Cognitive complaints remain a major issue for patients with epilepsy, leading the epileptologist at the University of Pennsylvania to share her insight into addressing them.
Kate Davis, MD, MSTR
Perhaps the most well-known impact of epilepsy, seizures can be a debilitating symptom. Although, the additional chronic impacts of the disease can be sometimes more devastating to a patient’s quality of life.
For Kate Davis, MD, MSTR, these symptoms are equally important—and equally as present in the clinic. In her work as an epileptologist at the University of Pennsylvania, Davis encounters these patients on a daily basis. While their cognitive issues can be caused by a number of factors, including seizures themselves, the medications being used, and possible comorbidities, an easy fix is not always available. To address this, several interventions can be used, some of which are device-based.
At the American Neurological Association’s 143rd Annual Meeting in Atlanta, Georgia, Davis sat with NeurologyLive to discuss the complication of cognitive issues faced by patients with epilepsy, and how these are being addressed in the clinic.
Kate Davis, MD, MSTR: I'm an epileptologist, and clinically, one of the biggest complaints that patients report is memory difficulties—difficulty with work, difficulty with remembering simple items sometimes, unfortunately, and sometimes even more significant cognitive impacts. Even though seizures are what really define the disease of epilepsy, the chronic symptoms in between seizures really have a tremendous impact on patients. The most common complaints are certainly cognitive, and mood is another complaint.
There are a lot of different factors that contribute to the cognitive complaints that the patients have that make it difficult from the provider perspective to know how to address it. One can be the seizures themselves, another can be the medications that we're using—which can also impact cognition—and a third can be the other comorbidities that go along with epilepsy, as I mentioned, mood difficulties.
There are a few approaches that one can take to help address cognitive complaints. One is to make sure that you're treating with the most optimal medications that will minimize the cognitive impacts that the patient's reporting. That's kind of the simplest thing I often do—refer patients for behavior therapy or cognitive therapy with a speech therapist. The purpose of that, really, is to teach them workarounds so that they can function better in their daily life, but that can be very productive. If they are stilling still having seizures, and they're not responsive to medication, you should consider whether surgical intervention to potentially cure their epilepsy is a good option for that patient. For some of those patients, as we discussed at the Special Interest Group at ANA 2018, the surgical intervention can actually either stop the progressive memory decline or result in an improvement in memory.
Certainly, at a tertiary care referral center like the University of Pennsylvania, we're seeing a lot of patients referred to us for drug-resistant epilepsy where they've tried and failed at least 2 seizure medications at adequate doses. In these patients, unfortunately, the literature supports that additional medication trials have a very, very low rate of rendering them seizure-free. This represents about one-third of all epilepsy patients, so it's a very large number of patients. Unfortunately, there's still a big treatment gap where a lot of patients aren't reaching surgical centers like the University of Pennsylvania. It's a conversation that I have almost daily when I'm in the clinic with patients because of the type of patients that we see.
The place where specialist super-specialists, like an epileptologist in a university setting, can play the most impactful role is if neurologists in the community refer patients that fit into that drug-resistant epilepsy group. That's actually an American Academy of Neurology guideline in terms of treatment of epilepsy and seizures, that if a patient is still having seizures despite a trial of 2 or more medications that they should be referred to a tertiary care center to see an epileptologist every 2 years.
It has been difficult to have communication, at least on the East Coast, and I think around a lot of the country. Major hospital networks are kind of creating conglomerates of many hospitals that creates kind of a structure for a referral. Penn’s doing that, a lot of hospital systems in the Philadelphia area are doing this, and so we end up being able to reach out through that network of hospitals. Our group, for instance, will go and give talks or meet with various different groups in the community teach them how to refer patients appropriately, what kind of services we can provide, what kind of answers we can give for their patients.
Transcript edited for clarity.