Working with Job Corps Students with Seizure Disorders John Kulig, MD, MPH Teresa Lowery, MD, MPH Debbie Jones October 23-24, 2013
Epilepsy Epilepsy is the most common neurological condition in adolescents and young adults. Epilepsy describes recurrent paroxysmal events (seizures) with excessive discharge of neurons leading to clinical symptoms. Affects 1-2% of the population. Can be well controlled for about 80% of patients with strict adherence to the prescribed treatment regimen.
Seizures Seizures are either partial (e.g., a jacksonian seizure) or generalized (e.g., petit mal and grand mal seizures) Progression of a seizure is characterized by several phases: prodrome aura ictal postictal
Grand mal seizure Tonic phase. Loss of consciousness occurs, and the muscles suddenly contract and cause the person to fall down. This phase tends to last about 10 to 20 seconds. Clonic phase. The muscles go into rhythmic contractions, alternately flexing and relaxing. Convulsions usually last for less than two minutes.
Grand mal seizure The following signs and symptoms occur in some but not all people with grand mal seizures: –Aura. Some people experience a warning feeling (aura) before a grand mal seizure. This warning varies from person to person, but may include feeling a sense of unexplained dread, a strange smell or a feeling of numbness. –A scream. Some people may cry out at the beginning of a seizure because the muscles around the vocal cords contract, forcing air out.
Grand mal seizure Loss of bowel and bladder control. This may happen during or following a seizure. Unresponsiveness after convulsions. Unconsciousness may persist for several minutes after the convulsion has ended. Confusion. A period of disorientation often follows a grand mal seizure. This is referred to as postictal confusion. Fatigue. Sleepiness is common after a grand mal seizure. Severe headache. Headaches are common but not universal after grand mal seizures.
First Aid for Seizures Keep calm and reassure other people who may be nearby. Prevent injury by clearing the area around the person of anything hard or sharp. Ease the person to the floor and put something soft and flat, like a folded jacket, under his head. Remove eyeglasses and loosen anything around the neck that may make breathing difficult. Time the seizure. Check for a medical alert bracelet. Do not hold the person down or try to stop his movements.
First Aid for Seizures Contrary to popular belief, it is not true that a person having a seizure can swallow his tongue. Do not put anything in the person’s mouth. Efforts to hold the tongue down can injure the teeth or jaw. Turn the person gently onto one side. This will help keep the airway clear. Stay with the person until the seizure ends naturally and he is fully awake. Be friendly and reassuring as consciousness returns. Do not offer the person water or food until fully alert.
Call 911 for emergency response if... The seizure lasts longer than five minutes without signs of slowing down. The person has trouble breathing afterwards, appears to be in pain or recovery is unusual in some way. The person has another seizure soon after the first seizure stops. The person cannot be awakened after the seizure activity has stopped. The person was injured during the seizure. The person becomes aggressive. The seizure occurs in water. The person has a health condition like diabetes or heart disease or is pregnant.
Is it really a seizure? What else could it be? Several conditions must be differentiated from epileptic seizures. These are “imitators of epilepsy.” In adolescents and young adults, these diagnoses can be classified into six broad categories: –Syncope –Psychological disorders –Sleep disorders –Paroxysmal movement disorders –Migraine –Miscellaneous neurological events
History As usual in medicine, evaluation starts with an accurate history. Here are some questions to consider: –What type of behavior occurred? Ictal and post ictal behavior? –Recent seizure history? –Childhood seizure history? –Family history? –Recent medication or drug or alcohol use?
History: Triggers Triggers include (but are not limited to) strong emotions, intense exercise, loud music and flashing lights Other physiological conditions such as fever, menstrual period, lack of sleep and stress can lower the seizure threshold rather than directly causing a seizure Photo-induced: may be inherited, may be caused by certain light triggers, are usually generalized, children are more susceptible and seizures may decline with age
Relevant Patient History Medication history - including non- prescription meds/supplements Past medical history - including head injury, stroke, intracranial infection and alcohol or drug abuse Family history - a positive family history is often associated with epilepsy
Physical Examination Physical and neurological examination - generally unrevealing but important when CNS infection or CNS hemorrhage are diagnostic possibilities
Diagnostic Studies Lab studies would include electrolytes, glucose, calcium, magnesium, complete blood count, renal function tests, liver function tests and toxicology screening Cerebral anoxia - complication of cardiac or respiratory arrest, carbon monoxide poisoning, drowning or anesthetic complication – assess underlying cause Lumbar puncture - indicated if presentation suggestive of an infectious process that involves CNS (e.g., meningitis)
Diagnostic Studies EEG (electroencephalogram) is an essential study. It may demonstrate epileptiform abnormalities in as few as 25% to as many as 70% of first seizures and makes a second seizure more likely. Use of sleep deprivation and provocative measures during the EEG, such as hyperventilation and intermittent photic stimulation, increases the yield. A normal EEG does not rule out epilepsy.
Diagnostic Studies: Neuroimaging Brain MRI is preferred over CT scan to identify a structural brain abnormality if the student’s first seizure was clearly not a provoked seizure, nevertheless noncontrast CT is suitable when an MRI is contraindicated or unavailable. MRI or CT scan results should not be interpreted in isolation. Many findings are nonspecific and may be incidental.
