FEATURE
characterised by epileptic seizures. Further to this, epileptic seizures come in various shapes and sizes (over 40 different kinds, in fact!), including brief, barely undetectable episodes (for example, absence seizures) and long periods of intense shaking which affects the full body.
In the UK, 600,000 people are affected by epilepsy of some sort or another, and when Northern Ireland is considered alone, the prevalence is 1.11% - higher than the rates in England, Scotland or Wales, and also higher than the overall UK numbers(3)
When this is considered, it’s clear that we have our work cut out in order to reduce these rates, and in assisting a greater number of people to become seizure-free.
When it comes to the causes of epilepsy, there are a number of factors that can lead to the emergence of this condition in a patient. In the majority of cases, genetics are implicated – in some instances, a single gene defect is responsible, although this is only in small numbers of patients.
Where a genetic factor is the cause, issues with ion channels, gamma- Aminobutyric acid (GABA), or G protein-coupled receptor malfunction bring about the condition in most instances.
Further to all this, epilepsy can be acquired – tumour, stroke, head trauma, and previous infection of the central nervous system can all be causative.
There are more exotic ways to acquire epilepsy as well – the presence of a pork tapeworm, cerebral malaria, or toxocariasis can all lead to the development of the condition.
So, what leads to an epileptic episode? Before we can answer that, we need to understand how the brain works in the first place!
When the brain functions normally, electrical activity is non-synchronous (i.e. the firing of a many neurons does not happen at the same time, and rather, happens in a stepwise manner in order to deliver signals from one area to another) bringing about a chain reaction that leads to the required activity either within the brain, or elsewhere.
In epilepsy, the excessive firing of the same neurons in a synchronised manner occurs, leading to the interruption of this normal working process, and the emergence of a seizure of some kind(4)
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This electrical behaviour is what leads to the detection of seizure being made possible by electroencephalogram (EEG), as this will detect both large impulses of activity, and the synchronisation of the activity(5)
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As pharmacists, we’re interested in the treatments for these conditions. In terms of guidance for the required treatments, there is no absence of advice from various specialist bodies, which pharmacists are encouraged to read at their leisure (doing so will allow you to be more attuned to your patients needs, and also to identify when incorrect or erroneous prescribing is taking place).
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As always, it’s not possible to delve into large amounts of detail within the constraints of this article, but important details of some of the more common drugs will be covered (Table 1).
Of course, it’s not just the drugs that we’re responsible for looking after, so it’s important that you’re fully capable of providing additional advice that patients may benefit from, particularly if they have just begun to suffer from an epileptic condition.
There are many useful resources online, and it’s a great idea to read and absorb this information, so that it becomes part of your counselling.
Moreover, pharmacists should be au fait with additional information provided within the BNF for patients diagnosed with epilepsy, particularly driving and the UK Epilepsy and Pregnancy register. This information is easily found prior to the monographs for antiepileptic medications.
Alzheimer’s disease Many patients and their families may think that Alzheimer’s and dementia are synonymous, however this isn’t the case.
In fact, “dementia” is an umbrella term, covering a number of conditions, all of which bring about symptoms of memory loss, difficulties in problem solving, thinking and language.
Dementia can include conditions such as vascular dementia, dementia with Lewy bodies, fronto-temporal dementia and Creutzfeldt-Jakob disease, amongst others(6)
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However, as previously mentioned, Alzheimer’s disease is the most common cause of dementia by far. Alzheimer’s is a condition which hits very close to home – according to Alzheimer’s Society figures, 15,770 patients are currently suffering from it in the Province, with this expected to rise to over 20,000 by 2017(7)
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As such, pharmacists should expect to deal with patients and their families at an increasing rate as time progresses, and ensure that they’re prepared to offer as much help as possible when it comes to the medications used.
Before we get into that, it’s a good idea to know how Alzheimer’s occurs. The disease is a form of progressive
It’s important to counsel patients and carers about this, in order to prevent the temptation to start on a higher dose in order to bring about accelerated improvements, as this won’t work, and may negatively affect the patient.
Due to the complex neurological nature of Alzheimer’s, there may be space for the use of other psychosocial
dementia, which leads to the loss of neurons and latterly, synapses from within the brain, whilst also bringing about the presence of two additional protein-based indicators – amyloid plaques (which are extracellular) and neurofibrillary tangles (intracellular).
