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Seizures and the Epilepsies: VA Services
Natalya Kan, BSN, RN, CNRN Nurse Coordinator, Epilepsy Center of Excellence West Los Angeles VA Medical Center
TO ACCESS AUDIO FROM YOUR TELEPHONE: Dial 701-801-1220 and enter Access Code 652-020-129
Overview for Today:
What are the VA Epilepsy Centers of Excellence (ECoE)? What kind of services are provided by the ECoE? What is a seizure? What is epilepsy? What are the causes for seizures? What types of seizures are there? What are seizure triggers? How is epilepsy diagnosed? What treatments are available for seizures? What kind of resources are available for veterans with seizures?
VETERANS WITH EPILEPSY │TAKE ACTION GROUP SEIZURES AND THE EPILEPSIES – VA SERVICES
VA Epilepsy Centers of Excellence Mission Statement: To improve the health and well being of Veteran patients with epilepsy and other seizure disorders through the integration of clinical care, outreach, research, and education. Founded in 2008 by the Department of Veterans Affairs (VA) under the Public Law S. 2162 16 sites that are linked to form 4 regional centers
Services provided: Outpatient epilepsy clinics Expert pharmacological treatment Inpatient video-EEG monitoring (EMU) Advanced diagnostic studies Surgical interventions Telemedicine
Regional Map of the ECoEs
ECoE Locations & Contacts Website: http://www.epilepsy.va.gov/
Did you know? 65 million people have epilepsy worldwide 2+ Million Americans have epilepsy 150,000 new cases in the U.S. annually 1 in 10 people have had a seizure Approximately 1 in 26 people in the US will develop epilepsy in their lifetime
Seizure vs. Epilepsy Abnormal electrical discharges in the brain Characteristics dependent upon location of the abnormal discharges Sign/Symptom Event
2 or more unprovoked seizures, separated by 24 hours Diagnosis Syndrome Characterized as having seizures that are spontaneous and recurrent
Image credit: Nucleus Medical Art, Inc/Getty Images
Focal (Partial) vs. Generalized
Causes of Epilepsy About 60-70% of people with epilepsy have unknown cause Other causes may include:
Traumatic brain injury (TBI) Infection in the brain Brain tumor Stroke Genetic factors Developmental conditions Metabolic disturbances
*Causes vary in different age groups
Seizure Triggers
Missed doses of Anti-Epileptic Drugs Lack of sleep Illness Stress Hormonal changes, menses Illicit drug/alcohol use Certain medications
When is it an emergency? First time seizure In persons with epilepsy diagnosis: Seizure that lasts longer than 5 minutes, or second seizure occurs without recovery Seizure that is different or longer in duration than typical events Seizure occurred in water Injury sustained with a seizure Pregnant or diabetic Recovery period is unusually long
Sudden Unexpected Death in Epilepsy (SUDEP) SUDEP refers to “death of a person with epilepsy without warning and where no cause of death could be found” Estimated occurrence: 1 death per 1,000 people with epilepsy 1 death per 100 people with epilepsy, who have frequent convulsive seizures that are poorly controlled with medications
Best prevention is to have as few seizures as possible = better seizure control
Diagnosing Epilepsy Medical history Neurological examination Blood tests Electroencephalogram (EEG) Magnetic resonance imaging (MRI)/Computed tomography (CT) Admission for in-patient video-EEG monitoring in an Epilepsy Monitoring Unit (EMU)
Electroencephalogram (EEG) Can detect abnormalities in the electrical activity of the brain EEG technologist performs the test by placing electrodes (flat metal discs) in different positions on the scalp Normal EEG tracing does not definitively exclude diagnosis of epilepsy Avoid caffeine for 8 hours before the test and in some cases may need to reduce sleep time night before test
Magnetic Resonance Imaging (MRI) Can detect structural abnormalities in the brain Non-invasive procedure that uses powerful magnets to construct pictures of the body Performed in specially shielded room MRI should NOT be used Image source: http://www.radiologyinfo.org/en/info.cfm?pg=headmr for patients with metallic objects in their bodies
Positron Emission Tomography Scan (PET)
Evaluates the energy activity of the brain by measuring how the brain uses up glucose, oxygen, or other substances How is it performed: Small amount of radioactive substance injected into vein -> attaches to glucose
Preparation:
Should not eat at least 6 hours before the PET scan
Usually obtained for presurgical evaluation
Image source: Jens Maus, 2010, public domain
