Page 504 - ILAE_Lectures_2015

primary care team can help the individual to understand the implications of epilepsy. The
following checklist for the first review of the patient by the primary healthcare team, after the
diagnosis of epilepsy has been made, may be helpful18:

 Discuss the diagnosis
 Review seizure frequency; consider the use of a seizure diary
 Discuss drugs – the benefits and side effects
 Discuss the impact on the patient’s lifestyle
 Find out what the patient knows and fill in the gaps
 Provide addresses of patient organisations
 Discuss contraception and pregnancy with women
 Agree a timetable for follow-up.

Active epilepsy
About 30% of people who develop epilepsy will continue to have seizures despite treatment
with AEDs, and the Epilepsy Needs Revisited document suggested that most of these will
require further specialist follow-up20. It is to the GP, however, that most people will have
ready access when problems arise. CSAG1 recommended that, for people in whom seizure
control is sub-optimal, a management plan should be formulated jointly by the hospital and
general practice. This would help to alleviate the mismatch which could occur when the
person’s epilepsy is being looked after by secondary or tertiary care, but when the individual
has access only to the GP when acute problems occur. During routine visits, GPs should
monitor drug dosages, seizure frequency, adverse drug effects, adherence to AED regimen
and any other problems1. The NICE guidelines further propose that, for each person with
epilepsy, there should be a comprehensive care plan, agreed between the individual and
primary and secondary care providers, and which includes medical and lifestyle issues19.
People should receive appropriate information and education about all aspects of epilepsy,
and some can be encouraged to manage their epilepsy more effectively through the Expert
Patients Programme11.

Controlled epilepsy
It is generally accepted that those no longer experiencing seizures can be returned to primary
care with provision for re-referral when necessary. The NICE guidelines suggest that people
should have a regular structured review, performed by either the GP or specialist depending
on the circumstances and severity of epilepsy, which should occur at least once a year19. Many
practices in primary care have built in templates for annual epilepsy reviews with the correct
read codes and standardised templates have been incorporated into electronic patient records
to facilitate teaching and to guide the review process.

The GP should re-refer the person to secondary care if the seizures are inadequately
controlled, or if there are specific medical or lifestyle issues, such as pregnancy or
consideration of withdrawal of AEDs.

Those not under current review
There may be problems in attempting to review all people with epilepsy, particularly those
who have not been reviewed for some years. People may not wish to be reminded of the
diagnosis, which may have been denied or concealed21, and there may be anxiety about the
prospect of change22. The best time to offer a review may be when a prescription is due21. In
keeping with the goal of person-centred medicine, it is suggested that the first requirement is
to define the main problems as seen by the person; whether directly seizure related, AED side
effects or psychosocial problems21. The correctness of the diagnosis should be challenged,
the frequency and severity of seizures ascertained, and all aspects of AED therapy, including
adherence to drug regimen, discussed.