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1

Prevalence: Approximately ___ of Canadians have epilepsy

0.6%

2

What is a seizure?

An abnormal, sudden excessive, uncontrolled electrical discharge of neurons within the brain, which may lead to a sudden, uncontrolled alteration in consciousness, motor or sensory ability, and/or behaviour.
It may be paroxysmal and episodic, as in epilepsy, or transient and acute, as after a head concussion.

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Epilepsy

is a symptom of a neurological disorder that is characterized by recurrent seizure activity.

Epilepsy is not a disease, it is a symptom of a neurological disorder - a physical condition - that from time to time produces brief disturbances in the normal electrical functions of the brain. Epilepsy is characterized by sudden, brief seizures whose nature and intensity vary from person to person.

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Paroxysmal:

short, sudden and frequent occurrence

5

Etiology of Epilepsy

Primary (idiopathic):
Abnormality in neuronal activity
Imbalance of neurotransmitters especially GABA
Combination of above

Secondary :
Other underlying problems that result in seizures

6

Common Causes of Seizures

In 50 - 60% of cases, the cause of epilepsy is unknown.
The following causes are most common:
brain tumour and stroke
head trauma of any type. The more severe the injury, the greater the chance of developing epilepsy
injury, infection, or systemic illness of the mother during pregnancy
brain injury to the infant during delivery may lead to epilepsy
aftermath of infection (meningitis, viral encephalitis)
poisoning, from substance abuse of alcoholism
www.epilepsy.ca

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PARTIAL SEIZURES

Partial seizures begin in one place in the brain, called the seizure focus, and affect only part of the brain.

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GENERALIZED SEIZURES

In generalized seizures, abnormal excessive electricity occurs throughout the whole brain at once, with no apparent focal point of onset or warning beforehand.

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Types of Partial Seizures:
(type 1)


These seizures are characterized by:
strange or unusual sensations, for example odours or visual abnormalities.
Other characteristics of SPS include sudden or restless movement, hearing distortion, stomach discomfort, and a sudden sense of fear. Alteration of consciousness or memory is generally not associated with simple partial seizures.
As mentioned before, partial seizures are localised to one region of the brain. Each region of the brain is responsible for certain body functions, sensations, and movements. By observing the motor manifestations and sensory responses during SPS, the neurologist may be able to determine the brain region affected. This may help determining which drugs are best for the treatment of each individual’s epilepsy.
The ICES has categorised simple partial seizures into 4 main categories: motor, sensory, psychic, and autonomic. Each category has several types of SPS.

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types of partial seizures 1/2
Complex partial seizures (CPS - formerly psychomotor or temporal lobe seizures)

:Complex partial seizures are often preceded by an “aura.” They are often identified by the manifestation of complicated motor and sensory action. The person can appear dazed and confused – random walking, mumbling, head turning, or pulling at clothing may be observed. These repeated idiosyncratic motions are often called automatisms and are usually not recalled by the person. There may be some change in consciousness or memory.
In children, this seizure should not be confused with absence seizures. CPS often originate in the temporal or frontal lobes of the brain.

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Generalized absence seizures (formerly petit mal):

Characterized by a complete loss of awareness. The person may stare into space and appear to be daydreaming or in a daze. Absence seizures are not preceded by a warning (aura) and are followed by normal activity by the individual. There is very minimal movement during the actual seizure so many times it may go unnoticed by others.
These seizures often occur in children. They may, however, develop into other types of seizures, such as complex-partial or tonic-clonic. (Absence seizures may be difficult to distinguish from Complex-partial seizures. Absence seizures are usually more quick in duration and have less recovery time than CPS.)
Absence seizures usually diminish into adulthood (opposite of tonic-clonic/grand mal seizures.)
There are two types of absence seizures: Typical Absence Seizures: They are non-convulsive and muscle tone is usually preserved. The seizure event usually lasts for less than 10 seconds in duration.
Atypical Absence Seizures: They are longer in duration than typical absence seizures. There may or may not be a loss in muscle tone and often tonic/clonic-like movements are observed.

