Epilepsy and Seizures
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with epilepsy. It addresses issues that may occur in RACF, particularly the:
Diagnosis of RACF residents newly presenting with a seizure; Ongoing management of residents with a pre-existing diagnosis of epilepsy; and Initial management of residents experiencing an acute seizure or status epilepticus.
This CIS covers:
About Seizures and Epilepsy; Assessment Management; Maintenance Medication; Management of a Seizure; Status Epilepticus; and Sources of Information Reference Cards:
Seizure Observation Chart
Seizures Record Chart
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Seizures and Epilepsy
Seizures are the most common neurological disorder exhibited by older adults. A seizure is defined as hyper-excitement of the neurons in the brain. A surge of electrical activity occurs within the brain leading to changes in levels of awareness or behaviour [1]. The signs and symptoms of a seizure vary considerably depending upon the part of the brain in which the surge of neuron activity occurs and the extent to which it spreads to other areas of the brain [2].
When seizures recur the condition is referred to as a seizure disorder or epilepsy. The incidence of epilepsy in the general population is 0.5%, however this increases between the ages of 60 and 80 years [3, 4]. Incidence of epilepsy in older adults is significantly under-reported due to a variety of factors, including vague presenting signs and symptoms [4]. More than 50% of all new onset epilepsy diagnoses are made in those aged over 60 years. There is an increased risk of epilepsy with the presence of numerous conditions that are associated with older age, including Alzheimer’s disease, hypertension and/or stroke [1, 2, 4]. The acute condition of status epilepticus is more prolonged in older adults and mortality is higher than in other age groups [2, 4].
Early recognition of seizures and development of an epilepsy management plan can increase quality of life, decrease the risk of injury and minimise further medical complications [1, 2, 4-7].
Assessment
The aim of assessment is to accurately determine:
Diagnosis of epilepsy if not already known; Type of seizures, as this determines the medication; Underlying causes or precipitating factors; and Adequacy of current management.
Assessment involves a detailed history of seizures, medication, co-morbidities, physical examination, and investigations.
A detailed history of the seizure event is one of the most significant factors in diagnosis, not only to determine if the episode was a seizure, but also in determining the type of seizure. A full description of the seizure episode should be reported to the resident’s doctor and documented in the resident’s history [1-5] .
The reference cards include a Seizure Observation Chart to document the occurrence of a seizure-like event, and a Seizures Record Chart to monitor seizures over time. The Seizure Observation Chart can be used to document [5, 6]:
Date and time of the event; What the person had been doing immediately prior to the event; What drew your attention to the event, e.g. a cry, stare, twitching; How quickly the signs progressed and how long did the event last; If the person’s body become stiff, jerked, twitched or convulsed; Any loss of consciousness and how long it lasted; If there were any associated skin, e.g. flushed, clammy, or breathing changes; Any incontinence or vomiting; Any injuries the person may have received during the event; and The person’s condition immediately following the event and time taken until full recovery.
It is recommended that the Seizures Record Chart be commenced on the first occurrence of a seizure-like event, to aid in diagnosis of epilepsy as well as to track ongoing response to management plans.
A full review of the resident’s medications, including over-the-counter preparations should be conducted to rule out drug interaction as a cause of the seizure [3, 4].
Physical examination should include system review and assessment of mental status.
The following investigations may assist diagnosis:
One or more EEGs can be used to confirm diagnosis (although sensitivity is poor) and determine type of seizure. Once a diagnosis of epilepsy has been made, repeated EEGs are not recommended [1-5]. An MRI is recommended if first-line medication regimes fail to adequately control the resident’s seizure frequency [1, 5]. A CT scan with contrast is usually adequate in older adults. Full blood examination, electrolytes, glucose and calcium levels, renal function tests, liver function tests and, when appropriate, drug screening, may assist in diagnosis [1, 3-5]. If the resident is already diagnosed with epilepsy, anti-epileptic drug (AED) levels may be tested if sub therapeutic or toxic levels are suspected.
A 12-lead ECG is also indicated [1, 5] to exclude cardiac cause of symptoms or seizure. If infection is suspected as a cause of seizures, lumbar puncture for CSF examination may be considered. Consider referring to a neurologist for residents experiencing new-onset of seizures, uncontrolled seizures, treatment failure or where there is doubt about diagnosis [1-3, 5].
