of antiepileptic drugs (AEDs). The authors present data on the validity of this scale, particularly when used in longitudinal studies. Participants included 55 healthy controls, 23 epilepsy patient controls, and 86 healthy volunteers who took various AEDs or placebos for 12 weeks as part of randomized, double-blind studies of AED effects on cognitive abilities. Test-retest reliability in the control groups averaged .80 (total score). Test-retest changes in the PNS were sensitive to AED usage in general (p < .001) and to each of the five AEDs tested but not to placebo. Test-retest changes in the PNS were strongly correlated with several scales of the Profile of Mood States but only weakly correlated with objective cognitive test measures. The PNS has satisfactory psychometric properties and is sensitive to AED usage in test-retest studies.

Cognitive impairment in adults with epilepsy: The relationship between subjective and objective assessments of cognition

AIM

This study aimed to assess the relationship between objective measures of cognition and subjective perception of cognitive functioning reported by patients with epilepsy and their caregivers.

METHODS

One hundred patients with epilepsy attending hospital neurology outpatient clinics and their caregivers were enrolled in this study. The EpiTrack (version 1) brief cognitive screening tool was used to measure objective impairment, the ABNAS questionnaire (A-B Neuropsychological Assessment Schedule) to assess subjective cognitive performance, and a version of the ABNAS designed to be completed by caregivers (C-ABNAS) to document caregivers' views. Patient anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS) and considered as covariates. Patients with an uncertain diagnosis of epilepsy or likely severe comorbid mood or anxiety disorders were excluded.

RESULTS

Data from 82 patients were analyzed after exclusion of patients with uncertain diagnoses or likely severe comorbid mood or anxiety disorders. Fifty-nine (72%) had a degree of objective cognitive impairment. Fifty (84.7%) of these 59 patients had 'high' ABNAS scores concordant with the objective assessment, and 43 (72.9%) had high C-ABNAS scores matching the abnormalities detected by objective screening. Of the 23 (28%) patients without objective cognitive impairment, seven (30.4%) had concordantly low ABNAS scores, and 10 (43.4%) had concordantly low C-ABNAS scores. Patient memory impairment was more often reported by patients themselves than by caregivers (p=0.011). Carers were significantly more likely to rate patients as having impaired motor coordination than patients themselves. A small part of the variance of the EpiTrack score was predicted by the C-ABNAS. Objective cognitive performance did not predict ABNAS or C-ABNAS scores.

CONCLUSIONS

Self-report or caregiver report questionnaires identify patients with epilepsy and objective cognitive impairment more accurately than patients with intact cognition. Those without objective evidence of cognitive impairment may, nevertheless, perceive themselves as having memory dysfunction; it is these patients, therefore, who most require both subjective and objective assessments of cognition, including carers' assessments, in order to establish the nature of their symptoms. None of these assessment measures can be used as a reliable proxy for another, each contributes individually to a comprehensive assessment of cognition, and all must be used in conjunction with measures of mood and anxiety.

Comparison of tolerability and adverse symptoms in oxcarbazepine and carbamazepine in the treatment of trigeminal neuralgia and neuralgiform headaches using the Liverpool Adverse Events Profile (AEP)

Background

Adverse effects of drugs are poorly reported in the literature . The aim of this study was to examine the frequency of the adverse events of antiepileptic drugs (AEDs), in particular carbamazepine (CBZ) and oxcarbazepine (OXC) in patients with neuralgiform pain using the psychometrically tested Liverpool Adverse Events Profile (AEP) and provide clinicians with guidance as to when to change management.

Methods

The study was conducted as a clinical prospective observational exploratory survey of 161 patients with idiopathic trigeminal neuralgia and its variants of whom 79 were on montherapy who attended a specialist clinic in a London teaching hospital over a period of 2 years. At each consultation they completed the AEP questionnaire which provides scores of 19–76 with toxic levels being considered as scores >45.

Results

The most common significant side effects were: tiredness 31.3 %, sleepiness 18.2 %, memory problems 22.7 %, disturbed sleep 14.1 %, difficulty concentrating and unsteadiness 11.6 %. Females reported significantly more side effects than males. Potential toxic dose for females is approximately 1200 mg of OXC and 800 mg of CBZ and1800mg of OXC and 1200 mg of CBZ for males.

