Non-Specialist Training Course

Version 12 March 2014

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• Icebreaker - introductions to each other (Name, profession, current posting, interest in and experience of epilepsy)

• Background of the training• Schedule• Pretest

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Non-Specialist Epilepsy Training: Day 1Name of the facilitator/s

8.00 – 8.30am Registration8.30 – 9.00am Icebreaker

Pre-testLearning objectives

9.00 – 10.00am

Introduction• Mental Health Gap Action Programme

(mhGAP)• General principles of care• Public health aspects of epilepsy

Break10.30 – 12.00 Seizures and epilepsy

• Share your experience• What are seizures/ epilepsy?

Lunch1.00 – 3.00pm Assessment and Management of epilepsy I

• When you suspect epilepsy• 4 possible treatment scenarios• Role play 1 (Assessment)

3.00 – 4.00pm Assessment and Management of epilepsy II• Antiepileptic medication• Role play 2 (Management)

4.00 – 4.30pm Recap and Closing

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Non-Specialist Epilepsy Training: Day 2Name of the facilitator/s

8.00 – 10.00am

Emergency management of seizures• Using the mhGAP-IG• First action• What you should do

Break10.30 – 12:00 Advice, Education and Follow up I

• Advice, education and psychosocial support

• Life style issuesLunch

1.00 – 3.00pm Advice, Education and Follow up II• Role play 3 (Psychoeducation)• Role play 4 (Psychoeducation)• Role play 5 (Follow up)Access to treatment: addressing health system barriers

Break

3.30 – 4.00pm Discussions

4.00 – 4.30pm Post-test

4.30 – 5.00pm Conclusion, evaluation, closing remarks

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PRETEST

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Learning objectives

• To be able to assess a person with epilepsy • To be able to assess and manage an acute seizure• To be able to prescribe and monitor antiepileptic

medication• To be able to provide follow-up appropriately• To be able to educate person with epilepsy/family about

their condition and its treatment • To be able to provide psychological support to person

and family.• To be able to understand when it is necessary to refer to

a specialist• To be able identify possible mechanism for improving

individual/family/community access to treatment for epilepsy

• To be able to complete and submit all patient and facility forms for monitoring and evaluation

Introduction

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Mental Health Gap Action Programme (mhGAP)

Play the video

• mhGAP is a WHO programme to scale up care for mental, neurological and substance use disorders

• Launched in 2008• The focus is on increasing non-

specialist care, including primary healthcare, to address the unmet needs of people with mental health disorders

• mhGAP Intervention Guide (mhGAP-IG) is a clinical tool developed by WHO which explains management of priority conditions using protocols for clinical decision-making

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mhGAP-IG modules

1. Depression2. Psychosis3. Bipolar disorder4. Epilepsy5. Developmental disorders6. Behavioral disorders7. Dementia8. Alcohol use and alcohol use disorders9. Drug use and drug use disorders10.Self-harm/suicide11.Other significant emotional or medically

unexplained complaints

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Mental Health and Non-specialized Health Care

• 5 minute group discussion

• What is your current role and responsibility relating to the management of epilepsy and mental health in general?

• Do you think epilepsy and mental health in general can be managed in primary health care? If yes, why?

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General Principles of Care

• Communication

• Assessment

• Treatment and monitoring

• Provision of social support

• Attention to overall well-

being

• Protection of human rights

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General Principles of Care: Communication

• Ensure that communication is clear, empathic, and sensitive to age, gender, culture and language differences

• Be friendly, respectful and non-judgmental at all times

• Use simple and clear language

• Respond to the disclosure of private and distressing information (e.g. regarding sexual assault or self-harm) with sensitivity

• Provide information to the person on their health status in terms they can understand

• Ask the person for their own understanding of the condition

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Epilepsy: Stigma & Discrimination

Many individuals with epilepsy are perceived by the community as weak, inhuman, dangerous or inferior because of their symptoms.

As a result of stigma, these people are excluded or they exclude themselves

• A father about his daughter with epilepsy. “Girls like her are only for house work, bringing her to your clinic is a waste of my time”

• “I can’t come to see a doctor. If someone sees me I’ll never get married”

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In your community

What are the daily challenges for persons with epilepsy?

• Employment?

• Education?

• Marriage?

• Social life?

• Abuse?

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Stigma and discrimination in the health care system

People with epilepsy can experience stigma and discrimination from the health system

• Can you think of any examples from your experience?

