The European Journal of Public Health Advance Access originally published online on January 30, 2006
The European Journal of Public Health 2006 16(5):484-486; doi:10.1093/eurpub/ckl011
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Miscellaneous |
Epilepsy among the homeless: prevalence and characteristics
Anne Laporte1, Anny Rouvel-Tallec2, Etienne Grosdidier3, Sandrine Carpentier1, Chantal Benoît4, Daniel Gérard5 and Xavier Emmanuelli3
1 Observatoire du samusocial de Paris, France
2 Department of neurology, Hospital Delafontaine, Saint-Denis, France
3 Samusocial de Paris, France
4 Department of neurology, Hospital Max Fourestier, Nanterre, France
5 Sanofi-Aventis, France
Correspondence: Dr Anne Laporte, Observatoire du Samusocial de Paris, 35 Avenue Courteline, 75012 Paris, France, tel: +33 1 43 71 13 24, e-mail: a.laporte{at}samusocial-75.fr
Received July 6, 2005, accepted December 7, 2005
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Abstract |
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Homelessness is associated with several risk factors for epileptic seizures. Epilepsy is a stigmatizing condition, which can lead to problematic social adjustment and competence. We found a markedly higher prevalence of seizures among the homeless than that estimated in the general population, with a large majority of non-alcoholic etiology. Unexpected proportion of subject taking treatment and compliance rate call for reflection on the optimal management of epilepsy in this population.
Keywords: alcohol, compliance, epilepsy, homelessness, prevalence, seizure
Epilepsy is a common chronic neurological disorder, with an estimated prevalence of 5–8 cases per 1000 persons in industrialized countries.1,2 Many people with epilepsy feel socially stigmatized, and several studies show that this contributes to reduced social interactions, social capital, and quality of life.3–5 Discriminatory behaviours still persist, notably in the workplace.6,7
Homelessness is associated with increased morbidity and mortality compared with the general population, and some medical problems are particularly prevalent such as seizures, chronic obstructive pulmonary diseases, arthritis, and musculoskeletal disorders.8–10 In 2003, a study was initiated among the homeless people seeking assistance from a welfare organization in Paris (France), to estimate the prevalence of epilepsy and to determine its characteristics and management practices.
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Methods |
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During spring 2003, all persons attending daily medical consultations were interviewed by a physician. Those with a positive history of seizures were invited to respond to a detailed questionnaire. For the analysis, we attempted to separate patients with epilepsy from those with alcohol-related seizures (ARS). Among alcoholic patients [daily alcohol consumption exceeded 40 g (men) or 20 g (women)11] seizures were attributed to alcohol when they began concomitantly with or following the onset of alcoholism. Seizures were attributed to epilepsy in all other cases.
The lifetime and active prevalence rates of seizures were calculated.12 Univariate and multivariate analyses (logistic regression) were performed with STATA-8 software.
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Results |
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During the study period, 592 adults, 84 women, and 508 men, attended at least one medical consultation (sociodemographic characteristics in Table 1). Eighty-six subjects reported at least one seizure over their lifetime history which amounts to 14.5% (95% CI 11.8–17.6) for the overall sample. This proportion did not differ significantly according to gender (Table 1). A logistic regression among men showed an increased risk of seizures among alcoholics and persons homeless for more than 2 years; and a lower risk among persons aged more than 60 years (Table 1).
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Among the 86 patients who reported a history of seizures, 54 were alcoholic, but 19 of these subjects were classified as non-alcoholic epilepsy (cf. Methods section). Thus, 59.3% were classified as having epilepsy and 40.7% as having ARS (Table 2). The prevalence of active epilepsy in the entire population was 8.1% (6.0–10.6).
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The epilepsy and ARS groups differed significantly with respect to the proportion of women, mean age at the first seizure, prior EEG, the percentage of treated patients, and factors predisposing to seizures (Table 2).
In 46.5% of cases the frequency of seizures increased following the onset of homelessness; the principal stated reasons were alcohol (75%), sleep privation (42.5%), anxiety (32.5%), and stress (27.5%). Seizures had an impact on the employment of 30.6% of subjects in the epilepsy group, of whom 78.6% had given up work entirely.
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Discussion |
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The prevalence of active epilepsy in the study population (8.1%) is markedly higher than that estimated in the general population (<1%).1,2 When ARS were included, 14.5% had a history of seizures. The hypothesis of over-reporting has poor probability, the social stigma attached to epilepsy tends to lead to under-reporting,13 and the subjects' declarations were validated by a thorough physician interview. The prevalence could be overestimated by the recruitment of the study population among medical consultation attenders, nevertheless, epilepsy was the stated reason for consulting in only 2.9% of cases.
These results suggest that epilepsy is a serious health problem among the homeless and that it contributes to the social exclusion process. Indeed, nearly one-fourth of the patients who reported seizures said they had to give up their job because of that. Furthermore, the observed increase in the proportion of persons with seizures after two years of homelessness, independently of alcohol consumption, suggests either that homelessness increases the risk of epileptic seizures and/or that seizures reduce a homeless person's chances of leaving the streets. In addition, the lower rate of epilepsy found among men aged more than 60 years, which is inconsistent with the literature data on age-specific prevalence,1,2 reflects the increased risk of death among epileptic homeless, as older age and ARS were found to enhance mortality among epileptic patients.14
Some cases could be misclassified, in the absence of imaging data. Nonetheless, this classification has the merit of underlining the importance of non-alcoholic etiologies among homeless epileptics, whereas other authors have tend to stress the role of alcohol.10,15
The proportion of subjects taking treatment for epilepsy (56.5%), and the compliance rate (77.1%), may have been overestimated. However, these results challenge certain prejudices regarding non-compliance and widespread alcoholism and call for reflection on the optimal management of epilepsy in this population.16 A change in attitude is clearly needed among the public and health care professionals towards people living with the triple stigmata of homelessness, alcoholism, and epilepsy.
Key points
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Acknowledgments |
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This work was supported by Sanofi-Aventis, France.
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References |
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