Archive \ Volume.11 2020 Issue 2

INTRODUCTION

Epilepsy patients experience a broad range of subjective cognitive impairments.^[1] Self-reporting of symptoms may be confounded by limited insight into their cognitive problems, concerns about the safety of AEDs, and cultural norms which may lead to reliance on other therapies.^[2,3]  CAM is taken by epilepsy patients as an alternative treatment option even though its effectiveness has not been established.^[4] The type of CAM used may vary due to differences in cultural norms and healthcare settings.^[5] Data on CAM usage and subjective cognitive impairment among epilepsy patients in Malaysia is limited. This study aimed to explore the prevalence of subjective cognitive impairment and its association with CAM usage among epilepsy patients. 

METHODS

Study Design

We conducted a cross-sectional survey of 100 epilepsy patients diagnosed at UKMMC. The study was conducted from March 2017 to November 2018.

Study Population and Sampling Method

Epilepsy patients attending the neurology clinic at the Universiti Kebangsaan Malaysia Medical Center. The patients were recruited from the neurology clinic at the Hospital Universiti Kebangsaan Malaysia. Data was collected using convenient sampling. A list of patients was obtained from the clinical appointment record and the patients were randomly called in the physicians' room. Patients were recruited based on the following criteria.

Inclusion criteria

Epilepsy patients attending the neurology clinic at the Hospital Universiti Kebangsaan Malaysia, who were 18 years or older, taking AEDs for at-least 6 months were included.

Exclusion criteria

Patients with a physical or psychiatric illness such as schizophrenia and major depression, critically ill patients, and those who refused to participate in this study and patients not fit to be interviewed determined by the physicians were excluded. 

Survey items

The questionnaires comprised of seven main sections which were adapted from previous studies.^[6,7] Section A captured basic socio-demographic data, including age, gender, religion, marital status, level of education, monthly income, number of comorbidities, and number of medications. Section B consists of the ABNAS questionnaire (A-B Neuropsychological Assessment Schedule) which was used to measure subjective cognitive performance. It comprises of 24 statements across five domains: fatigue, slowing, memory, concentration, and motor coordination and language, with an overall score from 0 (no symptoms) to 72 (severe symptoms). A cut-off score of above 15 (“high”) has been previously established to identify those with significant subjective symptoms. Section C of the survey covered the types of CAM used.

Translation

The forward and backward translation of the questionnaire was performed by a registered proof-reading company. The translated version of the form was then reviewed by two academicians and one practicing pharmacist who are well familiar with Malay and English languages.

Ethical Considerations

Ethical approval was obtained from the UKMMC human ethics committee and the reference number was UKM PPI/111/8/JEP-2017-138. Informed consent was obtained from all patients before participation in the study. 

Data Collection

The patients were approached in the physician’s room after they completed the doctor’s consultation. They were informed about the purpose of the research and invited to participate in the study. Written informed consent was taken from those patients who agreed to fill the self-administered questionnaires. When appropriate, the nurses also assisted the patients in filling the questionnaires.

Data Analysis

Statistical analyses were performed using the IBM SPSS Statistics Version 23. Data were analyzed using descriptive and inferential analysis. For categorical variables, frequencies and percentages were used, while for continuous variables describing the study population, descriptive statistics, which included mean and standard deviation (SD), were used.

RESULTS:

In total, 47 females and 53 males between the ages of 18 and 79 years were recruited in the study. The mean age was 40.18 (SD 17.9) years. Majority of the patients were Malay (n = 51), and Chinese (n = 36), and the remaining patients were Indian (n = 13). Patients represented a variety of education levels from no formal education to post-graduation. The number of comorbidities varied among patients (range between 0 to 4) with a mean of 1.87 (SD 1.01). Thirty-one percent (31%) of patients showed evidence for subjective cognitive impairment (ABNAS score >15). ABNAS scores were significantly higher among the Indian race and Hindu religion (p<0.01). The socio-demographic characteristics of patients, self-perceived cognitive impairment, and CAM usage are presented in Table 1.

Thirty-one (31%) patients scored themselves as ‘high’ on the ABNAS indicating self-perceived cognitive impairment. More than half of the patients reported moderate/severe problems in fatigue, slowing, and memory categories. The percentage of patients reporting problems in each of the ABNAS domains is shown in Table 2.

The prevalence of CAM use was found to be at 58% among the studied population. CAM use was more frequent in males (32%) as compared to females (26%). Seventy-nine percent of patients reported that they have heard of CAM. The primary sources of information on CAM were friends (39%), family (27%), internet (19%) and doctor (15%). The most commonly used CAM included vitamins and minerals (36%), ginseng (16%), antioxidants (15%), and acupuncture (12%). The majority (68.1%) of the patients reported that CAM is effective. The main reasons for using CAM were cheaper price, easy availability, and inadequate seizure control by AEDs. The type and distribution of CAM used are summarized in Table 3. There was a significant association between CAM usage and subjective cognitive status. The relationship between CAM usage and self-perceived cognitive impairment is shown in Table 4.

