The Multidisciplinary Team in the Treatment of Patients With Epilepsy

Abstract

Optimal care for people with epilepsy (PwE) requires a multidisciplinary patient-oriented team, a concept that emerged from oncology. This article reviews the role of advanced practice providers, dieticians, psychologists, pharmacists, psychiatrists, and social workers in working alongside neurologists in caring for PwE. The article examines training and licensure requirements, clinical needs, and scope of practice for these disciplines. The review concludes by providing recommendations and a framework for multidisciplinary care for PwE.

Introduction

Optimal care for people with epilepsy (PwE) is increasingly recognized as requiring a multidisciplinary, patient-oriented team. The Institute of Medicine’s 2012 epilepsy report Epilepsy Across the Spectrum lists 36 health professions that are engaged in the care for PwE and acknowledges that important elements of care may cross specialty boundaries. ¹ As such, team coordination is essential. Moreover, each team member should practice to full capability, as the American Academy of Neurology includes in its 2020 Position Statement on Advanced Practice Providers (APPs). ² With this perspective and knowledge that professionals do not always know the clinical range of those in other professions, this review discusses components of epilepsy care with the ultimate goal of improving clinical outcomes through fostering better integration of multidisciplinary teams.

The multidisciplinary needs for epilepsy care are reflected in the National Association of Epilepsy Centers (NAEC) requirement for Levels 3 and 4 centers, which specify specialist physicians, nurses, technologists, neuropsychologists, and social worker services. Beyond the capabilities of these professionals, many epilepsy centers also include pharmacists, dieticians, and psychiatrists. One piece of evidence for the benefits of this team approach was published by Li and colleagues, who demonstrated advantages in epilepsy diagnosis and outcomes even in low resource countries. ³ Epilepsy centers also have a large role in the evaluation and treatment of people with functional seizures, which is benefited by teams that also include psychotherapists. ⁴

The full range of relevant health care providers are not discussed in this review. Nevertheless, we have provided insights into roles, scopes of practice, limits of practice, and collaborative opportunities across 8 specialties: Clinical Nurse Specialist, Nurse Practitioner, Physician Assistant/Associate, Dietician, Pharmacist, Psychologist, Psychiatrist, and Social Worker. These include examples of the multidisciplinary clinical services that are in place at the authors’ individual programs. The session’s ambition was to spur reconsideration of multidisciplinary care through better understanding of the individual professions and the experiences of real-world teams.

Advanced Practice Providers

Many epilepsy centers have enriched the care they deliver to patients and their families by the addition and expansion of APPs within the multidisciplinary team. The term APPs is an umbrella term that includes Advanced Practice Registered Nurses (APRN) and Certified Physician Assistants (PA-C). The APRN profession can be further broken down into different certifications, with those applicable to the epilepsy practice including the Certified Nurse Specialist (CNS) and Certified Nurse Practitioner (CNP).

Each provider type including CNS, CNP, and PA-C have nuances to the certification and scope of practice they can provide. ⁵ A CNS is a graduate level registered nurse who focuses their practice model on 3 spheres: patient, nurse, and organization. The CNS plays a critical role in development of policies, research, education, teaching, consulting, and management. Their certificate can specialize in adult, pediatrics, and neonatal medicine, and they are required to renew their certification every 5 years with a minimum of 1000 clinical hours and 150 continuing education units (CEUs). ⁶ Similarly, a CNP is a graduate level registered nurse who can certify in the specialties of family medicine, emergency medicine, adult, pediatrics, neonatal, psychiatry, and women’s health. There are also postgraduate degrees available to gain further knowledge and skills in a variety of practice and leadership settings. CNPs renew their certification every 5 years, with a minimum of 1000 clinical hours every 2 years and 100 CEUs. Both CNS and CNP providers need a current RN state license to practice in addition to their APRN license, and both licenses are renewed through the nursing board. ⁷ A PA-C is a graduate level degree in PA studies from an accredited program, with a 15-month didactic phase and clinical rotations including internal medicine, emergency medicine, surgery, pediatrics, women’s health, family medicine, psychiatry, geriatrics, infectious disease, and typically 2 electives. Differently, with the PA degree, individuals can practice in any medical setting or specialty, are licensed through the medical board, and are required to take a recertification examination every 10 years and complete 100 hours of Continuing Medical Education (CME) every 2 years. ⁸