Conclusions

CBZ and OXC are associated with cognitive impairment. Pharmacokinetic and pharmacodynamic differences are likely to be the reason for gender differences in reporting side effects. Potentially, females need to be prescribed lower dosages in view of their tendency to reach toxic levels at lower dosages.

Side effects associated with AED could be a major reason for changing drugs or to consider a referral for surgical management.

A comprehensive neuropsychological description of cognition in drug-refractory juvenile myoclonic epilepsy

The study of juvenile myoclonic epilepsy is important in that: it is common and heterogeneous; the etiology is unknown; and patients report broad cognitive problems. We utilized a broad battery of neuropsychometric tests to assess the following: intellectual function, memory, language and naming, executive function, the impact of epilepsy, and antiepilepsy drug side effects. Sixty people with drug-refractory JME were interviewed, and performance was profoundly impaired across the range of tests. Impairments included the following: full-scale IQ (89, p<0.001); processing speed (86, p<0.001); visual memory (immediate and delayed) more affected than verbal memory; verbal fluency and inhibition (p<0.001); and self-reported drug side effects (p<0.001). Eighty-three percent of patients exhibited frank executive dysfunction, which was moderate to severe in 66%. Regression modeling confirmed that an early age at onset and the need for polytherapy were associated with poorer cognitive outcomes. This study confirms previous reports of executive dysfunction in a larger cohort and with greater statistical rigor. We also identified a high prevalence of neurotoxicity symptoms such as fatigue and poorer functioning across intellectual and memory tests than had previously been reported.

Tools for assessing quality of life in epilepsy patients

In this review, we attempt to bring the reader up to date with recent developments in the area of assessment of quality of life (QOL) of patients with epilepsy, in both the research and clinical contexts. We present evidence from recent publications on the major and most commonly used QOL instruments for both adults and children with epilepsy, including both strengths and limitations. We discuss both generic measures and ones that have been developed specifically for use in the epilepsy population. We draw attention to some of the broader issues that render the QOL assessment endeavor a somewhat complex one - in particular, that epilepsy is not a single condition, with a common clinical trajectory; and that QOL measures as currently configured almost universally focus on its negative impacts, largely neglecting the possibility of those affected being able to retain reasonable social adjustment and life satisfaction. Finally, we suggest that further work needs to focus on plugging the current evidence gaps in relation to psychometric and cross-cultural applicability issues; and on the value of QOL instruments in the clinical care setting. We conclude by highlighting a number of issues from the QOL literature that will, in our view, be the focus of increasing research interest in the next few years.

Patient Reported Outcome (PRO) assessment in epilepsy: a review of epilepsy-specific PROs according to the Food and Drug Administration (FDA) regulatory requirements

Despite collection of patient reported outcome (PRO) data in clinical trials of antiepileptic drugs (AEDs), PRO results are not being routinely reported on European Medicines Agency (EMA) and Food and Drug Administration (FDA) product labels. This review aimed to evaluate epilepsy-specific PRO instruments against FDA regulatory standards for supporting label claims. Structured literature searches were conducted in Embase and Medline databases to identify epilepsy-specific PRO instruments. Only instruments that could potentially be impacted by pharmacological treatment, were completed by adults and had evidence of some validation work were selected for review. A total of 26 PROs were reviewed based on criteria developed from the FDA regulatory standards. The ability to meet these criteria was classified as either full, partial or no evidence, whereby partial reflected some evidence but not enough to comprehensively address the FDA regulatory standards. Most instruments provided partial evidence of content validity. Input from clinicians and literature was common although few involved patients in both item generation and cognitive debriefing. Construct validity was predominantly compromised by no evidence of a-priori hypotheses of expected relationships. Evidence for test-retest reliability and internal consistency was available for most PROs although few included complete results regarding all subscales and some failed to reach recommended thresholds. The ability to detect change and interpretation of change were not investigated in most instruments and no PROs had published evidence of a conceptual framework. The study concludes that none of the 26 have the full evidence required by the FDA to support a label claim, and all require further research to support their use as an endpoint. The Subjective Handicap of Epilepsy (SHE) and the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) have the fewest gaps that would need to be addressed through additional research prior to any FDA regulatory submission, although the NDDI-E was designed as a screening tool and is therefore unlikely to be suitable as an instrument for capturing change in a clinical trial and the SHE lacks the conceptual focus on signs and symptoms favoured by the FDA.