Diagnosis
Diagnosis is based on detailed history of seizures, clinical examination, electro encephalogram (EEG) and appropriate neuro-imaging.
A diagnosis of epilepsy is made after the patient has had more than one event recognisable as a seizure [1-3] not related to fever. Diagnosis of epilepsy in people aged over 60 years is more difficult than in younger adults and children. Concurrent diagnoses can inhibit interpretation of diagnostic investigations and often vague signs and symptoms of seizures in older adults may go undetected or be misdiagnosed [2, 4, 6, 7]. In RACFs seizure events are frequently confused with dementia or behavioural disturbance due to the high prevalence of these conditions [2, 4]. Diagnosis of epilepsy can be compounded by an inadequate medical history or documentation, particularly if there is a substantial period of time between witnessed seizures [3].
Differential diagnosis
Table One outlines the primary distinguishing features of seizure-like events related to various causes. The following diagnoses should be considered in residents presenting with a seizure-like episode [2, 4]:
Syncope; Transient ischaemic attack (TIA); Transient global amnesia; Panic attack; Episodic vertigo; Stroke; Migraine; Memory disturbance and/or confusion; and Restless legs syndrome.
Table One – Variables that distinguish seizure differential diagnoses in older adults [2, 5]
|
|
Seizure
|
Syncope
|
TIA
|
Transient global amnesia
|
Panic attack
|
|
Premonition
Symptoms
|
None or
Aura symptoms
|
None; or
Lightheadedness
Nausea
Vomiting
Diaphoresis
Pallor
|
Palpitations
|
None
|
Lightheadedness
Nausea
Vomiting
Diaphoresis
Panic, fear
|
|
Precipitating
Factors
|
Sleep deprivation
Flashing lights
|
Postural change
Neck movements
Prolonged standing
|
Exercise
|
None
|
Stress
Social situations
|
|
Onset
|
Acute
|
Variable
|
Acute
|
Acute
|
Acute
|
|
Duration
|
1-2 minutes
|
Seconds-minutes
|
Minutes-hours
|
Hours
|
Variable
|
|
Movements
|
Variable tonic clonic movements depending upon where seizure affects brain
|
Loss of tone
Clonic jerking
|
Physical deficits dependant upon where occurs
|
None
|
None or
Pacing
Agitation
Rapid breathing
Stiffening of hands
|
|
Incontinence
|
Variable
|
Occasional
|
None
|
None
|
None
|
|
Heart rate
|
Increased or decreased
|
Variable
|
Normal
|
Normal
|
Increased
|
|
Postictal
|
Confusion
Sleep
|
Alert or mild confusion
|
Alert
|
Alert
|
Alert
|
Classification of seizure
Seizure type and aetiology determines management and choice of medication [1, 5, 8]. Seizures fall into two basic categories: partial or focal seizures and generalised seizures. Partial or focal seizures start in one part of the brain and have an effect on the part of the body controlled by that part of the brain. Generalised seizures occur throughout the whole brain and therefore involve the entire body. Figure One shows the International League of Epilepsy Classification of seizures [1, 5, 6].
Figure One: Classification of epileptic seizures [1, 5, 6, 8]
Partial or focal Seizures
Simple partial seizures
Simple partial seizures are localised seizures that occur in only one part of the brain. Signs and symptoms depend on the function that of the part of the brain in which the seizure occurs. There is no loss of consciousness with a simple partial seizure, and the event usually lasts for less than one minute, although it may spread and become a secondarily generalised seizure [6].
Complex partial seizures
Complex partial seizures also occur in only one part of the brain, however conscious state becomes altered, e.g. confusion, drowsiness. Whilst this type of seizure generally only lasts 1-2 minutes, altered conscious state may persist for hours [6].
Secondarily generalised seizures
Secondarily generalised seizures commence in one part of the brain like simple partial seizures and then spread throughout the brain to become a generalised seizure. These seizures always commence as a partial seizure, however the primary stage of the seizure may be short and hard to differentiate from a generalized seizure.
Generalised seizures
Absence seizures
Absence seizures (previously known as petit mal) involve the whole brain; the person (usually a child) loses awareness, although rarely is physical control lost. Absence seizures appear similar to daydreaming and therefore often go unnoticed. These seizures generally start suddenly and last only a few seconds, although they can occur many times daily [6].