With all the above degrees, practicing, and prescribing laws vary state to state. This can range from independent practice to supervised practice, or in a few states limited or restricted practice. A Drug Enforcement Administration registration is required if the state of employment permits prescribing, administering, dispensing, and procuring of level II-V controlled substance medications. ⁹ The mean salary for an APP across the United States is ∼$120 000, and can vary based on years practicing, specialty, and location. Regarding billing, APPs can bill for both inpatient and outpatient services, and Medicare pays 85% of the physician fee schedule. When an APP works at the top of their scope there are many opportunities to elevate patient access and quality care. In the outpatient setting, APPs can have autonomous clinic, paired or shared medical appointments, specialty clinics (such as pregnancy or neuromodulation), and assist with ambulatory needs such as telephone calls, electronic messages, medication refills, and letters. In the inpatient setting, APPs can provide care in the Epilepsy Monitoring Unit (EMU) through patient history and physical examinations, discharge paperwork, patient education, procedures, acute seizure management, and consult patient care.

When considering expanding the patient care team with an APP, it is important to review your specific needs to guide the best fit for your practice; this can include the age of patients you treat, APP degree and specialty, previous experience and interest, coverage needs, amount of collaboration available, state laws, salary, and continuing education requirements. Overall, collaboration with APPs within a multidisciplinary team is a means to increase patient access, optimize workload, and elevate the epilepsy care provided.

Psychologists and Psychogenic Nonepileptic Seizures

An important facet of epilepsy diagnosis is the potential for psychogenic nonepileptic seizures (PNES). Historically, patients with PNES have fallen in the gap between neurology and psychiatry, resulting in less than optimal treatment outcomes. More recent strides in PNES research have pointed toward early education and behavioral interventions as promising strategies. ¹⁰ However, several barriers continue to prevent universal access to these approaches.

First, PNES is often perceived as a monolith, instead of a symptom of underlying psychiatric and medical comorbidities that are often heterogeneous in nature. Patients diagnosed with PNES will often state “trauma” and “stress” were provided by their neurologist as the singular causal explanation for their symptoms, even in the absence of subjective self-report of either. Instead, research points toward psychiatric heterogeneity as the norm. ¹⁰ Anecdotally, what we see in our PNES clinic is a culmination of traumatic or adverse childhood experiences (for further review, see Bompair et al ¹¹ ), poor emotional coping strategies, psychiatric comorbidities such as longstanding undertreated anxiety disorders and severe mood dysregulation, as also sometimes chronic neurological comorbidities (eg, traumatic brain injury, chronic migraine). ¹¹ Subsequent treatment requires careful assessment and tailored mental health treatment approaches by mental health care providers familiar with PNES, in conjunction with ongoing education and treatment monitoring by a treating neurologist. ^10,12

The gap in care for patients with PNES is often widened by specific barriers. These include lack of access to gold standard diagnosis of this condition (eg, EMU monitoring with capture of the typical event), limited access to mental health care providers with a working knowledge of PNES and driving restrictions. After diagnosis, this diagnostic acceptance can be further complicated by disbelief about the diagnosis, longstanding mental health treatment stigma (held by both patients and their providers), limited buy-in by patients and other treatment providers for diagnosis/treatment, and fears of a change in personal identity with the shift from an epileptic to a nonepileptic diagnosis.

However, behavioral health care providers (psychologists, psychiatrists, and clinical social workers) embedded within medical systems are ideal partners for neurology to address these known gaps. Within our own system at UT Southwestern Medical Center and Parkland Health, we have used different strategies for over a decade to address these barriers, including routine EMU rounding by a mental health care provider, didactic education for neurology faculty and residents regarding provision of the initial PNES diagnosis, exposure to and reduction of mental health care stigma, and creation of accessible, first-step telehealth treatment for underserved patients with PNES. The latter was developed within the Parkland Behavioral Health Clinic and consists of (1) a clear and appropriate referral by the EMU to our clinical social worker for screening, (2) diagnostic and medication evaluation by a psychiatry resident or faculty member, (3) referral to the multimonth PNES skills group (led this author and a psychiatry resident completing a group therapy rotation), and (4) access to further PNES support group and/or individual therapy options as needed. We focused on maximizing the available resources within the clinic, instead of waiting to launch perhaps a more idealistic and costly clinical approach.

