Epilepsy in the Elderly: Why is it Different?
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Epilepsy in the Elderly: Why is it Different?
Brenda Y. Wu, M.D., Ph.D.
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Incidence of New Diagnosis of Epilepsy
Pohlmann-Eden B, Acta Neurol Scand 2005(suppl);181:40-46
> 60y/o, ~25%
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Etiology in Patients age 60
Ramsay, et al. Neurology 2004; 62 (5 suppl 2).
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Causes of Epilepsy
Annegers JF. The epidemiology of epilepsy. In: Wyllie E, ed. The treatment of epilepsy: principles and practice.3rd Ed, 2001:165-72
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Metabolic and electrolyte imbalance Stimulant/other pro-convulsant intoxication:
cocaine, anticholinergics, dopamine blockers, clozapine, immuno-suppressants, antibiotics, certain narcotics (e.g. Dilaudid)
Sedative or ethanol withdrawal Severe sleep deprivation Antiepileptic medication reduction or inadequate
AED treatment Hormonal variations or immunocompromise (e.g.
platelets) Stress Fever or systemic infection Concussion and/or closed head injury
Seizure Precipitants
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Ramsay, R. E. et al. Neurology 2004;62:24-29S
Seizure Types in Patients age 60
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Obscured by multiple medical problems ‘Atypical’ symptoms from commonly discussed seizure
types, often interpreted as caused by aging or depression Living alone, not being closely observed Half of delays—Patient did not seek for help. After 1st seizure, < 50% diagnosed (GTC—usually
immediately versus only 20% for CPS) Only < 73% ultimately diagnosed by primary care physicians
Under-diagnosed Epilepsy in Elderly
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Generalized: absence, tonic-clonic, atonicStaring, shaking, incontinence, tongue bite,
unresponsive Partial-onset epilepsy: simple or complex
AuraConfusion, incoherent speechOral or manual automatism Head turning
Typical Seizures for All Age Groups
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Auras are less common Often non-specific auras: e.g. dizziness Less automatism Prolonged post-ictal confusion Common initial presentations (1 or more): altered mental status
(41.8%), blackout/syncope/recurrent falls (29.3%), memory impairment (17.2%), dizziness (10.3%) & dementia (6.9%)
New onset sleep walking/sleep talking; vivid dreams with arousal (Night terror ? REM behavior sleep disorder? frontal lobe epilepsy); jerks in sleep
Symptoms in Late-onset Epilepsy
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Detailed history Clinical symptoms; Circumstances of event Past medical, neurological & psychiatric history, medications
Physical Exam, lateralizing neurological signs, cognitive function
Lab & Diagnostic studies: ECG Laboratory tests: immediately after events, supportive only Routine EEG (short) –low yield Long-term Video EEG monitoring—especially helpful, “gold-
standard”
Diagnosis
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First routine (short) EEGs (> age 60): Only seen in 35% with pre-existing epilepsy Only seen in 26% with late-onset epilepsy (onset after age 60) Past medical, neurological & psychiatric history, medications
Long-term video EEG: More than 50% in patient with vague or non-specific clinical
symptoms whose routine EEGs are normal or inconclusive if episodes are not captured.
Epileptiform Activities on EEG
Drury I. et al. Epilepsia. 1999; 40
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Clinical More severe injuries More prolonged postictal confusion
Impact on quality of life Less impact on employment Driving Competency of living independently
Treatment: more intolerance issues
Challenges
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Nonlinear pharmacokinetics of Phenytion
Birnbaum A., et al. Neurology. 2003; 60.
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Treatment of Epilepsy in Elderly
Medication(s) make me sick?
Is it the symptoms of the
disease?
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Drug of choice Drug interaction Adverse effect: imbalance, mood swing, sedation, sleep pattern;
weight changes; Co-existing medical problems: liver, kidney failure; Dosage
Speech impairment from AED adverse effect versus uncontrolled seizures
Compliance Management of precipitating factors: Sleep disorder (OSA etc),
conditions affecting sleep quality, stress management, chronic infections, hormonal and electrolyte disturbance
Treatment of Epilepsy in Elderly
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Epilepsy in elderly: high incidence but under-diagnosed Epileptic symptoms may be ‘atypical’ in elderly patients.
Detailed history and descriptions will be helpful for diagnosis.
Routine (short) EEG usually has low yield. Long term video EEG is more helpful to confirm the diagnosis.
Pharmacological treatment plan should be individualized for better tolerance and compliance.
Summary