Seizures and Epilepsy in Adults

This informal CPD article ‘Seizures and Epilepsy in Adults’ was provided by Wossenseged Asrat, MD from The Edge Medical Writing, an organisation that provides high quality medical writing support, tailored to meet the needs of medical education, product development, and the dissemination of medical information. It focuses on unraveling the enigmatic tapestry of seizures and epilepsy in adults, weaving together comprehensive insights and practical strategies to empower healthcare professionals to pursue optimal patient outcomes.

Introduction

A seizure is an uncontrolled electrical disturbance in the brain that can cause changes in behavior, abnormal body movements (convulsions), feelings, or levels of consciousness. It is a characteristic symptom of epilepsy that can also be caused by factors like head injuries, brain tumors, or certain medical conditions like hypoglycemia. (1)

Epilepsy is defined by the International League Against Epilepsy (ILAE) as "a disease characterized by an enduring predisposition to generate epileptic seizures." (2) According to World Health Organization, the prevalence of epilepsy in the general population is approximately 6 to 8 per 1,000 people, corresponding to a prevalence rate of 0.6-0.8%. (3)

Seizures and epilepsy are neurological disorders that require healthcare professionals to stay updated and engaged in Continuing Professional Development (CPD). Healthcare professionals must understand seizures and epilepsy in adults to provide high-quality patient care. They should thoroughly comprehend seizures and epilepsy in adults to identify symptoms and provide immediate life-saving interventions.

In many low-resource countries, there is a widespread misconception and stigma surrounding seizures and epilepsy. Healthcare professionals in these countries have an essential role in breaking down these misconceptions and educating the community about the medical nature of the disease.

CPD activities also allow healthcare professionals to enhance their understanding of the psychosocial impacts of seizures and epilepsy on adults. This knowledge enables healthcare providers to offer comprehensive care that addresses the medical aspects and their patients' emotional and social needs.

Types of seizures in adults

In adults, seizures can be classified into two main categories:

• Focal seizures and
• Generalized seizures

Understanding the differences is crucial for accurately diagnosing and optimally managing seizure disorders and epilepsy syndromes.

Focal seizures

Focal seizures, previously known as partial seizures, originate from a specific brain area. They can be further classified into two subtypes: focal onset aware seizures (formerly called simple partial seizures) and focal onset impaired awareness seizures (formerly called complex partial seizures). (2) Focal onset-aware seizures do not cause loss of consciousness and may involve abnormal sensations, emotions, or movements localized to one part of the body. In contrast, focal onset impaired awareness seizures involve altered consciousness or loss of awareness, with symptoms such as automatic behaviors, repetitive movements, or confusion. (2)

Generalized seizures

Generalized seizures involve both sides of the brain from the seizure onset. It can be further categorized into several types:(2)

• Absence seizures, also known as Petit-Mal seizures, typically occur in children but can persist into adulthood. They involve brief episodes of staring and temporal loss of awareness. Typical absence seizures start and end abruptly, lasting for a few seconds, while atypical absence seizures have a longer duration, and individuals may have some awareness of their surroundings during the seizure.
• Tonic seizures are characterized by sudden muscle stiffness.
• Rhythmic jerking movements
• Characterize clonic seizures.
• Brief shock-like muscle contractions characterize myoclonic seizures.
• Tonic-clonic seizures (formerly known as Grand-Mal seizures) involve loss of consciousness, body stiffness, rhythmic jerking movements, and atonic seizures (drop attacks), which cause sudden loss of muscle tone. 

Healthcare professionals must comprehensively understand these seizure types to provide accurate diagnoses and appropriate management for individuals with seizures and epilepsy disorders.

Causes of seizures and epilepsy in adults

Seizures and epilepsy in adults can have various causes, including genetic factors, head trauma, stroke, brain tumors, infections, electrolyte imbalances, neurodegenerative disorders, drug and alcohol withdrawal, autoimmune diseases, and idiopathic factors. (4)

• Genetic causes refer to inherited conditions or genetic mutations that increase an individual's susceptibility to developing seizures. These can play a role in various forms of epilepsy.
• Head trauma resulting from accidents or falls can lead to long-term changes in brain function and increase the risk of seizures.
• Stroke disrupts blood flow to the brain, triggering abnormal electrical activity and potentially causing seizures.
• Brain tumors disrupting the balance between excitatory and inhibitory neurotransmitters can trigger abnormal electrical discharges, leading to seizures.
• Certain infections, such as meningitis or encephalitis, can cause inflammation in the brain, upsetting normal function and increasing the risk of seizures.
• Intracranial space occupying lesions, like tumors or cysts, can interrupt normal brain activity and trigger seizures.
• Electrolyte and glucose imbalances can interfere with the normal electrical activity in the brain, leading to seizures.
• Neurodegenerative disorders result in the progressive degeneration of neurons, increasing the risk of seizures.
• Drug and alcohol withdrawal can lead to a hyperexcitable state in the brain, triggering seizures.
• Autoimmune diseases can cause inflammation in the brain, leading to seizures.
• Idiopathic cases have no identifiable cause contributing to seizures. 