Monitoring the cognitive effects of antiepileptic pharmacotherapy--approaching the individual patient

Cognitive side effects of antiepileptic drugs are common and can negatively affect tolerability, compliance, and long-term retention of the treatment. Furthermore, adverse cognitive effects of pharmacotherapy significantly affect everyday functioning and quality of life. Consequently, preservation of cognitive functions is an important aspect of epilepsy therapy. Knowledge of the patient's neuropsychological status before and after pharmacological interventions can help to decide on the appropriate treatment and, thus, can potentially improve individual medical care. Here, we suggest that cognitive monitoring of antiepileptic pharmacotherapy--like the assessment of seizure frequency, blood serum levels, electroencephalography or structural imaging--should be carried out as a matter of routine. In contrast to subjective measures, there are only very few neuropsychological instruments explicitly validated for the assessment of cognition along with antiepileptic pharmacotherapy. This review (1.) outlines indications and requirements for individual cognitive monitoring, (2.) discusses available diagnostic tools, and (3.) discloses relevant pitfalls. Neuropsychology, as demonstrated, provides evidence-based methods for monitoring cognitive effects of individual pharmacological treatments and, therefore, serves as a valuable tool for the quality and outcome control of antiepileptic therapies.

The development of a QALY measure for epilepsy: NEWQOL-6D

Cost-utility analysis is used to inform the allocation of healthcare resources, using the quality-adjusted life year (QALY) as the outcome measure. We report the development of an epilepsy-specific QALY measure (NEWQOL-6D) derived from the NEWQOL measure of health-related quality of life. Firstly, psychometric and Rasch analyses established the dimension structure of NEWQOL and generated a reduced health state classification system including one item per dimension. Secondly, health states generated by the classification system were valued using Time Trade Off, and the results were modeled to generate a utility score for every health state. A classification system with 6 dimensions (worry about attacks; depression; memory; concentration; stigma; control) was produced, and generalized least squares regression was used to generate utility scores for every health state. This study is the first attempt to derive an epilepsy-specific QALY measure, and the utility values can be used in the economic evaluation of emerging technologies for epilepsy.

Early detection of behavioral side effects of antiepileptic treatment using handheld computers

OBJECTIVE

Treatment-emergent side effects are frequent events, particularly during the uptitration of antiepileptic drugs. So far, monitoring of such adverse events in outpatients has often been limited to intervals of weeks or months. We here report the application of a new device for temporally fine-grained assessment of objective well-being and cognitive performance using personal digital assistants (PDAs).

METHODS

Twenty adult patients with epilepsy participated in this pilot study. Ten received add-on treatment with levetiracetam. Ten patients with constant medication served as a control group. Differences between groups with respect to self-rated cognitive condition, psychophysical condition, aggressiveness, and cognitive test performance in a concentration test assessed three times daily (morning, early afternoon, and evening), over the course of 6 days, were analyzed.

RESULTS

Levetiracetam-treated patients manifested an early augmentation of self-rated aggressiveness, which increased in intensity over the course of days. Aggressiveness reached a maximum in the early afternoon across days. There were no major changes in cognitive performance, except for an increase in morning performance in the control group.

CONCLUSIONS

This study demonstrates the feasibility of a new method of ambulatory assessment of behavioral and cognitive data during titration of antiepileptic drugs. Significant changes in aggressiveness under add-on treatment with levetiracetam were found to be dependent on the time of assessment during the day. These results suggest that PDA-based ambulatory monitoring of patients with epilepsy may be a promising tool for early detection of drug-related side effects and, thus, may constitute a significant improvement in patient care.

Cognitive dysfunction in epilepsy: case reports

Cognitive dysfunction in people with epilepsy is a frequently encountered but also easily overlooked problem. In this article three patients with epilepsy are presented with cognitive problems due to a relapse of seizures, due to continuing absence seizures or as a consequence of deteriorating mental functions resulting from frequent complex partial seizures. In the last patient the decline in mental functioning was also demonstrated in a disseminated activation pattern on her fMRI, which contrasts with the localised activity as seen in controls on fMRI. Suggestions how to handle these problems in daily practice are given.