Myoclonic seizures
Myoclonic seizures also involve the entire brain, and usually occur on waking or before bed when the person is tired. These seizures are characterised by uncontrolled muscle jerks and a brief a loss of consciousness [6].
Tonic-clonic seizures
Tonic-clonic seizures (previously known as grand mal) involve the whole brain. The seizure is characterised by two main phases – a tonic phase when the person stiffens and falls to the ground, and a clonic phase during which the body begins strong jerking. This type of seizure usually lasts only a few minutes, although afterwards the person is generally confused and drowsy for a number of hours [6].
Tonic seizures
Tonic seizures are characterised by the muscles stiffening and the person falling to the ground. These seizures frequently occur in clusters during sleep. People who suffer from tonic seizures are at risk of head injury from falls [6].
Atonic seizures
Atonic seizures affect muscle tone causing the person to collapse to the ground although recovery afterwards is fast. People who suffer from atonic seizures are at risk of head injury from falls [6].
Signs and symptoms
Signs and symptoms may occur before, during and after a seizure. The seizure may involve some or all of the following characteristics depending upon the type of seizure [9].
Pre seizure
Although some people experience no warning signs or symptoms, the following are regularly experienced immediately prior to a seizure [9]:
“Aura” symptoms including unusual smell, visual loss or blurring, feelings of deja-vu; Racing thoughts; Tingling feeling, often in the stomach; Fear, panic; Dizziness, light headedness; Headache; Nausea; and/or Numbness.
During seizure
Signs and symptoms may be isolated to one side of the body, or generalised throughout. In general, older adults experience less exaggerated physical signs than younger adults. Some signs/symptoms include [2-4]:
Black out, loss of consciousness; Stereotyped abnormal limb movements; Chewing movements, drooling, swallowing, tongue-biting, spitting, lip-smacking, tooth grinding; Difficulty talking, unusual sounds; Eyelid fluttering, eyes rolling back; Twitching movements, jerking, shaking; Stiffening, inability to move; Incontinence; and/or Breathing difficulty.
After seizure (postictal)
The postictal phase is generally longer in older adults. A variety of the following are commonly observed [9]:
Deep sleep; Memory loss, confusion; Writing and speech difficulties; Weakness; and/or Injuries, bruising, aching and pain from muscle activity.
Signs and symptoms of seizures in older adults may be different from, and more vague than those in younger adults. Older adults with epilepsy most frequently experience complex partial seizures. Although they generally experience seizures less often than younger adults, older adults usually exhibit a prolonged after-seizure (postictal) phase and have a higher risk of injury [2-4, 7].
Management
Management goals
The goals of management are to:
Prevent seizures; Promptly and appropriately manage seizures and status epilepticus; Reduce risk of injury; Minimize adverse effects of medications; and Increase the resident’s quality of life.
Management is based on a review of the resident’s seizure history, investigation results, type of epilepsy, and the resident’s personal preferences [4].
Management plan
Residents with epilepsy require a management plan to be developed by the GP with RACF staff, the resident and his or her relative/carer. The management plan should include:
Documentation of seizure occurrence and frequency (available in Reference Cards); Maintenance medication; Monitoring for drug interactions and adverse events; Acute care plan for seizures or status epilepticus (including PRN medication, emergency procedures); and Non-pharmacological strategies.
The plan should be reviewed at least annually, with referral to a specialist if the resident’s epilepsy remains poorly controlled [1, 5].
Non-pharmacological strategies
Prevention of seizures includes avoidance of exacerbating factors such as sleep deprivation, excess alcohol and psychological stress. Reduce the resident’s risk of injury through exposure to heights, water, fire and machinery [8]. Psychological interventions, such as relaxation therapy and cognitive behavioural therapy, may be used in conjunction with an AED medication regime. Although psychological interventions may improve the quality of the resident’s life, they have not been shown to have any effect on seizure frequency [1, 5].
All residents with a history of epilepsy should be educated to report symptoms to the RACF staff as soon as they occur wherever possible.
RACF staff should be provided with ongoing education on the assessment and management of seizures and status epilepticus, use of medications, and the importance of contacting emergency services as soon as possible if a resident is experiencing status epilepticus or having recurrent seizures within a 24-hour period [1, 5]. RACF staff and the pharmacist should work together to ensure that emergency medication is always available and not expired.
