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LEADing Issues in Epilepsy

LEADing Issues in Epilepsy

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Published by leeann_swenson
LEAD Newsletter January 2009
LEAD Newsletter January 2009

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Published by: leeann_swenson on Dec 13, 2010
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In This Issue…
Driving Privileges:Protecting YourPatients and Yourself 
Laura Hershkowitz, DO
Oh My, Such a State!(of Regulations):Driving and Epilepsy
Barbara Olson, MD
Case Study:Driving Privilege Issues
Raman Sankar, MD, PhD
Expert Interview:Practical Insights onDriving and Epilepsy
David M. Labiner, MD
Co-Executive Editors
David M. Labiner, MD
Interim Head, Department o NeurologyProessor o Neurologyand Pharmacy Practice& Science  The University o Arizona Tucson, Arizona
Georgia Montouris, MD
Assistant Proessor o NeurologyBoston University Schoolo MedicineDirector o EpilepsyServicesBoston Medical Center Boston, Massachusetts
Contributing Authors
Laura Hershkowitz, DO
Northshore ClinicalAssociatesErie, Pennsylvania
Barbara Olson, MD
Pediatric NeurologyAssociatesNashville, Tennessee
Raman Sankar, MD, PhD
Proessor and Chie,Rubin BrownDistinguished Chair Division o PediatricNeurologyDavid Geen School o Medicine at UCLAMattel Children’s HospitalLos Angeles, Caliornia
Dear Colleagues:
Welcome to the frst issue o the
LEADing Issues in Epilepsy 
newsletter. This series will help you to staycurrent on new issues, provide new insights into ongoing issues, and address critical topics that impact the management o your patients with epilepsy. Each newsletter will ocus on one topic, beginning with thisnewsletter’s ocus on driving and epilepsy. This issue o 
LEADing Issues in Epilepsy 
discusses how to help your patients deal with concerns surrounding driving. Driving a car is an important regular activity or most adults in the United States, may be vital tomaintaining an independent liestyle, and is even required or some jobs. This is a signifcant concernor most adults living with epilepsy, whether they need to obtain, regain, or simply maintain their driving privileges. This issue o our newsletter oers a eature article addressing saety and liability issues relatedto driving and epilepsy; a review o state statutes impacting driving privileges; an interview with David M.Labiner, MD an expert on the practical aspects o driving and epilepsy; and a case study discussing what to do when a patient’s driving privileges are revoked.At this time, we’d also like to introduce you to LEAD (Leadership in Epilepsy, Advocacy, and Development),an initiative created to support the epilepsy community by broadening awareness and understanding o issues that are critical to optimal patient management. Our vision in creating LEAD was to develop a coalitiono nationally recognized healthcare proessionals who treat patients with epilepsy and who are committedto advancing the treatment o epilepsy by creating innovative programs that can make a positive dierencein the lives o epilepsy patients. Our overall mission is to draw attention to current and emerging issuesregarding epilepsy through unique educational strategies and tools to address critical issues in epilepsymanagement.LEAD debuted at the 2007 American Epilepsy Society Annual Meeting in Philadelphia, where we presentedan overview o the initiative and the LEAD aculty’s frst educational programs—a consensus statement onminimum standards o care and a practice-based checklist or epilepsy management. We are pleased toreport that these consensus recommendations have been published in
Current Medical Research and Opinion
(vol 24, issue number 12, pages 3463-3477). Thank you or your interest, and we hope that you fnd
LEADing Issues in Epilepsy 
inormative and useulin your daily practice.Sincerely, 
 Tracy A. Glauser, MD
Raman Sankar, MD, PhD
LEAD Co-Chair LEAD Co-Chair Proessor o Pediatrics and Neurology Proessor and Chie, Rubin BrownDirector, Comprehensive Epilepsy Program Distinguished Chair Co-Director, Genetic Pharmacology Service Division o Pediatric NeurologyCincinnati Children’s Hospital Medical Center David Geen School o Medicine at UCLACincinnati, Ohio Mattel Children’s HospitalLos Angeles, Caliornia
ing Issues in Epilepsy:
What You Need to Know About Epilepsy and Driving 
riving a car is part o many routineactivities and is a central part o our way o lie in the United States,where over 75% o households with 2 or more adults have 2 or more cars.
For people living with epilepsy, the ability todrive can signicantly impact quality o lieand may be critical to maintain a normalliestyle that includes employment, social-izing, and healthcare visits.
However, sae
drivers need to be able to identiy changesin the trac and conditions around them,interpret these changes, and respondquickly and appropriately.
Seizures that occur during driving can adversely aect these abilities and requently cause seriousaccidents.
