CPAn Official Publication of the National Conference of Gerontological Nurse Practitionersand the National Gerontological Nursing Association

December 2007 Volume 1, Number 3

Sponsored by:

This activity is supported by an educational grant from Ortho-McNeil Neurologics, Inc., administeredby Ortho-McNeil Janssen Scientific Affairs, LLC.

Neurodegenerative Diseasesand Seizure Disorder

Part 3 of a 3-Part Continuing Education Series

Counseling Points™

2COUNSELING POINTS™

Faculty:

Nannette Brower, RN-C, BSN,BSW

Staff NurseATC HealthcareCherry Hill, New Jersey

Nancy D. Henry, RN, PhD-CGeriatric Nurse PractitionerGeriatric & Rehabilitative CareServices—NHCU

Greater Los Angeles VAHealthcare System

Assistant Clinical Professor, UCLASchool of Nursing

Los Angeles, California

Barbara Resnick, PhD, CRNP,FAAN, FAANP

ProfessorUniversity of Maryland School ofNursing

Baltimore, Maryland

Faculty Disclosure Statements:Nannette Brower, Nancy Henry,and Barbara Resnick have nothingto disclose.

Publishing Information:

PublishersJoseph J. D’OnofrioDelaware Media Group66 South Maple AvenueRidgewood, NJ 07450201-612-7676Fax: 201-612-8282www.delmedgroup.com

Editorial DirectorNancy Monson

Art DirectorJames Ticchio

Cover photo credit:© Carol Donner/PhototakeUSA.com

© 2007, Delaware Media Group, Inc. Allrights reserved. None of the contents maybe reproduced in any form without priorwritten permission from the publisher. Theopinions expressed in this publication arethose of the faculty and do not necessarilyreflect the opinions or recommendations oftheir affiliated institutions, the publisher, theNational Conference of GerontologicalNurse Practitioners, the National Geronto-logical Nursing Association, or Ortho-McNeilNeurologics, Inc.

Counseling Points™Neurodegenerative Diseases and Seizure Disorder

Continuing Education Information

Target AudienceThis educational activity is designed to meet the needs of busy gerontological nursesand advanced practice nurses, as well as neuroscience nurses, who are on the frontlines of managing elderly patients with seizures, in an effort to help them stay abreastof the latest research, treatment, and management options.

Learning ObjectivesUpon completion of this educational activity, the participant should be able to:

• Describe the prevalence and impact of seizure disorder in elderly patients with neu-rodegenerative disorders.

• Detail why neurodegenerative disorders combined with the aging physiologyincrease the risk of seizure disorder in the elderly.

• Describe the altered presentation of seizure disorder in the elderly with neurode-generative diseases.

• List the risks and benefits of antiepileptic drugs in elderly patients with seizure dis-order and neurodegenerative diseases.

Continuing Education CreditThis continuing nursing education activity was approved by the National Confer-ence of Gerontological Nurse Practitioners. Successful completion of this activityawards 1.2 contact hours.

The National Conference of Gerontological Nurse Practitioners is accredited as aprovider of continuing nursing education by the American Nurses CredentialingCenter’s Commission on Accreditation.

This program expires December 31, 2009.

Disclosure of Unlabeled UseThis educational activity may contain discussion of published and/or investigationaluses of agents that are not indicated by the FDA.The National Conference of Geron-tological Nurse Practitioners, the National Gerontological Nursing Association, Ortho-McNeil Neurologics, Inc., and Delaware Media Group do not recommend the use ofany agent outside of the labeled indications.The opinions expressed in the educationalactivity are those of the faculty and do not necessarily represent the views of theNational Conference of Gerontological Nurse Practitioners, the National Gerontologi-cal Nursing Association, Ortho-McNeil Neurologics, Inc., or Delaware Media Group.

DisclaimerParticipants have an implied responsibility to use the newly acquired information toenhance patient outcomes and their own professional development.The informationpresented in this activity is not meant to serve as a guideline for patient management.Any medications, diagnostic procedures, or treatments discussed in this publicationshould not be used by clinicians or other healthcare professionals without first evalu-ating the patient’s condition, considering possible contraindications or risks, reviewingany applicable manufacturer’s product information, and comparing any therapeuticapproach with the recommendations of other authorities.

3DECEMBER 2007

Dear Colleague,

Neurodegenerative diseases are of increasing concern to geriatric nurses and advancedpractice nurses as the American population ages. So, too, are seizures, which increase inprevalence as patients grow older.

In this issue of Counseling Points™ on seizures in the elderly, we explore the relation-ship between neurodegenerative diseases and seizure disorder. Neurodegenerative dis-eases such as dementia, stroke, and Parkinson’s disease enhance the risk of seizure dis-order in the elderly, information that is crucial to effective geriatric nursing. Nursesand advanced practice nurses need to know how to recognize seizure disorder in olderpatients with neurodegenerative diseases, because they may display behavioral symp-toms rather than involuntary motor signs and symptoms. Finally, these clinicians alsoneed to know how seizure treatment will impact concurrent medication regimens forneurodegenerative diseases.

Counseling Points™ on seizures in the elderly is an official publication of the NationalConference of Gerontological Nurse Practitioners (NCGNP) and the NationalGerontological Nursing Association (NGNA).We would like to thank Ortho-McNeilNeurologics, Inc. for sponsoring this publication under an educational grant.

We encourage you to send us your comments about the content of this and the othertwo issues in this series on seizure disorder, and we welcome your suggestions for top-ics you would like to see covered in future issues.A space is provided for your input onthe evaluation form on page 15.We also hope you’ll consider becoming involved withthe NCGNP and NGNA, if you’re not already; please visit our websites atwww.ncgnp.org and www.ngna.org for information on membership.