Maintenance Medication
Residents diagnosed with epileptic seizures should be commenced on anti-epileptic drugs (AEDs). Selection of medication should be made with consideration to the type of seizures, co-medication and co-morbidity, prognosis and the resident’s preferences. Older adults are more susceptible to medication side effects, drug interactions and neurotoxicity.
The aim of maintenance medication is to prevent seizures, preferably with monotherapy and minimal adverse effects, thereby increasing the resident’s quality of life [1-5]. Recommendations for maintenance medication for residents are based on the same principles as those for younger age groups and highlight the importance of regular monitoring of effectiveness of treatment [1, 5]. General principles in the commencement of an AED are:
Wherever possible use a single anti-epileptic drug [1, 3-5]; Start with a low dosage and gradually increase to therapeutic levels whilst monitoring the resident for side effects [1, 3-5]; If the first-line drug fails, commence an appropriate alternative AED by gradually increasing the dosage to the maximum tolerated before gradually decreasing the first medication [1, 5]; Using AEDs in combination is only recommended when use of single drug regimes have been ineffective in maintaining the resident seizure-free [1, 5]; and Regular blood tests are not routinely indicated unless toxicity is suspected [1, 5].
When a resident has been seizure-free for at least 3 years, withdrawal of AED may be considered. [1, 5, 8] The risks and benefits should be discussed the GP with RACF staff, the resident and his/her representative. Gradually withdraw medication over 2-3 months and monitor for seizure recurrence [1, 5]. If seizures recur, resume the previously effective dose.
Anti-epileptic drugs (AEDs)
First generation AEDs, phenytoin, carbamazepine and sodium valproate, are still the mainstay medications used in seizure management. Because the second generation AEDs are metabolised differently to first generation medications they have fewer side effects, lower risk of toxicity and less interactions with other medication. They are therefore recommended in the management of seizures in older adults [1-5]. Characteristics of AEDs are shown in Table Two.
Check for drug interactions when prescribing any AEDs. Monitor for delayed adverse effects, eg gum dysplasia, hirsutism, lymphadenopathy, hyponatremia from carbamazepine, liver dysfunction from sodium valproate [8]. Phenytoin and phenobarbitone, are associated with hypocalcaemic effects leading to osteomalacia (decreased bone mineral density) and increased rates of osteoporosis, fractures and injury from falls [2-5]. Routine use of calcium and vitamin D supplements should be considered.
Table Two: Characteristics of Anti-epileptic Drugs (AEDs) [1-5, 8, 10]
|
First Generation Medications
|
|
Medication
|
Prescribing
|
Side effects
|
Benefits
|
Problems
|
|
Phenytoin
|
- Used for partial & generalised tonic-clonic seizures
- 300mg daily
- Usually daily dose 200-500mg in 1 or 2 divided doses
|
- Gait disturbance
- Reduced bone mass density
- Increased risk of fractures
- Increased risk of osteoporosis
|
- Lower cost than newer medications
|
- Poor correlation between dosage & serum concentration levels
- Monitoring of blood levels recommended when adjusting dose
- Should not be administered within half an hour of PEG feeding
- Multiple drug interactions including antacids
|
|
Phenobarbitone
|
- Used for partial & generalised tonic-clonic seizures
- Commence 30mg daily
- Usual daily dose 60-120mg
|
- Sedation
- Multiple, not recommended for use in older adults without expert advice
|
|
- Multiple drug interactions
|
|
Carbamazepine
|
- Used for partial, generalised tonic-clonic & secondarily generalised seizures
- Controlled release form for twice-daily doses
- Commence 100mg daily
- Usual daily dose 400-1000mg
|
- Skin reactions
- Hyponatraemia
|
- Standard, controlled-released formulations available including a suspension
|
- Dose adjustments should be made slowly on commencement
- Processed by the liver, clearance slow in elderly
- Multiple drug interactions (with suspension)
|
|
Sodium Valproate
|
- Used for absence, partial, generalised tonic-clonic, myoclonic & secondary generalised seizures
- Twice-daily dosing
- Commence 500mg daily
- Usual daily dose 1-2.5g
|
- Liver toxicity (rare)
- Weight gain
- Tremor
|
- Oral & intravenous forms
- Quick to titrate to therapeutic levels
|
- Multiple drug interactions
|
|
Second Generation Medications
|
|
Medication
|
Prescribing
|
Side effects
|
Benefits
|
Problems
|
|
Gabapentin
|
- Used for drug-resistent focal epilepsy
- Multiple daily doses required for oral forms
- Commence 300mg bd
- Usually daily dose 1.2-3.6g
|
- Weight gain
- Ataxia
|
- Few drug interactions
- Interacts with antacids
|
- Wide dosing range due to variability in metabolism
|
|
Lamotrigine
|
- Used for absence, partial, generalised tonic-clonic, myoclonic & secondary generalised seizures