• What can you do to fight stigma and discrimination?

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As health providers we can:

• Change our own perception and attitude towards people with epilepsy

• Reaffirm that all persons with all types of disabilities must enjoy all human rights and fundamental freedoms.

• Play a large part in fulfilling these rights

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Why is epilepsy important?

• Epilepsy is common• Prevalence:

• 5 - 10/1,000• Incidence:

• In the developed world:• 40 – 70 /100,000 /year (50 /100,000 /year)

• In resource-poor countries:• 80 – 190 /100,000 /year (120 /100,000 /year)

• People with epilepsy are stigmatized and excluded• Some children with epilepsy are not allowed to go

to school• Epilepsy is life threatening

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Epilepsy is Life Threatening

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Why is epilepsy important?

More people develop epilepsy in resource-poor countriesPossible reasons:• Secondary epilepsy more common (central nervous

system infections and parasites, trauma, stroke etc)

Treatment is simple, inexpensive and effective - 70% can be seizure-free for life after 2 years of treatment

However approximately 75% of people with epilepsy in resource-poor countries do not get treatment: TREATMENT GAP

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Reasons for high treatment gap of epilepsy

Health system:• Epilepsy usually not a

priority for policy makers and clinicians

• Shortage of trained medical and para-medical personnel

• Lack of health facilities where epilepsy can be treated

• Lack of access to medications

• Absence of widespread health insurance

Community:• Cultural expectations• Stigma and

discrimination attached to epilepsy

• Patient’s beliefs• Logistics- expense,

distance from facilities

Reasons vary in different settings

Seizures and Epilepsy

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Share your experience

Has anyone of you witnessed a seizure ?

What did you see?

What are the local names for seizure/epilepsy in the community ? Do these names have negative influence?

What do people in your community believe about causes of epilepsy ? Could you give some examples ?

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Facts and Myths about Epilepsy/seizure

1. Seizures are easily transmitted by physical contact with the person suffering , or by their secretions or objects touched by them - FALSE

2. People with epilepsy are violent or crazy - FALSE

3. Epilepsy is caused by witchcraft, possession, or evil spirits - FALSE

4. Put a spoon into the mouth to prevent biting tongue during a seizure -

FALSE

5. People with epilepsy can not have normal life like others - FALSE

6. Children of people with epilepsy will develop epilepsy as well - FALSE

7. Epilepsy is always a life-long disorder - FALSE

8. With antiepileptic medicines 70% can be seizure-free when treated -

TRUE

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What are seizures?

Seizures are episodes of brain malfunction due to abnormal electrical discharges• Seizures can be classified as generalized or

partial according to the clinical presentation• We will only discuss generalized seizures today

Seizures can cause• Loss of consciousness• Convulsive movements (i.e. involuntary shaking

of body)• Incontinence of urine or stool • Tongue biting

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Typical example of seizure

Show video

https://dl.dropbox.com/u/28723432/Epilepsy%20Training%20Video.pptx

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What is epilepsy?

The condition in which people experience recurrent (at least twice), unprovoked seizures

• Recurrent = usually separated by days, weeks or months

• Unprovoked = there is no evidence of an acute cause of the seizure (e.g. febrile seizure in a young child)

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Difference in terminology (seizure/epilepsy)

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A cause of epilepsy: injury or trauma

If any one of them meet with a road accident and develop seizure immediately precipitated by head trauma.This should not be considered as epilepsy.

BUTIf the person recover and starts having seizures after weeks or months or years later as a result of head trauma.Then it is considered as epilepsy.

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What causes epilepsy?

Complications during childbirthHead injuryBrain infections

• Meningitis, encephalitis, cerebral malariaNeurocysticercosis (tape worm) Genetic, only in some casesSome epilepsy has no known causeStrokeIt is important to note that most epilepsy is not

inherited! People with epilepsy only rarely have children with epilepsy

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How can you help ?

Key actions for managing epilepsy and seizures:

1. Establish communication and build trust with persons with epilepsy and family

2. Conduct assessment taking case history and making diagnosis

3. Plan and start management4. Link with other services and supports 5. Follow up

Assessment & Management of Epilepsy

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When would you suspect epilepsy?

Master Chart, page 7 of the mhGAP-IG

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Principles of Care: If you suspect epilepsy, what do you do?