Sincerely,

Debra Bakerjian, PhD, MSN, RN, FNPPRESIDENT, NCGNP

Judith E. Hertz, PhD, RNPRESIDENT, NGNA

welcome

4

Introduction….John is a 77-year-old nursing home resident who is

known for his easy-going demeanor. The nursing home

staff is puzzled by his occasional episodes of intense anger.

Sudden and unprovoked, this behavior is totally out of

character for John.

….Margaret is an 85-year-old woman with severe dementia

who has frequent, sudden muscle contractions. Often, these

brief muscle contractions only affect one of her arms, but at

times her whole body is involved.

….Eleanor is a 69-year-old woman with Parkinson’s disease

residing in the community with her daughter, who is her

primary caregiver. At times, she is noted to stare and is

apparently unaware of her surroundings. At other times,

she will repeatedly blink her eyes. During these periods,

she shows no response when someone tries to get her

attention. Eleanor’s daughter states she is confused after

these episodes.

….Jeanie is a 60-year-old woman with Down syndrome

and dementia who recently moved into a long-term care

facility. The nurse entered her room this evening to find

Jeanie on the floor unconscious and experiencing rhythmic

twitching of her arms and legs.

Despite the differing presentations, each of the indi-

viduals described in the vignettes above is having

seizure activity.Whatever form it takes, seizure activity

negatively impacts on the quality of life and well-being

of the older adult. Thus, it is important for nurses

working with older adults to have an understanding of

the altered presentation of seizures in this population.

Older adults have the highest incidence of seizures

of any age group, although obtaining an accurate diag-

nosis and initiating appropriate treatment is often

delayed.1 Identifying seizures in this population can be

particularly challenging due to an altered presentation:

Behavior changes, increased confusion, and vague

complaints such as dizziness associated with seizures in

the elderly can easily be attributed to a variety of other

conditions.2-4

Overview of Seizure DisorderA seizure is a sudden alteration in normal brain activity

that results in distinct changes in behavior and/or body

function.Acute symptomatic (provoked) seizures occur

when there has been an acute insult to the central

nervous system (CNS). The risk of having an acute

symptomatic seizure rises each decade after the age of

60 (Figure 1).1,5,6 Stroke is the cause of nearly half of

such seizures and typically these seizures will occur

within 24 hours of a stroke event (Figure 2).8 Neu-

rodegenerative disorders are also implicated in pro-

voked seizures. Ten to 22% of those with Alzheimer’s

disease will experience at least one seizure, usually in

the later stages of the disease.9 Other causes of acute

symptomatic seizures in older adults include metabolic

disturbances, drug/alcohol withdrawal, trauma, brain

tumors, and infection.4 In approximately 50% of cases,

COUNSELING POINTS™

Neurodegenerative Diseasesand Seizure Disorder

Figure 1. Incidence of acutesymptomatic and unprovoked seizuresin the elderly.1,6

300

250

200

150

100

50

00 20 40

Age (yrs)

Inci

den

ce/1

00,0

00

Acute symptomatic Unprovoked

60 80

Used with permission from Epilepsia.

5

seizure disorder in older adults is idiopathic—that is,

no cause can be determined.5

The term epilepsy (seizure disorder) is used when

seizures are recurrent and unprovoked.While onset of

epilepsy can occur at any age, there is an increased risk

of both provoked and unprovoked seizures associated

with aging.5,6 In the United States, nearly a quarter of

the 2.3 million persons with epilepsy are over the age

of 65.7 New-onset epilepsy occurs in approximately

60,000 people over age 65 each year.7

While older adults often have chronic health prob-

lems such as cerebrovascular disease that put them at

increased risk of developing seizures, it is likely that the

process of aging itself also increases the risk of seizure

development.4 There are numerous changes in the

aging brain, including the loss of neurons, alterations in

brain chemistry, and histologic changes including lipo-

fuscin and amyloid deposits, that may predispose

patients to seizures.10 Amyloid deposition may play a

role in the development of both Alzheimer’s disease

and seizures. People with Down syndrome have a par-

ticularly high risk of developing Alzheimer’s disease:

This form of dementia occurs in more than half of

those over age 50 in this population, and up to 84% of

those with the combined Down syndrome and

Alzheimer’s disease presentation will have seizures.11 It

appears that what makes those with Down syndrome

highly susceptible to both Alzheimer’s disease and

seizures is that they have an extra copy of chromosome

21, which is involved in the production of amyloid

precursor protein.12

The most common type of seizure in older adults is

the complex partial seizure; however, the presentation

of these seizures can be very different from that seen in

the general population.3 In the general population,

these seizures usually originate in the temporal lobe

and are accompanied by a distinct aura. In older per-

sons, in contrast, complex partial seizures generally

originate in the frontal lobe of the brain, which is

involved in personality, intellect, speech, and move-

ment. Older adults often have a vague complaint such

as dizziness rather an aura. Another difference in

seizure presentation in this population is that automa-tisms (involuntary automatic behaviors such as lipsmacking or picking at clothing) do not occur as fre-quently as in younger persons. Post-ictal confusion,which is often present, also takes longer to resolve inolder versus younger adults.3

In most cases, seizures are brief and self-limiting.Prolonged seizure activity is indicative of status epilep-ticus, a life-threatening event. Status epilepticus isdefined as a single seizure lasting more than 5 minutesor a series of seizures occurring without regainingconsciousness. Status epilepticus is described as convul-sive or non-convulsive activity depending upon thepresentation. In convulsive status epilepticus, tonic-clonic seizure activity is seen, while in non-convulsivestatus epilepticus, behavior and cognition are affected.Non-convulsive status epilepticus is more difficult torecognize for this reason. Older adults are at greaterrisk of developing status epilepticus and face a greatermortality rate than the general population; thisincreased risk and poor outcome rises significantly inthose over age 80.13 Like other seizure activity in olderadults, stroke is often the precipitating factor for statusepilepticus. Other causes include low anti-epilepticdrug (AED) levels, hypoxia or anoxia, metabolic distur-

DECEMBER 2007

Figure 2. Epilepsy etiology in people>64 years of age.8

Trauma3.3%

Congenital0.5%

Idiopathic49.0%

Degenerative11.5%

Neoplastic2.7%

Infection0.5%

Vascular32.5%

Used with permission from Epilepsia.

