Epilepsy And Aged Care Resources

Medication should always be taken in accordance with the doctor’s instructions to maximise the beneficial outcomes of the medication and to prevent unwanted side effects. Around 70% of people with epilepsy can have good seizure control if they take their medication correctly.

There are two types of medications that can be prescribed for epilepsy:

1. Anti-seizure medications (ASMs).

ASMs are the most common treatment for people. While, they will not cure epilepsy, they can control seizure activity. ASMs are usually prescribed based on:

• how well they work for the person’s seizure type/s
• how well the person can tolerate them
• what other health-related conditions the person may have
• what medications are already being taken
• how seriously the seizures are affecting the person’s life.

There are many different types of ASMs available. A seizure free outcome is the optimal result sought for the older person and by the doctor.

2. Emergency Medication.

For epilepsy, emergency medication works by stopping the seizure activity if taken when a seizure occurs. Emergency medication reduces the impact of seizure activity on the person’s life. What does this mean for the older person? Commencing medication does not always mean that it must be taken forever, there are a few things that need to be considered:

• Understanding why the medication has been prescribed.
• Regular medical reviews as medication may only be needed for a limited time.
• Always taking medication in the dosage and at the time recommended by the doctor. General advice is that if a dose is missed it can generally be taken as soon as you remember. Do not double up on doses. It is advisable not to take the missed dose if it is close in timing to the next one. Keep a record of doses that have been missed.
• After starting medication it is important to note any changes in general health or seizure activity. If the medication is not managing seizure activity the doctor should be advised as soon as possible as the medication or dosage may need to be changed.
• Withdrawing from medication should always be carried out under medical supervision as stopping medication can provoke seizures and can potentially create a medical emergency.

It is quite common for people in their later years to have other health conditions which may require medication. This may have an impact on what type of ASM can be prescribed. People in their later years also experience differences in the way drugs are absorbed and broken down (metabolised) or cleared from the body.

It is good practice to ask the doctor to discuss the risks and benefits of all medication. The doctor will describe common side effects of the prescribed medication; however it is also good to ask the pharmacist to go through any possible side effects.

• Like any medication ASMs can cause some possible undesirable side effects, including: skin rashes, falls, difficulty concentrating or thinking, or problems with memory. People in their later years are more susceptible to side effects.
• ASMs can contribute to osteoporosis – a condition of decreased bone strength (thinning of the bones) which increases the risk of a broken bone. If taking ASMs for an extended period, bone density assessments may be necessary.

If the older person is having many seizures, or seizures which last a long time, the doctor may also prescribe emergency medication:

• The doctor will advise when the emergency medication is to be administered, how it is to be stored and how it is to be administered.
• Emergency medication information will be recorded in an Emergency Medication Management Plan (EMMP).
• Only medical practitioners or people who have been trained to administer emergency medication in accordance with this plan should do so.

Memory is one of the most important functions of our brain. For most people, as we age, lapses in our memory become more common. This can be frustrating and can affect daily life. People with epilepsy are at a higher risk of developing memory problems due to abnormalities in the frontal lobe of the brain.

There are two types of memories – short-term and long-term.

Short-term memory is used to process information which needs to be remembered for just a short time after first experiencing something. An example of this is when reading a sentence, our short-term memory allows us to remember what we read at the start of the sentence when we reach the end of the sentence.

We need to use our short-term memory to complete particular tasks e.g. calculating how many hours until we need to prepare dinner or playing a game, when this information is no longer needed it is discarded by our brain.

Long-term memory is information that is stored for a long period of time. This information may include things like where our childhood home was, what we did last year or even what we did a few hours ago. It can be very distressing for people when they cannot remember their past. This can be a recurring problem for people living with epilepsy, and can be even more frequent and increasingly distressing for people in their later years.

There are three phases to the memory process.

The first phase relates to learning. To be able to remember something new we must first pay attention and learn the new information. Having epilepsy can impact a person’s ability to pay attention over a period of time and may slow the speed of information processing. For some people with epilepsy processing new information can be overwhelming which can restrict their ability to maintain attention for long enough to commit the matter to memory. Important facts may be missed and memory is affected because the information is not being properly received.

The second phase is storage of information in the brain. For some people with epilepsy they may have difficulty in consolidating new information. Epilepsy can cause structural problems in parts of the brain responsible for memory and the storage of these memories.

The third phase is retrieval or recall. This is the brain’s way of finding and using the information that has been learnt. There are a number of factors which can make it difficult to recall information such as time pressure, being put on the spot or being asked to recall information out of context. Often, later in the day when the pressure is off, the information may be remembered more easily. It is difficult to remember information in isolation but when given further information the memory may more easily be recalled.