It is estimated that between50% and 60% o seizures that occur whiledriving result in accidents and approximately30% o all medical-related crashes havebeen attributed to seizures.
 The needs o people with epilepsy withregard to driving need to be balanced withthe potential risks to public saety. There-ore, a variety o state regulations havebeen designed to allow people with epilepsyto drive only i their seizures are controlled.In these patients, the risks associated withdriving are lower and more comparable withthose o individuals with other medicalconditions
Because seizure control iscentral to driving privileges, physicians playa pivotal role in determining driving rightsor patients with epilepsy.
The ollowing sections o this article briefy review thisimportant aspect o clinical practice andprovide basic inormation relevant tocounseling patients regarding their driving privileges.
Legal Issues and Driving With Epilepsy
For people with epilepsy, maintaining adriver’s license is surrounded by a number o legal issues. Individual state laws restrict drivers’ licenses or persons with activeuncontrolled seizures as well as providerules regarding how a license to drive maybe acquired in that state.
The principalocus o these regulations is to restrict driving or those at greatest risk o having aseizure while driving, most oten by requiring a seizure-ree interval prior to obtainindriving privileges.In most states, people with epilepsy must be ree o seizures or a set period o time,ranging rom 3 to 12 months beore theycan legally operate a car.
Although somedata have indicated that longer seizure-reeintervals may have the least risk or seizure-related accidents, states are trending towards requiring shorter seizure-ree intervalso 3 or 6 months.
One recent study oundthat seizure-related accidents did not increase signicantly when the requiredseizure-ree interval was decreased rom12 to 3 months.
Regulations and the degree o restrictionvary or each state and some states haveadopted regulations that assess individualclinical actors in determining whether aperson with epilepsy may drive.
Somestate regulations require periodic physicianreports led with the department o trans-portation or a medical review board. Whenand how these are led also varies by state.Further, some states mandate physicianreporting o epilepsy.
Another variationin laws isthat somestates allow patients with epilepsy to drivewhen their seizures are limited to certaincircumstances, such as or those who haveprolonged and/or consistent auras, purelynocturnal seizures, or seizures that arecaused by transient events.
 This myriad o laws makes physicianknowledge and understanding o the statelaws that apply specically to their patientscritical, which in some cases may alsoinclude knowledge o laws o neighboring states. Physicians need to know the localregulations regarding driving privileges or persons with epilepsy, as well as their ownobligations with regard to reporting. Unor-tunately, physician knowledge o applicabledriving laws may be decient.
In a recent survey o 209 physicians treating patientswith epilepsy, a large number were unableto correctly identiy the reporting require-ments or their state, suggesting that their understanding o the complexities relatedto individual state driving requirements or people with epilepsy may be inaccurate.Among respondents in this investigation,only 12% o amily practitioners, 14% o internal medicine physicians, and 27% o neurologists considered themselves to bevery knowledgeable o their state’s driving laws.
All physicians caring or patientswith epilepsy should review their state lawsor the specics that apply to their practice.In addition to knowing and adhering to thereporting laws in their state, physiciansneed to be aware o their own liabilities andthe impacts o privacy codes.
Immunityrom civil and/or criminal prosecution or ling epilepsy or seizure reports also variesbetween states, as does physician liabilityi a person with epilepsy drives and causesan accident.
I a physician knows that a person with epilepsy is driving contraryto medical advice, the physician has anobligation to the patient and the communityto report that patient to the driving authorities.In the event that a physician is ound tohave ailed in his/her responsibilities tothe wider community, the physician maybe personally liable to litigation by injuredthird parties.
In clinical practice,physicians may need to adequatelydocument in patient charts their having advised patients not to drive.
Similarly, patients may be ound guilty o dangerous driving i they ail to report their epilepsy as required by local authorities andsubsequently have an accident.
Patientswho mislead authorities or drive ater being told not to may experience civil and legalrepercussions, and insurance may not cover the patients i they are driving illegally.
Driving Privileges: Protecting Your Patients and Yourself 
by Laura Hershkowitz, DO
Physicians need to know the local regulations regarding driving privileges for persons with epilepsy, as well astheir own obligations with regard to reporting.
ing Issues in Epilepsy:
What You Need to Know About Epilepsy and Driving 
ing Issues in Epilepsy:
What You Need to Know About Epilepsy and Driving 
3All Seizures ImpactDriving Safety
Any seizure can impact driving ability andaccurately determining i a patient is trulyseizure-ree can be challenging. Most o theinormation a physician obtains regarding seizure occurrence or seizure reedomcomes directly rom the patient’s sel-report. However, patients may not accurately report or remember seizures.