6

bances, brain tumors, infection, drug/alcohol with-

drawal, and trauma.5 The immediate concern in status

epilepticus is to stop the seizure activity and maintain

cardiopulmonary functioning.

Stroke and SeizuresCerebrovascular disease, which includes cerebrovascu-

lar accident (CVA), hypertension, and vasculitis, is a

large contributor to disability and death. Annually,

about 700,000 people experience a new or recurrent

stroke.14 Many authorities consider seizure secondary

to stroke as a major cause of epilepsy in the elderly

population.8,15

According to Benbir et al, hemorrhagic and venous

infarctions are more commonly encountered in post-

stroke seizure patients than atherosclerotic or cardioem-

bolic strokes.16 These authors suggest that “strokes rep-

resent the most common etiology of epilepsy in

patients over the age of 60 years, with an incidence of

2-4% occurring in different studies.” Seizures can occur

early (within 7 days) or late (beyond 7 days) after a

stroke, and can be focal or generalized, but are usually

brief and associated with loss of consciousness when

they occur in the presence of hemorrhage.17

Status Epilepticus and Stroke

When remote symptomatic CVAs are combined with

acute stroke cases, stroke represents about 40% of eld-

erly patients with status epilepticus.18 Hence, stroke,

acute or remote, represents a major cause of status

epilepticus in the elderly.19 In a study of 342 patients

with status epilepticus who had their first seizure after

age 60, it was found that cerebrovascular disease was

the primary cause followed by head trauma.20 Hauser

described a retrospective population-based study in

which calculations revealed that almost 0.4% of people

who survive to age 75 will have had a previous episode

Many authorities consider seizure secondary

to stroke as a major cause of epilepsy in the

elderly population.

of status epilepticus.18

Etiology is a strong determinant of status epilepticus

mortality in the elderly. It is likely that the increased

risk of the elderly to develop CVA, systemic metabolic

disease, and progressive symptomatic conditions

(tumor, dementia) makes them more susceptible to

developing status epilepticus. The fact that stroke and

status epilepticus both have high mortality rates raises

the question of whether that high death rate is attrib-

utable to the severity of the underlying CVA or to the

effect of status epilepticus itself.

Dementia, Parkinson’s Disease, andSeizuresThe term “neurogenerative diseases” refers to a large,

clinically and pathologically heterogeneous group that

comprises all of the neurologic disorders leading to

dysfunction and eventual death of subsets of neurons in

highly specific functional anatomic systems of the body.

The most common neurodegenerative diseases of the

brain are Alzheimer’s disease (AD) and Parkinson’s dis-

ease, but also include Lewy body dementia, Hunting-

ton disease, and amyotrophic lateral sclerosis (ALS).21

According to Ramsay, et al, the second most common

cause of seizures in the elderly after cerebrovascular

disease is neurodegenerative diseases.22

Dementia

Degenerative dementias, such as Alzheimer’s disease, are

associated with an increased incidence of seizures.The

prevalence of seizures in patients with dementia ranges

from 10%-20%.23 McAreavey and colleagues deter-

mined in a survey of dementia inpatients that those

with seizure were younger and, according to one meas-

ure of mental status, significantly more cognitively

impaired than control group patients with dementia

only.24

Thomas indicates that Alzheimer’s-type dementia

and amyloid angiopathy are major causes of seizure,

while Romanelli et al identify Alzheimer’s disease as a

risk factor for new-onset generalized tonic-clonic

seizures in older adults.9,25

COUNSELING POINTS™

7

Sirven and Ozuna describe elderly persons as havingseizure presentation characterized by dementia-relatedsymptoms such as confusion, memory loss or delirium,and episodes of staring or disorientation.26 In addition,elderly persons can have unwitnessed seizures whenthey live alone or have limited social interactions.27

In a case study described by Ramsay et al, a primeexample of how cognitive assessment may aid in prop-er diagnosis and treatment of seizures is described asfollows: A 72-year-old woman living alone was admit-ted with a diagnosis of dementia due to episodes ofbeing “fuzzy” without a significant past medical histo-ry.22 On close examination, her electroencephalogram(EEG) revealed a dynamic change from a build-up ofpolymorphic delta activity followed by an abruptchange to a normal recording. The EEG recordingappeared to depict epilepsy, although it did not havethe morphology of epilepsy. Other than the atrophyseen on the CT scan, the clinical evaluation was unre-markable. Only after a video evaluation of the patientwas viewed did what appear to initially be dementialater become evident as seizures.

According to Bergey, the impact of epilepsy on thephysical health status of older adults is substantial andcompounded by co-morbidities found in this popula-tion.28 Given the limited information available on theincidence of seizures and that no reports exist ofseizure predictors in Alzheimer’s patients, Amatniek etal conducted a study to determine cumulative inci-dence and predictors of new-onset seizures in subjectswith mild Alzheimer’s disease in a cohort followedprospectively.29 The study replicated the observation ofearlier studies that an increased risk for unprovokedseizures exists in individuals with Alzheimer’s diseasecompared with others of the same age. This findingsupports the theory that seizures can be a part of thenatural history of Alzheimer’s disease.29-33

Elderly persons can have unwitnessed

seizures when they live alone or have

limited social interactions.

Seizure Semiology in the Elderly

Kellinghaus et al observe that the degenerative processes

of the aging brain do not influence the symptoms of

seizures in the same way as the myelinating and matu-

ration processes do in the first years of life.34 There are

no major differences in the frequency of seizure types

between the elderly and a younger control group

matched according to location of the epileptogenic

focus. Seizures with auras, automotor seizures with typ-

ical orofacial automatisms, and all seizure types with

complex, semi-purposeful movements occur equally in

both groups.

