a. lebron paige, m.d. clinical associate professor department of neurology a. lebron paige, m.d....
TRANSCRIPT
A. LeBron Paige, M.D.Clinical Associate
ProfessorDepartment of Neurology
A. LeBron Paige, M.D.Clinical Associate
ProfessorDepartment of Neurology
Iowa EFA Seizure Smart Conference – 3/2/2013
Epilepsy is a medical condition that produces seizures affecting a variety of mental and physical functions. When a person has two or more unprovoked seizures, they are considered to have epilepsy.
A seizure is the result of a strong sustained surge of electrical activity (discharges) that affects part or all of the brain.
Seizures can be brief or prolonged, typically less that 3 minutes, and can cause unusual movements, sensations, thinking, or can disturb many other body functions.
Seizures can be a subtle unresponsive staring (partial), a frighteningly dramatic convulsion (generalized), or in between.
Seizures can be caused by anything that can affect the brain, such as tumors, strokes, bleeding, infection, trauma, or unknown factors.
Treatments for epilepsy include medications, surgery, diet, electrical stimulators, and other emerging options.
Epilepsy Around the World
Epilepsy is one of the world’s oldest diseases.
Worldwide, 50-65 million people are living with epilepsy
80% of all people with epilepsy live in the developing regions.
75% of affected people in these developing countries do not get the treatment they need (9 out of 10 in Africa).
The World Health Organization (WHO) estimates that 6-10 people per 1000 have active epilepsy in the developing world. (conservative)
Epilepsy accounts for 0.5% of the global burden of disease
The social stigma surrounding epilepsy worldwide is often more difficult to overcome than the seizures themselves
Epilepsy - US Incidence
200,000 new epilepsy cases diagnosed annually in the USo 50,000 new cases of Parkinson’s Disease in the US annually
67 new cases of epilepsy per 100,000 population each yearo 62.6 individuals with lung cancer per 100,000 population per year
100 individuals with first convulsion per 100,000 population each yearo 124 women with breast cancer per 100,000 population
50% of new onset epilepsy cases present w/ Generalized Sz
70% of these new cases have no apparent cause
Incidence is greater in Black and socially disadvantaged populations
Highest epilepsy incidence is in > 65 y/o & is increasing in recent years
Partial seizures predominate in patients >10 y/o
Childhood Epilepsy – US Incidence
120,000 children per year will experience their first seizureo 75,000 – 100,000 of these are < 5 y/o with febrile seizures
45,000 children will receive a diagnosis of epilepsy per year
Highest incidence found in < 2 y/o, with adult levels in those > 5y/o
Childhood epilepsy incidence has been trending down in recent years
Generalized seizures are the most common in patients < 10 y/o
Most children with seizures will not develop epilepsy
Most children with epilepsy will outgrow the condition
Most children with epilepsy are normal in every other respect
300
250
200
150
100
50
00 20 40 60 80 100
AlcoholNeonatalOther provokedEpilepsySingle Total
Age
Inci
denc
e P
er 1
00,0
00 P
atie
nt Y
ears
l 4):S6-S14.
Complex 23%
Other partial
7%
Myoclonic 7%
Unknown/multiple
9%
Simple partial
11%
Other generalized
11%
Absence 13%
Complex partial
39%
Myoclonic 2%
Other generalized
4%
Other partial
9%
Simple partial
21%Tonic-clonic
25% Tonic-clonic
19%
Children <15 Years Adults 35-64 Years
Idiopathic 65.5%
Vascular 10.9%
Congenital 8.0%
Trauma 5.5%
Neoplastic 4.1%
Degenerative 3.5%
Infectious 2.5 %
Epilepsy in the Elderly
Stefan, H. Epilepsy in the Elderly, Acta Neurol Scand., 124: 223-237: 2011.
ELDERLY (>65 y/o) 18 y/o < ADULTS < 65 y/o
Epilepsy Prevalence - US
2.7 - 3 million active epilepsy patients in the US (~1% of the population)
30,000 Iowans carry a diagnosis of epilepsy
1% of Americans aged birth to 20 y/o have a diagnosis of epilepsy
3% of Americans aged birth to 75 y/o have a diagnosis of epilepsy
10% of Americans aged birth to 80 y/o have had at least one seizure
There are more Americans living Epilepsy than MS, Cerebral Palsy, Muscular Dystrophy, Parkinson’s Disease, ALS, and Tourette’s syndrome combined.
