Epilepsy: Problem Solving in Clinical PracticeBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7234.587/a (Published 26 February 2000) Cite this as: BMJ 2000;320:587
Dieter Schmidt, Steven C Schachter
Martin Dunitz, £49.95, pp 489
ISBN 1 85317 504 8
I enjoyed reading Epilepsy. Although we now understand epilepsy and manage it better than we did 10 years ago, some areas remain neglected and new problems have emerged because of recent advances in diagnosis and treatment. Schmidt and Schachter's book reviews over 30 such problems, and does it well.
The diagnosis and treatment of seizures in elderly people is a neglected area, and this book reminds us that epilepsy is underdiagnosed and undertreated in this age group. Carers are less likely to think of seizures as a cause of episodic abnormal behaviour in elderly people, and they are unlikely to undergo intensive video and electroencephalographic monitoring to make a diagnosis. Moreover, most doctors are likely to extrapolate their knowledge of treating younger adults to this age group—an approach that is fraught with pitfalls.
Schmidt discusses the 10 most common errors in treating epilepsy. Many of these are predictable, such as adding a second drug before the first one has failed and using suboptimal doses of new antiepileptic drugs. “Adding a drop of this or one tablet of that anticonvulsant will do the trick” may not do the trick—better to use the maximum tolerated dose of the first drug before adding this or that. With so many new drugs in the market and no clear guidelines on which one to add, Schmidt's commonsense advice is that the individual doctor should learn to use two new drugs well rather than experiment with several.
Surgery for epilepsy, especially for seizures originating in the hippocampus, is now an established treatment. Expert opinion tends to favour early rather than late surgery in order to avoid the brain injury that prolonged and recurrent seizures cause. Early surgery could also reduce the social disadvantages and psychological problems associated with chronic epilepsy. But it may mean diagnostic errors in selecting the right candidate for surgery. This dilemma is well highlighted in Epilepsy.
In an otherwise excellent publication I found the last chapter (“The team approach to treating epilepsy: when do we need it?”) unnecessary and elementary. Modern medicine is a team effort, and managing epilepsy is no different.
Neurologists should add this book to their “to be read list.” Others who refer to it will be rewarded with easy to use information. The problems might not go away, but, after reading this book, you should be able to deal with them better.