The notion that a different seizure semiology exists

in the elderly is based primarily on the findings of a

few hospital-based studies and one population–based

study.8,35-40 These studies used the current classification

of the International League Against Epilepsy (ILAE) of

1981 and distinguished only between simple partial,

complex partial, and generalized seizures. The specific

signs of seizure in the elderly reported in these studies

may have been due to the use of a less-adequate seizure

classification, the lack of an adequate control group

eliminating location-inherent differences in semiology,

and, especially in the case-population study, a different

recruitment setting.

Kellinghaus et al also note that simple motor

seizures like focal clonic seizures, versive seizures, and

bilateral asymmetric tonic seizures are seen less fre-

quently in elderly patients, a difference that might be

attributed to the higher number of patients with

generalized cerebral atrophy and white matter

lesions.34 Therefore, one could speculate that the

aging brain is less able to prevent the spread of focal

seizure activity.

Seizures and Epilepsy in the OlderAdult: When to Initiate SeizureTreatmentThe decision to initiate treatment with medication for a

seizure should be based on evidence of recurrent

seizures, onset of epilepsy as status epilepticus, or the

presence of a clear structural predisposition for seizures.10

DECEMBER 2007

8

In particular, medical interventions probably should be

initiated if the individual has seizures that impact quality

of life.

Treatment Options

Pharmacologic interventions are the primary manage-

ment of seizure disorder and treatment choices are

generally based on what is known about the seizure

(e.g., simple versus complex partial seizures, tonic

clonic, or myoclonic), the known co-morbidities of the

individual, and drug side effects.10,22 Consistent with

multiple clinical guidelines, it is emphasized that all

AEDs are equally efficacious for seizure control.41,42

The newer AEDS (Table 1), however, are known to

have fewer adverse effects than older agents such as

phenytoin and carbamazepine.41 In general, for older,

medically stable patients with idiopathic, generalized

seizures, lamotrigine and valproic acid are recommend-

ed as first-line treatments.10 Phenytoin and carba-

mazepine are also often used in this setting due to their

lower costs and previously established effectiveness.10

The specific risks and challenges of use of these drugs

in older adults are related to known hepatic changes

and altered drug metabolism that occurs with age, and

an increased likelihood of drug-drug interactions. It is

also challenging to utilize currently advised dosages

and drug serum levels, as these values were developed

in and for younger individuals. Drug choices and

potential side effects are shown in Table 2.

Decisions on drug use must be made based on indi-

vidual needs and side-effect profiles. With regard to

drug dosing, the guideline is to start low and monitor

drug response in terms of prevention of seizure.

Extended-release formulations may be helpful with

regard to drug adherence. Expense can further influ-

ence treatment decisions, with older AEDs generally

being less costly than newer AEDs.43 It is not clear,

however, what the potential costs of drug-drug interac-

tions and other negative outcomes may be that can

occur from use of the older treatment options (e.g.,

falls, fractures, confusion, sedation).

Certain drugs may offer a particular advantage in

select patient populations. For example, topiramate

may be helpful in obese patients as it can result in

weight loss; for the same reason, it should be avoided

in older adults with anorexia. Drugs with a more

favorable cognitive profile in terms of side effects

include gabapentin, tiagabine, lamotrigine, oxcar-

bazepine, and levetiracetam.43

Special Challenges Associated withMedication Management in Older Adults

Age-related physiologic changes in protein binding,

albumin levels, hepatic metabolism, renal clearance, and

absorption may influence AED metabolism and utiliza-

tion.44 Specifically, decreasing renal and hepatic function

with age decreases the body’s ability to eliminate med-

ication. There is also a decrease in oxidative metabolism

via the cytochrome P-450 enzyme system, which fur-

ther influences metabolism. In addition, there is a

decreased ratio of muscle to body fat influencing drug

binding. Therefore, a standard medication dose may

result in higher drug serum concentrations in an older

individual. In light of the reduced protein binding of

drugs that occurs with age, drugs that are highly pro-

tein-bound such as phenytoin and carbamazepine may

have normal or low plasma levels but high levels of free

drug in the plasma, ultimately resulting in toxicity.

Generally, based on their pharmacokinetics, the

COUNSELING POINTS™

Table 1. Older and Newer AEDs

Older AEDs Newer AEDs(Available Prior Year (Available After Year

to 1993) Introduced 1993) Introduced

Phenobarbital 1912 Felbamate 1993

Phenytoin 1938 Gabapentin 1993

Ethosuximide 1960 Lamotrigine 1994

Diazepam 1968 Topiramate 1996

Carbamazepine 1974 Tiagabine 1997

Valproic acid 1978 Levetiracetam 1999

Oxcarbazepine 2000

Zonisamide 2000

Pregabalin 2005

9DECEMBER 2007

Table 2. Medications for Seizure Management*

Drug Indication Advantages Disadvantages Adverse Events

Carbamazepine(Tegretol®)

Partial seizures Minimal sedation andcognitive adverse effects

Ataxia; diplopia; multipledrug interactions

Tremor; hyponatremia; lowerWBC; osteoporosis; rash;cognitive changes; drug-drug interactions

Felbamate(Felbatol®)

Partial seizures—used only inrefractory disease

None Risk of serious adverseevents

Aplastic anemia; weight loss;liver failure; gastrointestinalupset; sleep changes;headache

Gabapentin(Neurontin®)

Partial seizures No hepatic metabolism;drug interaction only withantacids

Dosage modificationneeded in patients withrenal disease; TID dosingrequired

Tiredness

Lamotrigine(Lamictal®)