- Commence 25 mg/day if treated with a liver enzyme inducer
- Commence 25 mg every 2nd day if on sodium valproate
- Max. daily dose 200-400 mg not in combination with sodium valproate
- Max. daily 100-200 mg dose in combination with sodium valproate
- Divided doses minimise adverse effects
|
- Severe rash (especially when used in combination with sodium valproate)
|
|
- Takes 1-2 months to reach optimal dose as dosage should be increased gradually to avoid side effects
|
|
Tiagabine
|
- Used for drug-resisent focal epilepsy
- Multiple daily doses required for oral forms
- Commence dose 2.5 mg daily
- Maintenance dose 30-45 mg daily
|
- Dizziness, tiredness, nervousness, diarrhoea
|
- Almost totally metabolised by the liver
- Few drug interactions
|
- Takes 1-2 months to reach optimal dose as dosage should be increased gradually to avoid side effects
|
|
Topiramate
|
- Used for drug-resistant focal epilepsy
- Twice-daily dosing
- Commence dose 25 mg
- Recommended daily dose is 200-400 mg in divided doses
|
- Metabolic acidosis
- Kidney stones
- Weight loss
- Use with caution in residents with glaucoma
|
- Comes in a variety of forms including tablets & sprinkle capsules
- Few drug interactions
|
- Takes 1-2 months to reach optimal dose as dosage should be increased gradually to avoid side effects
- Renal function requires regular monitoring
|
|
Vigabatrin
|
- Used for drug-resisent focal epilepsy
- Twice-daily dosing
- Dose 1500-3000 mg/day
|
- Drowsiness
- Mood changes
- Depression
- Aggression
- Psychosis (rarely)
- Visual field constriction
|
- Reduces phenytoin levels when used concurrently
|
- Avoid in patients with a past history of psychiatric illness
- Less effective in generalised epilepsies
- Requires visual field assessment every 6 months
|
Management of a Seizure
Goals of managing a resident experiencing a seizure are to [8]:
Reduce the risk of injury to the resident, or others; Maintain the resident’s airway and respiratory function; Relieve fever and pain; Clearly document the event for diagnosis and assessment of the resident’s condition; and Ensure the resident receives appropriate emergency care and follow-up management.
Following the report of a resident experiencing a seizure the GP may:
Review the resident for signs/symptoms of injury; Commence diagnostic investigations if this is the resident’s first seizure; Review the resident’s medication regime if there is a diagnosis of epilepsy; and Consider referral to a specialist.
Initial management of a tonic-clonic seizure
Reassure the resident and remain calm. Loosen any tight clothing on the resident and remove spectacles [11]. Assist the resident to lie down on the ground, place a pillow under the resident’s head and ensure the resident is in a safe area with no sharp or dangerous objects near by.
Roll the resident onto one side with the head and mouth angled toward the ground to prevent aspiration and airway blockage by the tongue [11]. Do not restrain the resident or place anything in the resident’s mouth [11].
Commence documentation of the seizure including timing of specific phases of the seizure. A documentation tool is provided in the Reference Card: Seizure Observation Chart [1-5]. After the seizure the resident may be confused, drowsy or agitated. Do not restrain the resident but ensure she or he is in a safe environment. Do not provide anything to eat or drink until the resident is fully alert [11]. After the seizure, the resident may have fever related to muscle activity and the effects of the seizure. Paracetamol may be administered for fever according to the resident’s medication regime or the RACFs standing orders. If the fever is unusually high (over 38.9°C), lasts more than 6 hours, or develops more than 3 hours after a seizure, the resident should be reviewed by his or her general practitioner to assess the possibility of aspiration pneumonia [11]. After the seizure, the resident may have headache, mouth discomfort, or back pain related to the muscular contractions, vertebral fracture or a fall. Paracetamol may be administered for pain according to the resident’s medication regime or the RACFs standing orders [11]. If pain is severe, the resident should be reviewed by his or her general practitioner to assess the possibility of a fracture [11]. If the resident has a diagnosis of epilepsy, document the event clearly in the resident’s notes. The tool provided in the Reference Card: Seizures Record Chart can be used to keep a summary record of the resident’s seizures. Inform other RACF staff of the event, and provide communication for the resident’s general practitioner and relatives according to the policies of the RACF. If this is the resident’s first seizure-like event, inform the resident’s general practitioner as soon as possible. The general practitioner may advise the resident be transferred to an acute care facility for full assessment [1, 5, 11].
