13

Chapter 2

Case Discussion/Presentation

Chapter Overview

This chapter presents the case discussion/presentation

and the overview of related literature and studies on the

subjects made by the researcher during exploration stage of

the case finding.

Review of Anatomy and Physiology of the Nervous System

Figure 1. Picture of the brain.

(www.images-search/yahoo.com)

The Nervous System is responsible for sensory and

perception of feelings and initiate voluntary and

14

involuntary actions based on signals transmitted through the

nerves to the brain.

The brain and the nervous system have multiple

functions that are vital for normal functioning of the body.

A nerve impulse is essentially an electrical stimulus that

travels over the cell's membrane.  It passes through the

axons and dendrites of the neurons. It travels via the

dendrites from the skin and then reaches the cell body,

axon, axon terminals and the Synapse of the neuron.

The Synapse is the junction between two neurons where

the impulse moves from one to the other. At the synapse

neurotransmitters are present These are chemical

transmitters of messengers that transmit the impulse. They

include Acetylcholine and Noradrenaline.

The impulse continues to the next dendrite, in a chain

reaction till it reaches the brain that in turn instructs

the skeletal muscles to work.

These reflexes are automatic, involuntary responses.

They may or may not involve the brain for example blinking

does not involve the brain. The Reflex arc is the main

functional unit of the nervous system that helps a person

reacts to a stimulus.

15

The brain is one of the largest and most complex organs

in the human body. It is made up of more than 100 billion

nerves that communicate in trillions of connections called

synapses. The brain is made up of many specialized areas

that work together:

The cortex is the outermost layer of brain cells.

Thinking and voluntary movements begin in the cortex.

The brain stem is between the spinal cord and the rest of

the brain. Basic functions like breathing and sleep are

controlled here. The basal ganglia are a cluster of

structures in the center of the brain. The basal ganglia

coordinate messages between multiple other brain areas.

The cerebellum is at the base and the back of the brain and

is responsible for coordination and balance.

The brain is also divided into several lobes: The frontal

lobes are responsible for problem solving and judgment and

motor function. The parietal lobes manage sensation,

handwriting, and body position. The temporal lobes are

involved with memory and hearing. The occipital lobes

contain the brain's visual processing system.

The brain is surrounded by a layer of tissue called the

meninges. The skull (cranium) helps protect the brain from

injury (Essentials of Anatomy and Physiology, 2009).

16

Pathophysiology (Brunner and Suddhart’s, 2012)

Figure 2. Pathophysiology of Seizure. Book-based.

Risk factors are the key factors that will determine if

a person will have seizure or not. If you have one or more

of the risk factors, your brain cells tend to function

abnormally when it send electrochemical signals. Once the

erratic cells perform erratically, there will be an

abnormality with the chemical responsible for brain

activity. This will now lead to abnormal brain activity

which will cause seizure activity. And if the seizures occur

Risk Factors: Genetics

Childhood abuse or trauma to the head

Environmental

Seizure activity

Continuous seizures, Epilepsy

Sending abnormal brain signals/chemical disturbance

Erratic cells perform erratically

The brain sending out abnormal signals to the erratic cells

Cells send electrochemical signals even after the task is done

17

repeatedly, then the client will be diagnosed with epileptic

syndrome.

Pathophysiology (client-based)

Risk Factors:

Genetics

Figure 3. Pathophysiology. (Client-based)

The client has a family history of seizure disorder.

Aside from having familial tendencies, what triggered the

seizure disorder in the client was having a very high fever

of 39.1 degrees Celsius after the first vaccination of

Hepatitis B Vaccine. It made the brain perform erratically

by sending an abnormal signal. The client experienced the

signs and symptoms of seizure activity. It is called febrile

seizure because the seizure was triggered by the very high

body temperature.

A very high fever of 39.1

Staring into space and appeared confused and irritable. Unusually sleepy (abnormal brain activity)heart racing, strong pulse.

Rigid body parts and loss of consciousness

Seizure Activity

Continous seizure

Epilepsy

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Signs and Symptoms

Epilepsy signs and symptoms vary from person to person

but there are symptoms that are generalized.

Table 5. Signs and Symptoms

Book based (Brunner and

Suddhart’s, 2012)

Client Based

Aura-a sensation at the start

of a seizure, may involve the

perception of an odd smell or

sound, spots appearing in

front of the eyes, or unusual

stomach sensations; an aura

is a seizure

The client was unable to

verbalize if there has been a

feeling of aura.

Staring Before the start of seizure,

mother claims that the client

was staring into space.

Loss of consciousness The client lost consciousness

a few moments after they

noticed that the client was

staring into space.

