Multimodal Quality of Life Assessment in Post-9/11 Veterans With Epilepsy

Abstract

Background and Objectives:Epilepsy is defined by the occurrence of multiple unprovoked seizures, but quality of life (QOL) in people with epilepsy is determined by multiple factors, in which psychiatric comorbidities play a pivotal role. Therefore, understanding the interplay between comorbidities and QOL across epilepsy phenotypes is an important step towards improved outcomes. Here, we report the impact of QOL across distinct epilepsy phenotypes in a cohort of post-9/11 veterans with high rates of traumatic brain injury (TBI).Methods:This observational cohort study from the Veterans Health Administration included post-9/11 Veterans with epilepsy. A process integrating an epilepsy identification algorithm, chart abstraction, and self-reported measures was used to classify patients into one of four groups: 1. Epilepsy controlled with medications, 2. Drug resistant epilepsy (DRE), 3. Post-traumatic epilepsy (PTE), or 4. Drug resistant post-traumatic epilepsy (PT-DRE). Summary scores for six QOL measures were compared across the groups, adjusting for age, sex, and number of comorbidities.Results:A total of 529 survey respondents with epilepsy were included in the analysis: 249 controls (i.e., epilepsy without DRE or PTE), 124 with DRE, 86 with PTE, and 70 with PT-DRE. Drug resistant epilepsy was more common in those with PTE compared with non-traumatic epilepsy (45% vs. 33%, odds ratio 1.6 (95% CI: [1.1-2.4], p=0.01)). Patients with PTE and PT-DRE had significantly more comorbid conditions in health records than those with nontraumatic epilepsy. Those with both PTE and DRE reported the lowest QOL across all six measures, and this persisted after adjustment for comorbidities, and in further linear analyses.Discussion:Among those with PTE, DRE prevalence was significantly higher than for non-traumatic epilepsies. PTE was also associated with higher burden of comorbidity, and worse overall QOL compared to those with non-traumatic epilepsies. People with PTE are distinctly vulnerable to the comorbidities associated with TBI and epilepsy. This at-risk group should be the focus of future studies aimed at elucidating the factors associated with adverse health outcomes and developing anti-epileptogenic therapies.

Posttraumatic Epilepsy and Dementia Risk

“…Few studies have considered differences by sex or race in associations of PTE with outcomes, but both head injury and PTE have been shown to be more common among men compared with women among younger populations, but these sex differences are no longer present among older individuals (ie, older than 75 years). 9,35,38 This is in contrast to our cohort where women were more likely to have a head injury; these differences are likely multifactorial and may be related differential self-reporting of head injuries or differences in diagnosis by sex in the represented communities. The results of this study may not be generalizable to other regions of the US or to population subgroups not represented in the ARIC study.…”

“…This population is substantially older than most prior studies examining associations of PTE with outcomes, where the mean age is younger than 45 years. [2][3][4][5][6][7][8][9][10]34 The highest incidence of head injury 35 and epilepsy 36 occurs among older individuals (ie, age 65 years or older), which highlights the importance of studying outcomes of PTE among middle-aged to older individuals. Herein, we report higher relative risk for dementia associated with PTE among individuals who were younger compared with older at study baseline.…”

“…This should be a priority for future research as prior studies have suggested that more severe PTE (eg, drug resistant PTE) is associated with worse shortterm outcomes compared with nondrug resistant PTE. 9 In addition, while the ARIC study dementia definition minimizes biases due to attrition, the addition of ICD and death certificate codes to the in-person and telephone assessment data results in lower sensitivity.…”

“…Posttraumatic epilepsy (PTE; ie, unprovoked seizures occurring more than 7 days after traumatic brain injury) accounts for 5% to 20% of acquired epilepsies . Prior studies show that PTE is associated with worse short-term (ie, within 2 years postinjury) functional, psychosocial, and cognitive outcomes, but there is limited understanding of long-term outcomes following a diagnosis of PTE.…”

Traumatic brain injury: Mechanisms, manifestations, and visual sequelae

“…An electroencephalogram (EEG) should be used when evaluating TBI patients because up to 25% of these patients may have sub-clinical seizure activity on EEG (Ronne-Engstrom and Winkler, 2006;Chen and Koubeissi, 2019). While drug treatment is generally effective in seizure control, some PTE patients are medication-resistant and difficult to manage (Gupta et al, 2014;Gugger et al, 2022).…”