Mistakes in Epilepsy Mistakes in Epilepsy CareCare
Orrin Devinsky, M.D.NYU Epilepsy Center
What do NBA coaches, What do NBA coaches, mothers and doctors have mothers and doctors have in common?in common?
The Diagnostic Bias 1st round v. 2nd round choice Diagnosis to doctor = child to mother
Reliance on prior diagnosis Failure to consider other disorders
Convulsive syncopeNonepileptic psychogenic
seizures Failure to consider diagnostic changes
Missing The Big Missing The Big Picture Picture
Focus on person, not diagnosis Listen, beyond the words to feelings See their world: situations influence health
Look patient in the eyes Speak with family and friends
Therapies are limited by medical box Therapists - cognitive, psychological, etc Pragmatic approaches (sometimes key!)
Compliance Sleep hygiene Memory lists
Missing Mood Missing Mood Disorders Disorders
All epilepsy patients at increased risk
Patients must tell; doctors must ask – both often fail
Refractory epilepsy Greater contributor to impaired Quality of Life than seizures
Depression in up to 50% Suicidal ideation - 20% in past 6 mos
Majority are untreated
Not So Benign Not So Benign EpilepsyEpilepsy
“Benign Epilepsies” Yes or No?
Absence Epilepsy Childhood (5-9 yo) vs. Adolescent (10-14 yo)
Benign Occipital Epilepsy Benign Rolandic Epilepsy
Absence Epilespy: A Absence Epilespy: A Wolf in Sheep’s Wolf in Sheep’s
Clothing Clothing 56 Absence Epilepsy v. 61 Juvenile Rheumatoid Arthritis patients Wirrell et al, Arch Pediatr Adolesc Med 1997;151:152-158
Remission 57% of absence epilepsy and 28% of JRA patients.
Absence epilepsy - increased academic, personal, and behavioral disorders (p<.001)
Ongoing seizures - poor prognosis Instead of saying ‘everything is fine’, we need to find ways to improve outcome
Circular Reasoning: Circular Reasoning: Benign Rolandic Benign Rolandic
Epilepsy is BenignEpilepsy is Benign The “Party Line”
99% outgrown No cognitive or behavioral problems Seizures easily controlled
Reality Are thousands of spikes each night really benign?
Increased attention and language disorders
Some are not so easy to control: clusters, aggressive course, poor AED response
Sarah Sarah
Mild epilepsy; considered ‘benign’ Onset at age 4; off meds - age 9 Attention deficit disorder - age 6 Reading comprehension problems at age 8
Problems persisted after meds were stopped
Was there a missed opportunity??
Juvenile Myoclonic Juvenile Myoclonic Epilepsy (JME) is Epilepsy (JME) is Lifelong: ?Wrong!Lifelong: ?Wrong!
JME: an idiopathic (genetic) epilepsy with myoclonic as predominant seizure type; +/- absence, tonic-clonic
A lifelong disorder requiring AEDs - standard teaching in current texts
Except that it is wrong - 25 year followup: one-third are seizure free off meds with no seizures or only myoclonus (Camfield & Camfield)
The Dangers of The Dangers of Expert ConsensusExpert Consensus
MRI offers no real advantage over CT in epilepsy diagnosis - 1986
Ketogenic diet is not effective - 1990 Felbatol (felbamate) is extremely safe – 1993
Experts convince themselves, other doctors and patients
Demand evidence or humility
We get used to what We get used to what we get used towe get used to
What do these all have in common? Lottery winners Quadriplegics Farmers whose roosters rape chickens
People who eat mediocre blueberries Parents of kids with Lennox-Gastaut Syndrome
Failure to ReassessFailure to Reassess Disorders change and evolve New situational factors arise Need to keep a fresh perspective Need to cast a broad differential diagnosis and consider a broad therapeutic strategy
What was is an excellent but sometimes dead-wrong indicator of what is
Errors in Assessing Errors in Assessing RiskRisk
Surgery is too dangerous Living with chronic epilepsy can be dangerous
Changing medications is too risky Change can be risky; No change can be risky
The grass is browner on the other side Breakthrough seizure
Living with chronic side effects has risks We accept the negatives we think we know but fear the change to make them better
Do no harm, but judiciously assess risk
Fear of Failure: Fear of Failure: Loss AversionLoss Aversion
People are loss averse ~ 2:1 ratio, irrationally avoid loss - neuroeconomics
People value what they have more than what they don’t have – Duke tickets Medications? Seizure control? The devil you know…
Doctors like to add medicines more than they like to take them away The gabapentin story
Failure to Understand Failure to Understand FramingFraming
“Surgery is 99.95% safe” is very different than “Someone died from surgery” or “1 in 1500 die”. Substitute benign brain tumor for epilepsy surgery
Mentally invert presentations to better understand pros and cons
Patients must trust their doctors, but they must also assess their doctor’s bias
The neurosurgeon, the radiation oncologist & the neuro-oncologist
Doctors and Patients Move Doctors and Patients Move in Packsin Packs
Doctors are influenced by peers, thought leaders, marketing – they are as susceptible to status quo, texts (eg, JME, absence) framing as are patients
Doctors in different medical centers, cities, and regions have different practices
Patients strongly influence each other – support groups, internet, etc
Humans are Anecdote Humans are Anecdote DrivenDriven
We evolved to understand individual instances very well, not statistics
A moving story about a castaway dog or sick children v. a genocide of ~800k Would you give more for a dog or 100 sick kids?