1. Take a full history (with New Patient Form) and do a physical examination, particularly:

1. Number of seizures in the last year (to determine if seizures are recurrent)?

2. Is there an acute cause for the seizures (to determine if the seizures are unprovoked)?

2. Ask for further information from carer/family

3. Assess, manage or refer, as appropriate, for any concurrent medical conditions

4. Assess for psychosocial problems, noting the past and ongoing social and relationship issues, living and financial circumstances and any other ongoing stressful life events

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Are there convulsive seizures?

Convulsive seizures are possible if there are convulsive movements plus 2 or more of the criteria below:

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If there are convulsive seizures, what next?

• Ask about and look for acute causes for the seizures

• Ask about• Fever (especially relevant in young children)• Headache • Meningeal irritation (e.g. stiff neck) due to

meningitis• Loss of consciousness, abnormal muscle tone

and posture (?cerebral malaria) • Was there a head injury?

• Metabolic abnormality (hypoglycemia, hyponatraemia)

• Alcohol or substance use/withdrawal

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What if there is not an acute cause?

Has the person had at least 2 convulsive seizures in the last year that occurred on 2 different days?

Ask• "How many seizures have you had in the last

year?"• "Were these seizures on different days?"

If the answer to all three steps is yes then the person is likely to have convulsive epilepsy

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mhGAP-IG (p.34)

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mhGAP-IG (p.35)

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Thus there are 4 possible scenarios

1. Non-convulsive seizures• If the abnormal movements are recurrent or if

there is any doubt consult a specialist• Follow up in 3 months

2. Convulsive seizures due to an acute cause (not epilepsy)

• Treat the acute cause of seizures• Refer to a hospital if neuro-infection, head

trauma or metabolic abnormality are suspected• Antiepileptic maintenance treatment is not

required• Follow up after 3 months and re-assess for

epilepsy

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4 possible scenarios

3. Only one convulsive seizure in last year and no acute cause (not epilepsy)

• Anti-epileptic maintenance treatment is not required

• Follow up in 3 months • If there are further seizures, re-assess for

epilepsy

4. Two or more convulsive seizures in the last year and no acute cause (epilepsy is likely)

• This scenario is the focus of this module

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Role play 1: Assessment

For the healthcare provider: A person new to your clinic comes in for an appointment. Assess the possibility that the person had a seizure.

For the person: You have had a fainting spell about a week ago. You didn't think it was a big deal, but your spouse has insisted that you see the doctor because you were shaking on the floor for about 1 minute. Afterwards, your spouse tells you that you were unresponsive for 5 minutes, but you were breathing. You have not had any health problems before this. You don't want to tell anyone.

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Management of epilepsy involves

Medication • Prescribing and monitoring antiepileptic drugs

(The vast majority of seizures can be controlled by antiepileptic drugs)

Education, people need to know about • The details of the condition• Lifestyle and safety issues• The importance of treatment adherence• How they will be followed up

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Medication: Choice of drug

Try to prescribe a drug that is always available in your area

Avoid prescribing expensive drugs • Good choices include phenobarbital, carbamazepine, phenytoin, or valproate (valproic acid)

Which antiepileptic drugs are available in your area?

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Starting Antiepileptic Drug TherapyRead mhGAP-IG p 37 section 2.1

• Start with one drug only

• “Start low, go slow:" start at a low dose and slowly increase

• Ask the person and family to keep a seizure diary

• If the person is on other long-term medications, consult the national or WHO formulary for possible drug interactions

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Example of a seizure diary

Ask the person (and carer) to keep a record of seizure history

What happened?(description of seizure)

When?(Day; time)

What medication did the person take?

Yesterday Today

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Starting Dose & Maintenance Dose

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More information about the medications

Please open mhGAP-IG to page 38

• In section 2.3 Pharmacological Treatment and Advice

• In section 2.3, read about anti-epileptic drugs that are available in your area

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Common side-effects of Anti-Epileptic Drugs

Dose Dependent Other

Phenobarbital Drowsiness, behavioral disturbance, hyperactivity

Phenytoin Drowsiness, double vision, ataxia. Long-term: gum hyperplasia, coarse face (children), hirsutism

Carbamazepine Drowsiness, blurry vision, double vision, dizziness, nausea, ataxia

Hyponatremia (usually asymptomatic)

Valproic Acid Drowsiness, tremor, weight gain, transient hair loss

Pancreatitis, thrombocytopenia, highest risk of hepatic failure

ALL can cause allergic reaction, bone marrow suppression, and hepatitis

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Dangerous side effects and drug reactionsPhenobarbital Excessive drowsiness Bone marrow suppression

• Low white blood count • Low red blood cell count• Low platelets count

Hepatic failureCarbamazepine Stevens-Johnson syndrome (right picture)

• Rash involving the eye or mouth membranes associated with a fever

Sodium Valproate (Valproic acid) Hepatitis or impaired hepatic

function Pancreatitis

REFER IMMEDIATELY!