 For example, patients with clear complex partial seizures who stop, stare, or haveautomatisms may report that they “haven’t had a big seizure in years.” Yet clearlythese patients may be unsae to drive.Part o the challenge or physicians is toobtain all relevant inormation rom a patient regarding all seizures that the patient maybe experiencing, even those o lesser magnitude.Patientswith anyalterationin con-sciousnessshould not be driving and absence or complex partial seizureswhile driving can be as dangerous astonic-clonic seizures.
In addition to discussions with the patients,physicians should also elicit discussionswith seizure witnesses and patient care-givers. A witness to the seizures may beable to conrm that the patient is totallyresponsive during the seizure.
In both direct patient evaluations and discussions withcaregivers or amily, the attending physicianshould probe the occurrence o any smaller seizures by including questions and topicssuch as those in the
. This will assist them in determining i the patients are reeo all seizures, even those that they may not recognize or remember as seizures. Patientsshould only consider driving i they are reeo any seizures that alter their conscious-ness or ability to ully respond.
Driving Safety and New-Onsetvs Breakthrough Seizures
State laws that base driving privileges onseizure-ree intervals derive rom researchon new-onset seizures. However, in clinicalpractice, 2 broad subgroups o patientswith epilepsy actually exist and each hasdistinct patterns o seizure control: patientswith new-onset seizures and more reractorypatients with recurring seizures.
In general,approximately 64% o patients have a goodprognosis and can achieve seizure-reestatus with monotherapy or by a combina-tion o antiepileptic drugs (AEDs).
The earlyresponse to therapy in this group is a avor-able prognostic actor or seizure reedom. The other 36% may represent a group withreractory epilepsy at the outset, oten withunderlying structural cerebral abnormalities,making successul treatment a challenge.
Logically,the 2types o clinicalpatientsmay dier in actualdriving risk. For example, i a patient withnew-onset epilepsy begins medication andremains seizure-ree, the medication ismost likely controlling the seizures. In thistype o patient, the state-mandated seizure-ree interval may realistically indicate arelatively low risk o a seizure while driving.Conversely, another patient who is on amedication regimen and yet experiences abreakthrough seizure may present a dierent situation entirely. A patient receiving anappropriate AED dose or multiple medicationswho experiences additional seizures may bein the latter more intractable group. In thesecond example, the patient may be at ahigher risk o a seizure and caution shouldbe taken in counseling this patient to drive,as waiting time beyond the state-mandatedseizure-ree interval may be warranted todetermine seizure reedom.
Special Driving Allowancesand Safety
Caveats in the laws o some states allowing patients driving privileges in certain situa-tions or when patients have specic seizurecharacteristics represent other potentialconcerns about driving saety and patient counseling. Some states allow patients todrive i a prolonged aura or warning reliablyoccurs beore seizures, i the seizures occur only at night, or i the seizures present withno loss o consciousness.
These excep-tions are broadly based on the patients’ability to stop driving i they were toanticipate a seizure occurring. However, inpractice, patients may overestimate their ability to stop or avoid driving prior to apotential seizure.Driving privileges or patients with nocturnalseizures pose unique concerns and shouldbe considered only when the exclusivelynocturnal seizure pattern has been rmlyestablished.
For example, patients withnocturnal seizures on a multiple AED regimenmay be allowed to drive and work during theday. However, i those patients are not trulyseizure-ree during the daytime, they couldexperience a daytime seizure that may leadto a car accident.Auras pose other practical concerns regard-ing their use as the basis or special driving privileges. As discussed earlier, patientsmay not actually know whether they areaware during the aura o a temporal lobeseizure.
Although some patients with somesimple partial seizures may be sae todrive, such as those with a sensory aura or some simple motor maniestations, goodpractice is to question witnesses regarding awareness during an aura.
For example, aew patients may be certain that they onlyexperience auras and not seizures. However,these patients can be put on a monitoring unit, push the button indicating an aura,and then experience a multiple-minuteperiod o conused unresponsiveness.Aterwards, the patients may have nomemory o the seizure, and again claimto have only experienced an aura.Driving privileges based on special excep-tions may require additional patient coun-seling. Patients need to understand what constitutes a seizure and how their seizurescan impact driving saety. Even with warning or no loss o consciousness, some patientsmay not actually have the ability to respondquickly enough and stop driving.
 Table. Probing for Occurrence of Any Seizures
Sample Questions
 Do you have episodes o eeling ar away?Do you have episodes o eeling stuck?Do you have episodes o missing time?Do you catch yoursel staring o?Do you have occasions where you are unable to speak?
Patients who drive when unsafe have broad societalimplications, since driving with seizures can impact not only the person with epilepsy, but everyone onthe road, as well as their families.
ing Issues in Epilepsy:
What You Need to Know About Epilepsy and Driving 

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