Providing Quality Epilepsy Care for Veterans

Safety

Epilepsy has inherent risks for injury. Patients and their families often need to be informed about risks and risky behaviors to avoid. A frank discussion about safety is prudent. What to do for the patient during a seizure should be addressed. For convulsive seizures: Protect the patient from injury by placing something soft between the patient’s head and the floor, keep the patient on his or her side; do not restrain the patient or put anything in the mouth; stay calm and time the seizure; as the patient gains consciousness, talk to the patient and be reassuring. For nonconvulsive seizures: Stay with the patient; time the seizure; gently guide the patient away from dangerous situations like streets or stairs; stay with the patient until he or she is back to normal, and reassure the patient.

Driving

People with epilepsy identify driving as one of their major concerns; therefore, it is important for HCPs to properly counsel patients with seizure disorders and their families about driving (Figure).²⁰ In general people with controlled seizures are permitted to drive in every state in the U.S., but people with uncontrolled seizures are restricted from licensure. Despite the desire and necessity to drive for many individuals with epilepsy, seizures while driving pose risks for crashes, which may result in property damage, injuries, and death.²¹ Factors, such as duration of seizure freedom, help predict the risk for crashes. The legal rules for determining control and administering restrictions are a complex mix of federal and state laws, regulations, and local practices, which vary widely across the country.^21,22 The standards also change over time; updated information is available from local state authorities and on good informational sites, such as those of the Epilepsy Foundation.

The key standard for determining accident risks is the seizure free interval, which is the duration of time a person with epilepsy has been seizure-free.^21-23 In the U.S., the accepted period for seizure freedom varies from about 3 months to 12 months, depending on individual state rules.²⁴

California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania require mandatory reporting. Generally physician groups in the U.S. and elsewhere oppose such mandatory reporting, because of the concern that their patients will not report their seizures, and thus may not receive appropriate treatment. Indeed, patients with epilepsy often do not tell physicians about their seizures, fearing loss of driving privileges and other social consequences.^21,23 Providers should make an effort to determine seizure frequency and whether the patient is being truthful. This information then provides a background for the provider to discuss driving issues.

Injury

People with epilepsy are susceptible to injury during a seizure and need to be counseled regarding safety, particularly when seizures are not well controlled. Hazardous situations include being near stoves or cooking, bathing alone, swimming alone, working at heights without a safety harness, and using power tools.²⁶

Sudden Unexplained Death

Patients with recurrent seizures have an increased risk for accidental fatality and for sudden unexplained death in epilepsy (SUDEP), which accounts for up to 17% of all deaths in people with epilepsy. The risk for sudden death from recurrent seizures increases 2.3 times compared with the risk in the general population.²⁵ A SUDEP is an unexpected death in a person who has epilepsy with no other obvious cause of death.²⁶ Because increased seizure frequency, the presence of tonic-clonic seizures, and other accidental risks of seizures are associated with SUDEP, the subject should be discussed with patients and their families, to encourage adherence to treatment. Epileptologists also discuss these risks with patients and their families when surgical interventions are being considered. The potential risks for injury or SUDEP may offset the surgical risks when pursuing a potentially curative epilepsy procedure.

Women of Childbearing Age

In January 2015, the ECoE started a women veterans epilepsy workgroup with the goal of improving clinical care within the VAHCS to provide education to patients, family members, and VA health care providers about the care of women with epilepsy.

Providers need to be aware that seizure medications that induce certain hepatic enzymes can lead to hormonal contraceptive failure (Table 2).²⁷ Preconception folic acid supplementation (with at least 0.4 mg) should be considered, because it may reduce the risk of major congenital malformations.²⁸ The goal of epilepsy management prior to conception is to maximize seizure control with the optimal seizure medication to avoid the need to make changes during the pregnancy.

During pregnancy, the volume of distribution increases and seizure medication metabolism may change requiring dose adjustment. The best predictor of seizure frequency during pregnancy is a woman’s epilepsy pattern prior to conception. Seizure freedom for 9 months prior to conception is associated with a 84% to 92% likelihood of seizure freedom throughout the pregnancy.²⁹

International seizure medication pregnancy registries have provided valuable information regarding the risk of major congenital malformation (MCM) of development, which seems to be a consequence of seizure medication therapy and not epilepsy itself. The risk of MCM associated with seizure medication therapy is about 4% to 5% compared with 1.5% to 3% in the general population.^30,31 A seizure medication table that supplements the existing VA ECoE information specifically addresses women’s issues with the recognition that recent revisions to the teratogenicity classification have been made by the FDA (Table 2).³² If possible, valproate should be avoided during pregnancy due to its higher rate of MCM and impact on neurocognitive function.³³ Obstetrical input is essential in arranging routine prenatal fetal testing. Although women with epilepsy do not have a substantially increased risk of undergoing a cesarean section, delivery in a hospital obstetric unit is advised.

Postpartum women veterans with epilepsy should be encouraged to breast feed since the potential benefits seem to outweigh any established risk of seizure medication exposure to the infant. No relative impact on cognition was found in breastfed infants exposed to a variety of seizure medications.³⁴ Following delivery, vigilance is needed to monitor for sleep deprivation, postpartum depression, and the safe care of the infant.³⁵ Care of women with epilepsy does not end with pregnancy planning, additional important topics include psychiatric comorbidities, catamenial epilepsy, and bone health, which are unique to women veterans with epilepsy.