Status Epilepticus
A person who remains in a prolonged seizure state has status epilepticus. It is a medical emergency [1, 5, 8]. Particularly in older adults, status epilepticus can lead to significant morbidity and mortality, often related to delay in seeking appropriate treatment [5]. A resident has status epilepticus if he or she [1, 5]:
Remains in a convulsive seizure state for 5 or more minutes; Exhibits serial convulsive seizures consisting of 3 or more within one hour; AND/OR Exhibits persistent non-convulsive seizures.
Goals of management are as for a tonic-clonic seizure, plus:
Maintain the resident’s airway and cardiac function; Reduce the length and/or frequency of seizures; and Promptly seek emergency assistance for airway management and IV medication.
Medication
Benzodiazepines such as diazepam, clonazepam or midazolam are recommended to control acute seizures that may become status epilepticus. These medications enhance the actions of natural brain chemical neurotransmitters that decrease transmission of nerve signals thereby reducing nervous excitation associated with seizures.
It is recommended that residents who are at risk of status epilepticus have a PRN order for rectal diazepam 10-20 mg or buccal or intranasal midazolam 5-10mg, unless contraindicated [1, 5, 8, 11] for prompt treatment to stop the seizure. These administration routes are preferred over intra-muscular administration, as drug absorption is quicker and less erratic.
Status epilepticus requires transfer and management in an acute facility where respiratory arrest can be effectively managed and the resident can receive intravenous diazepam, clonazepam or midazolam [8]. The cause of the status epilepticus should be sought and treated [8].
Initial management of status epilepticus
Reassure the resident and remain calm. Follow the procedure for management of an acute tonic-clonic seizure. If the seizure continues and the resident is assessed as being in status epilepticus, maintain the resident’s airway and administer oxygen via a face mask [1, 5].
Assess the resident’s cardiac and respiratory function [1, 5]. Residents in status epilepticus should be initially managed with diazepam 10-20 mg rectally or buccal or intranasal midazolam 5-10mg [1, 5, 8, 11]. Administer according to the prescriber’s orders. Contact emergency services to transfer the resident to an acute care facility for ongoing assessment and management, unless contra-indicated, for example, the resident and/or representative prefer the resident to be managed within the RACF. In particular residents for whom this is a first seizure should be transferred to an acute care facility immediately [1, 5, 11]. Continue to monitor and reassure the resident until emergency services arrive. Continue a precise and comprehensive documentation of the resident’s seizure events. Complete transfer paperwork as per the RACF’s policy and contact the resident’s next-of-kin or representative according to instructions in the resident’s history. Follow up investigations include therapeutic blood levels if on anti-epileptic drugs, blood tests as outlined under “Investigations”, and in the case of this being a resident’s first seizure episode, diagnostic investigations [1, 5].
Sources of Information
Where to go for more information
Epilepsy Foundation of Victoria
The Epilepsy Foundation of Victoria provide information, support and counselling around epilepsy. The Foundation has a commitment to raising the profile of epilepsy within the community. The Foundation also provide a library collection with public access at 818 Burke Road,Camberwell, Victoria 3124.
Contact: Mon-Fri 9am-5pm: 1300 852 853 Australia-wide Epilepsy help line or (03) 9805 9111
Epilepsy Action Victoria
Epilepsy Action Victoria provides resources for people with epilepsy and their carers including a phone advice line, home visits, community education; seminars and professional development for health professionals; and provision of epilepsy resources and educational materials.
56 East Concourse BEAUMARIS VIC 3193
Contact in business hours: 9589 1811 or 1300 EPILEPSY
Further reading
In addition to the references, the following are recommended:
The Epilepsy Foundation of Victoria’s website at http://www.epinet.org.au provides a comprehensive resource for information about seizures and epilepsy. Epilepsy Action Australia provides a comprehensive resource on epilepsy and seizures at its website http://www.epilepsy.org.au/.