Partial seizures Interaction with AEDsonly

Dosage modificationneeded in patients withliver disease

Prolonged half life; rash

Levetiracetam(Keppra®)

Partial seizures;myoclonic seizures;tonic-clonicseizures

Effective in the treatmentof multiple types ofseizures

Possible impact onbehavior

Unusual thoughts orbehaviors; fever; chills; bodyaches; flu symptoms;depression

Oxcarbazepine(Trileptal®)

Partial seizures Low side-effect profile Photosensitivity; doseshould be adjusted whenthe glomerular filtrationrate is <30

Hyponatremia; fatigue;altered cognition

Phenytoin(Dilantin®)

Partial seizures Low cost Many drug andfood/nutrient interactions

Peripheral neuropathy;gingival hypertrophy; frozenshoulder; osteoporosis; rash;cognitive changes; drug-drug interactions

Pregabalin(Lyrica®)

Partial seizures;generalizedseizures

Reduced platelet counts;increased blood creatininekinase levels with associatedmuscle pain; sedation;dizziness; edema; weightgain; impaired cognition

Tiagabine(Gabitril®)

Partial seizures None Dosage modificationneeded in patients withliver disease

Slowed thinking; tiredness

Topiramate(Topamax®)

Partial seizures;generalizedseizures

Interaction with AEDsonly; weight loss

Weight loss; dosagemodification required ifcreatinine clearance is <60mL per minute

Weight loss; renal stones;slowed thinking

Valproic acid(Depakene®)

Generalizedseizures; absenceseizures

Broad-spectrum efficacy Extensive protein binding;multiple drug interactions

Tremor; effect on plateletfunction; drug-druginteractions

*Optimal dosage is based on prevention of seizure, not on reaching therapeutic drug levels.AEDs=anti-epileptic drugs; TID=three times a day; WBC=white blood count.

10

older AEDs tend to be more difficult to manage thanthe newer AEDs.The older AEDs are mostly metabo-lized by the P-450 enzyme system, which can impactother drugs being used by the individual. Conversely,the newer AEDs are metabolized via the glucuronida-tion system with less risk of drug-drug interactions.For example, gabapentin, levetiractam, and pregabalinare almost 100% cleared by the renal pathway andtherefore have a low risk for drug-drug interactions.

Although a therapeutic range has been establishedfor the older medications, treatment should be drivenby cessation of seizures without side effects from med-ications, rather than based on a recommended thera-peutic range.45 Moreover, older adults can have a totalphenytoin serum concentration that is below the ther-apeutic range, yet have unbound concentrations thatare within the therapeutic range.

Treatment Complications Associated withCo-morbidities

Older adults commonly experience multiple co-morbidities that not only contribute to the incidenceof seizures but likewise impact treatment. Co-morbidities can impact adherence to medications dueto cognitive impairment, degenerative joint diseaseand functional impairment, or vision changes—all ofwhich can make it difficult for patients to rememberhow to manage their medications. Likewise, condi-tions associated with dysphagia, diplopia, and absorp-tive disorders can influence medication management.

Treatment Consequences: Adverse Effectsof AEDs

AEDs can be associated with hypersensitivity, dose-related adverse events, or adverse events related tochronic use. In particular, older adults are more sensi-tive to dose-related events such as ataxia, which canoccur at doses lower than those seen in younger indi-viduals. The major problem with adverse events inolder adults is that they can have a significant impacton function. Associated ataxia, peripheral neuropathy,tremor, hyponatremia, and/or soft-tissue changes caninfluence the individual’s ability to ambulate safely or

engage in activities of daily living. Table 2 providessome of the most common adverse events.

Dosing and Administration Considerations

If the first AED prescribed is not well tolerated at lowdoses or does not stop seizures, an alternative agent canbe tried. If the first drug initiated is well tolerated butdoesn’t control the seizures, then a second drug can beadded. Generally administered via the oral route, theabsorption of carbamazepine is decreased when givenduring nasogastric feeding.To improve absorption, car-bamazepine suspension should be mixed with an equalvolume of dilutant prior to being inserted into thenasogastric feeding tube.

Discontinuation of PharmacologicManagementConsideration can be given to stopping medication ifthe patient is free of seizures for 2 to 5 years.When adecision to withdraw an AED is made, the drug shouldbe tapered no faster than every 4 to 6 weeks in decre-ments of 20%.46 If a subsequent seizure occurs, imme-diate treatment of seizures for institutionalized olderadults can be started with diazepam administered as abuccal squirt or rectal suppository.

The Role of the Nurse and AdvancedPractice NurseThe main concern of the nurse and advanced practicenurse during a seizure is to protect the person experi-encing the episode from harm and to maintain a patentairway. In the event that this is a first seizure or if seizureactivity is prolonged (status epilepticus), immediateemergency medical care is needed. Table 3 describesnursing interventions during seizure activity.47

Seizure Documentation

Seizure documentation is a valuable tool both in mak-ing the diagnosis of seizure disorder and in evaluatingthe efficacy of treatment. Observation and documenta-tion should include the following:• What preceded the seizure• Duration of the seizure

COUNSELING POINTS™

11

• Description of motor movement or rigidity type,where the seizure started, its progression, and partsof the body involved

• Position of eyes, size of pupils, staring, unrespon-siveness

• Position of head• Automatisms (twitching, jerking movements, or

other atypical movements)• Vocalizations (humming, talking, etc.)• Confused or combative or other behavior changes• Stiffness of extremities• Incontinence of bowel or bladder or emesis• Loss of consciousness—when and for how long• Falling to the ground• Injury during the seizure• Behavior after the seizure—confusion, weakness,

paralysis, sleep, or inability to speak.• Medical interventions (medication, oxygen, vagus

nerve stimulation) during the episode.47

Psychosocial ImplicationsThe onset of a seizure disorder in the older adult has anumber of psychosocial implications. Epilepsy, unfortu-nately, remains a stigmatized illness. Older persons mayremember a time when there were many misconcep-tions and limited treatment options available. Educatingolder adults with seizure disorder and their families isimportant. Support groups and resources such as TheEpilepsy Foundation (www.efa.org) will prove helpful.