In sum, PNES symptoms often reflect relatively complex underlying psychiatric and medical comorbidities that can feel overwhelming to a system and/or provider. However, partnerships between neurology and behavioral health providers are invaluable for identifying and addressing barriers to appropriate care. Finally, creation of a treatment access point that focuses on simply creating access to mental health care for PNES is an excellent starting point for any health care system.

Neuropsychiatry

Epilepsy is a quintessential neuropsychiatric disorder, reflected in part by the International League Against Epilepsy’s definition extending beyond solely seizures to include its cognitive, psychological, and social impacts. ¹³ First recognized by Hippocrates and later supported by epidemiologic studies, there is a bidirectional relationship: people living with epilepsy have increased rates of incidence and prevalence of psychiatric disorders and those with psychiatric diagnoses, for example, depression, anxiety disorders, and prior suicide attempts, are at higher odds of later developing epilepsy. ^{14 -19} The mechanisms behind this bidirectional relationship are most certainly multifactorial, and likely include disturbances within and between neural networks, disruption to neurotransmitter systems, as well as inefficiencies in stress homeostasis modulated by the hypothalamic-pituitary-adrenal axis. ²⁰

Neuropsychiatry is a specialty focused on caring for patients and advancing scientific knowledge through the understanding of brain-behavior relationships. ^21,22 This is a field of medicine that views the divide between the brain and the mind as nonexistent, working to erase this division so as to improve on the diagnosis and treatment of complex brain disorders. Neuropsychiatrists have unique training pathways which may include either a combined residency in neurology and psychiatry, or completion of an accredited Behavioral Neurology & Neuropsychiatry fellowship following a residency in psychiatry. ^23,24 While neuropsychiatrists are valuable team members in the multidisciplinary care of people living with epilepsy, there are many psychiatric providers who can serve in this much needed capacity. These can include general adult psychiatrists, child and adolescent psychiatrists for pediatric populations, consult-liaison psychiatrists, psychiatric mental health nurse practitioners, and physician associates to name a few.

Neuropsychiatrists assess for predisposing, precipitating, and perpetuating factors contributing to psychiatric disorders, and do so by utilizing a holistic biopsychosocial framework. ²⁵ Several variables must be considered, such as whether the psychiatric symptoms are correlated with the seizure itself, occurring in the hours to days before (pre-ictal), during (ictal), or following a seizure (post-ictal). The clinician must be attentive to the nuances of pharmacokinetics, searching for medication interactions that may affect the metabolism or excretion of psychotropic treatments. Pharmacodynamic effects are of equal importance, such as a decline in mood following removal of an anti-seizure medication (ASM) with mood stabilizing properties, or a worsening of mental status subsequent to introducing an ASM with higher predilection to psychiatric and behavioral side effects. ²⁶

In 2019, Dr Rebecca Fasano and Dr Andres Kanner published a call to action titled “Psychiatric complications after epilepsy surgery…but where are the psychiatrists?” This and the work of many of others underscore the rates of psychiatric disorders being even higher in those living with pharmacoresitant epilepsy. ^{27 -31} While a number of studies have demonstrated improvements in mental health by a year or more following epilepsy surgery, there can be a heightened vulnerability to recurring, worsening, or de novo psychiatric symptoms in the months following epilepsy surgery. ^{31 -33} A baseline psychiatric evaluation should be completed prior to epilepsy surgery, with the patient having regular follow-up in the postsurgical period. While presurgical neuropsychologic assessment is imperative, this cannot supplant the role of a comprehensive psychiatric evaluation. There remain, however, barriers to the integration of mental health specialists within epilepsy teams, including health care system organization, payment structures and time allocation, and the availability of clinicians with psychiatric training. ²⁷

