Transcript Epilepsy Lecture Series-1

Epilepsy in the Elderly:
Why is it Different?
Brenda Y. Wu, M.D., Ph.D.
Incidence of New Diagnosis of Epilepsy
> 60y/o, ~25%
Pohlmann-Eden B, Acta Neurol Scand 2005(suppl);181:40-46
Etiology in Patients  age 60
Ramsay, et al. Neurology 2004; 62 (5 suppl 2).
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
Seizure Precipitants
 Metabolic and electrolyte imbalance
 Stimulant/other pro-convulsant intoxication: cocaine,
anticholinergics, dopamine blockers, clozapine, immunosuppressants, 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 Types in Patients  age 60
Ramsay, R. E. et al. Neurology 2004;62:24-29S
Under-diagnosed Epilepsy in Elderly
 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
Typical Seizures for All Age Groups
 Generalized: absence, tonic-clonic, atonic
 Staring, shaking, incontinence, tongue bite, unresponsive
 Partial-onset epilepsy: simple or complex
 Aura
 Confusion, incoherent speech
 Oral or manual automatism
 Head turning
Symptoms in Late-onset Epilepsy
 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
Diagnosis
 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”
Epileptiform Activities on EEG
 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.
Drury I. et al. Epilepsia. 1999; 40
Challenges
 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
Nonlinear pharmacokinetics of Phenytion
Birnbaum A., et al. Neurology. 2003; 60.
Treatment of Epilepsy in Elderly
Medication(s)
make me sick?
Is it the
symptoms of the
disease?
Treatment of Epilepsy in Elderly
 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
Summary
 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.