A seizure disorder diagnosis is a life-altering eventfor an older adult and can compromise his or her qual-ity of life. Seizure-related falls can result in injuriessuch as fractures that, in turn, can limit mobility andself-care activities. The older adult or family membersmay question the safety of the patient continuing tolive on his or her own. Falls and fall-related injuries,seizure-related or not, often lead to nursing homeplacement in the older adult population.48 In addition,independence may be limited when driving privilegesare revoked until it has been established that treatmentis controlling seizure activity.

Older adults with newly diagnosed seizure disordermay curtail previously enjoyed activities. Some activi-

ties such as swimming may be unsafe if seizures are

poorly controlled. In addition, patients may withdraw

from socialization due to fear of embarrassment.

There appears to be a correlation between major

depression and epilepsy.Those who develop epilepsy in

later life tend to report greater anxiety and depression,

and to rate their overall quality of life as lower than

those who have been living with epilepsy for some

time.49 Studies have found that there is a six times

greater incidence for developing epilepsy in those with

major depression.50 Some question the validity of these

retrospective studies. The medications that are com-

monly used in treating people with major depression

in years past included benzodiazepines, which have

themselves been linked to seizure development.51 It

appears that psychiatric co-morbidities, including

depression, worsen with seizures.4

DECEMBER 2007

Table 3. Nursing Interventions DuringSeizure Activity47

• Do not restrain someone during a seizure.

• Protect the person from injury by clearing the immediate

area of any hazards.

• Protect the head as much as possible—e.g., place padded

siderails on the bed and outfit the patient with protective

head gear if he or she is known to have frequent seizures,

especially generalized ones.

• Do NOT place anything in the person’s mouth.

• If possible, turn the person’s head to the side to prevent

aspiration of pooling respiratory secretions. Have suction

equipment readily available in case it becomes necessary

to suction the person.

• Monitor for color changes and administer oxygen if there

is a color change.

• Observe for respiratory depression, which can occur dur-

ing seizures.

• Remain with the person until consciousness is fully

regained. It is not unusual for someone who has had a

seizure to sleep afterwards. Place the person lying on his

or her side (recovery position) if possible.

• Document seizure activity.

12

SummarySeizure is an important differential diagnosis to consid-

er in the care of older adults. Decisions to treat or not

to treat the older individual, however, need to be made

carefully based on the impact of the seizure on the

quality of life of the individual balanced against the

side effects of drug management. Using this approach

to facilitate the evaluation and treatment of older adults

for seizure will help nurses and advanced practice nurs-

es optimally manage this potentially devastating clinical

problem.

References

1. Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovokedseizures in Rochester, Minnesota: 1935-1984. Epilepsia. 1993;34:453-468.

2. Sirven J. Funny spells: Recognizing and diagnosing seizures. Slide set from9th Annual Teleconsult in Epilepsy. Accessed 8/9/07 at www.aesnet.org.

3. Sirven J. Management of epilepsy in older adults. Clin Geriatrics.2000;8:1. Accessed 8/9/07 at www.cl inicalgeriatr ics.com/article/1098.

4. Rowan AJ. Epilepsy in older adults: Common morbidities influence devel-opment, treatment strategies, and expected outcomes. Geriatrics.2005;60:30-34.

5. Hauser WA. Epidemiology of seizures and epilepsy in the elderly. In:Rowan AJ, Ramsay RE, eds. Seizures and Epilepsy in the Elderly. New-ton, Ma: Butterworth-Heinemann. 1997;7-18.

6. Annegers JF, Hauser WA, Lee JR, et al. Incidence of acute symptomaticseizures in Rochester, Minnesota: 1935-1984. Epilepsia. 1995;36:327-333.

7. Begley CE, Famulari, Annegers JF, et al. The cost of epilepsy in the Unit-ed States: An estimate from population-based clinical and survey data.Epilepsia. 2000;41:342-351.

8. Hauser WA. Seizure disorders: The changes with age. Epilepsia.1992;33(suppl 4):S5-14.

9. Thomas RJ. Seizures and epilepsy in the elderly. Arch Intern Med.1997;157:605-617.

10. Velez L, Selwa L. Seizure disorders in the elderly. Am Family Physician2003;67:325-332.

11. Porth CM. Pathophsiology Concepts of Altered Health States, 5th ed. Lip-pincott: Philadelphia, Pa. 1998;1321.

12. Menendez, M. Down syndrome, Alzheimers disease, and seizures. BrainDev. 2005;27:246-252.

13. Hessdorfer DC, Logroscino G, Cascino G, et al. Incidence of statusepilepticus in Rochester, Minnesota, 1965-1984. Neurology. 1998;50:735-741.

14. American Heart Association. Heart Disease and Stroke Statistics—2007Update. Accessed 9/27/07 at www.americanheart.org/download-able/heart/1166712318459HS_StatsInsideText.pdf.

15. Annergers JF, Rocca WA, Hauser WA. Causes of epilepsy; contributionsof the Rochester Epidemiology Project. Mayo Clinic Proceedings, MayoClinic. 1996;71:570-575.

16. Benbir G, Ince B, Bozluolcay M. The epidemiology of post-stroke epilep-sy according to stroke subtypes. Acta Neurol Scand. 2006;114:8-12.

17. Feleppa M, DiIorio W, Saracino DM. Early poststroke seizures. Clin ExpHypertens. 2006;28:265-270.

18. Hauser WA. Status epilepticus: Epidemiologic considerations.Neurology. 1990;40:(5suppl 2):9-13.

19. Waterhouse EJ, Delorenzo RJ. Status epilepticus in older patients. DrugsAging. 2001;18:133-142.

20. Sung CY, Chu NS. Status epilepticus in the elderly: etiology, seizure,type and outcome. Acta Neurol Scand.1989;80:51-56.