Clinical Dieticians

Clinical dietitians provide Medical Nutrition Therapy to mitigate medical conditions, assess diet adequacy, and drug-nutrient interactions by utilizing nutrition-related interventions. While the role most dietitians play for PwE is management of ketogenic therapies (high fat, low carbohydrate dietary patterns that promote nutritional ketosis for the purpose of seizure management or KT), there is evidence to support broader involvement among the epilepsy population to improve patient outcomes and reduce health care costs. People with epilepsy are at higher nutritional risk compared to the general population in part due to comorbidities like autism or cerebral palsy, which can contribute to food selectivity and feeding impairments. Additionally, drug-nutrient interactions and adverse effects from ASM can result in nausea, vomiting, diarrhea, altered metabolism of various vitamins and minerals, or sedation. ³⁴ The combination of these factors can promote malnutrition or nutrient deficiencies, which may exacerbate seizures.

Malnutrition may lower the seizure threshold as it causes disruptions in protein and energy metabolism, deficiencies in various nutrients, as well as impairment in immune system. Medical complications of epilepsy, seizure treatments with ASMs or ketogenic therapy, and psychosocial factors can in turn contribute to malnutrition promoting a cycle that may worsen a patient’s epilepsy. ³⁵ In children with intractable epilepsy, 40% met criteria for malnutrition. ³⁶ A review of adult patients with refractory status epilepticus found 9% were malnourished at baseline; the prevalence increased to 45% at discharge. Those with or at risk of malnutrition had worse outcomes (P < .05) and longer hospital length of stay (82 ± 49 days vs 44 ± 23 days; P = .007). ³⁷

Dietitians assess patients by reviewing medical history, growth, labs, and dietary intake. Dietary interventions include vitamin/mineral supplementation, dietary modifications, or nutrition support (enteral or parenteral). Management of patients on KT require care coordination across health care providers, Durable Medical Equipment companies, and schools/care facilities. Successful dietary modifications often require motivational interviewing and individualized education that necessitate more frequent monitoring and longer appointment times than other disciplines. Logistics for this level of monitoring can be challenging in some States as dietitians are not universally recognized as billable providers, forcing nutrition services to be a “value-add” at some facilities.

Regardless of reimbursement, dietitians remain uniquely qualified to identify and properly address nutritional concerns that impact PwE. Early and effective interventions may improve patient outcomes by preventing and correcting malnutrition or nutrient deficiencies and reduce health care costs and hospital length of stays.

Pharmacists

Of the many confounding factors in the care of PwE is the management of ASMs. While the newer generation ASMs tend to have more straightforward kinetic profiles from the earlier generation ASMs, ^38,39 optimal management still requires attention to both pharmacokinetic and pharmacodynamic drug interactions, and unique adverse effects. This may be particularly true in the elder patient, or those with medical or mental health comorbidities.

The role of clinical pharmacists has long been established in the hospital setting, and indeed several analyses has demonstrated reduced overall costs, and improved patient outcomes that correlate with clinical pharmacist staffing and integration. ^40,41 While historically, this role has been seen as primarily ensuring accurate and safe medication dispensing, this role has been progressively expanding since the middle of the last century. This expanded role includes epilepsy care, both on the inpatient unit, as well as the clinic. Indeed, the first demonstrated impacts of pharmacists involvement in therapeutic management and patient education in patients with epilepsy was reported by Allen et al in 1978. ⁴²

Since then, there has been a steadily growing global literature demonstrating the impact of clinical pharmacists in multiple roles ranging from patient/caregiver education, motivational interviewing to improve ASM adherence, to direct patient medication management, and medication assessment both in the EMU and ambulatory clinic. ⁴³ Indeed, NAEC publish guidelines with specific criteria for Epilepsy Centers specify that access to consultation with a clinical pharmacist with pharmacological expertise or interest in epilepsy is included as a service that should be provided at the highest-level epilepsy centers (Level 3/Level 4). ⁴⁴