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Side Effects (Phenytoin)

Phenytoin• gum hyperplasia

(overgrowth)• Skin rash: consider

Stevens-Johnson Syndrome

• Anemia or other blood problem

• Hepatitis

In all cases, REFER!

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Common Drug Interactions

Level increased by Level decreased by

Phenobarbital Valproate, Phenytoin, Sulfa drugs

Phenytoin Isoniazid, Rifampin, Valproate, Cimetidine, Fluoxetine

Carbamazepine Erythromycin, Isoniazid, Cimetidine, Fluoxetine

Phenytoin, Phenobarbital

Valproic Acid Azidothymidine, Tricyclic anti-depressants

Phenytoin, Phenobarbital

Oral Contraceptive Pills, Protease

inhibitors, Warfarin

Decreases Levels of

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Education: medication

Explain to the person and family

• The need for prompt medical treatment

• The time to onset and duration of treatment

• Potential side effects and what to do if they occur

• The risk of further seizures if missing doses

• The importance of follow-up and plan for follow

up

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Quiz time

What is the starting dose for adults? Maintenance

dose?

Is the medication given once or twice daily?

What is the starting dose for children? Maintenance

dose?

What are the side effects?

What would you do if the person experiences side-

effects?

How would you monitor progress and side effects?

What would you do if seizures continue despite

medications?

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How to manage a child with epilepsy and intellectual disability and behavioural problems?

Always assess children with epilepsy for intellectual disability and behavioural problems

If there is intellectual disability and behavioural problems• Consult with a specialist for management of epilepsy• Avoid phenobarbital and phenytoin

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Special management for women with epilepsy

Always give folate 5 mg/day to prevent birth defectsAvoid valproate which can cause birth defectsIf pregnant

• Consult with a specialist for management• Avoid using more than one antiepileptic drug • Advise hospital delivery and more frequent

antenatal visits• At delivery, give 1mg vitamin K IM to the

newborn The anti-epileptic medicines presented in this module

are safe for breastfeeding. However, please be aware that some other anti-epileptic medications may NOT be safe. Always consult a specialist

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How and when to stop antiepileptic drugs

No seizures within the last 2 yearsDiscuss the decision to stop medication with

person/carer, weighing up the risk of the seizures starting again

In some cases of epilepsy, long-term antiepileptic drug therapy might be required

Reduce treatment gradually over 2 months

Refer to a specialist if you are not sure to stop antiepileptic medications

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FAQs about anti-epileptic drugs

1. What should I do if I miss a dose?

2. My prescription is 250mg twice a day but I only

have a 500mg. Can I break it in half? Can I take

500mg once daily?

3. Do I take the drug every day when I'm not having

seizures?

4. How long should I take the medication?

5. What should I do if I am planning a pregnancy?

6. Should I keep on breastfeeding my baby?

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Key messages about anti-epileptic medication

• Taking the medication as prescribed is essential• Consult your healthcare provider in case of

recurrence of seizures or side-effects• Consider stopping treatment if there have been no

seizures for two years. • Explain that there is a risk of seizure recurrence after

stopping the medication (10-20%).• It should be done in consultation with family

• For women of child bearing age • Give folic acid and avoid valproate• Plan hospital deliveries and give the newborn 1mg IM of Vit

K• Breastfeeding is safe

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When to refer

• Side effects and drug reactions• Poor seizure control• If you are not sure how and when to stop

antiepileptic medications• If you are not sure whether it is epilepsy or not (to

confirm the diagnosis)

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Role Play 2: Management

You are a primary care provider

A person who has had two seizures in the last month has come to visit you.

After your assessment, there is no clear cause of the seizures and the person is otherwise well

Discuss your treatment plan with the person with specific focus on the medication you will use, including its risks and benefits

Emergency Management of Seizures

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Why is management of seizures an emergency?

• Prolonged or repeated seizures can result in brain injury

• Prolonged or repeated seizures can result in death if not treated immediately

• Seizures can be a symptom of a life-threatening problem, like meningitis

• Treatment can end seizures or shorten seizure duration

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What do you need for management of an acute seizure?