Epilepsy Monitoring Unit (EMU) Elective in-patient admission (5-7 May utilize triggers to day stay) with video-EEG optimize stay/achieve goal monitoring Temporarily taper off Purpose of EMU: seizure medications Diagnose seizure vs. other Sleep deprivation condition Flashing lights in Evaluation for surgical eyes/fast breathing exercises intervention Characterize and localize Patient agreement to: seizures Remain in the room for Medication management duration of admission Goal of EMU admission is to Follow seizure capture typical seizure precautions events/spells on both video and EEG recording
Treatment Options Medications – Anti Epileptic Drugs (AEDs) Surgical/Stimulation options: Epilepsy Surgery Vagus Nerve Stimulation Therapy (VNS) Responsive Neurostimulation System (RNS) Deep Brain Stimulation (DBS) of anterior thalamic nucleus* MRI-guided Laser Ablation (Visualase) Ketogenic Diet (primarily studied and utilized with children)
Goal of Anti-Epileptic Drug (AED) Therapy
About 60-80% of persons with epilepsy can gain control of seizures with medications Over 25 different AEDs available AED chosen considering age, seizure type, other medical conditions, other medications (interactions), lifestyle, women of childbearing age
SEIZURES
SIDE EFFECTS
Epilepsy Surgery For drug-resistant epilepsy Goal: seizure freedom by a surgery that is aimed at removing the area of the brain that is causing the seizures Presurgical evaluation – Additional advanced diagnostic tests to determine eligibility/safety of surgery
Vagus Nerve Stimulation Therapy (VNS)
Image source credit: http://us.livanova.cyberonics.com/
Responsive Neurostimulation Therapy (RNS)
Image source credit: http://www.neuropace.com/wp-content/uploads/2015/11/Patient_Manual.pdf
Deep Brain Stimulation (DBS)* Electrodes implanted in the anterior nucleus of the thalamus
Neurostimulator implanted under the skin in the upper chest and connected by wire to the electrodes in the brain
Image source credit: https://www.epilepsysociety.org.uk/deep-brain-stimulation
Ketogenic Diet High-fat, low carbohydrate, low protein diet Critical to maintain and monitor by specialist May be admitted to initiate the diet
Primarily used in children
VA contact numbers 24-hour TeleCare Nurse Advice Line: Veterans registered in VAMCs of West LA, San Diego, Loma Linda, Las Vegas, Long Beach 1-877-252-4866
24/7 Veterans Crisis Line – all locations: 1-800-273-8255, Press 1
Pharmacy - Greater Los Angeles VA: 1-800-952-4852
Resources • VA Epilepsy Centers of Excellence: http://www.epilepsy.va.gov/ • VA ECoE Patient Education: http://www.epilepsy.va.gov/Patient_Education.asp • Epilepsy Foundation of Greater Los Angeles: http://endepilepsy.org/ • American Epilepsy Society (AES): https://www.aesnet.org/ • YouTube: Veterans and Epilepsy educational videos: https://www.youtube.com/watch?v=yx45kHDoEqo&lis t=PL3AQ_JVoBEyzDfAHEptumOPB-PFTH_ya-
References
American Association of Neuroscience Nurses. (2009). Care of the Patient With Seizures. Glenview, IL: AANN. Berg, A.T., Berkovic, S.F., Brodie, M.J., Buchhalter, J., Cross, J.H., Emde Boas, W., Engel, J., French, J., Glauser, T.A., Mathern, G.W., Moshé, S.L., Nordli, D., Plouin, P., & Scheffer, I.E. (2010). Revised terminology and concepts for organization of seizures and epilepsies: Report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia, 51(4): 676-685. doi: 10.1111/j.1528-1167.2010.02522.x Black, J.M., & Hawks, J.H. (2009). Medical-Surgical Nursing: Clinical Management for Positive Outcomes. St. Louis, MO: Saunders. Donner, E.J. (2011). Explaining the Unexplained; Expecting the Unexpected: Where are We with Sudden Unexpected Death in Epilepsy? Epilepsy Currents, 11(2), 45-49. American Epilepsy Society. Hickey, J.V. (2014). The Clinical Practice of Neurological and Neurosurgical Nursing. Philadelphia, PA: Lippincott Williams & Wilkins. Hutsell, P. (n.d.). Seizure Telemetry Module: An Education and Competency Module for Seizure Telemetry RNs. Portland, OR: Portland, Oregon VA Medical Center. Panayiotopoulos, C.P. (ed), Benbadis, S.R., Beran, R.G., Berg, A.T., Engel, J., Galanopoulou, A.S., Kaplan, P.W., Koutroumanidis, M., Moshe, S.L., Nordli, D.R., Serratosa, J.M., Sisodiya, S.M., Tatum, W.O., Valeta, T., Wilner, A.N. (section eds) (2010). Atlas of Epilepsies, Vols I-III. London: Springer. The National Epilepsy Education Alliance (2009). Epilepsy 101: The Ultimate Guide for Patients and Families. Medicus Press. Wyllie, E., Cascino, G.D., Gidal, B.E., & Goodkin, H.P. (2011). Wyllie’s Treatment if Epilepsy: Principles and Practice. Philadelphia, PA: Lippincott Williams & Wilkins.
QUESTIONS + ANSWERS
VETERANS WITH EPILEPSY │TAKE ACTION GROUP SEIZURES AND THE EPILEPSIES – VA SERVICES
OPEN DISCUSSION
VETERANS WITH EPILEPSY │TAKE ACTION GROUP SEIZURES AND THE EPILEPSIES – VA SERVICES
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“The First Line of Defense: Medications from A to Z” Sunita Dergalust, PharmD West Los Angeles VA Medical Center
VETERANS WITH EPILEPSY │TAKE ACTION GROUP SEIZURES AND THE EPILEPSIES – VA SERVICES