Repeated jerking of a single

limb

The mother did not notice any

jerking movement made by the

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client

Hand rubbing The mother did not notice any

hand rubbing

Lip smacking The mother notice a lip

smacking which sometimes lead

to lips bleeding

Picking at clothing The mother did not notice any

picking at clothing

Fear/Panic The client did not exhibit

any fear or panic

Heart racing, Palpitations The mother claimed that the

client exhibit heart racing

and the strong pulse

Perception of an odor, taste

or smell

None as claimed by the client

Loss of bowel or bladder

control

Nothing was noted

Postictal state a state of

drowsiness, alteration in

responsiveness, and or

confusion

The client seemed irritable

and confused and unusually

sleepy.

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Foot stomping Nothing was noted

Unable to move body parts The client was unable to move

as noted by the mother before

he lost consciousness

This table shows the signs and symptoms exhibited by

the client on the onset of seizures as explained by her

mother. The Client experiences loss of consciousness few

moments after the noticing staring into space, then jerking

of the extremities then he will pass out.

Risk Factors

The risk factors include genetic factors, childhood

abuse or head trauma, environmental factors, drug overdose,

chemical abnormalities, and history of complex febrile

seizures.

If you already have an epilepsy, the following factors

can increase your chance of having an epilepsy:

Sleep deprivation

Alcohol

Hormonal changes (such as those that occur at points

during the menstrual cycle)

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Stress

Flashing lights, especially strobe lights

Use of certain medicines

Missing doses of anti-epileptic medicines

Diagnostic Test (Book Base)

EEG

An Electro Encephalo Gram (EEG) is a non-invasive and

painless diagnostic test used to measure electrical impulses

between brain cells. By placing electrodes on your scalp,

the frequency of these impulses can be measured and recorded

on a graph. Abnormalities in your regular brain waves can be

used to identify the presence, location and severity of your

seizures. It will locate the focus of abnormal electric

discharges, if present; to establish a diagnosis of

epilepsy; and identify the specific type of seizure.

SPECT

A Single-Photon Emission Computed Tomography (SPECT) is

a diagnostic imaging technique that measures blood flow

through your brain. A small amount of a radioactive tracer

will be introduced into your body that will emit particles

22

measured by a SPECT camera. The greater the blood flow, the

more particles are emitted. This allows doctors to visualize

the functions of certain parts of your brain. As the data is

collected, an image of the brain is generated with different

coloured areas to represent varying amounts of blood flow.

This information will indicate if certain areas of your

brain are getting too much or too little blood (and oxygen).

Areas where seizures occur usually show increased blood

flow. This test is not usually necessary for diagnosing

epilepsy. If your doctor recommends a SPECT test, you will

likely also require an MRI.

PET

A Positron Emission Tomography (PET) is an imaging

technique that measures your brain’s activity through its

use of sugar and oxygen. Radioactive tracers are introduced

into your body which release tiny particles called

positrons. These positrons react with electrons in your

bloodstream, releasing energy. Computers are able to

generate images of your brain activity, using the data

gathered from measuring the released energy. This data

enables doctors to determine where your seizures occur.

CT Scan

23

A Computed Axial Tomography scan (CAT or CT scan) is a

non-invasive and painless test. CT scans produce cross-

sectional images (tomographs) of areas in your body that

will be examined by doctors to look for abnormalities (eg.

scar tissue, blood clots or tumours). For epilepsy, this

usually involves a scan of your head to look for possible

origins of seizures. The machine looks like a large box with

a donut shaped hole in the middle (a gantry). You will lie

on a platform that slides in and out of the gantry as the x-

ray rotates around you. Low radiation x-rays pass through

your body and are captured by detectors. Computers use this

information to produce a 2-D image of the area.

MRI

A Magnetic Resonance Imaging (MRI) is a noninvasive

diagnostic test that uses a powerful magnet to measure

magnetic field changes in the brain. MRIs produce many

detailed cross-sectional images (“slices”) of the brain’s

internal structure. These images can be used to detect

structural abnormalities and may help pinpoint the cause of

seizures. This is considered to be the most important scan

when diagnosing epilepsy because it produces a very accurate

representation of your brain. This procedure is generally

non-invasive, although a contrast dye may be administered by

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a needle to provide the doctor with a clearer image.

Functional MRIs (fMRIs) monitor neural signals through

changes in blood flow.

MEG

A Magneto Encephalo Graphy (MEG) is a new tool used to

generate a representation of your brain’s magnetic fields.

By analyzing brain activity, the MEG can help localize areas

in your brain causing the seizures. Doctors can then use

this information to help determine what is provoking your

seizures.

