Epilepsy is a common and complex neurologic condition marked by recurrent seizures. It has been diagnosed in more than 87,000 veterans enrolled in the VA health care system, 16% of whom have comorbid traumatic brain injury (TBI), and nearly 25% also have posttraumatic stress disorder (PTSD).1 These comorbidities were even more common in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans: TBI in 52.6% and PTSD in 70.4%. With 25 drugs for seizures and 2 approved devices, treatment of epilepsy can prove challenging to providers whose goal is to balance seizure control and adverse effects (AEs).
Despite the therapeutic armamentarium, about one-third of people with epilepsy have poorly controlled seizures, and an untold number may experience delays in referral to higher levels of epilepsy care or undergo troubling antiepileptic medication AEs and comorbid psychiatric disorders that have profound impacts on quality of life (QOL).
Quality generally has been defined as “providing the right care to the right patient at the right time and in the right way to achieve the best possible results.”2 Much work has been done over the past 2 decades to identify “the right care” for epilepsy patients.3
The American Academy of Neurology (AAN) has developed evidence-based, clinically focused guidelines on numerous topics, including antiepileptic drugs and women’s health, and has developed quality measure sets.4,5 More broadly, the Institute of Medicine (IOM) proposed 13 recommendations, including improving quality of care, establishing epilepsy centers and an epilepsy care network, educating health professionals about epilepsy, and providing education for people with epilepsy and their families.6
Within the VA, health care for veterans with epilepsy is changing in part by the Epilepsy Centers of Excellence (ECoC), established by federal law. The ECoE’s primary missions are to improve quality of and access to epilepsy specialty care to improve the health and well-being of veteran patients with epilepsy and other seizure disorders through integration of clinical care, outreach, research, and education to VA providers and patients.7
The goal of this article is to outline the key elements of quality epilepsy care and make recommendations for providing quality care in the VA health care system.
Diagnosis and Seizure Types
Quality care for veterans with epilepsy begins with the provider reviewing pertinent history and establishing the clinical characteristics of the patient’s seizures and epilepsy. The provider should ask about the first signs of the seizure or warning (aura), the seizure (ictal period), and the period after the seizure (postictal period). Seizure histories from the patient and observers are critical.
The first step is to define whether the patient’s seizures are generalized, that is, start all over the brain at once, or focal, starting in one area of the brain. The patient’s initial sensation at the onset of a seizure (aura) may help localize onset and define focal seizures. For example, déjà vu sensations often point to seizure onset in the mesial temporal lobe and hippocampus. Focal seizures can spread and cause cognitive dysfunction, including aphasia and amnesia, or evolve into a generalized convulsion (tonic-clonic seizure). Many patients present with a generalized tonic-clonic seizure and have had brief focal seizures that were not considered seizures by the patient or by other providers. This seizure type should be clarified by asking specifically about paroxysmal symptoms. For example, brief periods of confusion that are episodic may be focal seizures. In general, focal seizures are stereotyped and may have a feature that helps in establishing the diagnosis. Many temporal lobe seizures are associated with lip smacking behaviors (oral buccal automatisms).
Tonic-clonic seizures may begin without an aura and are generalized from onset. Patients with this type of seizure may have electroencephalogram (EEG) findings that define a generalized abnormality, which consist of frontocentral spike and wave discharges in the EEG. In the VA population, the first generalized tonic-clonic seizure may occur while in the military. Some of these patients have juvenile myoclonic epilepsy, and a history of brief jerks on waking (myoclonus) may have been occurring but not recognized as seizures. The treatment of seizures, in part, depends on whether they begin focally or are generalized at onset.
Often people with epilepsy have multiple seizure types. The types of seizures should be documented and, if possible, corroborated by a witness. Epileptic seizures tend to be stereotyped and of relatively brief duration, usually < 2 minutes. The period after a seizure may be followed by a more prolonged period of neurologic dysfunction that includes confusion and fatigue. These symptoms may be the only indication that the patient has had a seizure.
At each clinic visit, the characteristics of the patient’s seizures should be reviewed and the frequency of seizures documented. A calendar to track seizure frequency is helpful to understand precipitating factors and response to treatment.
The health care provider (HCP) should look for the cause of a patient’s epilepsy. It is important to ask the patient about family history, age of first seizure, occurrence of febrile seizures, developmental history, past history of meningitis or encephalitis, history of childhood seizures or spells, and history of brain lesions, including tumors, strokes, or TBI. Most patients with epilepsy do not have a clear cause for their epilepsy, but the cause may be clarified with EEG and magnetic resonance imaging (MRI) testing.