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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  

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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