Equipment

Light Source for checking pupils

IV Canula and givingset1

Syringes

Needles appropriate for deep IM injections

Materials for stabilizing the neck in case of trauma (can

be made locally)

Blood pressure cuff

Stethoscope

Thermometer

Glucometer or other ability to measure serum glucose

Medications

50% glucose IV fluid

Diazepam/Lorazepam for IV delivery

Oxygen and tubing for delivery via facemask2

Phenobarbital and/or Phenytoin for IV delivery

Special situation

Magnesium sulfate for IM delivery

2% Lignocaine

Hydralazine for IV delivery

Antibiotics/Antimalarials

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Using the mhGAP-IG for acute seizures

A person is brought into the clinic, and is unconscious

We will now use the mhGAP-IG to assess and manage our case study

Open the mhGAP-IG p 32

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Case Study: Group discussion

What are always your first actions

ABCs• Check airway• Ensure breathing• Check for good pulses and circulation

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First action in All Cases: Check ABCs

1. Airway2. Breathing3. Circulation

DO NOT leave the person alone

Place in recovery position

Make sure NOTHING is in the mouth

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Do not force anything into the mouth during a seizure

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If the person is still unconscious, use the recovery position

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What you should do ?

Stay calm.

Loosen any tight clothing and remove eyeglasses.

Clear the area of any potential hazards, but do not interfere with their movements

If you can do so safely, turn the person’s body to the side to permit the draining of fluids.

Something soft should be placed under the head.

Stay with the person. Continue to monitor the person after the seizure.

Assist him/her to a quiet comfortable place and allow time to rest

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What you should NOT do ?

Do NOT attempt to stop the seizure with physical form!

Do NOT restrain the person or try to hold them down in any way!

Do NOT force anything between their teeth or put anything in their mouth!

Do NOT give the person anything to eat or drink until s/he has fully recovered consciousness!

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Measure and document vital signs

1. Blood Pressure2. Temperature3. Respiratory rate

These must be measured and accurately documented

In particular, respiratory rate should be counted. The patient may be using drugs that cause respiratory depression

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What to look for on physical examination?

• Signs of head and/or spinal trauma

• Pupils: Dilated? Pinpoint? Unequal? Unreactive?

• Signs of meningitis: stiff neck, vomiting

• Weakness on one side of body or in one limb• In unconscious people, who are unresponsive

to pain, you may notice that one limb or side of

the body is “floppy” compared to the other

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What should you ask?

To assess severity:1. If unconscious, ask an accompanying person:

“Has there been a recent convulsion?”2. How long was the impaired

consciousness/convulsion?3. How many episodes of convulsions were there?

You also need to ask about:4. Head trauma or neck injury5. Fever, vomiting, headache (to assess for

meningitis)6. A history of epilepsy7. Other medical problems (see next slide)

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Ask about other medical conditions

1. Are they diabetic? Are they on any medications?• Could this be low blood sugar?

2. Are they HIV-positive? Are they on any medication?3. Could this be an infection(e.g. meningitis, cerebral

malaria)? 4. Is there any chance of poisoning?5. Could this be electrolyte imbalance (e.g.

hyponatremia)?6. Is this person a drug user or a heavy drinker?

• If yes, in addition to managing their acute seizures, you will need to do an assessment according to the Drug and Alcohol Use sections of the mhGAP-IG or refer

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Case study continues

The person starts to convulse again.

What are always your initial actions

First action in all cases; ABC• Airway • Breathing • Circulation

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Further management of acute seizure

Start intravenous fluids• IV Glucose slowly, 30 drops/minute

Adults: Give IV Diazepam 10mg slowly OR IV Lorazepam 4mg slowly

Children: Give diazepam IV 0.2 -0.5 mg/kg slowly (maximum 10 mg) or lorazepam IV 0.1 mg/kg(maximum 4mg), if available

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I cannot get the IV placed! What should I do?

If you cannot place an intravenous cannula• DO NOT GIVE IM DIAZEPAM, it is poorly and

erratically absorbed• Give rectal diazepam

• Use the rectal formulation if available• If the rectal formulation is not available, the IV formulation

can be used• Adults: 10mg • Children: 0.2 – 0.5 mg/kg (maximum 10mg)

Do not forget to place an IV cannula after the seizure has stopped

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Rectal diazepam

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What if the seizure doesn't stop?