Of all neurological Dz, only Migraine & Stroke is more prevalent than Epi
70% of people with epilepsy are controlled (> 5yr) on medications
Overall almost 10 % of new patients fail to gain control of seizures despite optimal medical management.
• 25.8% of children with mental retardation
• 13% of children with cerebral palsy
• 50% of children with both disabilities
• 10% of Alzheimer patients
• 22% of stroke patients
• 8.7% of children of mothers with epilepsy
• 2.4% of children of fathers with epilepsy
• 33% of people who have had a single, unprovoked seizure
The basic underlying risk of developing epilepsy is about 1%, but individuals in certain populations are at higher risk.
Seizure Freedom by Seizure Type
One year seizure free rates in patients treated with medications alone.
Epilepsy Mortality
Cause of death among 3340 Epilepsy patients over 30 years
Cause of Death Proportion of all Deaths
Non-CNS Tumors 23%
CNS Tumors 5%
Heart Disease 26%
Stroke 15%
Epilepsy 7%
Trauma 9%
Respiratory Disease 3%
Pneumonia 1%
Other 11%
Epilepsy Mortality - SUDEP
Sudden, Unexpected, Death in Epilepsy1. Decedent has diagnosis of epilepsy2. Death is Sudden3. Death is Unexpected4. Death is not the result of trauma5. Death is not the result of drowning6. No evidence that death was associated with status epilepticus7. No structural or toxicological cause on post-mortem examination
Factors that increase the risk of SUDEP1. Young adulthood (children at low risk)2. Early epilepsy onset & long duration3. Poorly controlled seizures4. Poor medication compliance5. Unsupervised sleep environment (prone position)6. Generalized convulsion > Complex partial seizures >> myoclonic or absence7. Epilepsy Surgical Candidates
16
SUDEP Incidence by Group
Information Sources
The Institute of Medicine (NAS), Epilepsy Across the Spectrum, 2012
The Epilepsy Foundation of America [http://www.epilepsyfoundation.org/]
The World Health Organization (WHO) [http://www.who.int/research/en/]
National Cancer Institute [http://seer.cancer.gov/statfacts/html/all.html]
Neurological disorders: public health challenges, World Health Organization, 2006
Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia. 1993;34:453-468.
D. Hirtz, D. J. Thurman, K. Gwinn-Hardy, et al., How common are the ''common'' neurologic disorders? Neurology 2007;68;326.
Ficker, DM, Sudden Unexplained Death and Injury in Epilepsy, Epilepsia, (Supp1.2):S7-S12, 2000
Thomson, T. , Sudden unexpected death in epilepsy: current knowledge & future directions. The Lancet Neurology, Sept. 2008
Stefan, H. Epilepsy in the Elderly, Acta Neurol Scand., 124: 223-237: 2011.
Trinka, E, et al., Cause-specific mortality among patients with epilepsy: Results from a 30-year cohort study, Epilepsia, ** (*):1–7, 2012
Epilepsy Discrimination
The Code of Hammurabi (1780 B.C.) established that a person with epilepsy could not marry, testify in court, and voided slave purchases
In both China and India, epilepsy is commonly viewed as a reason for prohibiting or annulling marriages.
In the United Kingdom, a law forbidding people with epilepsy to marry was repealed only in 1970.
In the United States, until 1956 it was illegal in 17 states for people with epilepsy to marry, and into the 1970s it was legal to deny them access to restaurants, theatres, rec centers and other public buildings.
1973 brought the first limited US laws to prohibit discrimination, but not until 1990 with the Americans with Disabilities Act was there uniform protection against discrimination.
PMD
General Neurologist(s)
Level-4Epilepsy Center
Spells are Likely Seizures
Seizures are Refractory to two Medications
Epilepsy Care Pathway
Patient has “Spells”
Level-4 Epilepsy Center•Comprehensive Diagnostic Capability
•New & Experimental Medications
•Epilepsy Surgery Experience
•Implantable Stimulators
•Radiation treatment vs. Surgery
•Access to National Epilepsy Expertise
National Association of Epilepsy Centers
22Englot, DJ, et al., Epilepsy Surgery Trends in the United States 1990-2008, Neurology, 78;1200 (2012)