Diagnostic Test (Client Base)

These are the diagnostic tests that are needed to

determine the final diagnosis of the client. The client had

undergone the following diagnostic test:

The client was supposed to have a Lumbar Puncture done

but the family refused.

Prevention

To prevent seizures, the patient must avoid activities

that trigger seizure activities. The client must record

every seizure activity and record all the things that the

25

client did before the seizure occurred. It is essential for

a client to know the things that could trigger seizure

activities such as extraneous activities and alcohol

drinking. It is advisable for a client to continue drinking

the medications as prescribed by the doctor.

Advice the client to rest in between activities so that

the client will not be too tired but at the same time, the

client can function as well as a normal person can. A person

with seizure should warn the people around her to be aware

of his/her condition since there is a safety precaution to

be followed if a person did have a seizure disorder.

Complications

Hypoxic brain damage and mental retardation may follow

repeated seizures. Depression and anxiety may develop. Long-

term social interaction may also occur. Repeated seizures

can lead to epileptic syndrome, wherein the person can

experience seizure with serious complications such as Status

Epilepticus.

Nursing Management/Interventions (Book base)

General Care and Injury Prevention

26

Perform periodic physical examinations and laboratory

tests for patients taking medications known to have

toxic hematopoietic, genitourinary, or hepatic effects.

Provide ongoing assessment and monitoring of cardiac

and respiratory functions.

Monitor the seizure type and general condition of

patient.

Turn patient to side-lying position to assist in

draining pharyngeal secretions.

Have suction equipment available if patient aspirates.

Monitor IV line closely for dislodgment during

seizures.

Protect patient from injury during seizures with padded

side rails, and keep under constant observation.

Do not restrain patient’s movements during seizure

activity. Do not insert anything in patient’s mouth.

Controlling Fear of Seizures

Reduce fear that a seizure mat occur unexpectedly by

encouraging compliance with prescribed treatment.

Emphasize that prescribed antiepileptic medication

must be taken on a continuing basis and is not habit-

forming.

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Assess lifestyle and environment to determine factors

that precipitate seizures, such as emotional

disturbances, environmental stressors, onset of

menstruation, or fever. Encourage patient to avoid such

stimuli.

Encourage patient to follow a regular and moderate

routine in lifestyle, diet (avoiding excessive

stimulants), exercise and rest (regular sleep

patterns).

Advise patient to avoid photic stimulation (e.g. bright

flickering lights, television viewing); dark glasses or

covering one eye may help.

Encourage patient to attend classes in stress

management.

Improving Coping Mechanisms

Understand that epilepsy imposes feelings of fear,

alienation, depression, discrimination and social

isolation, and uncertainty.

Provide counseling to patient and family to help them

understand the condition and limitations imposed.

Encourage patient to participate in social and

recreational activities.

28

Instruct patient to avoid over-the-counter medications

unless approved by health care provider.

Provide comprehensive mental health services to

patients who exhibit symptoms of schizophrenia or

impulsive or irritable behavior.

Promoting Home and Community-Based Care

Teaching patients of Self-care

Instruct patient and family about medication side

effects and toxicity.

Prevent or control gingival hyperplasia, a side effect

of Phenytoin (Dilantin) therapy, by teaching patient to

perform thorough oral hygiene and gum massage and seek

regular dental care.

Provide specific guidelines to assess and report signs

and symptoms of medication overdose.

Instruct patient to keep a drug and seizure chart,

noting when medications due to illness.

Teach patient to keep a drug and seizure chart, noting

when medications are taken and any seizure activity.

Instruct patient to notify physician if unable to take

medications due to illness.

Teach patient to keep a drug and seizure chart, noting

when medications are taken and any seizure activity.

29

Instruct patient to take showers than to tub baths to

avoid drowning and never swim alone.

Encourage realistic attitude toward the disease;

provide facts concerning epilepsy.

Instruct patient to carry an emergency medical

identification card or wear an identification bracelet.

Advise patient to seek preconception and genetic

counseling if desired (inherited transmission of

epilepsy has not been proved).

Medical Management (Book base)

The management of epilepsy and status epilepticus is

planned according to immediate and long-range needs and is

tailored to meet the patient’s needs because some cases

arise from brain damage and others are due to altered brain

chemistry. The goals of treatment are to stop the seizures

as quickly as possible, to ensure adequate cerebral

oxygenation, and to maintain a seizure-free state.

An airway and adequate oxygenation (intubate if

necessary) are established, as is an

IV line for administering medications and obtaining blood

samples for analysis.

