SEIZURES IN THE NURSING HOME
CLINICAL PRACTICE GUIDELINE

DISEASE RECOGNITION

• Seizure in resident with known “seizure” diagnosis
• Presumed new onset or first time seizure activity
• Change in mental status without convulsion or loss of consciousness

CONTEXT / / COMMUNICATION

All residents should be evaluated for these changes with treatment given to resolve condition and prevent worsening. If the resident is moribund treatment is intended to enhance comfort. The facility nurse should communicate with the
responsible party with MD or NP contact as needed.

ASSOCIATED RISKS

• Conditions: DM, CVA (commonly embolic), seizure disorder, hypo/hypertension, hyponatremia, hypercalcemia, hypomagnesemia, primary or secondary CNS tumors, infections (CNS or other), dementia, metabolic encephalopathies, uremia, anoxia, hepatic failure
• Medications: alcohol and benzodiazepine withdrawal, hypoglycemic agents, drugs that lower seizure threshold (Cipro, Wellbutrin, Amantadine), drug intoxication (theophylline, isoniazid)
• Head trauma (new or old)

DEFINITIONS

Provoked seizure: convulsion triggered by systemic and/or neurological condition

Unprovoked seizure: convulsion occurs without identifiable cause or explanation

Epilepsy: two or more unprovoked seizures

CLASSIFICATION OF SEIZURES
Generalized		Partial or focal
Bilaterally symmetrical with local onset		Begins locally
Convulsive Tonic-clonic Myoclonic Clonic Tonic Atonic	Non-convulsive Absence Atypical Complex	Simple No MS change or loss of consciousness Motor signs Somato -sensory signs  autonomic symptoms Psychic symptoms	Complex Loss of  consciousness &/or change MS Aura then MS change or MS change at onset	Partial with secondary generalized Simple or complex evolving to generalized

PHYSICAL EXAMINATION

• Pertinent to assess overall physical and mental status - check for new focal deficits as in CVA/TIA
• Vital signs, accucheck, pulse oximetry (if resident seen immediately after seizure)

DIAGNOSTIC WORK-UP

• For new seizure: 1^st - blood work – drug levels, electrolytes, serum calcium,  magnesium, glucose, kidney function, ammonia (in liver disease), UCS.
• 2^nd – if blood work negative and presumed seizure activity continues order EEG. Order MRI if brain lesion possible.
• For established seizure diagnosis: 1^st - drug levels 2^nd -  as indicated to rule out concurrent cause
• For status epilepticus(with or without previous diagnosis of seizure and unrelieved by PRN IM anti-seizure drug): ER evaluation

TREATMENT OPTIONS
First seizure	Known seizure diagnosis
Treat reversible causes	If drug levels non-therapeutic increase drug dose until therapeutic level reached – discontinue drugs that have lowered seizure threshold
If seizures continue during work up and treatment of reversible causes order Ativan 1 mg IM Q8 hrs prn for seizure (may repeat in 30 minutes for new seizure)	If drug level therapeutic but seizures continue start 2^nd anti-seizure medication
If seizures continue, without reversible cause, start on drugs as follows: Generalized: Dilantin 100mg Q12 hr, titrate to therapeutic dose, add Tegretol 100mg Q 12hr if Dilantin not adequate at therapeutic level, titrate to therapeutic dose Partial: Tegretol 100mg Q 12hr, titrate – add Neurontin 300mg Q 12hr if Tegretol alone, at therapeutic levels, inadequate	If two medications inadequate consider Neurontin 300mg Q 12 hrs or Lamictal 100mg Q 12hrs (start at 25mg QD if on Depakote) or Keppra 500 mg Q 12 hours [if ESRD 500 mg QD]
If seizures continue on two drugs, at therapeutic or tolerated level, consider referral to neurologist	If seizures continue consider referral to neurologist

DRUG INTERACTIONS/RECOMMENDATIONS
Dilantin	Dilantin level increased interacting with Coumadin, sulfa, Tagamet, Amiodarone Decrease Digoxin, Tegretol level and Haldol concentration separate by 1 hours from bolus tube feed dosing interval for liquid is Q6-8 hrs Increase or decrease by 30-50 mg per day once plasma concentration is > 10ug/ml
Tegretol	Decrease Dilantin, Depakote level Increased with Isoniazid, Tagamet, Verapamil contraindicated in bone marrow suppression monitor CBC, BUN, LFTs at baseline and periodically
Depakote	Decrease Dilantin level Increase Tegretol level contraindicated in liver disease monitor LFTs, platelets, INR at baseline and periodically
Neurontin	Decreased absorption with antacids no interaction with other anti-seizure drugs
Lamictal	Lamictal level increased with Depakote
Phenobarbital	Decreased Dilantin & Tegretol concentrations

COMMENTS

If end stage and seizures occur use Ativan (see Palliative Care Guideline)
If blood level subtherapeutic and resident is without seizure activity do not increase drug dose

References for Seizures

1. Allen, TG: Understanding and Diagnosing Seizures Disorders in Advance for Nurse Practitioners, January, 1995, 28-30.
2. Awadalla, S., Doster, SK et al: Neurologic Emergencies in Internal Medicine in The Washington Manual of Medical Therapeutics, 28^th Edition, 1995, 541-542.
3. Browne, TR, Holmes, GL: Epilepsy in N Eng J Med, Vol. 344, No. 15, April 12, 2001, 1145-1151.
4. Haider, A., Tuchek, JM et al: Seizure Control: How to use the new antiepileptic drugs in older patients in Geriatrics, September 1996, Vol.51, No.9, 42-45.
5. Hertz, S., Gottesman, M.: New Antiepileptic Medications in Emergency Medicine, March, 1997, 17-34.
6. Isselbacher, KJ, Braunwald, E. et al: Epilepsy in Harrison’s Principles of Internal Medicine, 13^th Edition, 1995, 698-702.
7. Pourmand, R.: Seizures and epilepsy in older patients: Evaluation and management in Geriatrics, March, 1996, Vol. 51, No. 3, 39-52.
8. Stajich, JM: Seizure Disorders in Clinicians Review, October, 1994, 96-98.

EMS/10.99
©EMS
Revised 05.04

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