12

Tonic-clonic seizures (formerly grand mal):

A generalized convulsion occurring in two phases. In the tonic phase, there is stiffening of the muscles, the person loses consciousness and falls, as the body grows rigid. In the clonic phase, body extremities jerk and twitch. The seizure event may often be ended by another tonic phase. After the seizure, consciousness returns slowly. When the person wakes up, they are often confused or disoriented.

This seizure, while perhaps the type of epilepsy most visible in the public mind, is not the most common. Approximately two-thirds of people with epilepsy have complex partial seizures.
A secondary generalized tonic-clonic seizure begins locally (with partial seizure) and it may be preceded by an aura.

13

Myoclonic Seizure:

There is no loss of consciousness during this type of seizure. It is often associated with single or repetitive jerking motions of the muscles (myoclonus). Myoclonic seizures are primarily observed in young children and infants. They are rarer in adults.

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Atonic/akinetic –

loss of muscle tone

15

Aura

Sensation or warning before a seizure
Sometimes gives person time to lie down and prevent falling injury
Varies person to person
May be:
Change of body temperature, feeling of tension or anxiety
Musical sound, strange taste or striking odour
Description helps to identify focal point of seizure
May not be followed by a full-scale seizure
Aura is actually a simple partial seizure

16

Postictal Phase

First few minutes after the seizure may be limp and nonresponsive

Pupils begin to react to light and return to their normal size

After about 5 min, may be sleepy, semiconscious, confused, unable to speak clearly, and uncoordinated; have a headache; complain of muscle aches; and have no recollection of the seizure event. This phase usually lasts less than 15 min.

Temporary weakness, dysphasia, or hemianopia lasting up to 24 hr after the seizure may be experienced.

Get help if confusion lasts more than one hour following seizure

Once fully conscious and stable, person may be very tired and sleep for several hours

17

Treatment

Secondary Seizures - remove/treat underlying cause

Primary Epilepsy
Drug therapy: Antiepileptic medications – the major component of therapy
Surgery
Vagal nerve stimulation (VNS)
Remove seizure foci from brain

18

Antiepileptic Drugs (AEDs)

Most people with epilepsy can be successfully treated with medicines known as anti-epileptic drugs (AEDs). AEDs do not cure epilepsy, but they can prevent seizures from occurring.
There are many different AEDs. Generally, they work by changing the levels of the chemicals in your brain that conduct electrical impulses. This reduces the chance of a seizure.
The drugs used to treat epilepsy are often referred to as first-line and second-line drugs. This does not mean that one type of drug is better than the other, but it refers to when the drugs were first introduced. First-line drugs are older and have treated epilepsy for decades. Second-line drugs are much newer.

19

Nursing Diagnosis

Deficient knowledge related to unfamiliarity with purpose, precautions, and side effects of AEDs

Desired Outcome: Before hospital discharge, patient verbalizes accurate knowledge about the prescribed AED.

20

General Points - AED

Brand vs. generic - generic medicine usually works well, but it may not generate the same blood levels as brand name
Starting schedule - started slowly to minimize side effects
Blood levels: Target blood levels are broad guides to clinical use.
desirable level depends upon the type and number of seizures, side effects, taking one vs. multiple drugs and other clinical factors.

21

side effects of AED

Side effects: brief compilation of the most common and most worrisome, not a full list:
fatigue, dizziness, unsteadiness, blurry vision, stomach upset, headaches, and reduced resistance to colds, memory and thinking problems.
Weight gain or Weight loss (depending on drug)
Suicide warning: suicide warning on all AEDs, but the actual risk for suicide due to AEDs is quite low.

22

EFFECTS ON INTERNAL ORGANS

Effects on internal organs: All AEDs can cause problems with blood counts (white cells, red cells and platelets), or liver or other internal organs,
All AEDs can produce either mild or severe allergic reactions.
One, called the hypersensitivity syndrome, produces fever, rash, fluid accumulation, swollen lymph nodes, possible liver injury and confusion
Mechanism: Mechanisms of action in the brain for antiepileptic drugs are described in simple form: most AEDs have multiple mechanisms of action to block seizures.
Not a cure: Although AEDs are called “antiepileptic,” they do not cure epilepsy, but just suppress seizures while the medications are in the body.