Pharmacologic Therapy

30

Medications are used to achieve seizure control. The

usual treatment is single-drug therapy.

IV diazepam, lorazepam, or fosphenytoin is

administered slowly in an attempt to halt the

seizures.

General anesthesia with a short-acting barbiturate

may be used if initial treatment is unsuccessful.

To maintain a seizure-free state, other

anticonvulsant medications (carbamezipine,

primidone, phenytoin, Phenobarbital, ethosuximide,

and valproate) are prescribed after the initial

seizure is treated.

Surgical Management

Surgery is indicated when epilepsy results from

intracranial tumors, abscess, cysts, or vascular anomalies.

Surgical removal of the epileptogenic focus is

done for seizures that originate in a well-

circumscribed area of the brain that can be

excised without producing significant neurological

effects.

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29

Table 6. Drug Study

DRUG NAME ACTION CLASSIFICATION INDICATION CONTRAINDICATION ADVERSE EFFECT

NURSING CONSIDERATION

Phenobarbital 60mg 1tab/day

Long-acting barbiturate. Sedative and hypnotic effects of barbiturates appear to be due primarily to interference with impulse transmission of cerebral cortex by inhibition of reticular activating system. CNS depression

CENTRAL NERVOUS SYSTEM AGENT; ANTICONVULSANT; SEDATIVE-HYPNOTIC; BARBITURATE

Long-term management of tonic-clonic (grand mal) seizures and partial seizures; status epilepticus, eclampsia, febrile convulsions in young children. Also used as a sedative in anxiety or tension states; in

Acute intermittent porphyria, oversensitivity for barbiturates, prior dependence on barbiturates, severe respiratory insufficiency and hyperkinesia in children are contraindications for phenobarbital use.

Drowsiness or dizziness;problems with memory or concentration;excitement, irritability, aggression, or confusion

Before taking phenobarbital, tell your doctor or pharmacist if you are allergic to it; or to other barbiturates (such as primidone, secobarbital); or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic

30

may range from mild sedation to coma, depending on dosage, route of administration, degree of nervous system excitability, and drug tolerance. Initially, barbiturates suppress REM sleep, but with chronic therapy REM sleep returns to normal.

pediatrics as preoperative and postoperative sedation and to treat pylorospasm in infants.

reactions or other problems.

Nursing Care Plan

31

Table 7

Assessment Diagnosis Outcome Identification

Planning Intervention Evaluation

Subjective:

“Kapag inaatake ng seizure ‘yung anak ko kinakabahan ako hindi ko alam ang gagawin”, as verbalized by the client’s mother.

Objective:

Overprotection of the client

Stressed out as manifested by

Knowledge Deficiency of the Disease Process

To improve the knowledge of the client’s mother regarding the disease process

Within 4 hours of nursing interventions, the mother of the client will verbalize understanding of the disease process

Health Teaching about Seizure.

Demonstrate what to do first then letting the mother do it by himself.

Demonstrate what to do before, during, and after the seizure then let the mother do it so he will clearly understand what to do if seizure occurs.

After 4 hours of nursing interventions, the client’s mother verbalized understanding of the disease process. He demonstrated understanding of what to do before, during, and after the seizure.

Goal met

32

restlessness

Nursing Care Plan

Table 8

33

Assessment Diagnosis Outcome Identification

Planning Intervention Evaluation

Subjective:

“Bigla na lang nanginig ‘yung anak ko”, as verbalized by the client’s mother.

Objective:

Weakness Facial

grimace Irritability

V/S taken as follows:

BP 120/90

T 37.3

PR 110

RR 20

Risk for Trauma related to loss of large muscle coordination.

Patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect itself from injury.

Within 8 hours of nursing the Patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect itself from injury.

Explore with the patient the various stimuli that may precipitate seizure activity.

Discuss seizure warning signs and usual seizure signs

Evaluate need for protective head gear

Maintain strict bed

After 8 hours of nursing interventions, the patient was able to demonstrate behaviors, lifestyle changes to reduce risk factors and protect her son from injury.

Goal met.

34

rest if prodromal signs or aura experienced

Reorient patient following seizure activity

Collaborative:

Administer medications as prescribed

35

Review of Related Literature

Foreign Literature

Epilepsy is recognized as a collection of heterogeneous

syndromes characterized by additional conditions that coexist

with seizures and impacts over 50 million people worldwide.

Cognitive, emotional, and behavioral comorbidities are common.

