Introduction

Epilepsy is the most common chronic neurological disorder of dogs, with an estimated prevalence of 0.62–0.75% in the general dog population.^1–3 Management of the disorder requires continuing medical care to help prevent complications and ensure a good quality of life (QOL) for both the dog and owner. As owner involvement is vital to a successful outcome, owners should be educated on the responsibilities of managing a dog with epilepsy, including close observation for seizure activity, daily administration of medications, monitoring for adverse effects of the medication, and committing financially to the cost of medication as well as regular veterinary evaluations. However, there are few published reports evaluating these factors involved in the long-term management of epilepsy in dogs.^4,5

The purpose of the current study was to expand the information available to veterinary professionals and the companion animal industry by surveying owners of dogs affected by seizures regarding their experiences, practices, and satisfaction in treating a pet with epilepsy. In particular, the authors sought to determine the number and types of treatments administered, owner and pet response to therapies, costs associated with treatment, reported QOL, owner lifestyle changes resulting from caring for a pet with seizures, and sources of information utilized by owners.

Materials and Methods

An online survey was created by the authors^a. The survey was made available via a link on the authors' Canine Epilepsy research website (cvm.ncsu.edu/research/labs/clinical-sciences/companion-animal-epilepsy/). The survey was also publicized through websites related to canine epilepsy, including Epil-K9 (www.canine-epilepsy.com), Toby's Foundation (www.tobysfoundation.org), and Epi-Guardian Angels (www.canine-epilepsy-guardian-angels.com). All participants voluntarily answered the survey. The survey was approved for distribution by the North Carolina State University Institutional Review Board.

Survey forms were developed using traditional survey design techniques and were adapted for online use. Owners were asked to respond to 59 questions that included a combination of short answer, multiple choice, and Likert-scale responses. The range of questions included general demographic data, seizure information, and medication history as well as questions designed to assess QOL (Appendix 1). The survey program was such that it was not possible to force an answer for every question; consequently, respondents could successfully submit the survey with questions left unanswered. The survey instrument was available online from July 2011 through August 2012.

Results

Treatment

Data on number of daily antiepileptic drugs administered to dogs is summarized in Figure 1. The most common anticonvulsant being administered was phenobarbital, which was given to 86% of dogs, followed by bromide (52%), levetiracetam (29%), zonisamide (22%), and gabapentin (6%). One hundred sixty-five dogs (81%) were reported to have adverse effects associated with administration of antiepileptic medication. Commonly reported adverse effects included increased thirst (93%), ataxia (51%), lethargy (45%), and increased appetite (43%). Statistical analyses were performed to identify any association between drug administered and these adverse effects. Associations were noted between phenobarbital and increased appetite (p = .019), ataxia (p = .0047), and lethargy (p = .011). Lethargy was also associated with the administration of bromide (p = .0003), levetiracetam (p = .026), and zonisamide (p = .0071). Other reported adverse effects included anxiousness, panting, increased urination, increased liver enzymes, and cognitive changes. Additional antiepileptic medication was administered to 59% of dogs at the time of seizures, including additional doses of oral maintenance medication and/or benzodiazepines, such as diazepam or midazolam, administered rectally or intranasally.

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Respondents were asked to estimate their average monthly cost for antiepileptic medication. Of the 217 owners who answered this question, the median monthly expenditure was $51–75, with a range of $0 to greater than $200. Ten percent of owners reported spending over $200/mo on antiepileptic medication. The financial breakdown is depicted in Table 1.

TABLE 1 Owner-Reported Average Monthly Expense for Antiepileptic Medication

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Quality of Life

Quality of life was assessed by evaluating responses to eight questions with a bipolar response scale of 1 (strongly agree) to 5 (strongly disagree) (Appendix 1, questions 36–43). Questions were worded such that a better QOL corresponded to a response of 1 in some instances and a response of 5 in others. For the analyses, scales from all questions were standardized such that a high response to any question was positive. Respondents reported a significant decrease in overall QOL after the onset of seizures but before starting antiepileptic medication in their dog, compared to before seizures began (p < .001) (Figure 2).