There are a number of ways that people with epilepsy can develop memory problems. These include:

• Seizures – Seizures are believed to affect the storage of memory in people with epilepsy. Having seizures over a long period of time can negatively effect memory functions.
• Anti-seizure medications – Anti-seizure medications (ASMs) have a number of side effects, one of them can be a negative impact on people’s cognitive functioning. The impact of ASMs on attention and memory is common although some people on lower doses of ASMs find that taking the medication will help with their memory.
• Surgery – Some people experience increased memory difficulties after epilepsy surgery. It has been found that the risk of this can, in most cases, be identified by a specialist before the surgery.
• Anxiety and depression – Our mood can impact on our ability to attend to, learn and recall information. When we feel anxious or depressed it is harder to focus on information which, in turn, makes it harder to remember information.
• Stress and fatigue – When we feel stressed or tired we place more demands on our minds which can affect our ability to retain and recall information. Keeping a healthy sleep and exercise routine is important for people with epilepsy as this helps manage stress and fatigue levels.

Managing risk is about identifying negative seizure or medication impacts and putting in place strategies to manage them.

Depending on the seizure type there may also be a number of safety issues which need to be considered, they could include always swimming with a companion, having on-call or in-house support overnight and the need for support with commuting.

Managing risk is an important part of the epilepsy management process. The first step in managing risk is identifying the risk factors that apply to each person. Just as each person’s epilepsy presentation is different, each person’s risk assessment will determine different risks to be managed.

For the older person the level of risk and what supports they will need to manage the risk will depend on a number of factors. Does the older person:

• live independently in their own home with a partner or family?
• live independently in their own home alone?
• live independently in their own home alone with carer support visits?
• live in a supported care environment e.g. aged care facility?

The degree of independence and support available to the older person has a direct impact on the risk associated to an activity. Living independently and alone for example creates a higher level of risk in the home as compared with living within an aged care facility where risk is managed as a matter of course.

When managing risks it is important to look at strategies that will either remove the risk e.g. do not participate in an identified risky activity, or reduce the risk e.g. participate with appropriate protection or support.

Risk management considerations:

• Living independently and alone carries risk if no one can enter the house to assist when needed; key-locks provide entry to the home in the event of an emergency. Regular visits by family and/or friends also reduces isolation.
• Floor surfaces can present trip or slip hazards; minimise surface clutter and ensure there are no loose floor coverings.
• Bed pillows present a suffocation risk for night seizures; firm pillows or antisuffocation pillows are safer to use.
• Falls present a risk of hitting furniture or items in the home; limiting clutter within the home reduces the risk of injury in the event of a fall.
• Remove the risk of injury by avoiding working or walking on ladders and ledges.
• Reduce the risk of drowning, should you have a seizure while swimming by always swim with a companion.
• Reduce the risk of head injury by wearing a helmet when there is ongoing seizure activity resulting in falls.
• Reduce the risk of falls when shopping or engaging in community activities by being aware of the immediate environment, keeping hands free as a support or having a companion.

Bathing carries additional risks for older people with epilepsy, consider:

• bathroom and toilet doors that open outward rather than inward, which can be opened in case of a fall or install safety/lift off hinges.
• using a shower which is safer than a bath, as it reduces the risk of drowning should a seizure occur.
• using a shower chair which is safer than standing in a shower, to reduce the risk of falling.
• attaching a shower head/rose to a bath tap and taking a shower sitting down with the bath plug out, which is safer than a bath.

Kitchens can present many hazards due to flame, heat, sharp knives and wet surfaces. Consider the use of a microwave instead of the stovetop and a food processor rather than a knife to reduce risks associated with seizures that involve involuntary movements or falls.

Take care with floor surfaces in wet areas to minimise the risk of slipping or tripping.

Driving and travelling carry additional risks for older people with epilepsy. Refer Information Page – Travelling and epilepsy.

A late-onset diagnosis of epilepsy can have a substantial impact on a person as it changes the known and understood world of the person, a world that has been built over a lifetime of experiences.

Epilepsy differs from other chronic illnesses or age related conditions in its unpredictability. The older person may have no control over the seizure events; this is something that is often very hard for them to come to terms with.

The impact of epilepsy is also different for every person. This can leave the older person living with epilepsy feeling fearful, isolated and not understood, impacting on the way they see themselves and their level of self-esteem, confidence and independence.

Older people with epilepsy experience poorer sleep, decreased mental status and can have a higher prevalence of depression and anxiety. For an older person with low self-esteem these impacts can be intensified.

Mental health is very important and an instrumental part of maintaining a healthy self-image. Talking to a doctor and family or friends about what is happening and how living with epilepsy impacts life, is the first step in looking after mental health.