Seizures are typically divided into two main categories: partial

(focal) and generalized. Generalized seizures affect both

cerebral hemispheres from the onset of the seizure. Seizures

produce loss of consciousness, either for long periods of time or

temporarily, and are sub-categorized into generalized tonic-

clonic, myoclonic, absence, or atonic subtypes. Partial seizures

affect an area within one cerebral hemisphere of the brain and

are the most recurring type of seizure experienced by patients

with epilepsy. Partial seizures are further subdivided into

simple partial seizures, where consciousness is retained; and

complex partial seizures, where consciousness is diminished or

lost.In the treatment of epilepsy, no one anti-epileptic drug

(AED) has been shown to be the most effective, and all AEDs have

published side effects. AEDs are selected following consideration

of side effects, ease of use, cost, and physician knowledge.

Patients with newly diagnosed epilepsy who require treatment can

be started on standard, first-line AEDs such as carbamazepine,

36

phenytoin, valproic acid, or phenobarbital. Alternatively, newer

AEDs introduced in the past decade may be used. These include

gabapentin, lamotrigine, oxcarbazepine, or topiramate. Between

70% and 80% of individuals are successfully treated with one of

the AEDs now available and success rates primarily depend on the

etiology of the seizure disorder. However, the remaining 20%–30%

of patients have either intractable or uncontrolled seizures or

suffer significant adverse side effects to medication. As with

the selection of first-line therapy, choosing the appropriate

drug for the treatment of refractory epilepsy must be based on

the appreciation of each drug’s characteristics and risks for

each individual patient. An emerging market economy is defined as

an economy with low-to-middle per capita income. Such countries

constitute approximately 80% of the global population, are often

rapidly-growing and represent about 20% of the world’s economies.

Although the term emerging market is loosely defined, countries

that fall into this category, range from big to small, and are

often considered emerging because of development and reform

programs that have been put in place to launch their markets

globally. Consequently, although China is considered one of the

world’s foremost economic leaders, it is grouped into the

emerging market category together with much smaller economies

with fewer resources, such as Sudan or Bulgaria. Epilepsy is

common in patients admitted to hospitals in emerging

37

markets.However, there are reported differences in the

epidemiology, economic burden, and outcome of epilepsy in these

regions compared to high-income countries; although few data from

the former regions exist. Applying the International League

Against Epilepsy definition of epilepsy is problematic in these

areas, as patients often arrive at health facilities without

adequate documentation of the seizure duration. The goal of

treatment for patients with epilepsy is no seizures with little

to no side effects. However, due to variabilities in clinical

presentation and available resources, treatments are highly

individualized and vary widely. The objective of this study is to

systematically review the literature on epilepsy to identify

incidence and prevalence rates, economic data, unmet needs, and

treatment patterns in those emerging markets which contain the

majority of the world’s population. (Angalakuditi, 2011)

Epilepsy is a chronic disease characterized by the risk of

recurrent seizures. In developed countries, an average of 4 or 5

of every 1,000 people has epilepsy. In developing countries, this

rate can be as high as 43 per 1,000 people. According to the

World Health Organization, the disability caused by epilepsy

accounts for about 0.5% of the global burden of the disease

measured by disability-adjusted life-years. As a result, epilepsy

ranks just after psychiatric conditions such as alcohol

38

dependence. The global health care bur-den of epilepsy is

comparable to that of breast or lung cancer. Some cultures

believe that epilepsy represents demonic possession. Although

epilepsy arises from a transient dysfunction in the brain, fear

and ignorance still lead to discrimination and feelings of shame.

In the public mind and in the laws of some countries, epilepsy is

strongly associated with mental illness and cognitive

disabilities — unfortunate generalizations that unfairly affect

many people with epilepsy. Such pervasive social stereotyping is

difficult to overcome. Previous surveystesting knowledge,

atitudes, beliefs and treatment of people with epilepsy have

focused on the general public, students or teachers. Dentists and

other health care workers, who represent one of the more highly

educated and influential groups in society, however, have not

been surveyed. Undoubtedly, their perspectives about people with

epilepsy have an impact on their professional interactions with

this patient population. Their social response to this

population, independent of their provision of medical care, may

influence the way their community views people with epilepsy.

Because the dental care of patients with epilepsy is important,

and some reports in the literatureindicate there may be

disparities in their care, compared with that of the general

population, we surveyed all the dentists in London, Ontario, to

determine their knowledge about and attitudes to epilepsy, and

39

their willingness to provide dental care to people with epilepsy.

(Aragon, 2008)

Epilepsy is the second most occurring neurological disorder

with an incidence rate of 1 % of the entire population. In

Denmark alone approximately 4.000 new cases are seen every year.

To be diagnosed with epilepsy often means a big change in a

persons life, and affects the daily rutines of the entire family.

