Significant improvement in quality of life (tx effect 7.1 pts)

Significant improvement in cognitive performance

No difference when working memory training was added

Patients reported high satisfaction with HOBSCOTCH

There are 2 million people in the US living with epilepsy.

Problem: New medications & treatments ≠ success

Comorbidities affect quality of life more than the seizures.

30% will have depression

50% will have cognitive impairment

Untreated comorbidities affect:

Seizure control & management

Employment, productivity

Activities of daily living

Social relationships

85% of epilepsy costs are indirect; epilepsy causes 89.4 million days/year of “role impairment” in the US.

Gap in care: limited treatments to address comorbidities . (Institute of Medicine report, 2012)

Improving Memory and Quality of Life In Epilepsy Tracie A. Caller, MD, MPH

COGNITIVE FUNCTION in EPILEPSY

COGNITION

SEIZURES

OUR AIM:

RATIONALE

Setting: Dartmouth-Hitchcock Epilepsy Center (DHEC), a Level 4 Epilepsy Center providing care to 1500 patients per year in a rural 3-state setting (NH, VT, ME).

VISIT 1: In Person

•Memory Education & Reattribution

• Intro to PST

•Receives HOBSCOTCH Workbook & Day Planner

• Training in relaxation techniques

VISIT 2-7: Phone Call

•Using PST to address memory problems in the domains of organization, disease management, & social skills.

• Exercise solutions as homework

•Ongoing education about memory strategies by the memory coach

VISIT 8: In Person

•Review progress

•Develop maintenance plan

• Encouragement to continue learned skills HOBSCOTCH plus (H+): added

Nintendo DS® Brain Age©

training 5 times /week

The workbook guides

patients through each

session & teaches

memory strategies

GLOBAL AIM: To improve the recognition and treatment of comorbid cognitive dysfunction in the adult epilepsy population.

SPECIFIC AIM: To implement a self-management program for adult epilepsy patients reporting cognitive dysfunction, to improve quality of life, memory function, seizure control, & patient/provider satisfaction.

Most patients screened reported memory & attention problems which interfered with daily life.

Treating concurrent depression did not consistently improve memory.

Gap: No current treatments to address memory/cognition.

INTERVENTION & MEASURES:

HOBSCOTCH was created by a multidisciplinary group to address patient needs & minimize barriers to treatment.

HOBSCOTCH is an 8-week self-management intervention delivered in 1-hour sessions by an ARNP or RN, providing:

Psychoeducation

Self-awareness training & reattribution

Memory compensatory strategies

Application of these strategies in day-to-day life using problem solving therapy (PST).

HOBSCOTCH plus (H+) performed additional cognitive training using Nintendo DS® Brain Age© program.

RESULTS CONCLUSIONS & NEXT STEPS

QOLIE-31 score (SE)†

Worry 59.5 (3.8) 9.1 (3.2) -2 (3.9) 11.1 (0.7, 21.4) 0.04

Quality of Life 61.9 (1.8) 2.1 (2.7) -6 (3.3) 8.2 (-0.8, 17.1) 0.07

Emotion 66.4 (2.3) 0.3 (3.5) -8.6 (4.3) 8.9 (-2.7, 20.5) 0.13

Energy 45.6 (2.5) 5.2 (3.2) -6 (3.9) 11.1 (0.5, 21.7) 0.04

Cognitive 40.5 (2.3) 9.3 (3) 5.3 (3.6) 4 (-5.8, 13.8) 0.42

Medication 49 (4) 7.7 (5.3) -6.5 (6.5) 14.2 (-3.3, 31.8) 0.11

Social 56.6 (3.6) 2.5 (3.7) -2 (4.6) 4.5 (-7.8, 16.8) 0.47

QOLIE-31 overall score 53.2 (1.7) 5 (2.2) -2.2 (2.7) 7.1 (0, 14.3) 0.05

RBANS score (SE)‡

Immediate 85.7 (2.1) 4.3 (2.3) 1.7 (2.8) 2.5 (-5, 10) 0.5

Visuospatial 87.3 (2.4) 3.7 (2.9) -1.2 (3.6) 5 (-4.5, 14.4) 0.3

Language 86.4 (2) 1.6 (2.6) -2.8 (3.2) 4.4 (-4.2, 13) 0.31

Attention 86.2 (2.8) 2.9 (2.4) -8.9 (3) 11.7 (3.7, 19.8) 0.005

Delayed 80.3 (2.8) 6.4 (2.4) 2 (3) 4.4 (-3.6, 12.4) 0.27

RBANS total score 80.6 (1.9) 4.9 (1.6) -2.3 (2) 7.1 (1.9, 12.4) 0.009

PHQ-9 total score (SE)§ 9 (0.7) -0.7 (1) 1.2 (1.2) -1.9 (-5, 1.3) 0.23

NDDI-E depression score (SE)¶ 14.1 (0.5) -0.4 (0.6) 0.7 (0.8) -1.1 (-3.2, 1) 0.3

FACT-COG score (SE) 66.1 (3.5) 11.4 (4.7) 6.3 (5.7) 5.1 (-10.3, 20.6) 0.51

BRIEF-A Global Executive

Composite score (SE) 66.9 (1.3) -2.9 (1.3) -0.5 (1.5) -2.4 (-6.5, 1.7) 0.25

Outcomes age-adjusted Baseline (49) H/H+ (29) Controls (20) Txt Effect p-value

Screening can identify comorbidities that impact quality of life, but interventions to address them are needed.

HOBSCOTCH is a self-management program which improves quality of life and objective cognitive performance in patients with epilepsy.

This intervention may be applicable to other patient populations or clinical settings.

Next steps: Expanding to other clinics/populations, & assessing cost-effectiveness .

HOBSCOTCH is part of the CDC’s Managing Epilepsy Well Network and is supported by the CDC (3U48DP001935-04S3)

Co-Authors: Robert Ferguson, PhD, Robert Roth, PhD, Karen Secore, ARNP, Faith Alexandre, Wenyan Zhao, PhD, Tor Devin Tosteson, ScD, Patricia L. Henegan, MS, Barbara C. Jobst, MD.

Affiliations: Leadership Preventive Medicine Residency, & Department of Neurology, Dartmouth-Hitchcock Medical Center; The Dartmouth Institute for Health Policy & Clinical Practice, Hanover NH; Cheyenne Regional Medical Group., Cheyenne WY

INITIAL WORK TARGETED SCREENING & TREATING DEPRESSION:

Cost of intervention, reimbursement

Time burden

Resources, training

↑ QOL, memory, function

↓ Memory-related anxiety

↓Health care utilization (ED visits, admissions)

Societal costs, Employment

MEASURES