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An overall, composite QOL score was computed by compiling responses to questions, with a possible score of between 8 and 40 and a higher overall score indicating a better QOL. The mean QOL score was 29.3, with a range of 15–40. Overall QOL was significantly associated with seizure type, with a higher QOL reported in dogs that experienced isolated seizures rather than clusters (p = .043), had a lower average monthly seizure frequency (p = .0041), did not experience side effects from the antiepileptic medication (p < .0001), and were not given additional medication during episodes of seizures (p = .031). Quality of life was not found to be associated with the number of antiepileptic medications being administered or the average monthly cost of the medication.

Discussion

The primary objective of this study was to provide insight into owner's attitudes and perceptions regarding the management of a dog with epilepsy. Such information is important as we seek to enhance support for pets facing long-term care needs within the veterinary profession. Epilepsy has a significant impact on caregivers, and increasing our understanding of the depth and breadth of this impact will ultimately allow for more effective management of pets with epilepsy. In particular, the availability of caregiver-derived data can prove valuable in the education of owners of pets with new onset seizures by providing first-hand information on the impact the disorder may have on them.

The long-term care model is well established for several chronic medical conditions affecting human patients and focuses on patient and caregiver education regarding disease-related factors as well as caregiver burden and QOL issues. Studies on human epilepsy have demonstrated that the provision of information at the onset of the disorder results in caregivers having greater levels of confidence and competence in managing the disease as well as increased levels of understanding from the patient themselves.⁶ Similar factors appear to play a role in the management of canine epilepsy. A long-term, prospective, longitudinal study of canine epilepsy determined that the large majority of owners reported that support from, regular contact with, and easy access to the veterinarian was important in reducing their anxiety associated with their dog's epilepsy.⁵ This support included provision of information on epilepsy in general as well as instructions on handling the animal during a seizure and therapeutic regimen. Thus, dog owners who have greater levels of support may be better equipped to provide the long-term care required for their pet.

Demographic data obtained from this study is similar to that previously reported for dogs with epilepsy. Dogs in this study had a mean onset of seizures at 2.5 yr of age, and it is generally accepted that dogs with idiopathic epilepsy have an age of seizure onset of 6 mo to 6 yr. Although a specific cause for seizures was not a prerequisite for survey completion, 89% of dogs in this study were reported to have presumed or confirmed idiopathic epilepsy. Similarly, the breeds most commonly represented in the survey, namely, the Labrador retriever, border collie, Australian shepherd, and German shepherd dog, have all been reported to have an increased prevalence of epilepsy (Jaggy et al. 1999, Hulsmeyer et al. 2010, Weissel et al. 2012, Kearsley-Fleet et al. 2013).^2,7–9 However Australian shepherds and border collies have been reported to have a severe form of epilepsy, and it is possible that owners of these dogs may consequently be more willing to complete a survey related to epilepsy.^8,9 In addition, these breed groups may already have a higher level of owner-to-owner interaction related to epilepsy and may have publicized the study to a greater extent compared to other breed groups.

Forty-five percent of respondents reported good control of their dog's seizures, with an average seizure frequency of less than 1 a mo. This included 12% of dogs that were reported to be free of seizures in the 6 mo prior to survey completion. Although remission from seizures is typically reserved for dogs that have been seizure free for a year or longer, this number is comparable to the 15% remission rate previously reported for dogs.⁵

Survey respondents reported that 62.5% of dogs either died or were euthanized due to their epilepsy. Previous studies have reported that 50–74% of all deaths with idiopathic epilepsy can be attributed to this disorder.^5,8,10 The death rate includes dogs that succumb during seizures or from seizure complications as well as dogs that are euthanized due to seizure complications, treatment related adverse effects, or poor seizure control.

The authors were particularly interested in assessing QOL in this study, as this is often one of the most frequently asked questions by both owners and veterinary professionals in developing a treatment plan that supports the needs of the pet while considering the factors involved in owner's decisions regarding long-term care. Not surprisingly, owners reported that their dogs' QOL worsened after being diagnosed with epilepsy compared to before the onset of seizures. This likely reflects the perceived negative effects of seizures on the dogs' physical well-being as well as the realization that epilepsy frequently necessitates alterations in lifestyle and lifelong medical management. However, the composite QOL score that took into account factors related to both the dog's and the owner's well-being over the long-term provided a positive rating, with a mean score of 29 on a composite scale of 8–40, suggesting that most owners are comfortable with the level of care involved and the impact of the disease on their pet. Furthermore, an inverse association was identified between QOL score and monthly seizure frequency, presence of cluster seizures, and the administration of additional medications during a seizure, all of which are indicators of severe or poorly controlled epilepsy. One would expect poorly controlled epilepsy to have a negative impact on QOL for both the dog and owner.