Luckily, it is today possible to treat most epileptics and to

keep them seizure free, but around 25% will have to find a way of

living with the seizures to a smaller or larger degree. Epileptic

seizures There exists a high number of different types of

epilepsy, and also an equally high number of seizure types. These

seizures range from the common muscle spasms, many people would

recognise as an epileptic seizure, to a short term, almost

undetectable, loss of awareness. Most epileptic individuals

however will experience the same seizure type from time to time.

What is common for all epileptic seizures is that during the

seizure the affected person is unable to fully control his or her

body. The loss of control is sudden and unexpected.

Epi-Care is produced with an aim of warning relatives or medical

personal when nightly seizures or spasms, with muscle activity

occur.The majority of people suffering from epilepsy can be

treated with medicine. Some will even improve from complicated

40

brain surgery, however this is only a minority.The best care is

decided from an individual and thorough description of seizures,

seizure types, as well as seizure duration and frequency. A

thorough seizure description will often mean that the time from

diagnose to the optimal seizure treatment is significantly

shortened. Epi-Care can be of significant help in creating a

thorough seizure description. The Epi-Care log can keep track of

the numbers of nightly seizures, and at the same time, warn if or

when a major seizure should occur.( http://danishcare.dk/uk/?

page_id=37)

The likelihood of young people taking their epilepsy medication

as prescribed might be improved by ensuring they have a good

understanding of their condition and its treatment, research

suggests.Scientists at the University of Michigan carried out a

study involving 88 adolescents with epilepsy and their

parents.Surveys were carried out to assess both patients’ and

parents’ knowledge of epilepsy and expectations of treatment, as

well as their adherence to medication.The findings show that

young people with a good understanding of epilepsy tended to

adhere to their treatment regimes more closely than those with

poor knowledge of the condition.A good understanding among

parents was also found to be beneficial, according to a report in

the journal Epilepsy & Behaviour.The researchers concluded:

41

“Interventions that enhance adolescents’ knowledge of epilepsy

and their treatment plan, while ensuring that teens and parents

are in agreement with regard to epilepsy treatment, might

contribute to better adherence.”Encouraging young people to take

their medication is vital for improving outcomes, as non-

adherence is associated with a high frequency of seizures and a

worsened prognosis.Yet a study in the Journal of the American

Medical Association, published in 2011 by researchers at

Cincinnati Children’s Hospital, found evidence that more than

half of children with newly diagnosed epilepsy do not take their

seizure medications as prescribed.(

http://www.epilepsyresearch.org.uk/improving-youngsters-

knowledge-of-epilepsy-may-boost-treatment-adherence/)

Local Literature

People with epilepsy in the Philippines suffer from anxiety

and from depression. Living with epilepsy presents many

challenges affecting many aspects of life, including

relationships with family and friends, school, employment and

leisure activities (Hazel Patagua, 2012).

The Annual Neuroscience Department Research Contest was held

on September 10, 2009 at the Department Conference Room.  There

were ten original papers that were presented from the Sections of

42

Adult and Pediatric Neurology in three categories: Case

Report/Case Series, Descriptive, and

Analytical. The Annual Philippine Neurologic Association research

forum was held on October 17, 2009 at UST Hospital. Four original

papers from PGH were presented as finalists by their primary

authors.  Dr. Janet Adajar of Pediatric Neurology won 3rd place

in the Descriptive category with her paper on the EEG findings of

patients with Complex Febrile Seizures while Dr. Jude Bayana of

Pediatric Neurology won 4th place in the same category with his

paper on the use of newer antiepileptics for neonatal

seizures.  Dr. Natasha L. Fabiaña of Adult Neurology won

3rd place in the Analytical Category for her paper entitled, Risk

Factors for the Development of Seizures and Epilepsy among Post

Stroke Patients in a Tertiary Hospital: A Retrospective Cohort

Study. Dr Aloysius Domingo of Adult Neurology won 4thplace for

his meta-analysis, Secondary Prevention After Cerebrovascular

Events: Will Angiotensin Receptor blockers Protect? (SPACE-

WARP).  The other original papers submitted were qualified for

poster presentation which was held during the PNA Annual

Convention.  In the said event, the paper of Dr Jhaphet Agunias

entitled Parkinsonism as sequela of cyanide poisoning by

intentional silver jewelry cleaner ingestion: A Case Report won

2nd place in poster presentation. (pgh.gov.ph)

43

Treating the patient at home is appropriate when the patient

is known to experience seizures, and if his seizures are brief.

According to the Philippine League Against Epilepsy, the

following steps can be done when helping out a patient during an

acute seizure episode:

Stay calm.

