Table 12.

Special issues in epilepsy

Special population	Strategies
Cognitive impairment	Causes
	Duration and frequency of seizure
	Effect of AEDs, control of seizures
	Structural abnormalities on MRI
	Subjective cognitive complaints are quite common in epilepsy patients (44%). However, on examination, such cognitive impairment is not present in these patients. This might be due to concurrent depression and anxiety disorders
	In elderly patients at the onset itself if cognitive functioning is affected, clinically significant impairment may develop gradually
	Generalized cognitive impairment is seen with idiopathic
	Generalized epilepsy, whereas TLE is associated with memory impairment.[31] However TLE causes wider network dysfunction leading to other cognitive deficits too. A major concern has been about progressive decline in cognitive functioning. There are mixed findings about this in literature
	Another question is whether cognitive impairment persists in spite of seizure control and it has been observed that minor deficits persist especially if there is underlying pre-existent brain damage
	Epilepsy surgery is also associated with cognitive impairment. An estimated 44% risk of verbal memory problems and 34% risk of naming difficulties were found in a systematic review. Resection of dominant temporal lobe, normal memory score before surgery, late onset, no hippocampal sclerosis, and poor seizure control are some of the predictors of memory problems postsurgically
Suicidality	There is an increased risk of suicide I patients with epilepsy. 3%–7% patients commit suicide. The risk multiplies 4–5 times than in the nonepileptic population. Temporal lobe involvement in focal dyscognitive seizures increases this risk 25 times
	Suicidality also shows a bidirectional relationship with epilepsy, thus increasing the risk of epilepsy 5 times in patients with suicidal tendencies[13]
	Causes of suicidal thought, suicide attempts, and completed suicides in epilepsy are many. Psychosocial consequences of epilepsy, associated mood disorder in the form of severe depression, command hallucinations during ictal period, agitation, and borderline personality traits are some of the reasons for suicidality. It is also suggested that suicidal risk increases due to some antiepileptic medication, though evidence does not yet support this finding[13]
	An assessment for suicidal ideation and suicidal behavior is very essential for prevention and early intervention
Personality changes	Particularly in those with TLE, certain behavioral traits have been classically described, including social viscosity (tendency to prolong social encounters), humorlessness, circumstantiality, hyposexuality, and obsessionalism.[22] These have been seen more commonly with left-sided TLE or GE
	Other studies have demonstrated hyper-religiosity to be associated with bilateral temporal lobe foci. This specific pattern of inter-ictal personality syndrome has been commonly labelled to as Gastaut Geschwind syndrome[22]
	Personality traits such as emotional instability, immaturity and disinhibition have been noted in patients with JME and have been thought to be a consequence of frontal lobe pathology
	A thorough evaluation including detailed history of symptomatology and assessment of personality (including psychological tests) is required
	The potential role of AEDs in the presentation of certain symptoms (such has irritability, hyposexuality) also needs to be kept in mind since these could be a result of side effects of AEDs
Aggression	Aggression could be a direct consequence of ictal phenomena or can be caused by underlying personality, comorbid psychiatric disorders, and psychosocial stressors
	Peri-ictal aggression is classically nonspecific, purposeless, disorganized, and generally directed toward things in the immediate vicinity[32]
	Instances of aggression have particularly been noted in cases where patients are restrained since it is associated with the worsening of confusion[22]
	A detailed evaluation of the type, intensity, frequency of the aggression episodes, its temporal connection with seizures along with video EEG may be required to understand the exact picture
	Management of aggression is generally directed towards treatment of the cause. In cases where aggression is suspected to be a result of seizure activity, prompt control of seizures with AEDs will help in preventing fresh episodes of violence
	In cases where aggression is related to a comorbid psychiatric disorder such as depression or psychosis, treatment of these conditions may help in reducing instances of aggression
Children	In the younger children, epilepsy is frequently associated with ADHD and autism[33,34]
	In older children and adolescents, it is associated with behavioral problems, mood and anxiety disorders, personality disorders, and psychotic disorders
	ADHD commonly presents as inattentive type and is 2–3 times more common than in general population[34]
	As per current literature based on multiple RCTs, methyphenidate 0.3–1 mg/kg can be safely given for ADHD even in children with epilepsy with no added risk of seizure worsening[21]
	Data on atomoxetine and amphetamines are lacking, hence should only be prescribed in case of nonresponse to methylphenidate based on an informed decision and with proper clinical monitoring
Epilepsy surgery	Following epilepsy surgery, mood disturbances in the form of depressive features or lability occur in the first 6–12 weeks. This is seen in almost 25% of patients and especially in those with temporal lobe surgery. In 10% of patients, depressive features persist requiring treatment for the same[7]
	Interictal psychosis may arise for the first time after surgery
	A large multicenter study has shown that there is improvement in depressive features following surgery if there is good seizure control postsurgically[14]
	Hence, it is necessary to evaluate for mood disturbances after surgery, follow up regularly to see if they persist, also see the seizure control with surgery, and accordingly decide to treat these patients
	It is essential to rule out depression in presurgical evaluation, as it is associated with poorer seizure control after surgery
Substance use disorders	Substance use can lead to seizures in intoxication, in over dose, in withdrawal, and in long-term toxicity. This can lead to nonadherence to treatment in seizure disorder and poor seizure control. In an Indian study conducted in 450 prisoners, the prevalence of epilepsy was 1.4 times higher among substance using prisoners. Alcohol, cannabis, and opioids were the most commonly used substances[35]

MRI – Magnetic resonance imaging; EEG – Electroencephalography; ADHD – Attention deficit hyperactivity disorder; RCTs - Randomized controlled trials; AEDs – Anti epileptic drugs; TLE – Temporal Lobe epilepsy; GE – Generalized epilepsy; JME – Juvenile myoclonic epilepsy