23

*phenytoin (Dilantin)

alters brain cell sodium channels, which has the effect of limiting rapid firing of the brain cells. It is inexpensive
side effects are unsteadiness & moderate cognitive problems.
long-term potential cosmetic (body/face hair growth, skin problems), & bone problems (osteoporosis).
Typical adult dose is 300-400 mg per day
Small changes in phenytoin dose can cause large changes in serum drug levels, so the blood levels can be hard to regulate.
The target serum level is 10-20 mcg per ml.

24


valproic acid (Depakene, Depakote, Depacon)

standard broad-spectrum AED & no other AED is more effective for generalized seizure types
significant side effects: weight gain, tremor, hair loss, GI upset, blood count decreases, hepatic or pancreatic injury, osteoporosis, birth defects in up to 10% (folic acid can help to prevent them). T
Typical adult dose is 250 mg - 500 mg TID, but dose can be higher

25

Benzodiazepines:

used as anti-seizure drugs, sedatives, tranquilizers and muscle relaxants. Benzodiazepines increase the effectiveness of GABA, the brain’s main inhibitory neurotransmitter.
clonazepam (Klonopin) - long-acting
Side effects include sedation, thinking/memory impairment, mood changes, addiction.
typical adult dose is 0.5-1.0 mg TID
clorazepate
diazepam
lorazepam (Ativan)

26

Barbiturates:

phenobarbital (Solfoton) - increases the effect of GABA, (main inhibitory neurotransmitter )
sedation, thinking/memory problems and depression
Osteoporosis & mildly addictive & requires slow W/D
birth defects
100 mg per day
target serum level is 10-40 mcg per ml.
I

27

Iminostilbenes:

carbamazepine (Tegretol)
partial seizure medicine
Affects sodium channels, & inhibits rapid firing of brain cells
side effects include GI upset, weight gain, blurred vision, low blood counts, low blood sodium (hyponatremia)
400 mg tid
oxcarbazepine (Trileptal)
Slightly different from carbamazepine, it is at least as effective, &may have fewer side effects, except for more risk for low blood sodium (hyponatremia)
More $$$

28

Client education: AEDs

Drug administration - name, dosage, times
Must not stop taking even when seizures stop
Should be taken at same times daily
Take with food
Review:
Drug-drug/drug-food interactions
What to do if side effects occur
What to do if a dose is missed or cannot be taken
Need for regular blood checks for therapeutic levels

29

Vagus Nerve Stimulation

For simple/complex Seizures
Prevents seizures by sending small pulses of electrical energy to the brain via the vagus nerve
Electrode implanted in chest wall, pt has hand held magnet that is pressed during aura
Why/how it works not known

30

Surgery
for epilepsy

Brain surgery for epilepsy is performed, in a small percentage of cases, and usually only when other treatments fail to adequately control seizures

31

At the completion of the seizure

Keep client in recovery position on his/her L side
Take client’s vital signs
Perform neurological checks
Document the incident
Seniors at high risk for postictal confusion

32

Special care for senior after a seizure:

Get help if breathing is laboured , if chest pain or unusual pain of any kind including headache
Check for secondary injury
Postictal confusion
Be calm, comforting and reassuring during – call MD if confusion lasts >60 minutes
Steer gently away from danger without restraining

33

Status Epilepticus

recurring seizures between which consciousness does not return
If a seizure does not stop within 5 minutes or repeats without recovery, call for immediate help
Risk of going into status epilepticus (potentially life-threatening event)
For any seizure event that appears to be different than those normal for the individual or lasts abnormally long help should be called.
Tx: IV Diazepam or lorazepam and Dilantin

34

May NOT drive if:

Any seizures in last 12 months
AEDs that are currently causing drowsiness or poor muscle control
Non-compliant with therapy
Persistently drinking to excess

35

Multiple Sclerosis

Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS

Inflammatory response resulting in random or patchy areas of plaque in the white matter of the CNS

Usually characterized by periods of remission and exacerbation (flares)

Affects vision, speech, walking, writing, and memory.