21. Przedborski S, Vial M, Jackson-Lewis V. Neurodegeneration: what is itand where are we? J Clin Invest. 2003;111:3-10.

22. Ramsay RE, Rowan JA, Pryor FM. Special considerations in treating theelderly patient with epilepsy. Neurology. 2004;62(5suppl2):S24-S29.

23. Ramsay RE, Pryor F. Epilepsy in the elderly. Neurology. 2000;55(5suppl1): S9-S14.

24. McAreavey MJ, Ballinger BR, Fenton GW. Epileptic seizures in elderlypatients with dementia. Epilepsia. 1992;33:657-660.

25. Romanelli MF, Morris JC, Ashkin K, et al.Advanced Alzheimer’s diseaseis a risk factor for late-onset seizures. Arch Neurol. 1990;47:847-850.

26. Sirven JI, Ozuna J.Diagnosing epilepsy in older adults: what does itmean for the primary care physician? Geriatrics. 2005;60:30-35.

27. Van Coll AC. Epilepsy and EEG in the elderly. Epilepsia. 2002;34(suppl 3):94-102.

28. Bergey GK. Initial treatment of epilepsy: Special issues in treating the eld-erly. Neurology. 2004;63(10suppl4):S40-48.

29. Amatniek JC, Hauser WA, DelCastillo-Castaneda C, et al. Incidence andpredictors of seizures in patients with Alzheimer’s disease. Epilepsia.2006;47:867-872.

30. Risse SC, Lampe TH, Bird TD, et al. Myoclonus, seizures, and paratoniain Alzheimer disease. Alzheimer Dis Assoc Disord. 1990;4:217-225.

31. Bjork RJ, Pleumer S, Scandura D. Incidence of seizures in a residentialAlzheimer care facility. Epilepsia. 1995;36:244.

32. Forstl H, Burns A, Levy R, et al. Neurologic signs in Alzheimer’s disease:results of prospective clinical and neuropathologic study. Arch Neurol.1992;49:1038-1042.

33. Lehotovirta M, Soininen H, Helisalmi S, et al. Clinical and neuropsycho-logical characteristics in familial and sporadic Alzheimer’s disease: rela-tion to apolipoprotein E polymorphism. Neurology. 1996;46:413-419.

34. Kellinghaus C, Loddenkemper T, Dinner DS, et al.Seizure semiology inthe elderly: A video analysis. Epilepsia. 2004;45:263-267.

35. Drury I, Selwa LM, Schuh LA, et al. Value of inpatient diagnostic CCTV-EEG monitoring in the elderly. Epilepsia. 1999;40:1100-1102.

36. Lanceman ME, O’Donovan C, Dinner D, et al. Usefulness of prolongedvideo-EEG monitoring in the elderly. J Neurol Sci. 1996;142:54-58.

37. Keranen T, Rainesalo S, Peltola J. The usefulness of video-EEG monitoringin elderly patient with seizure disorders. Seizure. 2002;11:269-272.

38. McBride AE, Shih TT, Hirsch LJ. Video-EEG monitoring in the elderly: areviw of 94 patients. Epilepsia. 2002;43:165-169.

39. Luhdorf K, Jensen LK, Plesner AM. Epilepsy in the elderly: prognosis.Acta Neurol Scand. 1986;74:409-415.

40. Tinuper P, Provini F, Marini C, et al. Partial epilepsy of long duration:changing semiology with age. Epilepsia. 1996;73:162-164.

41. Pugh MJ, Foreman PJ, Berlowitz DR. Prescribing antiepileptics for the eld-erly: differences between guideline recommendations and clinical prac-tice. Drugs Aging. 2006;23 861-875.

42. Glauser T, Ben-Menachem E, Bourgeois B, et al. ILAE treatment guide-lines: Evidence based analysis of antiepileptic drug efficacy and effec-tiveness of initial monotherapy for epileptic seizures and syndromes.Epilepsia. 2006; 47:1094-1020.

43. Asconape JJ. Some common issues in the use of antiepileptic drugs. SemNeurol. 2002;22:27-39.

44. Gidal BE. Drug absorption in the elderly: Biopharmaceutical considera-tions for the antiepileptic drugs. Epilepsy Research. 2006; 68(supp 1):S1-S4.

45. Jannuzzi G, Cian P, Fattore C, et al. A multicenter randomized controlledtrial on the clinical impact of therapeutic drug monitoring in patients withnewly diagnosed epilepsy. Epilepsia. 2000;41:222-230.

46. Lackner TE. Strategies for optimizing antiepileptic drug therapy in elderlypeople. Pharmacotherapy. 2002; 22:329-364.

47. Nettina S. Lippincott Manual of Nursing Practice, 8th ed. Lippincott:Philadelphia, Pa. 2005, 544-550.

48. Tinneti ME, Williams CS. Falls, injuries due to falls, and the risk ofAdmission to nursing home. N Engl J Med. 1997;337:1279-1284.

49. Waterhouse E, Towne A. Seizures in the elderly:nuances in presentationand treatment. Cleve Clin J Med. 2005;75(suppl 3):S26-37.

50. Hesdorffer DC, Hauser WA, Annegers JF, et al. Major depression is arisk factor for seizures in older adults. Ann Neurol. 2000;47:246-249.

51. Chandlee CD. Does major depression increase the risk for seizures inolder adults? J Watch Neurol. Accessed 8/6/07 at www.neurology.jwatch.org/cgi/content/full/2000/501/6.

COUNSELING POINTS™

13DECEMBER 2007

• Older adults have the highest incidence of seizures of any age group, although obtain-ing an accurate diagnosis and initiating appropriate treatment is often delayed due toan altered presentation of the disorder.