References
Stokes, T., Shaw, E., Juarez-Garcia, A. , J., Camosso-Stefinovic., R., Baker, Clinical Guidelines and Evidence Review for the Epilepsies: diagnosis and management in adults and children in primary and secondary care. 2004, London: Royal College of General Practitioners. Waterhouse, E.,Towne, A., Seizures in the Elderly: Nuances in Presentation and Treatment. Cleveland Clinical Journal of Medicine, 2005. 72(supp 3): p. S25-S38. Velez, L. ,Selwa, L., Seizure Disorders in the Elderly. American Family Physician, 2003. 67(2): p. 325-332. Gidal, B.,Privitera, M., Advances in Identifying Seizures in the Elderly. 2005 Scottish Intercollegiate Guidelines Network, SIGN, Dignosis and Management of Epilepsy in Adults: A national clinical guideline. 2004 Epinet, Epinet - Epilepsy Foundation of Victoria, in http://www.epinet.org.au/default.asp (accessed March 2006), Victoria, Epilepsy Foundation of. 2005 EpilepsyScotland, Epilepsy in later life conference: Key issues. 2005 eTG, Therapeutic Guidelines: Neurology Version 2, in http://www.tg.com.au(accessed June 2006), eTG. 2002 Schachter, S., Symptoms of a Seizure, in http://www.epilepsy.com (accessed March 2006), epilepsy.com. 2004 Kilpatrick, C, New antiepileptic drugs. Australian Prescriber, 1999. 22: p. 61-63. Schachter, S., First Aid for Seizures, in http://www.epilepsy.com/epilepsy/firstaid_seizures.html (accessed March 2006), epilepsy.com. 2003
Levels of Evidence
The guideline has been developed using the process outlined in the GP and Residential Aged Care Kit. This Clinical Information Sheet is based on recommendations stemming from Level I evidence produced by the National Asthma Association Australia and Level I evidence produced jointly by National Institute of Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN).
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
Stokes, T., Shaw, E., Juarez-Garcia, A. , J., Camosso-Stefinovic., R., Baker, Clinical Guidelines and Evidence Review for the Epilepsies: diagnosis and management in adults and children in primary and secondary care. 2004, London: Royal College of General Practitioners. |
2004 |
Level IV C evidence |
2. |
Waterhouse, E.,Towne, A., Seizures in the Elderly: Nuances in Presentation and Treatment. Cleveland Clinical Journal of Medicine, 2005. 72(supp 3): p. S25-S38. |
2005 |
Level IV C evidence |
3. |
Velez, L. ,Selwa, L., Seizure Disorders in the Elderly. American Family Physician, 2003. 67(2): p. 325-332. |
2003 |
Level IV C evidence |
4. |
Gidal, B.,Privitera, M., Advances in Identifying Seizures in the Elderly. 2005 |
2005 |
Level I evidence |
5. |
Scottish Intercollegiate Guidelines Network, SIGN, Dignosis and Management of Epilepsy in Adults: A national clinical guideline. 2004 |
2004 |
Level I evidence |
6. |
Epinet, Epinet - Epilepsy Foundation of Victoria, in http://www.epinet.org.au/default.asp (accessed March 2006), Victoria, Epilepsy Foundation of. 2005 |
2006 |
Level IV C evidence |
7. |
EpilepsyScotland, Epilepsy in later life conference: Key issues. 2005 |
2005 |
Level IV C evidence |
8. |
eTG, Therapeutic Guidelines: Neurology Version 2, in http://www.tg.com.au(accessed June 2006), eTG. 2002 |
2006 |
Level IV C evidence |
9. |
Schachter, S., Symptoms of a Seizure, in http://www.epilepsy.com (accessed March 2006), epilepsy.com. 2004 |
2006 |
Level IV C evidence |
10. |
Kilpatrick, C, New antiepileptic drugs. Australian Prescriber, 1999. 22: p. 61-63. |
1999 |
Level IV C evidence |
11. |
Schachter, S., First Aid for Seizures, in http://www.epilepsy.com/epilepsy/firstaid_seizures.html (accessed March 2006), epilepsy.com. 2003 |
2006 |
Level IV C evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material developed in local RACFs. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, eg developed in RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Epilepsy and Seizures
The following reference cards are designed to be used in conjunction with the Epilepsy and Seizures Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Seizure Observation Chart
Seizures Record Chart
Downloads and Printing
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