DISCUSSION

Epilepsy is a stigmatizing neurological disorder that often results in a significant physical, psychological, and financial burden on individuals and families.^[8] Problems associated with epilepsy are further aggravated when patients neglect the antiepileptic drug (AED) therapy due to limited insight into their cognitive problems, anxiety, concerns about the safety of AEDs, and cultural norms and begin depending on other options of treatments.^[9,10] The goal of this study was to evaluate patient’s self-perceived cognitive impairment and its association with CAM usage among epilepsy patients.

More than half of the patients reported moderate/severe problems in fatigue, slowing, and memory categories of ABNAS. Similar results for fatigue, memory, and motor symptoms were reported by patients in the previous study except for slowing which was higher in this study. ^[11]  Concentration and language problems were less reported in this study. The perception of impaired cognition was more prevalent among the Indian race and Hindu religion. Race, religion, and cultural influence may affect the medication-taking behavior. A study done in India showed that although patients were convinced of the necessity of AED, some doubted their personal need for AED. More than half reported strong concerns about the potential negative effects of AED. ^[12] However, studies were done in the UK and South Africa, patients reported high necessity and low concerns about AED side effects. ^[13,14] This shows that patients with different cultural and racial backgrounds will have different medication seeking behavior.

The findings revealed a high prevalence of CAM usage among epilepsy patients. The global prevalence of CAM use reported in previous studies was between 7.5% and 73.3%. The statistics also showed that CAM was more abundantly used in developed countries compared to that in the developing countries.^[4] Although Malaysia is a developing country, the higher prevalence of CAM usage may be due to the multi-racial culture in Malaysia where the people have various treatment choices ranging from culturally specific traditional medicines to modern CAM.

The most popular CAM reported in this study were vitamins and minerals, ginseng, antioxidants, and acupuncture. The type of CAM usage varied between different age-groups. Acupuncture, traditional Chinese and Malay medicines were mostly used by elderly patients while the younger population was seen to be widely using vitamins and supplements due to marketing and promotional strategies used by the companies to attract younger patients. The higher use of CAM in the elderly can be justified by the increased number of chronic diseases, most of which can only be controlled and not cured in the current therapeutic scenario.^[15,16] The types of CAM used in this study were comparable to previous studies, other than some variation that was caused by differences in cultural and traditional norms.^[17,18]  For example, in Western countries, the use of vitamins, herbs, and yoga was more prevalent.^[19-21] Prayer for health and amulets was common in Middle-eastern countries.^[22] In India, Ayurveda was more frequently practiced.^[23,24] Whereas, in Taiwan, traditional Chinese medicines were seen to be used more frequently.^[25]

There was a significant association between CAM usage and patient self-perceived cognitive impairment, patients with higher self-perceived cognitive impairment were more likely to rely on CAM as compared to patients with low self-perceived cognitive impairment. This highlights the need for further examination of such patients. Community pharmacists and doctors should educate the patients on the safety of AEDs and expected side effects and also encourage them to report healthcare professionals upon appearing any unwanted side effects. Moreover, appropriately counsel the patient on CAM use and misuse, and possible interactions with AEDs. This may indirectly optimize the therapeutic outcome and minimize interactions with AED, hence improving a patient’s quality of life.

Limitations

Although the current study has highlighted a significant association between self-reported cognitive symptoms and CAM usage, this finding should be utilized in caution due to several possible limitations. A substantial number of patients refused to take part in this survey, the study cohort may not fully represent the whole epilepsy population. As we have described earlier, cultural components may also influence the practice of CAM, thus different geographical regions may have different findings. Additionally, an intensive investigation into the effects of CAM’s use on epilepsy control would provide insight into the potential benefit and harm of CAM.

CONCLUSION

A high prevalence of CAM usage among epilepsy patients was identified. There was a significant association between CAM usage and subjective cognitive impairment. The use of CAM and its types should be explored with patients before clinical decisions are made to achieve the best treatment outcomes from AED therapy. There is a need for patient education related to CAM use and AED therapy.