As the disease progresses, atrophy of regions including the temporal and parietal lobes, frontal cortex and the cingulate gyrus occurs, leading to the reduction in various functions, including those mentioned above(8)
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When it comes to the treatment of Alzheimer’s, it’s firstly worth noting that there is no cure available. Indeed, treatments that are currently available offer only small reductions in symptomatic appearance, and are mostly palliative in nature.
The treatments for Alzheimer’s revolve around acetylcholinesterase inhibiting drugs. This is due to the fact that Alzheimer’s brings about the destruction and reduction in activity of cholinergic neurons, reducing the effect of acetylcholine as a neurotransmitter.
The use of these drugs prevents the normal enzymatic breakdown of this transmitter, increasing its concentration at the synapse, and allowing greater stimulation of the cholinergic neurons which remain.
These drugs are indicated for use in mild to moderate forms of the condition, and there is evidence to support their use in bringing about cognitive improvement in patients.
Whilst these drugs (donepezil, galantamine, rivastigmine) all function in mostly the same way, there are some differences, with donepezil being a reversible inhibitor, rivastigmine being a reversible, but non-competitive inhibitor, and donepezil offering nicotinic receptor agonist properties, which may offer some advantages.
One of the newest drugs for Alzheimer’s, memantine, acts via antagonizing glutamate receptors – overproduction of glutamate can lead to brain cell death via excitotoxicity – bringing about the reduction of brain atrophy by different means.
Each of these drugs will come with their own dosing guidelines, with most involving a step-up dosing regimen, which needs to be carefully followed.
“Dementia” is an umbrella term, covering a number of conditions, all of which bring about symptoms of memory loss, difficulties in problem solving, thinking and language.
aspects of treatment, which may offer benefits to the patient via neurological stimulation.
These techniques may include behavioural interventions, emotional interventions, and also cognition- orientated treatments, which involves the provision of information to the patient about time, place and person in order to ease the patient’s understanding, and reduce distress.
Due to the nature of Alzheimer’s and other dementias, pharmacists should be acutely aware of the problems that may arise from the condition in relation to treatments, and be able to advise accordingly.
An obvious example will be the inability of the patient to remember to take their medication, which may be resolved by the use of MDS systems, or the use of novel technologies, which will remind patients to take their next dose.
Pharmacists should also ensure that they take action where possible, if the patient is not in a position to manage their medicines, or if you are worried for your patient’s welfare, contacting the most appropriate professional (often the patient’s GP). n
References (1) World Health Organisation. What are neurological disorders?. 2016; Available at:
http://www.who.int/features/qa/55/en/. Accessed 02/15, 2016. (2) Nelson LM, Tanner CM, van Den Eeden S, McGuire vM. Neuroepidemiology: from principles to practice. : Oxford University Press; 2004. (3) Joint Epilepsy Council. Epilepsy prevalence, incidence and other statistics. 2011; Available at:
http://www.epilepsyscotland.org.uk/pdf/Joint_Ep ilepsy_Council_Prevalence_and_Incidence_Septe mber_11_(3).pdf. Accessed 02/15, 2015. (4) Jefferys JG. Basic mechanisms of epilepsy. Epilepsia 2009. (5) Epilepsy Action. EEG tests and epilepsy. 2014; Available at:
https://www.epilepsy.org.uk/info/diagnosis/eeg- electroencephalogram#information. Accessed 02/15, 2016. (6) Alzheimer's Society. Types of Dementia. 2016; Available at:
https://www.alzheimers.org.uk/site/scripts/docu ments.php?categoryID=200362. Accessed 02/15, 2016. (7) Alzheimer's Society. Local Dementia UK statistics (Northern Ireland). 2016; Available at:
https://www.alzheimers.org.uk/site/scripts/downl oad_info.php?fileID=5. Accessed 02/15, 2016. (8) Shelley J. Allen and David Dawbarn. Pathophysiology of Alzheimer’s disease. 2011; Available at:
http://oxfordmedicine.com/view/10.1093/med/9 780199569854.001.0001/med- 9780199569854-chapter-4. Accessed 02/15,
2016.
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