U.S. veterans deployed since 2001 suffer high rates of epilepsy and other neurological disorders, and the VA now has more than 100,000 patients being treated for seizure, epilepsy or related diagnoses. The challenge is not only differentiating the types of seizures and appropriately treating them but also to getting the care where it is needed. In response, the VA’s Epilepsy Centers of Excellence are expanding telehealth services.
By Sandra Basu
CLEVELAND — With the increasing number of VA patients treated for seizure, epilepsy and related diagnoses, the the challenge is getting the care where it is most needed.
That is one goal of the national Epilepsy Centers of Excellence (ECoE) network, which cared for 56% of those patients, VA Director of Neurology Robert Ruff, MD, PhD told U.S. Medicine.
The number of patients with seizure, epilepsy or related diagnoses is up from 105,092 in fiscal year 2011 to 107,475 in FY 2013. It has been increasing in recent years, partly because the risks of developing the condition have been greater for veterans who served during Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND).
At the Michael E. DeBakey VAMC in Houston, a veteran undergoes epilepsy testing with David Chen, MD, Richard A. Hrachovy, MD and Neurology Outpatient Clinic Director Vitor Pacheco, MD. Photo by Fran Burke, public affairs specialist
A study presented late last year at the American Epilepsy Society’s 67th Annual Meeting in Washington noted that veterans not only have high rates of epilepsy diagnoses overall, but also that “more young and female veterans are being diagnosed with epilepsy. OEF/OIF/OND veterans are at particularly high risk of TBI, PTSD and seizure diagnoses.”
“We still have to deal with the consequences of what happened for over 10 years, and those issues will stay with us,” Ruff said of the conflicts in Iraq and Afghanistan.
Studies have indicated that penetrating brain injuries are associated with a 50% risk of post-traumatic epilepsy, compared with 30% in nonpenetrating head injury.
To respond to the growing needs, the ECoE is expanding its telehealth offerings. For example, beginning in FY 2014, the ECoE began piloting a program in some locations so that veterans with epilepsy could webcam with specialists instead of having to drive to them.
In 2010, Cmdr. Keith Stuessi, a family physician with the Concussion Restoration Care Center, examines Sgt. Gorge Segura at Camp Leatherneck, Afghanistan, after a 100-pound roadside bomb exploded 30 meters away from him during a foot patrol. Those types of head injuries are blamed for the increase in seizure disorders among returning veterans. Photo by Staff Sgt. Jennifer Brofer
“It makes absolute sense for people who cannot travel to do that,” Ruff said about the video-telehealth clinics, which are in a pilot program this year.
ECoE was established through federal legislation in 2008 to better equip VA to provide care for veterans with epilepsy and in anticipation of those who would develop epilepsy as a result of head trauma. The epilepsy care network consists of 16 sites that are linked to form four regional centers. The ECoE sites serve as hubs that are then connected to 52 spoke sites throughout the system.
The ECoE offers both inpatient and outpatient services. For example, VA’s polytrauma centers are connected to epilepsy care sites so that veterans with brain injuries, who are at greatest risk for post-traumatic epilepsy, can be closely followed.
“Each of the rehab centers for TBI is directly connected with an epilepsy center. Specifically, the Epilepsy Monitoring Unit (EMU) is located on the polytrauma center site,” Ruff explained.
With returning servicemembers, much of the focus is on psychogenic non-epileptic seizures (PNES), which have a different etiology than seizures caused by electric disturbances in the brain. A 2011 study found that 25% of all EMU discharges of veterans at one VAMC over a 10-year period were for PNES. More recent research presented by the same investigator found that, following the EMU diagnosis of PNES at a VAMC, most of the veterans continued to report seizures, even after three years of follow-up. More than 80% of PNES patients received anti-epileptic drugs (AEDs) for seizures prior to EMU evaluation but were able to remain continuously off the drugs through 36 months of follow-up.