Essential medical history for seizures and epilepsy in adults

When assessing adult patients with seizures or epilepsy, gathering a pertinent history is crucial. This section highlights the essential historical elements needed to understand their condition effectively.

Onset of Seizures:

The age at which seizures first occur can provide important information in distinguishing between childhood-onset and adult-onset epilepsy. It is crucial to understand the characteristics of the first seizure, such as its duration, nature, and triggering factors, as this can provide valuable insights into the underlying cause and helps to predict possible disease outcomes. (5)

Seizure Description:

This entails capturing vital details such as seizure type, duration, and accompanying symptoms like aura, loss of consciousness, and muscle contractions. (6)

Provoking Factors:

Identifying potential triggers like sleep deprivation, alcohol, stress, missed medication, drug use, or toxin exposure is essential for prevention and patient education.

Past Medical and Surgical History:

Uncovering pre-existing conditions (brain trauma, stroke, tumors, infections, neurodevelopmental disorders) provides insights into seizure causes. Documenting previous brain or central nervous system surgeries impacts treatment decisions.

Family History:

Exploring the presence of epilepsy or other neurological disorders within a person's family history can provide valuable insights into potential hereditary factors. (7)

Essential physical examinations to assess seizures and epilepsy in adults

When assessing seizures or epilepsy in adults, a thorough physical examination is vital for diagnosis and management. Here are essential investigations to consider: (8)

Emergency ABC of Life: (9)

• Prioritize airway, breathing, and circulation (ABC) in emergencies.
• Check for signs of airway obstruction, breathing rate, oxygen saturation, pulse rate, and blood pressure.
• Address life-threatening conditions promptly before further examination.

General Physical Examination:

• Perform a comprehensive examination, including vital signs and signs of systemic illnesses.

Cardiac Evaluation:

• Evaluate the heart for arrhythmias or other cardiovascular conditions that may trigger seizures.
• Assess heart sounds, rhythm, and rate.
• Consider an electrocardiogram (ECG) to detect cardiac abnormalities. 

Neurological Examination:

• Assess cognition, motor function, sensation, and coordination.
• Evaluate consciousness, memory, speech, muscle strength, deep tendon reflexes, and sensation. 

Essential laboratory tests and imaging studies for assessing seizures and epilepsy in adults

Evaluation of individuals presenting with seizures and epilepsy necessitates a comprehensive assessment encompassing laboratory tests, imaging studies, and advanced diagnostic procedures. This section emphasizes the crucial investigations required to aid in diagnosing, managing, and understanding seizures and epilepsy in adults.

Laboratory Tests: (10)

• Complete Blood Count (CBC): A CBC is instrumental in identifying underlying infections, anemia, or systemic abnormalities that may contribute to seizures.
• Comprehensive Metabolic Panel (CMP): This panel evaluates electrolyte imbalances, liver and kidney function, and glucose levels while assessing for metabolic disorders.
• Toxicology Screen: Conducting a toxicology screen is essential to rule out substance abuse or exposure to toxic substances, which can trigger seizures.
• Anticonvulsant Drug Levels: Monitoring the levels of anticonvulsant medications aids in assessing therapeutic drug levels and ensuring optimal dosing.  

Imaging Studies: (10)

• Electroencephalogram (EEG): EEG is a primary tool for diagnosing and classifying seizures and epilepsy. It records electrical brain activity, determining the type and localization of seizures.
• Magnetic Resonance Imaging (MRI): An MRI scan of the brain provides detailed images to identify structural abnormalities such as tumors, vascular malformations, or brain lesions that may contribute to seizures.
• Computed Tomography (CT) Scan: CT scans are helpful in emergencies to evaluate acute intracranial causes of seizures, such as hemorrhage or trauma. 

Advanced Studies:

• Video EEG Monitoring
• Neuropsychological Testing
• Genetic Testing

Fundamental principles for effective emergency and chronic medical management for seizures and epilepsy

Seizures and epilepsy are neurological conditions that require comprehensive management to improve patients' quality of life. As healthcare professionals, it is essential to be familiar with the various treatment options available and the importance of emergency management during acute seizure episodes.

Emergency Management:

During a seizure episode, prompt intervention is crucial to ensure the patient's safety. If necessary, position the patient in a safe area, protect them from injury, and provide reassurance to both the patient and any bystanders. Avoid restraining or forcefully stopping the seizure, as it may lead to harm. Once the seizure subsides, monitor the patient closely and provide appropriate post-seizure care.

For a detailed protocol on emergency management of seizures in adults, please refer to the "Emergency Management of Seizures Protocol" provided by the Epilepsy Foundation (www.epilepsy.com).

