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Significant improvement in quality of life (tx effect 7.1 pts)
Significant improvement in cognitive performance
No difference when working memory training was added
Patients reported high satisfaction with HOBSCOTCH
There are 2 million people in the US living with epilepsy.
Problem: New medications & treatments ≠ success
Comorbidities affect quality of life more than the seizures.
30% will have depression
50% will have cognitive impairment
Untreated comorbidities affect:
Seizure control & management
Employment, productivity
Activities of daily living
Social relationships
85% of epilepsy costs are indirect; epilepsy causes 89.4 million days/year of “role impairment” in the US.
Gap in care: limited treatments to address comorbidities . (Institute of Medicine report, 2012)
Improving Memory and Quality of Life In Epilepsy Tracie A. Caller, MD, MPH
COGNITIVE FUNCTION in EPILEPSY
COGNITION
SEIZURES
OUR AIM:
RATIONALE
Setting: Dartmouth-Hitchcock Epilepsy Center (DHEC), a Level 4 Epilepsy Center providing care to 1500 patients per year in a rural 3-state setting (NH, VT, ME).
VISIT 1: In Person
•Memory Education & Reattribution
• Intro to PST
•Receives HOBSCOTCH Workbook & Day Planner
• Training in relaxation techniques
VISIT 2-7: Phone Call
•Using PST to address memory problems in the domains of organization, disease management, & social skills.
• Exercise solutions as homework
•Ongoing education about memory strategies by the memory coach
VISIT 8: In Person
•Review progress
•Develop maintenance plan
• Encouragement to continue learned skills HOBSCOTCH plus (H+): added
Nintendo DS® Brain Age©
training 5 times /week
The workbook guides
patients through each
session & teaches
memory strategies
GLOBAL AIM: To improve the recognition and treatment of comorbid cognitive dysfunction in the adult epilepsy population.
SPECIFIC AIM: To implement a self-management program for adult epilepsy patients reporting cognitive dysfunction, to improve quality of life, memory function, seizure control, & patient/provider satisfaction.
Most patients screened reported memory & attention problems which interfered with daily life.
Treating concurrent depression did not consistently improve memory.
Gap: No current treatments to address memory/cognition.
INTERVENTION & MEASURES:
HOBSCOTCH was created by a multidisciplinary group to address patient needs & minimize barriers to treatment.
HOBSCOTCH is an 8-week self-management intervention delivered in 1-hour sessions by an ARNP or RN, providing:
Psychoeducation
Self-awareness training & reattribution
Memory compensatory strategies
Application of these strategies in day-to-day life using problem solving therapy (PST).
HOBSCOTCH plus (H+) performed additional cognitive training using Nintendo DS® Brain Age© program.
RESULTS CONCLUSIONS & NEXT STEPS
QOLIE-31 score (SE)†
Worry 59.5 (3.8) 9.1 (3.2) -2 (3.9) 11.1 (0.7, 21.4) 0.04
Quality of Life 61.9 (1.8) 2.1 (2.7) -6 (3.3) 8.2 (-0.8, 17.1) 0.07
Emotion 66.4 (2.3) 0.3 (3.5) -8.6 (4.3) 8.9 (-2.7, 20.5) 0.13
Energy 45.6 (2.5) 5.2 (3.2) -6 (3.9) 11.1 (0.5, 21.7) 0.04
Cognitive 40.5 (2.3) 9.3 (3) 5.3 (3.6) 4 (-5.8, 13.8) 0.42
Medication 49 (4) 7.7 (5.3) -6.5 (6.5) 14.2 (-3.3, 31.8) 0.11
Social 56.6 (3.6) 2.5 (3.7) -2 (4.6) 4.5 (-7.8, 16.8) 0.47
QOLIE-31 overall score 53.2 (1.7) 5 (2.2) -2.2 (2.7) 7.1 (0, 14.3) 0.05
RBANS score (SE)‡
Immediate 85.7 (2.1) 4.3 (2.3) 1.7 (2.8) 2.5 (-5, 10) 0.5
Visuospatial 87.3 (2.4) 3.7 (2.9) -1.2 (3.6) 5 (-4.5, 14.4) 0.3
Language 86.4 (2) 1.6 (2.6) -2.8 (3.2) 4.4 (-4.2, 13) 0.31
Attention 86.2 (2.8) 2.9 (2.4) -8.9 (3) 11.7 (3.7, 19.8) 0.005
Delayed 80.3 (2.8) 6.4 (2.4) 2 (3) 4.4 (-3.6, 12.4) 0.27
RBANS total score 80.6 (1.9) 4.9 (1.6) -2.3 (2) 7.1 (1.9, 12.4) 0.009
PHQ-9 total score (SE)§ 9 (0.7) -0.7 (1) 1.2 (1.2) -1.9 (-5, 1.3) 0.23
NDDI-E depression score (SE)¶ 14.1 (0.5) -0.4 (0.6) 0.7 (0.8) -1.1 (-3.2, 1) 0.3
FACT-COG score (SE) 66.1 (3.5) 11.4 (4.7) 6.3 (5.7) 5.1 (-10.3, 20.6) 0.51
BRIEF-A Global Executive
Composite score (SE) 66.9 (1.3) -2.9 (1.3) -0.5 (1.5) -2.4 (-6.5, 1.7) 0.25
Outcomes age-adjusted Baseline (49) H/H+ (29) Controls (20) Txt Effect p-value
Screening can identify comorbidities that impact quality of life, but interventions to address them are needed.
HOBSCOTCH is a self-management program which improves quality of life and objective cognitive performance in patients with epilepsy.
This intervention may be applicable to other patient populations or clinical settings.
Next steps: Expanding to other clinics/populations, & assessing cost-effectiveness .
HOBSCOTCH is part of the CDC’s Managing Epilepsy Well Network and is supported by the CDC (3U48DP001935-04S3)
Co-Authors: Robert Ferguson, PhD, Robert Roth, PhD, Karen Secore, ARNP, Faith Alexandre, Wenyan Zhao, PhD, Tor Devin Tosteson, ScD, Patricia L. Henegan, MS, Barbara C. Jobst, MD.
Affiliations: Leadership Preventive Medicine Residency, & Department of Neurology, Dartmouth-Hitchcock Medical Center; The Dartmouth Institute for Health Policy & Clinical Practice, Hanover NH; Cheyenne Regional Medical Group., Cheyenne WY
INITIAL WORK TARGETED SCREENING & TREATING DEPRESSION:
Cost of intervention, reimbursement
Time burden
Resources, training
↑ QOL, memory, function
↓ Memory-related anxiety
↓Health care utilization (ED visits, admissions)
Societal costs, Employment
MEASURES