Martin C. Salinsky, MD, of the Portland, OR, VAMC, was the lead author of both studies and pointed out, “the unsatisfactory seizure outcomes underscore the need for effective PNES treatment protocols within the VAMC. On a positive note, the elimination of unnecessary AED therapy could avoid potential side effects and reduce the cost of care.”
With PNES, Ruff said, “what is important is to appropriately recognize what they are so you don’t mistreat a person.”
Click the above graphic to expand to full-size in a new tab
As the need for care increases, ECoE is seeking to expand the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), introduced in FY 2013, according to the center’s annual report. Through this program, healthcare providers can present their patient cases through video-teleconferencing to a multi-disciplinary epilepsy team in a remote location. That team suggests a treatment plan and provides advice to the provider during the session. In addition, through SCAN-ECHO, epilepsy specialists also are able to offer short courses on current standards of epilepsy care to primary care clinicians on site.
VA launched its overall SCAN-ECHO initiative in 2012 to increase access to specialty care services for veterans in rural and medically underserved areas. In its first year of implementation, the San Francisco ECoE SCAN-ECHO team discussed over 20 patients via telehealth, and the goal now is to expand SCAN-ECHO programs to the Northwest, Northeast and Southeast Regions.
In addition to the other telehealth initiatives, Ruff said that a Store and Forward program is being used in some places to allow collection and storage of EEG data at one medical center, which forwards it to a specialist at a different site. The specialist is then able to read and interpret the EEG before sending the information back to the medical center to help in the diagnosis of epilepsy.
“What this means is that a VA that previously wasn’t able to recruit a neurologist to do the interpretation is still able to provide the service for veterans,” Ruff explained.
Supplements Improve Bone Density in Patients Using AEDs
A recent study by VA researchers suggested that vitamin D and calcium supplementation could improve the bone mineral density (BMD) of epilepsy patients who are treated with antiepileptic drugs (AEDs) and that adding a bisphosphonate could help prevent new fractures.
For the study, the Antiepileptic Drug and Osteoporosis Prevention Trial (ADOPT), VA researchers evaluated whether use of a bisphosphonate (risedronate) in addition to calcium and vitamin D in male veterans with epilepsy on long-term AEDs prevents the loss of BMD. The incidence of new morphometric vertebral and nonvertebral fractures also was tracked.
Over two years, 80 male veterans with epilepsy were followed, with 53 completing the study. All of the study participants received calcium and vitamin D supplementation and were randomized to risedronate or placebo.
Participants received total body, hip and spinal bone density assessments at baseline, one year and two years following study enrollment.
By the end of the study, significant improvement was noted in bone density in 69% and 70% of patients in the placebo and active drug groups, respectively. In addition, patients taking risedronate showed a significant increase in bone density at the lumbar spine, compared to subjects in the placebo group, according to the results.
“Our findings suggest calcium and vitamin D with or without risedronate improves bone density in epilepsy patients taking AEDs. However five new vertebral fractures were observed in the placebo group and none in the active medication group. Adding risedronate to the supplements appears to prevent new fractures in this group of veterans,” said lead author Antonio Lazzari, MD, of the VA Boston Healthcare System.
The study authors wrote that, to their knowledge, “this study is the first longitudinal prospective randomized placebo controlled trial of prevention and treatment of bone loss in male veterans with epilepsy who underwent long-term AEDs treatment and had normal or low bone mass.”
1Lazzari AA, Dussault PM, Thakore-James M, Gagnon D, Baker E, Davis SA, Houranieh AM. Prevention of bone loss and vertebral fractures in patients with chronic epilepsy — antiepileptic drug and osteoporosis prevention trial. Epilepsia. 2013 Nov;54(11):1997-2004. doi: 10.1111/epi.12351. Epub 2013 Sep 6. PubMed PMID: 24010637.
VHA medical facilities should ensure that its providers are following three key opioid risk mitigation strategies, including conducting urine drug screening, a recent report recommended.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.