Treatment Options:

The primary goal of treating seizures and epilepsy is to achieve seizure control and minimize the impact on a patient's daily life. Treatment options may include:

• Antiepileptic Medications (AEDs): AEDs are the cornerstone of epilepsy treatment. These medications work by stabilizing the electrical activity in the brain, reducing the likelihood of seizures. The choice of AED depends on various factors such as seizure type, patient age, comorbidities, and potential drug interactions. Regularly monitoring drug levels and adjusting the dosage is essential to optimize seizure control while minimizing side effects. (11)
• Ketogenic Diet: A ketogenic diet may be considered for patients with drug-resistant epilepsy. This high-fat, low-carbohydrate diet mimics the metabolic state of fasting, leading to changes in brain metabolism that can reduce seizure frequency. (12)
• Vagus Nerve Stimulation (VNS): VNS is a non-drug treatment option for patients with partial-onset seizures who have not responded to medication. A small device is implanted under the skin, delivering electrical impulses to the vagus nerve, which can help reduce seizure frequency and severity. (13) 

For adults with refractory seizures and epilepsy, surgical intervention may be considered a treatment option when medications and other non-surgical approaches have failed to provide adequate seizure control. Surgical procedures aim to identify and remove or modify the epileptic focus, the specific brain area where the seizures originate.

Lifestyle modifications, safety measures, support groups, and emergency management approaches

Living with seizures and epilepsy can present unique challenges for adults. However, by implementing certain lifestyle modifications and safety measures and utilizing support groups, individuals can enhance their overall well-being and effectively manage their condition.

Lifestyle Modifications:

Adopting certain lifestyle modifications can significantly contribute to seizure control and overall health. These modifications may include maintaining a regular sleep schedule, managing stress through relaxation techniques or counseling, and avoiding triggers such as alcohol, drugs, or flashing lights. Maintaining a balanced diet, exercising regularly, and adhering to prescribed medication regimens can help stabilize seizure activity and promote overall wellness.

Safety Measures:

Implementing safety measures is crucial to minimize potential risks associated with seizures. Creating a safe home environment is essential; removing sharp objects and securing furniture can prevent injury during seizures. Individuals with epilepsy should also consider carrying an identification card to ensure appropriate assistance is provided during emergencies.

Support Group:

Engaging with support groups can be immensely beneficial for individuals with seizures and epilepsy. These groups offer a platform to connect with others who share similar experiences, providing emotional support, practical advice, and a sense of community.

Conclusion

Seizures and epilepsy in adults are complex neurological conditions. The article explored the different types of seizures in adults, emphasizing the need for healthcare providers to understand these presentations comprehensively. Additionally, it discussed the various causes of seizures and epilepsy in adults, the significance of accurate assessment and the utilization of diagnostic tools, and the importance of identifying underlying factors to guide appropriate management.

The management of seizures and epilepsy should adopt a holistic approach encompassing medical interventions and lifestyle modifications. Overall, this article aimed to provide health professionals with valuable insights into the complexities of seizures and epilepsy in adults, empowering them to provide optimal patient care.

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References

1.      Epilepsy Foundation. Understanding Seizures. Available from: https://www.epilepsy.com/learn/about-epilepsy-basics/what-seizure.

2.      Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epileptic. 2017;58(4):522-530.

3.      World Health Organization (WHO). Epilepsy. February 2023. Retrieved from https://www.who.int/news-room/fact-sheets/detail/epilepsy.

4.      Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official report: A practical clinical definition of epilepsy. Epilepsia. 2014;55(4):475-482. doi:10.1111/epi.12550

5.      Nabbout R, Andrade DM, Bahi-Buisson N, et al. Outcome of childhood-onset epilepsy from adolescence to adulthood: Transition issues. Epilepsy Behav. 2017;69:161-169. doi: 10.1016/j.yebeh.2016.11.010

6.      Huff JS, Murr N. Seizure. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430765/.

7.      Kaneko S, Okada M, Iwasa H, Yamakawa K, Hirose S. Genetics of epilepsy: current status and perspectives. Neurosci Res. 2002;44(1):11-30. doi: 10.1016/s0168-0102(02)00065-2

8.      Nowacki TA, Jirsch JD. Evaluation of the first seizure patient: Key points in the history and physical examination. Seizure. 2017;49:54-63. doi:10.1016/j.seizure.2016.12.002

9.      Kliem PSC, Tisljar K, Baumann SM, et al. First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study. J Clin Med. 2022;11(2):435. doi: 10.3390/jcm11020435

10.   Hammond, N. (n.d.). How Do Doctors Diagnose Epilepsy? Healthline. Retrieved from https://www.healthline.com/health/epilepsy/epilepsy-diagnosis

11.   International League Against Epilepsy (ILAE): www.ilae.org/guidelines.

12.   Neal EG, Chaffe H, Schwartz RH, et al. The ketogenic diet for the treatment of childhood epilepsy: A randomised controlled trial. Lancet Neurol. 2008;7(6):500-506. doi:10.1016/S1474-4422(08)70092-9

13.   Ben-Menachem E. Vagus nerve stimulation, side effects, and long-term safety. J Clin Neurophysiol. 2001;18(5):415-418. doi:10.1097/00004691-200109000-00005