36

MS Affects:


Women affect more than men 3:1
Onset usually 15-50 years of age
Primarily Caucasians
European descent
Increased risk if 1st degree
relatives
life expectancy: 15-50+

37

Difficult to diagnose MS because:

Difficult to diagnose because:

More than 50 symptoms are linked to MS
each person develops symptoms differently
Many of the symptoms mimic problems that occur with other diseases
No diagnostic blood test
Symptoms usually come and go over months or years
Many symptoms are vague, hard to quantify and may be attributed to stress by GPs therefore no neurologist referral
(ie: fatigue, sexual dysfunction, depression and cognitive difficulties)

38

MS Etiology

Unknown
Autoimmune disorder
Genetic component
Immunologic
Viral
Environmental

39

The classic picture of the relapsing-remitting type of MS (RRMS) occurs in 85% of cases. The course of the disease may be mild or moderate, depending on the degree of disability. Relapses develop over 1 to 2 weeks and resolve over 4 to 8 months, after which the client returns to baseline. Of the 85% who start with relapsing-remitting disease, more than 50% will develop secondary progressive MS (SPMS) within 10 years; 90% develop it within 25 years (Costello & Harris, 2003).
Progressive-relapsing MS (PRMS) occurs less often, that is, in only 5% of clients with MS. It is characterized by the absence of periods of remission, and the client's condition does not return to baseline. Progressive, cumulative symptoms and deterioration occur over several years.
Primary progressive MS (PPMS) involves a steady and gradual neurologic deterioration without remission of symptoms. The client has progressive disability with no acute attacks. Clients with this type of MS tend to be between 40 and 60 years of age at onset of the disease.
Secondary progressive MS (SPMS) begins with a relapsing-remitting course that later becomes steadily progressive. Attacks and partial recoveries may continue to occur.
(Ignatavicius, Donna D.. Medical-Surgical Nursing: Critical Thinking for Collaborative Care, Single Volume, 5th Edition. Saunders Book Company, 042005. 46.5.1).

MHM

40

Relapsing-Remitting MS

Acute episodes
recovery and stable course between relapses
85% of cases

41

Secondary-Progressive MS

Begins with a relapsing-remitting course
later becomes steadily progressive

42

Primary-Progressive MS

steady and gradual neurologic deterioration
no remission of symptoms
progressive disability with no acute attacks
10% of cases

43

Progressive Relapsing MS



follows a progressive course from onset
punctuated by relapses
significant recovery immediately following relapse
between relapses there is gradual worsening of symptoms

44

Signs and symptoms

Primary: direct result of damage
weakness, tremors, tingling, numbness, paralysis and bladder/bowel problems
Secondary: result from primary
Paralysis leads to bedsores and bladder/urinary incontinence problems
Tertiary: Social, psychological, & vocational complications
Depression very common


45

Dysmetria:

inability to direct or limit movement

46

Scotomas:

changes in peripheral vision

47

Nystagmus:

involuntary eye movement

48

Hypalgesia:

decreased sensitivity to pain

49

Dysarthria:

slurred speech

50

Neurological Assessment FOR MS

Review history and ask about any changes to vision, mobility or senses
S & S intermittent? Progressive?
OLDCARTS or PQRSTU
Assess:
Cranial nerves
Coordination
Strength
Reflexes
Sensation

51

Diagnostic Tests FOR MS

MRI
Evoked potentials
Lumbar Puncture (to assess CSF for proteins)

52

Three Categories of MS Treatment

Underlying Course of the Disease

Treatment of Exacerbations

Specific MS symptom treatment
(Treatment of exacerbations must be done with corticosteroids to manage acute attacks. These are substances related to hormones that are produced by adrenal glands. Help to reduce swelling and inflammation in the plaques of demyelination.
)

53

DRUG THERAPY FOR MS

Therapies include:
Biological response modifiers
Immunosuppressives
Steroids
Antispasmodic drugs
Adjuvent therapy


54

Approximately ___of patients with MS experience bladder dysfunction and approximately 68% experience bowel problems

80%