• The risk of having an acute symptomatic seizure rises each decade after the age of 60.

• While older adults often have chronic health problems such as cerebrovascular diseasethat put them at increased risk of developing seizures, it is likely that the process ofaging itself also increases the risk of seizure development.

• The most common type of seizure in older adults is the complex partial seizure. Thepresentation of these seizures can be very different from that seen in the general popu-lation.

• Stroke represents a common cause of seizures and status epilepticus in older adults.

• The second most common cause of seizures in the elderly after cerebrovascular diseaseis neurodegenerative diseases, such as dementia and Parkinson’s disease.

• The decision to initiate treatment with medication for a seizure should be based on evi-dence of recurring seizures, onset of epilepsy as status epilepticus, or the presence of aclear structural predisposition for seizures.

• All antiepileptic drugs are equally efficacious for seizure control, but the newer agentshave fewer adverse effects than the older agents.

• Decisions on drug use must be made based on individual needs and side-effect pro-files.

• Treatment should be driven by cessation of seizures without side effects from medica-tions, rather than based on a recommended therapeutic range.

• Consideration can be given to stopping a medication if the patient is seizure-free for 2to 5 years.

• The main concern of the nurse and advanced practice nurse during a seizure is to pro-tect the person experiencing the episode from harm and to maintain a patent airway.

• Seizure documentation is a valuable tool both in making a diagnosis of seizure disorderand in evaluating the efficacy of treatment.

• There appears to be a correlation between major depression and epilepsy.

Neurodegenerative Diseasesand Seizure Disorder

CPCounseling Points™

14COUNSELING POINTS™

1. What percentage of patients with Alzheimer’sdisease will experience at least one seizure, usuallyin the later stages of the disease?A) 2%-4%B) 5%-8%C) 10%-22%D) 25%-30%

2. Which of the following changes in the brainpredisposes older adults to seizures?A) loss of neuronsB) changes in brain chemistryC) histologic changes including lipofuscin and amyloid

depositsD) all of the above

3. Older adults with combined Down syndrome andAlzheimer’s disease are at greater risk ofdeveloping seizures than other elderly adults.A) TrueB) False

4. According to Benbir et al, which types of strokesare more commonly encountered in post-strokeseizure patients?A) Hemorrhagic infarctionsB) Venous infarctionsC) Atherosclerotic infarctionsD) Both A and B

5.According to a retrospective study conducted byHauser, what percentage of people who survive toage 75 will have had a previous episode of statusepilepticus?A) 0.4%B) 0.8%C) 1.3%D) 2.0%

6. The second most common cause of seizures in theelderly after cerebrovascular disease is:A) alcohol/drug withdrawalB) neurodegenerative diseasesC) metabolic disturbancesD) brain tumors

7. Which of the following anti-epileptic drugs (AEDs)may be helpful in obese patients as it can result inweight loss?A) GabapentinB) LamotrigineC) OxcarbazepineD) Topiramate

8. Common adverse events associated with manyAEDs include all BUT which of the following?A) TremorB) Peripheral neuropathyC) Low blood glucoseD) Drug-drug interactions

9. When a decision is made to withdraw an AED, thedrug should be tapered no faster than every 4 to 6weeks in decrements of:A) 5%B) 10%C) 20%D) 30%

10. Retrospective studies indicate that there is a ___greater incidence for developing epilepsy in thosewith major depression.A) 3 timesB) 4 timesC) 5 timesD) 6 times

Counseling Points™Neurodegenerative Diseases and Seizure Disorder

Continuing Education PosttestTo receive credit, please read the newsletter in its entirety and answer the posttest and program evaluation ques-tions using the answer key on page 15. Please fax the form to Delaware Media Group at (201)612-8282.A certificate will be awarded for a score of 80% (8 correct) or better and will be mailed to you within 4-6weeks.There is no charge for CE credit.

15DECEMBER 2007

Fax form to (201) 612-8282

Fax form to (201) 612-8282

Counseling Points™: Neurodegenerative Diseases and Seizure DisorderTo assist us in evaluating the effectiveness of this activity and to make recommendations for future educational offerings, please take a few minutes tocomplete this evaluation form. You must complete this evaluation form to receive acknowledgment for completing this activity.

Please answer the following questions by circling the appropriate rating:

1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree

Extent toWhichYou AgreeWith the Following Statements: (Please circle the appropriate number on the scale.)

1. A diagnosis of dementia does not increase the likelihood of a seizure. .......................................................................................................... 1 2 3 4 5

2. Stroke is well-accepted as the most common etiology of epilepsy in the elderly. .......................................................................................... 1 2 3 4 5

3. Seizures rarely occur beyond 7 days after a stroke. .................................................................................................................................... 1 2 3 4 5

4. Parkinson’s disease can sometimes precipitate seizure disorders in the elderly. ..................................................................................... 1 2 3 4 5

Extent toWhich Program Activities Met the Identified Objectives: (After completing this activity, I am now better able to:)

5. Describe the prevalence and impact of seizure disorder in elderly patients with neurodegenerative disorders. ................................. 1 2 3 4 5

6. Detail why neurodegenerative disorders combined with the aging physiology increase the risk of seizure disorder in the elderly. 1 2 3 4 5

7. Describe the altered presentation of seizure disorder in the elderly with neurodegenerative diseases. ................................................. 1 2 3 4 5

8. List the risks and benefits of antiepileptic drugs in elderly patients with seizure disorder and neurodegenerative diseases. .............. 1 2 3 4 5

Overall Effectiveness of the Activity: (The content presented:)

9. Was timely and will influence how I practice.......................................................................................................................................... 1 2 3 4 5

10. Enhanced my current knowledge base .................................................................................................................................................. 1 2 3 4 5

11. Addressed my most pressing questions................................................................................................................................................... 1 2 3 4 5

12. