Literature Collection

Recent research reported an association between pediatric Restless Leg Syndrome (RLS) and psychiatric disorders, in particular attention-deficit hyperactivity disorder in which shared symptoms, such as restlessness and difficulty concentrating, can make differential diagnosis challenging. Comorbidities with depression and anxiety, present in adults, have to be considered in children. Behavioral and psychosomatic disorders and autism can be associated with RLS. Both neurobiologic mechanisms and clinical implication could explain the several comorbidities. In clinical practice, pediatric RLS patients should be evaluated for the presence of psychiatric disorders to tailor multidisciplinary intervention and integrated treatment.

Psychogenic nonepileptic seizures (PNES) are relatively common but poorly understood and often misdiagnosed as epilepsy, which can lead to unnecessary procedures and treatments along with the possibility of failure to engage patients in necessary behavioral health care. Despite a superficial resemblance to epilepsy, in PNES, the underlying cause has long been considered to be psychological. However, increasingly integrated theories of causation invoking genetics, environmental factors, temperament, and early childhood experiences are being proposed. Rarely is a nonepileptic event intentional, in which case it could be due to factitious disorder or malingering, but by definition, PNES themselves are never intentional. "Pseudoseizure" is a now-outmoded term for paroxysmal events that appear to be epileptic seizures but do not arise from the abnormal excessive synchronous cortical activity that defines an epileptic seizure. Patients and healthcare practitioners alike are prone to misinterpret "pseudoseizure" as indicating that the patient is "faking" or otherwise feigning the events when, in fact, the events are involuntary behavioral responses to underlying psychological triggers or stresses. Other terms used in the past that should now be avoided are hysterical seizures, functional seizures, stress seizures, and others.  Distinguishing PNES from epileptic seizures may be difficult at the bedside, even for experienced clinicians. Indeed, some researchers have characterized PNES as occupying a no-man's land at the intersection between Neurology and Psychiatry. Diagnostic delay of years with PNES is common. Video electroencephalography (video-EEG) of a typical event showing the absence of epileptiform activity during the spell in the setting of a compatible history is the gold standard for diagnosis. Between 20% and 40% of patients referred to epilepsy monitoring units for difficult-to-control seizures are ultimately found to have PNES. A recently reported pediatric series examined 15 years of video-EEG monitoring and found that the final diagnosis was PNES in nearly 20% of monitored individuals; eventual discontinuation of antiseizure medication (ASM) on the grounds of initial misdiagnosis was necessary for nearly 25%.  Correct diagnosis is imperative for the successful treatment of PNES. Still, misdiagnosis is common, especially among primary care and emergency physicians, nearly two-thirds of whom reported their belief that video-EEG is not needed for diagnostic confirmation in a recent study. A comprehensive history and examination are vital steps toward a correct diagnosis. Consultation with neurology is nearly always beneficial; admission to an epilepsy monitoring unit for video-EEG analysis is almost always required. Referral to a comprehensive epilepsy center may be helpful in challenging cases.  The diagnosis of PNES needs to be conveyed to the patient effectively and empathically; doing otherwise carries a non-trivial risk of prompting confusion, anger, or resentment, any or all of which can then exacerbate PNES symptomatology. Diagnostic disclosure is particularly delicate if a given patient was previously diagnosed with epilepsy, and patients with a history of trauma or abuse can easily be re-traumatized by a clumsily rendered diagnosis. Above all, the clinician must acknowledge and underscore that help is available for the patient's symptoms, that these symptoms are real, and that symptoms represent a source of distress to the patient, family, and friends.  Treatment of PNES may be complex, but it is clear that ASMs are of no benefit, and they may cause harm.ASMs should be discontinued unless they are in use to manage concomitant epilepsy, chronic pain, or mood disorders; continuation of ASMs after the PNES diagnosis has been made is associated with poor outcomes. Psychotherapy is effective and can improve seizure frequency, overall psychosocial functioning, and health-related quality of life. 

