2. Neurology Stuff Bill Hall October 2011

4. Famous neurologists Babinski Charcot Freud Tourette

5. Neurology impact • 20% of beds occupied • 1 in 7 of US population sees doctor a year • 28% of disability

6. Patients per Neurologist • UK 150k • Europe 8-34k

7. Neurology workload for GPs • 1700 per year per 10k population • Increase in migraine and vertigo

8. Neurology workload for GPs

9. RCGCP neurology curriculum key messages • Managing epilepsy is a key competence for general practice. • Neurological emergencies. • Appropriate referrals for neurological problems • Manage neurological conditions in primary care (e.g. chronic headache)

10. All evidence based of course...

11. Menu for today • Epilepsy management in general practice • QoF epilepsy requirements • QoF referral management and neurology • Common neurology conditions in general practice

12. Epilepsy Care in General Practice *

14. Famous people with epilepsy (PWE) *

15. Florence Griffith Joyner ‘Flo-Jo’ (1959–1998) Sprinter Records in 100 & 200 mDeveloped seizures in her thirties Cavernous angioma on autopsy. SUDEP in sleep

16. Prince John (1905–1919) • Youngest son of George V • Epilepsy from 4 until his death after a seizure aged 13. • The shame of his epilepsy, along with other neurological problems, meant he was kept from the public eye.

17. Joan Of Arc (1412–1431) • Epileptic seizures with clear auditory and visual hallucinations are very rare.

18. GPs and epilepsy • Unsure • Lack confidence • A bit scared • Not really my thing • Like asthma was? • Like diabetes was?

19. Official Documents • CMO’s action plan 2002 • SUDEP report 2002 • SIGN guidelines 2002 • NICE guidelines 2004 • NSF 2004 • nGMS contract 2004,2006,2011

20. * So what is epilepsy?

21. Definitions Epilepsy is a condition • characterised by recurrent epileptic seizures • unprovoked by any immediate underlying cause

22. Epileptic Seizure • episode of paroxysmal nervous activity • uncontrolled and unpredictable • originates in the grey matter of the brain • effects depend on origin and spread • can cause sensory, motor or somatic symptoms • spectrum of dysfunction • little or no impact • loss of consciousness and convulsions

23. Convulsions • Convulsions are a manifestation of seizure activity in the motor cortex

24. How many people have epilepsy? * • Active epilepsy 0.5% • Lifetime risk >2% • 10 per GP • 1 new case per year per GP

25. First seizure • 30-40% chance of a second one • Highest in first year • <10% after 2 years • Normal EEG + no cause 25% • Abnormal EEG or cause 90%

26. Should a first seizure be treated? * • Halves risk of second seizure – 15-20% • No change in prognosis • Patient choice the key

27. Who should make the diagnosis? * • GP? • Specialist? • Neurologist? • New seizure clinic? • GPwSI?

28. How is diagnosis made? * • Almost all on history • Eye witness • NO Gold Standard Investigation • 20% wrong in epilepsy clinics • Only 7% GP referrals NOT epilepsy

29. GPwSI • Interest • Training • Standards

30. Epilepsy Specialist Nurse • ‘Sapphire Nurse’ • Sponsored by Epilepsy Action • Two years • Trust have to take on after

31. Epilepsy Specialist Nurse • Popular • Improve knowledge • No difference in ‘hard’ outcomes Erica Chisaga ILEA ESN of the year

32. Prognosis * • SMR 2.6 • Sudden death 1:1000 per annum • Males, poor adherence, soon after diagnosis • 30-40% easily controlled • 30% seizures continue

33. Classification * Current • Partial • Generalised Coming soon… Engel classification • Seizure description • Seizure type • Syndrome • Aetiology • Impact

34. Partial seizures • Simple • Complex (impaired consciousness) • Evolving

35. Generalised seizures • Absence • Myoclonic • Tonic +/- clonic • Atonic

36. Redundant... *. • Grand mal • Petit mal • Epileptic

37. What sort of seizure is this? Video

38. What sort of seizure is this? Video 2

39. Differential diagnosis * • Vasovagal syncope • Pseudoseizures • Cardiac syncope • Hyperventilation • TIAs • Migraine

40. Which drugs? • Partial + secondary generalised • CBZ, oxcarbazepine, valproate, lamotrigine • Idiopathic generalised • Lamotrigine, valproate • Drug resistant • Gabapentin, pregabalin, topiramate, tiagabine, levetiracetam • Still used sometimes • Clobazam, acetazolamide

41. Blood levels? * • What do you think? • Don’t bother

42. Drug strategy • Patients like newer drugs best • Titrate up slowly • Stop when side effects intervene • Add second drug • Try & remove first drug

43. Drug side effects • Weight gain • Headache • Sedation • Cognitive blunting • Psychotic reactions?

44. Other treatments • Aromatherapy • Herbal medicine • Vagal stimulation • Diet • Surgery • Drug resistance • 70% seizure free

45. Useful interventions • Epilepsy organisations • Epilepsy Action • National Society for Epilepsy • Telemedicine • Epilepsy dogs

46. Learning disability • 50% have epilepsy • Multidisciplinary approach • Ditch phenobarbitone?

47. Contraception * • Don’t use carbamazepine • If you do, • 50mcg COC pill is needed + warnings • Depot-Provera 10 weekly • No POP or implants • 3 tablets of levonorgestrel for emergency contraception

48. Preconception • 5mg folic acid • Vit K • Risks of drug v. risks of seizures • Adjust dose? • Normal foetal risk 2-3% • AED foetal risk 4-9% • Breast feeding is fine

49. General practice’s job • Register • Initial screen, provisional diagnosis • Refer • Inform • Review • after diagnosis. • annually • Women’s issues

50. General practice’s job Initial diagnosis Fits faints & funny turns