Loosen clothing around neck.

Turn the patient's head to one side to avoid choking and/or

aspiration.

Do not hold the patience down or shake and slap in an

attempt to rouse him, as they can injure the patient.

Do not put anything inside the patient's mouth.

Call a doctor when it is a first time seizure, of if the

seizure recurs or is prolonged (more than 5 minutes)

Taking prescribed anti-seizure medication regularly can help

prevent recurrent seizures. The removal of brain tissue where

seizures take place is also a preventive measure. For those with

severe cases of epilepsy, a special diet is advised to alter body

chemistry. Avoiding conditions known to trigger seizures (such as

bars with rapid, flashing lights, sleep deprivation) can help

prevent seizures from occurring.

44

Seizures in the Philippines, The following medical centers in

the Philippines have available Neurology/Seizure clinics:

Jose Reyes Memorial Hospital

Makati Medical Center

Philippine Children's Medical Center Seizure Clinic

St. Luke's Medical Center: Comprehensive Epilepsy Program

UERM Seizure Clinic

UP-PGH Seizure Clinic

UST Hospital Seizure Clinic (health.com.ph)

Foreign Study

Primary care physicians, including pediatricians, admit that

they are not as familiar about specific aspects of epilepsy as

they should be and that they need more training in management of

the disease.

Several recent surveys of health care professionals who care for

children with epilepsy revealed what epilepsy specialists would

consider to be misconceptions about treatment and management of

pediatric epilepsy. In a survey that focused on surgery practices

for intractable epilepsy, nearly two-thirds of responding

physicians (58% were pediatricians) were unsure whether surgical

intervention should be considered for patients who fail

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anticonvulsant drug therapy, although specialists know that

surgery is the current guideline.

Another survey of pediatricians in Canada found that only 34% of

respondents said they knew of sudden unexplained death in

epilepsy (SUDEP), a rare but serious complication of frequent

seizures, and just 57% knew that children with epilepsy are at

increased risk for sudden, unexpected, unexplained death.

Specialists say that awareness of SUDEP is vital.

A third survey of behavioral health professionals who treat

children with epilepsy found that 84% wanted more training in

managing the psychopathologies of pediatric epilepsy in order to

play a more effective role in multidisciplinary care for such

patients.(American Epilepsy Society, 2012)

Out of all subjects, 88.5% (n=552) had a postgraduate

education, while 11.5% (n=72) had only an undergraduate degree.

The authors found that physical educators, nutritionists and

physiotherapists received lower scores on their epilepsy

knowledge than other health professionals. Health professionals

are considered better-educated group inside the society,

especially with regards to healthcare issues. Thus, it is

important they also have an accurate and correct knowledge about

epilepsy. The findings of the present study indicate an

imperative improvement in education about epilepsy, as well as an

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inclusion of formal programmes for epilepsy education especially

for non-medical professionals. An improvement in epilepsy

education might contribute to an improvement in epilepsy care and

management. (Vancini, 2012)

In the arm of the survey that focused on physician attitudes

toward referral of children for surgical evaluation, only 51% of

respondents agreed that epilepsy surgery after 3 years of failed

antiseizure medication should be considered; 49% either disagreed

or were unsure. About a quarter (25%) felt patients in whom the

ketogenic diet fails should be considered for surgery, with more

than half (54%) being unsure and 23% not thinking this would be

helpful. Only 43% agreed that patients should be evaluated for

surgery after failed vagus nerve stimulation. Perhaps most

concerning was that 63% of the survey population was unsure

whether surgery would be effective for children with partial (or

focal) epilepsy and 7% didn't think this would be an effective

option. "This one really broke my heart," said Dr. Perkins.

"Focal epilepsy surgery has the highest positive response rates,

and having two thirds plus of respondents saying they don't agree

with it or aren't sure that it would be beneficial, tells me that

we have completely failed in communicating what we do to

professionals who would be referring to us." Up to 90% of

patients with partial epilepsy respond to surgery, noted Dr.

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Hovinga. All kids with epilepsy should be considered for surgery,

but that doesn't mean all of them should get it, Dr. Perkins

stressed. "It's important to identify children with intractable

epilepsy who might benefit from surgery. We need to go back to

our baseline and reevaluate, especially as evolving technologies

have rolled in, and we have better imaging and better diagnostic

procedures determining if a particular person qualifies for

surgery or not."Just because a patient comes to an epilepsy

center for an evaluation doesn't mean that patient is removed

from primary care. "We're here as an augmentation, if others want

us to comanage or guide," said Dr. Perkins. "These patients need

to be getting the evaluations and there's a block in that

process." Asked about referring patients with generalized

epilepsy for surgery, 61% of survey participants were unsure and

24% disagreed. Although such referrals are "a bit trickier than

focal epilepsy" because the surgery may be for palliative care

reasons, the surgery would still "vastly improve qualify of life

for many of patients and their families," said Dr. Perkins.