In many settings, properly credentialed (which typically includes 1-2 years of postgraduate specialty residency training) pharmacists can practice under collaborative practice, or scope of practice agreements that allow the pharmacist to directly see patients with complex, and time-intensive medication management needs. ^43,45 In a report by Taube, Clinical Pharmacist Practitioners in a Veterans Affairs Comprehensive Epilepsy Program, provided direct patient care responsibilities that included ASM initiation, dose adjustment, relevant laboratory monitoring, or referral to other services such as mental health, social workers, PT/OT in patients who had an established diagnosis of epilepsy. These expanded roles have the potential to not only improve patient care but also to improve patient access for routine follow-up, and allow time for the epileptologist to see new, or more complex patients. ⁴⁵

Social Workers

As clinically trained and licensed Master’s level professionals, Clinical Social Workers have the ability to intervene in a broad scope of service, including provision of therapy, crisis intervention, psychoeducation, resource navigation, advocacy, and quality improvement and research initiatives. With such versatile practice, Social Workers are found across many settings, such as therapy practices, in schools, child protection agencies, in advocacy and leadership positions, and the medical system. Furthermore, Social Workers are uniquely positioned to examine the impacts of societal issues and social determinants of health on evidence-based practice, access to care, and patient outcomes, thus making them invaluable consultants to other members of a multidisciplinary medical team. This person-centered and societally informed approach allows Social Workers to “meet their clients where they are at,” while also honoring the individuals’ self-determination and autonomy.

As a profession that is “devoted to helping people function the best they can in their environment,” ⁴⁶ Social Work practice lends itself well to working within an epilepsy patient population, as PwEs’ psychosocial situations may at times be just as complex as their epilepsy is to treat. This population may not only be managing their epilepsy diagnosis but also concerns related to navigating poverty, behavioral health challenges, educational and vocational stressors, adult transition, domestic violence, and communication challenges. It is crucial for medical teams to understand their patients’ experience with their epilepsy care and self-management within the lens of their environment, the factors that impact their well-being, and the barriers they may experience in accessing their care and adhering to their treatment.

The expertise Social Workers hold enables them to provide medical team members with insight and guidance when navigating these nuanced patient situations. Social Workers can support team members in striking balance with holding space for a patient’s lived experience and values and their epilepsy care needs, while considering potential impacts of social determinants of health and barriers to accessing the recommended care. When provided the opportunity to practice at the top of their license, social workers can offer invaluable clinical support, knowledge, and insight to patients, families, and their medical teams. While skilled with resource navigation and case management aspects, Social Workers are adept with implementing direct clinical interventions, such as psychosocial assessment, brief therapy, or therapeutic groups, which could significantly enhance the resource offerings and access to care for patients within an epilepsy clinic setting.

Conclusions and Recommendations

Multidisciplinary teams in service of patient care involve professionals across a variety of disciplines that collaborate to optimize patient care. Multidisciplinary teams came from oncology in the 1980s when it was found that the addition of chemotherapy regimens to other modalities of treatment (chemotherapy and surgery) was found to provide significantly better treatment options. ⁴⁷ In this article, we discuss a variety of professionals and the services that they can provide to improve the care of PwE. We recommend that epilepsy teams be organized around 3 spheres with regard to multidisciplinary care; all professionals are involved in patient and peer education.

Epilepsy clinical care: Advanced Practice Providers are able to work with epileptologists to effectively deliver outpatient and inpatient epilepsy services, from caring for patients to patient education as well as assisting with phone calls and in box messages.

Mental Health and Social Services: Psychologists and social workers are able deliver mental health services as well as a variety of services regarding vocation, housing, and care transitions. These services are best delivered embedded within neurology.

Specialized care services: Pharmacists, dieticians, and neuropsychiatrists deliver specialized care to treat nutritional issues and utilize dietary therapies, optimize medications, and patient adherence as well treat psychiatric issues in PwE and assist in surgical assessment. Motivational interviewing may be utilized to improve patient outcomes.

In conclusion, the 3 interdisciplinary spheres that we describe above allow the provision of high quality and personalized care for a variety of patients with epilepsy.