Management Goals of epilepsy management: 1.Controlling seizures 2.Avoiding treatment side effects 3.Maintaining or restoring quality of life It is appropriate to refer the student to a neurologist when establishing and formulating a course of treatment. Referral to a epilepsy specialist may be necessary if there is doubt about the diagnosis and/or if the student continues to have seizures.
Management Psychological considerations: –Loss of independence –Employment –Insurance –Ability to drive –Self esteem –Hospitalizations/ED visits –Medication effects
Antiepileptic Drugs (AEDs) When to start AEDs –For patients with most seizure types, treatment is usually deferred until the second seizure has occurred. When to stop AEDs –Treatment is typically continued for 2 years in a patient who is seizure-free, at which point medications are tapered over 6 weeks. Arch Neurol. 1999;56(9):1073-1077
Adverse effects of AEDs systemic physical effects, such as weight gain, GI distress, rash neurotoxic effects, such as sedation, dizziness, tremor, ataxia cognitive impairment adverse behavioral changes potential teratogenicity drug interactions (e.g. OCPs) expense and stigma hypersensitivity reactions (rare) bone marrow or liver failure (rare)
Seizure Precautions Transportation –No driving unless seizures well controlled for an interval specified by state DMV –Wear bicycle helmets and protective gear –Stay clear of the platform edge when using public transportation
Seizure Precautions Bathroom safety –Showering instead of bathing –Shatterproof glass in shower doors –Shatterproof bottles (shampoo etc.) –No electrical equipment near water –Non-skid strips in shower stall
Seizure Precautions Kitchen safety –Cook with a partner –Use back burners of the stove to prevent burns –Use shatterproof containers –Limit use of knives and other sharp kitchen utensils
Disability Considerations Legal Updates Disability Data Accommodations Career Technical Restrictions Need to Know
Changes to the ADA With the reauthorization of the ADA in 2009, now known at the Americans with Disabilities Act Amendments Act (ADAAA), certain changes to the law affect how we determine who is considered a person with a disability. Let’s take a look at those changes that directly affect us in Job Corps. https://www.federalr egister.gov/articles/2 011/03/25/2011- 6056/regulations-to- implement-the- equal-employment- provisions-of-the- americans-with- disabilities-act-as
Mitigating Measures & Substantial Limitation Mitigating measures shall not be considered in determining whether a person is someone with a disability or not. –That means that someone who is stable on medication can still be considered an individual with a disability. Clarifies that a condition is still a disability if it substantially limits a major life activity when active even if there are periods of remission or the condition is episodic.
Major Life Activities Major life activities have been expanded to include major bodily functions such as the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine and reproductive functions. Certain impairments will virtually always be found to result in substantial limitation in performing certain life activities. –Epilepsy is one of the examples of specific impairments that should easily be concluded to be a disability within the regulations. [Section 1630.2(j)(3)]
Substantial Limitation An impairment does not need to prevent or severely or significantly restrict a major life activity to be considered “substantially limiting.” –The determination of whether an impairment substantially limits a major life activity still requires an individualized assessment. –Not every impairment will constitute a disability. The ADAAA states that the definition of disability should be interpreted in favor of broad coverage of individuals.
Disability Data Count or not Count? Does the person have a diagnosis of seizure disorder/epilepsy? Are the symptoms under control? –If so, what were the symptoms and the individual’s condition prior to medication management? –What would the person’s condition be like without the benefit of medication or other supports? Does the seizure disorder impact any major systems (i.e., the neurological system, brain functioning, etc.)? Remember, the ADAAA reminds us to interpret the definition of disability in favor of broad coverage of individuals and epilepsy is one of the impairments virtually always considered a disability within the regulations.
Possible Accommodations Install rubber matting on floor in work area; add padded edging to corners and edges in work and/or living areas Install machine guarding Use rolling safety ladders with handrails and locking casters Provide head protection Provide eye protection Use fall protection Develop “Plan of Action” Provide 2-way radios
Possible Accommodations Provide private or secure rest area during breaks Use a flicker-free monitor (LCD display, flat screen) Use a monitor glare guard Allow frequent breaks from tasks involving computer Provide alternative light sources Replace fluorescent lights with full spectrum lighting Use natural lighting source (window) instead of electric lighting
Restricting Trade and/or Other Activities The only restriction that may be made for a student to a trade or any other part of the program is if that student’s participation poses a significant risk to the well-being of the student, other students, or staff as determined by the center physician. Restrictions may be temporary in nature (i.e., stabilization on a new medication) and may include: –Restriction regarding the use of machinery and equipment –Restriction of participation in driver’s education training
Trade Determinations There are no trades that are specifically selected as “appropriate” for individuals who have seizure disorders. Likewise, there are no trades that are automatically restricted for individuals simply because an individual has a seizure disorder. Each situation has to be reviewed on a case-by-case basis. Career counseling may be provided to the applicant and/or student and could include such topics as: –Physician imposed restrictions –Accommodation options suggested by RAC or an agreed upon accommodation plan with RAC –Essential functions of the job
Need to Know The Health & Wellness Manager (HWM) determines which staff needs to know essential health care information for the safety of the student and/or the staff and other students. Sharing need to know information does not mean that the student’s diagnosis is disclosed. The staff are provided with the symptoms and behaviors that they are monitoring for and trained how to respond to each of them. All staff should have access to the accommodation plan screen in CIS.