The presence of medication-related adverse effects was also shown to be associated with a poor QOL. Adverse effects of antiepileptic medications are fairly common and are of considerable concern to owners of pets that require chronic therapy. Over 80% of dogs in the present study were reported to have adverse effects associated with drug administration. A significant association was noted between the presence of lethargy as an adverse effect and the four most common antiepileptic drugs administered: phenobarbital, bromide, zonisamide, and levetiracetam. It is not surprising that antiepileptic drugs, which act by suppressing brain excitability, would cause lethargy or sedation. An association between phenobarbital administration and both ataxia and increased appetite were also demonstrated in this study. These side effects have been commonly reported in dogs administered phenobarbital.^11,12

Published information on owner-perceived QOL in the long-term management of dogs with epilepsy is limited. A 1999 study involving 19 owners who had participated in a 2 yr prospective, longitudinal clinical study with dogs that were being administered phenobarbital for chronic seizures demonstrated positive ratings similar to those in the present study.⁵ Owners in this prior study reported a willingness to maintain their dog on long-term therapy for epilepsy, with 95% disagreeing that their dog was leading a poor QOL since beginning treatment. Furthermore, all owners reported that the work necessary to maintain their epileptic pet was not a burden or detriment to their own QOL. However, another prospective, longitudinal study of 63 dogs diagnosed with epilepsy that were followed up until death, euthanasia, or a maximum of 12 yr described 60% of owners reporting that having a dog with epilepsy had a negative influence on their daily life.⁴ These differing results may be due to the broader study population and a longer, defined follow-up period utilized in the latter study. Additional research is needed in this area to better characterize the QOL issues that are important in the long-term management of dogs with epilepsy.

A survey instrument was recently developed and validated for owners of dogs with epilepsy that aims to provide disease-specific questions for the pet owner relating to physical, social, and neurobehavioral aspects of QOL for both the pet and caregiver.¹³ Although this instrument was not available at the time of our study, our survey incorporates some of the same themes, including seizure frequency, adverse effects of antiepileptic drugs, and restrictions on the owners' life related to caring for a dog with epilepsy. The development of a validated survey reinforces the importance of assessing QOL in the long-term management of dogs with this disorder and will serve as a useful tool in further research into this aspect of canine epilepsy.

One facet of long-term care that has not been addressed in previous studies is the financial burden associated with the management of a dog with epilepsy. Respondents in our survey spent a median of $50–75 each mo on antiepileptic medication. This did not include additional expenses associated with the dog's care, including regular veterinary visits and hospitalization as needed for management of cluster seizures or status epilepticus. Thus, the long-term management of a dog with epilepsy can necessitate a substantial financial commitment on the part of the owner.¹⁴ Interestingly, QOL was not associated with the number or cost of the antiepileptic medications being administered, reflecting the commitment of these owners to their dogs. It is possible that the data is biased in this regard, as owners that demonstrate strong commitment to their dogs and epilepsy may have been more likely to complete this voluntary survey.

Aside from the potential for bias with respect to the population of dog owners surveyed, other limitations of the study require mention. These limitations include respondent bias, based on the self-reporting nature of the survey responses and their susceptibility to recall bias. In addition, there is potential for bias in the survey instrument itself, particularly since our survey was not validated. Finally, the survey program utilized did not require respondents to answer all questions, resulting in incomplete data for some questions.

Conclusion

This survey provides information on owners' perspective regarding the long-term management of a dog with epilepsy. Overall, owners of dogs with epilepsy reported positive scores for QOL, although QOL scores were lower for owners of dogs with severe or poorly controlled epilepsy and medication-related adverse effects. Despite the financial burden involved in managing a dog with epilepsy, monthly medication cost was not associated with QOL score. Such information should prove useful to veterinary professionals by providing them with a better understanding of the needs of dogs with epilepsy and the support that their owners seek as well as in the education of owners related to the care and treatment of a dog recently diagnosed with epilepsy. In addition, these results can be used as a framework for future studies on canine epilepsy to better characterize the long-term care requirement of this population with the goal of improving overall outcomes for both pets and their owners.