Rwanda v. OJ Simpson – media coverage Vaccines cause autism (NO!)
Humans are Anecdote Humans are Anecdote DrivenDriven
Sabril (vigabatrin) can cause blindness
Felbatol (felbamate) can be deadly People can become vegetables after spinal taps
You only need to hear about one bad case…and it doesn’t have to be true
Need to examine the evidence
Failure to Failure to Understand NumbersUnderstand Numbers
The medical literature is very confusing, even for scientists and doctors
Few doctors and fewer patients have formal statistical training
The Monte Hall problem AED/blood count/liver tests and Cancer Screening – America often makes the politically correct choice, not the best patient care choice
Failure to be HumbleFailure to be Humble
Most people don’t enjoy admitting that they don’t know something
Doctors are expected to have answers, to have therapies, and if they are honest, people go to other doctors or alternative therapists – catch 22
Tell a white lie or admit ignorance?
Common Errors in Common Errors in TherapyTherapy
Wrong diagnosis Wrong medication selection Failure to use medications systematically Start low, go slow Consider time of doses v. seizure
Benign Rolandic Epielspy Consider strategies to reduce side effects
For dizziness – oxcarbazepine (Trileptal) after solid breakfast, not empty stomach
Failure to document changes carefully Nonadherence (noncompliance)
Fatigue: Diagnosis Fatigue: Diagnosis and Causation and Causation
Premature exhaustion in mental or physical activities, weariness, lack of energy
Common in epilepsy patients AEDs Other drugs (eg, psychiatric drugs) Seizures
Epilepsy wave activity Depression Sleep disorders
Two Great Lies in Two Great Lies in EpilepsyEpilepsy
Seizures don’t hurt the brainThey cause structural and functional impairment that can progress over time
Seizures are never fatalSUDEP
0 25 50 75 100 125 150 175 200
Annual incidence per 10,000 population
Sudden Unexplained Sudden Unexplained Death Death
in Epilepsy (SUDEP)in Epilepsy (SUDEP)General population (2–3)
Epilepsy incidence population (5)
Epilepsy prevalence population (7)
Patients in clinical trials (30–50)
Patients undergoing vagus nerve stimulation (41)
Patients referred to epilepsy centers (50–60)
Surgical candidates (90)
Surgical failures (150)
QOL: QOL: A Different ViewA Different View
QOL - Defined by patient not MD Should patient’s perspective be filtered through “objective medical lens”? - NO
QOL is about listening, changing perspective, and using the patients’ view as ultimate measure of outcome
QOL: Clinical QOL: Clinical RelevanceRelevance
QOL issues most relevant to chronic disorders, problems beyond disease symptoms
Hypertenstion – -blockers v. ACE inhibitors (Experts wrong!)
Epilepsy is a paradigm of a QOL disorders: seizures are infrequent, AED effects, comorbid disorders (depression, migraine) & psychosocial problems are often chronic
Stay Focused Stay Focused PositivelyPositively
Learn to reduce Learn to reduce stressstress
Use your mindUse your mindExerciseExercise