PracticeUpdate Conference Series - ANZAN 2018

seizure etiology and management strat- egies in this demographic. This retrospective chart review included patients age ≥18 with a hospital separa- tion coded as ICD-10 G40 (epilepsy), G41 (status epilepticus), or R56.9 (convulsions not otherwise specified) who presented from 2008–2016 at a large metropolitan private hospital. A total of 97 episodes of emergency department attendance for a first seizure and 54 episodes of hospital-onset sei- zures were identified. Median patient age was 70 years in the community-onset seizure cohort and 80.5 years in the cohort with hospital-onset seizures. Symptomatic seizure risk factors were identified in 26.8% of the community- onset seizure cohort and 63.0% of the cohort with hospital-onset seizures. These factors included exposure to known proconvulsant drugs in 38.89% of the cohort with hospital-onset seizures. Antiepileptic drugs were prescribed on discharge to 74.2%of the community-onset seizure cohort and 81.5% of the cohort with hospital-onset seizures. Far fewer patients received a scheduled review by a neurologist (58.8% of the community-onset seizure cohort and 35.2% of the cohort with hospital-onset seizures). Dr. Foster concluded that more older patients than usually reported was stud- ied, providing important insights into seizure etiology and management strat- egies in this demographic. “We found that patients with recurrent untreated seizures often exhibited subtler seizure semiology and were more likely to exhibit normal MRI and EEG results than those presenting immediately following new-onset seizures,” she said. “Clinicians should be mindful of these differences. Caution is needed when prescribing known proconvulsant drugs, especially tranexamic acid, and physicians should be mindful of their prescription of antiep- ileptic drugs on discharge.” Adequate follow-up with a neurologist is needed to monitor further seizure activ- ity, address risk factors for seizures, and assess any ongoing need for an antiep- ileptic drug. She added, “Future studies will review mortality and morbidity in cohorts with a first seizure, with a view toward identifying areas for improvement in assessment and management of a first seizure.”

with significantly more provoked seizures occurring in the hospital. Exposure to proconvulsant drugs, tranexamic acid in particular, was a major risk factor.” She continued, “We also noted variation from International League Against Epilepsy diagnostic criteria for epilepsy regarding the decision to prescribe antiepileptic therapy. This variation reflected the complex nature of seizures, epilepsy, and the importance of tailoring treatment to individual patients.” Drs. Foster and Holper concluded that patients with recurrent, untreated seizures often exhibit subtler semiology and are more likely to exhibit normal MRI and EEG results than those presenting immediately following new-onset seizures. The cohort with recurrent, untreated sei- zures tended to receive more inpatient investigations and antiepileptic drug pre- scriptions, and was offered more timely neurology follow-up than the cohort with new-onset seizures. “Results showed,” Dr. Foster stated, “that community-onset seizures were more likely to be unprovoked, and hospital- onset seizures, more likely to be provoked, mostly from exposure to proconvulsant drugs.” She added, “This pilot study provided val- uable information on the current paradigm of management of a first seizure. The

results have laid a foundation for more extensive studies into morbidity and mor- tality of patients with first seizures, as well as assessment and management of first seizures in the emergency department.” “We further analyzed patient and clinical characteristics of the cohort of patients with a first-ever seizure vs the cohort with recurrent untreated seizures,” Dr. Foster explained. Drs. Foster, Holper, and Kwan charac- terized first seizures in the emergency department vs the ward in elderly patients. Dr. Foster explained that seizures are common in hospitals, as either presenta- tions to emergency departments or as hospital-onset seizures. The latter occur in ward patients hospitalized for illnesses unrelated to seizures. Prompt identifi- cation of seizure etiology is important because identification affects prognosis and management choices. Acute symptomatic seizures due to acute disturbance of brain function are far less likely to recur than unprovoked seizures. Through timely investigation and spe- cialist review, individual risk of seizure recurrence is assessed. Such assessment then guides therapeu- tic decisions including antiepileptic drug choice. The present study included more older patients than usually reported. As such, it provided important insights into

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ANZAN 2018 • PRACTICEUPDATE CONFERENCE SERIES