Ironically, more than half of the doctors agreed that surgery

might improve quality of life for children. "It's another one of

those discordances" where doctors might think a particular

intervention might help but they're not sure about the specifics,

said Dr. Perkins. Changing attitudes can be accomplished only

through education, perhaps using webinars or other electronic

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tools, but most likely through old-fashioned "shoe leather" --

getting in your car and visiting doctors in the field, said Dr.

Perkins. "On a local basis, it's incumbent on us to reach out to

our referral sources outside of neurology and neurosurgery who

are nonepileptologists -- into the pediatrician and family

practice offices -- and make sure they understand these

things."(Anderson, 2012)

Health professionals need good skills in communication and

patient education They play an essential role in educating

patients and families about the epilepsies and in directing them

to accurate and reliable resources and tools to improve

knowledge, skills, and self-management. In contrast, poor

clinician-patient communication is a major barrier to patients'

ability to successfully navigate the health care system, act on

basic health instructions, and self-manage chronic or other

health conditions. Studies indicate that patients recall as

little as half of what their physicians tell them during an

outpatient appointment. Physicians need to confirm that patients

understand their condition (e.g., specific seizure type, epilepsy

syndrome, seizure triggers), how to carry out treatment and

medication instructions, and risks associated with their

condition and nonadherence or discontinuation of their treatment

regimen. However, in one diabetes study, physicians assessed

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patients' recall and comprehension of new concepts in only one in

five patient encounters, even though such practices have been

shown to improve clinical outcomes. Therefore, it is critically

important that health professionals provide patients and their

families with written information about their specific seizure

type, epilepsy syndrome, and treatment plan to augment

discussions that happen in the clinical setting.

In order to educate patients and families effectively, health

care providers must be knowledgeable and skilled in communicating

and conveying information that meets the individual needs and

preferences of patients. A UK survey highlighted the desire of

patients with epilepsy to have physicians who are both

knowledgeable and effective communicators. In addition, patient-

rated quality of care also increases when health care providers

use patient-centered communication and shared decision making. it

is important that health professionals learn how to

recognize the critical junctures for patient and family

education—at diagnosis, during the first year, when there is

a change, in treatment options (e.g., introduction, switch,

discontinuation), or when a new concern develops;

understand the specific information needs and preferences of

patients and their families and take into consideration

factors related to health literacy and culture, including

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cultural differences that may exist between them and their

patients;

listen actively and put the patients and their needs first

when providing education and counseling;

be competent in patient and family education and

communication, including targeting education to the specific

needs of the patient;

be comfortable discussing risks associated with the

epilepsies and their treatments including SUDEP, suicide,

and status epilepticus be aware of informational resources

for patients and families that are available online and

through local epilepsy organizations; and

promote the use of self-management tools and programs.

(Stuart, Muir, 2008)

Local Studies

About 25 percent of individuals begin to have seizures

during puberty. There are also studies pointing to higher

rates of seizures among “low-functioning” persons with

autism. Dr. Sosa advised her audience to treat the

underlying cause of seizure in order to have good seizure

control and thus improve the quality of life of the person

affected. With other pediatric neurologists like her, CNSP

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promotes and provides access to quality neurological

healthcare for Filipino children.

CNSP conducts teaching and training seminars to the

physicians as a way to improve the level of child neurology

practice. In partnership with organizations like Autism

Society Philippines, CNSP Caravans already reached Naga,

Dagupan, Samar and Lucena. Doctors, parents, rural health

physicians, midwives and nurses are the target audience in

each identified locality. The thrust of the caravan project

is to teach the participants in identifying

neurodevelopmental disability in children and then providing

basic developmental intervention techniques to the

community(Manila Bulletin, 2012).

In the Philippines alone, 80 percent of the population know

little about the disease. Despite affordable medicines, some

people resort to alternative solutions like exorcism or

herbs from traditional healers. (www.thepoc.net)

More than two million people in the Philippines -- about 1

in 150 -- have experienced an unprovoked seizure or been

diagnosed with a seizure disorder. For about 80 percent of

those diagnosed with a disorder, seizures can be controlled

with modern medicines and surgical techniques.

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However, about 20 percent of people with a disorder will

continue to experience seizures even with the best available

treatment. Doctors call this situation intractable epilepsy

(Philippine Center for Epilepsy, 2012).