BACKGROUND: An academic detailing model has improved self-efficacy of memory clinic clinicians to identify and manage complex behavioral and psychological symptoms in persons with dementia (BPSD). The purpose of this report is to describe a systematic approach to adapting a clinician education program previously delivered in two primary care integrated memory clinics for improving the management of BPSD to also be deliverable outside a memory clinic setting, in generalist primary care clinics. The RE-AIM/PRISM implementation framework guided the approach. METHODS: Application of the RE-AIM/PRISM framework to the academic detailing program for BPSD was mapped. Framework-guided qualitative interviews were completed with experienced (Champion) and inexperienced (Novice) program stakeholders including questions on perceived gaps in clinical care (BPSD management) and barriers and facilitators to the educational model. Inductive and deductive qualitative thematic analytic approaches were used, the latter organized by RE-AIM domains and multi-level context. Convergence or divergence in organized themes by stakeholder experience shaped examination of fit and interactions among domains, components and strategies of the model for pre-implementation adaptations planning for non-memory clinic primary care clinicians. RESULTS: A pragmatic application of the RE-AIM/PRISM framework was completed for collecting qualitative feedback from stakeholders, identifying multi-level contextual barriers and facilitators, and planning adaptations to our clinician education program. A description of the clinician stakeholders, the approach and one example of a clinician and intervention-level theme identified across RE-AIM domains for the program, self-efficacy in the management of BPSD, and resulting planned adaptations were shared. CONCLUSIONS: We provide a novel qualitative application of the RE-AIM/PRISM framework to inform adaptations for an intervention for primary care that incorporates feedback from both current experienced and future inexperienced program stakeholders. This approach can be used to identify multi-level contextual barriers and facilitators to reach, adoption, implementation, and effectiveness of this clinician education programs approach, academic detailing, for future primary care teams.

BACKGROUND AND OBJECTIVES: We conducted a quality improvement initiative to implement standardized screening for anxiety among adolescents with headache and/or epilepsy receiving outpatient neurology care at a quaternary health care system, consistent with recommendations from the American Academy of Neurology. Our SMART (Specific, Measurable, Achievable, Relevant, and Time-Based) aim was to screen ≥90% of established patients aged 12 years or older seen by a participating health care professional using a standardized anxiety screener by February 2024. METHODS: This initiative was conducted in patients seen for follow-up by 17 participating neurology health care professionals. Health care professional opinions were assessed before and after implementation of the Generalized Anxiety Disorder-7 (GAD-7), administered as a previsit questionnaire distributed using the electronic health record. The integrated workflow included a best practice advisory (BPA) alert that permitted easy access to interventions and automatic population of education materials into the after-visit summary. After 12 months of use (March 2023 to February 2024), we assessed demographic and diagnostic information, GAD-7 completion rates, anxiety symptom severity, BPA utilization, and health care professional acceptance of the intervention. RESULTS: The GAD-7 was completed for 64% of 3,671 encounters and by 71% of 2031 unique patients. The GAD-7 was more often completed for encounters if the patient was female, younger, or White or had a headache diagnosis. Among unique patients, anxiety symptoms were minimal in 50%, mild in 24%, moderate in 17%, and severe in 10%. Severe anxiety symptoms were more often present in female patients or those with a headache diagnosis. Among patients with severe anxiety symptoms, 66% had established behavioral health care plans and, for remaining patients, referrals were made to community behavioral health care professionals (11%), or pediatric psychologists (4%) or social workers (3%) within neurology. Clinicians indicated that the approach was easy to use and improved the quality of patient care. DISCUSSION: We implemented standardized EHR-based screening for anxiety symptoms for pediatric neurology patients, most of whom had headache or epilepsy. Screening was feasible, and approximately one-quarter of patients had moderate or severe anxiety symptoms. Future work will focus on improving completion rates of previsit questionnaires including the GAD-7 and optimizing clinician actions based on the screening data.