It is important to remember that epilepsy is one of the most common neurological conditions experienced by people today, so an older person living with epilepsy does not have to go it alone.

Self-esteem issues can present as:

• lack of motivation
• dependency on assistance to complete normal day to day activities
• unwillingness to participate in normal known activities
• risk taking behaviour
• attention seeking behaviour
• difficulty forming and maintaining friendships
• lack of self-care and/or risk of self-harm
• fear of rejection or judgement by others, concerns over stigmatisation

Concerns about ageing itself are recognised as having psychosocial impacts such as fears about becoming isolated, experiencing loneliness and losing independence which can be present in an older person’s thinking prior to a diagnosis of epilepsy. For older people living with epilepsy the link between concerns about health coupled with managing their epilepsy can compound these psychosocial issues.

People with low self-esteem can experience protracted negative feelings which can exascerbate depression and anxiety and lead to additional feelings of anger, shame or guilt. Understanding this impact is crucial for providing the appropriate supports to an older person.

Staying active and mentally alert is good for mind and body. A healthy lifestyle also helps with the medical management of epilepsy.

A diagnosis of epilepsy does not mean an older person cannot socialise with family or friends or keep doing the recreational activities that they enjoy. People with epilepsy can continue to take an active part in leisure activities, sport and recreation with the right approach to managing risk.

An active lifestyle which includes activities that exercise the mind and the body. Activities such as walking, stretching, yoga, Tai Chi, bowls, swimming, and dance can help the older person maintain a good level of fitness.

A 20–30 minute walk every day is an ideal exercise for maintaining a good level of fitness. If this is too much to begin with it can be broken up into two or three 10 minute walks. In an aged care setting this could be a walk around the garden or participation in lifestyle and leisure activities. A good level of fitness improves the chance of maintaining independence, managing health issues and recovery from illness, as well as reducing risk related to epilepsy.

A healthy diet which includes plenty of fruits and vegetables, good quality fats such as avocado and olive oil, staying away from high sugar foods and limiting alcohol intake.

Sufficient fluid intake is an important part of living a healthy and active lifestyle. The body needs the right level of fuel and water to stay active.

The body also needs the right amount of sleep to maintain a healthy body which can engage in an active lifestyle. Older people living with epilepsy report poorer sleep patterns, generally people who exercise regularly and stay active experience better sleep. Managing poor sleep patterns is therefore an important part of achieving an active lifestyle for the older person living with epilepsy.

There are many strategies that can be tried to improve sleep, including:

• Understanding the internal body clock, everyone is different so it is important to know how much sleep the person requires to function effectively.
• Making sure the bedroom is conducive to sleep, with light, temperature and noise under control.
• Being mindful. Reduce mind chatter prior to sleep. Consider relaxation techniques such as meditation or gentle music.

For many older people living with epilepsy, travelling away from the familiarity of home may be a daunting prospect; however for most people, with a little planning, it will be achievable.

A person living with epilepsy or seizures may be eligible to hold a driver licence for private vehicles as long as their seizures are well-controlled.

The ability of a person with epilepsy to hold a driver licence, at any age, depends on the likelihood of them having a seizure while driving and the impact of a seizure on their ability to drive.

When travelling or going on holidays

There are a number of measures that can be taken to ensure that time away is enjoyable and safe. Here are some tips to consider before travelling:

• Medication must be taken at the usual times.
• Take a doctor’s letter detailing the epilepsy diagnosis, the name of the medications, how much is to be taken and that it is for personal use only, along with a copy of the prescriptions. It is best to keep the medication in its original packaging.
• Have enough prescriptions to cover the time away from home if travelling within Australia or overseas. If travelling overseas it may be difficult to obtain medication whilst in another country therefore in most cases it will be necessary to take enough medication to cover the entire journey.
• Pack medications in a clear plastic bag, stored in carry-on luggage. This will reduce the risk of the medications being lost in transit.
• Be aware of seizure triggers, e.g. jetlag, tiredness, dehydration.

When licensed to drive

Any person who holds a current driver licence and develops any serious or chronic medical condition or disability including epilepsy and seizures, is required by law to report their condition to the relevant state driving authority. The authority will advise whether a medical report is required, if required it must be no more than six months old.

National driving guidelines for assessing fitness to drive outline the different circumstances under which driving may or may not be permitted for people living with epilepsy.

Assessing fitness to drive is managed separately by each state driving authority.

If there have not been any seizures for 12 months since the loss of licence, it may be possible to have the licence reinstated. The frequency of periodic reviews may vary depending on the medical report and the opinion of the state driving authority’s medical advisors.