Seizure Management Across Health Care Settings: Long-Term Care Perspective

Donald Vollmer, MD, and Winston Wong, PharmD, highlight the long-term care perspective on seizure management, aiming to cover seizure identification and drug treatment considerations for the older adult patient population.

• Speaker: Donald E. Vollmer, MD, Medical Director, Millennium Care & Rehab, Huntsville, TN
• Moderator: Winston Wong, PharmD, President of W-Squared Group, Longboat Key, FL

This video series is sponsored by Sunovion Pharmaceuticals, Inc and is part of a 4-part series on “Seizure Management Across Health Care Settings.” View the rest of the series here.

Read the full transcript:

Dr Wong: Welcome to an installment of PopHealth Perspectives, seizure management across healthcare settings. We have Dr Donald Vollmer who represents the long-term care perspective. Dr Vollmer is the medical director of Millennium Care and Rehab, as well as the medical director of several other healthcare facilities, such as NHC Murfreesboro and geriatrics consulting. He is a hospice and palliative medicine specialist in Tennessee, specializing in family medicine and geriatric care with over 17 years of experience. Welcome Dr Vollmer.

Dr Vollmer: Oh, thank you so much.

Overview of Seizures

Dr Wong: To initiate our discussion Dr Vollmer, what is the impact of seizures on the elderly or asked in a different way, what is the burden of illness?

Dr Vollmer: Well, in dealing with seizures, especially in long-term care, there's of course increasing in falls, the quality of life can be impacted negatively as far as injuries that can occur, the burden of medication load added to that patients have to take, the cost of the medication, the fear that a lot of the residents have of having seizures when they're walking. A lot of them have had a fall as a result of the seizure. Perhaps they've been in a car wreck at some point of their life because of a seizure. And so, they very frequently will limit their activities because of their fear of having seizures.

Dr Wong: So, thinking of the long-term care facility, what are the challenges for patients with seizures?

Dr Vollmer: There’s challenges that they have just as far as ... like I talked about limiting their quality of life, side effects of medications that can make them very fatigued or grumpy, make it harder for them to participate in activities. A lot of them will limit what they do because they're fearful of having a seizure, or people seeing them have a seizure, because very often it's very memorable. There's a lot of times the seizures can be very painful. When they wake up, they may have bit their tongue, damaged their teeth, or injured themselves in some other way.

Diagnosis of Seizures

Dr Wong: So, as we dive a little more into identifying the types of seizures that occur in the elderly in long-term care facilities, how are these seizures recognized and how are they diagnosed?

Dr Vollmer: A lot of them come into the facility and they already have a clinical diagnosis, usually of focal seizures. So, most of them have already been identified. But a lot of them will have a grand mal seizure; that's very obvious where the staff reports them passing out and then writhing around, biting their tongue, possibly losing consciousness. So, in those cases it's pretty drastic. But I just had a case the other day where I newly diagnosed seizures where the patient was in therapy, been very alert and oriented, and suddenly the nurses called me and they said they just aren't themselves. They just suddenly are very slow in speech, very confused, not knowing where they are, just like, they're a completely different person. And it just happened suddenly and so at that point, I made the diagnosis empirically of focal seizures and started treatment for focal seizures.

Dr Wong: Is it common that in a long-term care facility that seizures, in general, would be missed or disregarded by the nursing staff or other care providers?

Dr Vollmer: Yeah, very frequently. Of course, a lot of times they're just nodding off. They're already a demented population very frequently where they're not able to give a good history. So, sometimes seizures are very subtle, absence seizures where there's really almost nothing noticeable or staring, just very minor facial movements. And so very frequently that is not recognized by the staff, but just confusion, altered level of consciousness. A lot of times, unnecessary emergency room visits because they're just not themselves is typically what we hear; where the family says that they've changed, and there are a lot of workups for urinary infections, lots of blood work, just trying to figure out why these people suddenly have this change in their level of consciousness.

Dr Wong: As we talk about trying to recognize or identify new seizure patients in a long-term care facility, how do you recognize the focal seizure versus a non-seizure condition?

Dr Vollmer: Generally, what I notice with seizures is just how sudden there's a change in level of consciousness. People are very postictal; where they're fine one minute and then literally very confused, disoriented, and have a significant different level of consciousness just seconds to minutes later. Other conditions that cause the delirium, or a change in the level of consciousness, tend to happen much more slowly. The other thing is too, when they're postictal they tend to clear up very quickly as well. And so, it's kind of the timing and duration that are the biggest clues for me.

Dr Wong: So, I'm assuming then, as you kind of mentioned, as they pull out of it very quickly, I guess that's kind of your differential diagnosis versus a stroke as well then?

Dr Vollmer: Yeah. So, with the stroke, the change, it's more focal with a stroke, and it has a more permanent duration than with a seizure.

Management of Seizures in Long-Term Care

Dr Wong: So once a patient is identified as a seizure patient, how should they be managed? Is it just, as you just mentioned, is it just purely empiric medications, or is there a whole treatment plan that needs to be put together?

Dr Vollmer: Well, for the people that I take care of, if it's a new diagnosis, I mean, of course I always get a blood panel, start up some blood work. But I start empiric treatment and usually I give it a shot myself first. If I'm unable to get the seizures under control with a couple medications, I might refer them onto a neurologist. And if there's not a change in their baseline that suggests that they've had a new stroke, or something like that, then I'll definitely start treatment myself at the facility. It's really not much utility to get an EEG there; that isn't accurate or helpful most of time in ruling it in or out, very low yield, and so I empirically start treatment.

Dr Wong: Okay. So, as you start treatment within the facility, is there a comprehensive or multidisciplinary care team that kind of jumps in and helps support that patient, as well as that patient not only with the seizures, but maybe with other chronic conditions?

Dr Vollmer: Yeah, definitely in meetings they talk about the new diagnosis. Therapy is involved in that so seizure precautions will be added to the plan of care, the appropriate blood work if needed, education for the patient and the family regarding what is likely a seizure diagnosis, so all that will be covered in care plan.

Dr Wong: Okay. And as you're treating the seizure patients within your facility, do you have total control of the regiment? In that, are you just adding meds, or discontinuing medications, or totally changing medication regiments in order to go and basically control the seizures in your patients?

Dr Vollmer: So, when I'm picking a medication for one of my long-term care patients that's been diagnosed with focal seizures, I'm now looking at tolerability and efficacy. I prefer a medication that can be given with or without food, through a feeding tube, something that's once daily. And it's especially ideal if I don't have to monitor blood work levels because sometimes that's difficult to coordinate in the facility, or sometimes it's difficult to draw blood from these residents.

Dr Wong: Okay. So, let's talk about a multidisciplinary comprehensive care team. Can you describe maybe what a best practice might look like in terms of having a multidisciplinary team monitoring, and treating, and managing a patient with seizures?

Dr Vollmer: Ideally with a multidisciplinary team in place, the physician will make the diagnosis and there will be communication with the staff, the nurses, the therapists, seizure precautions; people will be educated on what to look for in case it recurs. The pharmacist will look at the medications and look for potential side effects or interactions with other medications, and whether there needs to be lab monitoring. And then the team will just work together, communicate with the family, and try and make sure that the patient is getting the treatment that they need.

Final Remarks

Dr Wong: So, this concludes this segment of the Pop Health Perspectives, and thank you, Dr Vollmer for your time and this informative discussion.

Dr Vollmer: Thank you.