Special issues in the management of young children, older adults, and the developmentally disabled

Acute Abortive Therapies for Seizure Clusters in Long-Term Care

OBJECTIVES

To describe acute seizure treatment for the long-term care setting, emphasizing rescue (acute abortive) medications for on-site management of acute unexpected seizures and seizure clusters.

DESIGN

Narrative review.

SETTING AND PARTICIPANTS

People with seizures in long-term care, including group residences.

METHODS

PubMed was searched using keywords that pertained to rescue medications, seizure emergencies/epilepsy, seizure action plans, and long-term care.

RESULTS

Seizure disorder, including epilepsy, is prevalent in long-term care residences, and rescue medications can be used for on-site treatment. Diazepam rectal gel, intranasal midazolam, and diazepam nasal spray are US Food and Drug Administration (FDA)-approved seizure-cluster rescue medications, and intravenous diazepam and lorazepam are approved for status epilepticus. Benzodiazepines differ by formulation, route of administration, absorption, and metabolism. Intranasal formulations are easy and ideal for public use and when rectal treatment is challenging (eg, wheelchair). Intranasal, intrabuccal, and rectal formulations do not require specialized training to administer and are easier for staff at all levels of training compared with intravenous treatment. Off-label rescue medications may have anecdotal support; however, potential disadvantages include variable absorption and onset of action as well as potential risks to patients and caregivers/care partners. Delivery of intravenous-administered rescue medications is delayed by the time needed to set up and deliver the medication and is subject to dosing errors. Seizure action plans that include management of acute seizures can optimize the quality and timing of treatment, which may reduce emergency service needs and prevent progression to status epilepticus.

CONCLUSIONS AND IMPLICATIONS

Seizure disorder is prevalent across all ages but is increased in older adults and in those with intellectual and developmental disabilities. Prompt intervention may reduce negative outcomes associated with acute unexpected seizures and seizure clusters. Seizure action plans that include acute seizures can improve the treatment response by detailing the necessary information for staff to provide immediate treatment.

Recommendations for development of acute seizure action plans (ASAPs) from an expert panel

PURPOSE OF REVIEW

Disease-related treatment action plans for acute exacerbations providing information that may be helpful for self-management for patients and caregivers are commonly used for chronic conditions such as asthma and diabetes. However, among patients with epilepsy, a review of the literature suggested that the majority did not have an action plan in place for acute seizure treatment.

RECENT FINDINGS

Currently, there is a lack of unified guidance on seizure action plans (SAPs) in the literature. In the authors' opinion, available formats have limitations for practical use and may not be easily customizable to individual patients, and they are not often designed to provide simple-to-follow steps for rapid immediate steps to determine and initiate appropriate treatment of seizure emergencies. Our group reviewed current examples of SAPs and provided guidance on the development of acute seizure action plans (ASAPs) designed to facilitate rapid, appropriate acute care in the community and to be as useful as possible for a wide range of care partners, including those with limited experience.

SUMMARY

This paper provides agreed upon expert opinion recommendations and considerations for goals, development process, types of content, and format for an ASAP.

Implementation of an evidence-based seizure algorithm in intellectual disability nursing: A pilot study

Based on the results of the Surrogate Decision-Making Self Efficacy Scale (Lopez, 2009a), this study sought to determine whether nurses working in the field of intellectual disability (ID) experience increased confidence when they implemented the American Association of Neuroscience Nurses (AANN) Seizure Algorithm during telephone triage. The results of the study indicated using the AANN Seizure Algorithm increased self-confidence for many of the nurses in guiding care decisions during telephone triage. The treatment effect was statistically significant -3.169(p < 0.01) for a small sample of study participants. This increase in confidence is clinically essential for two reasons. Many individuals with ID and epilepsy reside within community-based settings. ID nurses provide seizure guidance to this population living in community-based settings via telephone triage. Evidenced-based training tools provide a valuable mechanism by guiding nurses via best practices. Nurses may need to be formally trained for seizure management due to high epilepsy rates in this population.

Seizure emergency plans: patient results from a cross-sectional epilepsy survey

Guidance for seizure emergency plans exists, although their impact and extent of use in patients with epilepsy are undetermined. This study's primary purpose was to measure the estimated use and content of seizure emergency plans. Secondary objectives included measuring: disease severity, quality of life, productivity, and adherence among patients with and without a plan. An online survey was conducted among 408 patients with epilepsy (ages 18-64) who took one or more antiepileptic drugs. Only 30% of patients reported having a plan, which included avoiding injury, notifying a physician, resting/relaxing, and seeking emergency assistance. Those with a plan were more likely to have experienced more seizures in the past year, to have missed school/work, to have incurred injury, to have visited the ER, to have been hospitalized, to fear additional seizures, and to have lost a job. Seizure emergency plans appear to be reserved for adults with more severe disease, but there may be clinical benefits to developing a plan for all adult patients with epilepsy.