• It could be Status epilepticus Status epilepticus is defined as:

1. More than 30 minutes of continuous seizure activity OR

2. Two or more sequential seizures without full recovery of consciousness between seizures

What would you do? Use the mhGAP-IG to answer.

• If the seizure does not stop 10 minutes after the first dose of diazepam, give a second dose of the same amount

• Refer the person to hospital as this is an emergency

• Do not give more than 2 doses of diazepam

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What if you suspect a brain infection or trauma?

If there are signs and symptoms (e.g. fever, vomiting, rash)

1.Manage the seizure as we have discussed

2.Initiate treatment:- For brain infection (IV antibiotic for meningitis, etc)- For trauma (Stabilize the neck, etc)

3.Refer to hospital as this is an emergency

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What if the woman is pregnant and has seizures?

A pregnant woman who has no history of epilepsy and presents with seizure may have eclampsia

Eclampsia is a condition in which one or more convulsions occur in a pregnant woman suffering from high blood pressure, The condition poses a threat to the health of mother and baby

If there is a midwife in your clinic, call them to assist. They may have had training in how to manage eclampsia

Refer to a hospital as this is an emergency

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What if the person is a child with fever?

It could be a febrile seizure

Febrile seizures are events occurring in children (3 months to 5 years of age) who are suffering from fever and don't have any neurological illness or brain infection

Two types of Febrile Seizures1. Complex, these need to be ruled out2. Simple Febrile Seizures

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What is a complex febrile seizure?

Please open the mhGAP-IG to page 34 and read the red box

It is a complex febrile seizure if one of the criteria is present

• Focal – starts in one part of the body• Prolonged – more than 15 minutes• Repetitive – More then 1 episode during the

current illness

A complex febrile seizure needs to be referred to hospital

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Management of simple febrile seizures

1. Look for possible causes and manage fever according to the local IMCI guidelines

2. Observe for 24 hours

3. Follow-up in 1-2 months to assure no further seizures

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Summary for acute seizure management

1. Why is the management of seizures an emergency?1. Prolonged seizures can cause brain injury and death2. Seizures can be a symptom of another disease (e.g.

meningitis)

2. If a person presents convulsing in your clinic, what are the initial actions that you should take?

1. ABC and positioning 2. Asses and manage simultaneously

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Key messages from acute seizure management

• Seizures are a symptoms not a cause, you need to look for a cause

• If the person presents convulsing it is an emergency and needs to be treated urgently

a) seizures can a sign of a life-threatening problem

b) seizures can result in brain injury or death!

• In persons who are having seizures, assessment and management should be done at the same time

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When to refer

• Suspected brain infection, trauma, metabolic abnormality

• If the seizure continue after first dose of diazepam• Suspected Eclampsia• Complex febrile seizure

Advice, Education and Follow up

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Advice, Education and Psychosocial Support

• Education needs to be provided to the person and the family

• If alone, ask the person to attend with important family at the next appointment. Repeat the education at that time

• You can train a social worker or community health worker to offer education and psychosocial support

• What would you do if people do not want to tell their family that they have epilepsy?

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Advice, Education and Psychosocial Support

• Explain what a seizure is and what epilepsy is

• Be clear that epilepsy is not contagious

• Discuss the nature of the seizures and the possible causes

• Make certain they understand that this is a chronic condition. The person will need to be on medication for at least 2 years

• Warn them about rebound seizures if the medication is stopped abruptly

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Advice, Education and Psychosocial Support

REASSURE • Most people with epilepsy can control their

seizures with medications DISCUSS

• Explain treatment options and possible referrals

PROVIDE • The family needs detailed plans for what to do

when a seizure occurs at home

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When a seizure occurs at home

Action for the person• If there are warning signs, lie down in safe place to avoid a

fall or injury

Action for the carers• Make certain the person is in a safe place

• Move any sharp or dangerous objects in their vicinity

• If they are near fire or a body of water, move them to a safe area

• Put the person in the recovery position (image on next slide)

• Make sure that the person is breathing properly

• Do not try to restrain or put anything in the person’s mouth

• Stay with the person until the seizure stops and they wake up

• Remind the carer that epilepsy is not contagious

93 |mhGAP-IG base course - field test version 1.00 – May 2012 93

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Support (life style issues )

Explain• People with epilepsy can lead normal lives • They can marry and have children• It is rare for a person with epilepsy to have

children with epilepsy• Parents should not remove children with

epilepsy from school

You may need to contact the school if the teachers are unwilling to take a child with epilepsy

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Safety Risks (life style issues )

People with epilepsy can do most jobs but should avoid• Heavy machinery• High places • Collecting water from open bodies of water

People with epilepsy should avoid swimming alone and cooking on open fires

You need to discuss how the family can accommodate lifestyle changes, e.g. can someone else do the cooking or observe while the person is cooking?