REFERENCES

1. Mounfield H, Dahlqvist P, Glynn M, Habberstad A, Vital T, Baker GA, Feichtinger M, Ryvlin P. Patient perceived cognitive side effects of antiepileptic drug treatment: an international perspective. J Neurol Sci. 2005 Jan 1;238:S135.
2. Helmstaedter C and Elger C. Behavioral markers for self-and other-attribution of memory: a study in patients with temporal lobe epilepsy and healthy volunteers. Epilepsy Res. 2000; 41: 235-43.
3. Ferrari CMM, de Sousa RMC, and Castro LH. Factors associated with treatment non-adherence in patients with epilepsy in Brazil. Seizure. 2013; 22: 384-9.
4. Farrukh MJ, Makmor-Bakry M, Hatah E, and Tan HJ. Use of complementary and alternative medicine and adherence to antiepileptic drug therapy among epilepsy patients: a systematic review. Patient Pref Adherence. 2018; 12: 2111.
5. Kim IJ, Kang JK, and Lee SA. Factors contributing to the use of complementary and alternative medicine by people with epilepsy. Epilepsy Behav. 2006; 8: 620-4.
6. Aldenkamp A and Baker G. The Neurotoxicity Scale-II: results of a patient-based scale assessing neurotoxicity in patients with epilepsy. Epilepsy Res. 1997; 27: 165-73.
7. Brooks J, Baker GA, and Aldenkamp AP. The A–B neuropsychological assessment schedule (ABNAS): the further refinement of a patient-based scale of patient-perceived cognitive functioning. Epilepsy Rres. 2001; 43: 227-3
8. Hovinga CA, Asato MR, Manjunath R, et al. Association of non-adherence to antiepileptic drugs and seizures, quality of life, and productivity: a survey of patients with epilepsy and physicians. Epilepsy Behav. 2008; 13: 316-22.
9. Faught E, Duh MS, Weiner JR, Guerin A, and Cunnington MC. Nonadherence to antiepileptic drugs and increased mortality: findings from the RANSOM Study. Neurology. 2008; 71: 1572-8.
10. Hatah E, Lim KP, Ali AM, Shah NM, and Islahudin F. The influence of cultural and religious orientations on social support and its potential impact on medication adherence. Patient Pref Adherence. 2015; 9: 589.
11. Samarasekera SR, Helmstaedter C, and Reuber M. Cognitive impairment in adults with epilepsy: The relationship between subjective and objective assessments of cognition. Epilepsy Behav. 2015; 52: 9-13.
12. Verma A and Kumar A. Belief in medication and adherence to antiepileptic drugs in people with epilepsy: a cross-sectional study from rural India. Int J Neurosci. 2018; 128: 1168-73.
13. Chapman S, Horne R, Chater A, Hukins D, and Smithson W. Patients' perspectives on antiepileptic medication: relationships between beliefs about medicines and adherence among patients with epilepsy in UK primary care. Epilepsy Behav. 2014; 31: 312-20.
14. Egenasi C, Steinberg WJ, and Raubenheimer JE. Beliefs about medication, medication adherence, and seizure control among adult epilepsy patients in Kimberley, South Africa. South African Family Practice. 2015; 57: 326-32.
15. Sharma E, Dubey AK, Malhotra S, Manocha S, and Handu S. of complementary and alternative medicines in Indian elderly patients. Natl. J. Physiol. Pharm. Pharmacol. 2017; 7: 929.
16. Abdullah N, Borhanuddin B, Patah AEA, et al. Utilization of Complementary and Alternative Medicine in Multiethnic Population: The Malaysian Cohort Study. J Evid Based Integr Med. 2018; 23: 2515690X18765945.
17. Islahudin F, Shahdan IA, and Mohamad-Samuri S. Association between belief and attitude toward preference of complementary alternative medicine use. Patient Pref Adherence. 2017; 11: 913.
18. Jasamai M, Islahudin F, and Samsuddin NF. Attitudes towards complementary alternative medicine among Malaysian adults. J Appl Pharm Sci. 2017; 7: 190-3.
19. Sirven JI, Drazkowski JF, Zimmerman R, Bortz J, Shulman D, and Macleish M. Complementary/alternative medicine for epilepsy in Arizona. Neurology. 2003; 61: 576-7.
20. Liow K, Ablah E, Nguyen JC, et al. Pattern and frequency of use of complementary and alternative medicine among patients with epilepsy in the midwestern United States. Epilepsy Behav. 2007; 10: 576-82.
21. McConnell B, Applegate M, Keniston A, Kluger B, and Maa E. Use of complementary and alternative medicine in an urban county hospital epilepsy clinic. Epilepsy Behav. 2014; 34: 73-6.
22. Al Asmi A, Al Maniri A, Al-Farsi YM, et al. Types and sociodemographic correlates of complementary and alternative medicine (CAM) use among people with epilepsy in Oman. Epilepsy Behav. 2013; 29: 361-6.
23. Bhalerao M, Bolshete P, Swar B, et al. Use of and satisfaction with complementary and alternative medicine in four chronic diseases: a cross-sectional study from India. Natl Med J India. 2013; 26(2):75-7.2013.
24. Tandon M, Prabhakar S, and Pandhi P. Pattern of use of complementary/alternative medicine (CAM) in epileptic patients in a tertiary care hospital in India. Pharmacoepidemiol Drug Saf. 2002; 11: 457-63.
25. Kuan Y-C, Yen D-J, Yiu C-H, et al. Treatment-seeking behavior of people with epilepsy in Taiwan: a preliminary study. Epilepsy Behav. 2011; 22: 308-12.

^a = Independent t-test, ^b= Chi-square test

a= Chi-square test.