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Safety Risks (life style issues )

People with epilepsy should avoid

• Excessive alcohol

• Recreational drugs

• Sleep deprivation

• Flashing lights

National laws related to the issue of driving and epilepsy need to be observed

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Review Questions (Education)

What should the carers do if the person has a seizure at home?

What are some of the risks that people with epilepsy should avoid?

What can you do to help keep a child with epilepsy in school?

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Role play 3: Psychoeducation

• You have made a management plan for a person with epilepsy

• The person works in a rice field everyday. The field is covered in water up to the knee. The person cooks dinner for the family with an open fire every night

• The healthcare provider must explain that the risks of epilepsy in relation to the person's working and social life

• After explaining, the healthcare provider will answer the person's questions with advice, education and support

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Role play 4: Psychoeducation

• You have made a management plan for a 8-year boy with epilepsy

• The parents are worried about him taking medication but equally worried about the risks of further seizures

• His seizure event at school created panic in the class room, his teacher has requested his parents to take him back and admit him in a special school. The parents and the teacher come to visit you.

• The healthcare provider must explain that going to school is not a risk and that the parents and teacher should not remove the boy from school

• After explaining, the healthcare provider will answer the parents and teacher's questions with advice, education and support

100 |

Link with other services and supports

In your community,What are the services and supports available for

people with epilepsy?

Whom would you contact for specialist support?

Are there services and other resources to help people with their needs for• Employment• Equal access to education• Being part of community activities

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Follow up

Confirm that the person and family understand the plan for treatment and follow up

Follow up• once a month for the first 3 months• then once every 3 months

Explain that the person can come in whenever needed and that the person should come in immediately if there is another seizure

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Follow up: What to ask at your appointment1. Is seizure frequency getting better or worse

• Are they keeping a seizure diary?

2. Have there been drug specific side effects? • Make sure to check the list of possible side

effects

3. Assess treatment adherence • Have they taken their medications as directed?

If not, why?

4. Any other issues? • e.g. problems in the community or family?

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Follow up

What do you do if the person experiences side effects?• If the side effects are minor, try decreasing the

dose• Some side effects will require that the medication

be stopped (e.g. Stevens-Johnson syndrome)

Some side effects are not dose-dependent. If the person has these, the medication needs to be stopped

The best dose is the smallest that gives seizure control

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Follow up

What do you do if there are more seizures?

Check the adherence to medicationIf the person is taking the medication and still has

seizures, increase to the maximum dose or the highest tolerated dose

If there is still poor seizure control• Refer to a specialist • Do not add another medication

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Follow up

• If there are side effects or poor response, follow up monthly

• If seizures are infrequent and high medication doses produce side effects, it may be better to accept some seizures

• You must meet every 3 months, even if the seizures are well controlled

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Role play 5: Follow up

• You have started the person with epilepsy on phenobarbital

• They have been taking the medication for 1 month and have come in for the first follow up appointment

• Conduct the follow up appointment according to what we have learned in the last slides

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Key messages

• Epilepsy is not inherited or contagious• Assessment has two key steps

• Determine if the person has convulsive seizures• Rule out acute causes

• Epilepsy can be treated effectively with anti-epileptic drugs in non-specialized healthcare

• Adherence to treatment and regular follow up are critical

• The person and the family need education and support

• People with epilepsy can lead normal lives• Children with epilepsy can go to a normal school

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Improving access to treatment (participatory group activity )

Purpose of this activity is to find out potential barriers toward accessing treatment for epilepsy at individual, family and community level.

Identify potential health system barriers in providing effective management for epilepsy at primary care level . (E.g. health professionals knowledge, attitude ,and behaviour )

Activity: Brainstorm and identity the problems and potential intervention.

Bring out possible strategy and intervention to improve the access to treatment for epilepsy.

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Intervention matrix

After the brainstorm session, the groups will list out the identified barriers /problems and opportunity for intervention

Identified problems /barrier

Desires situation /condition

Intervention /strategies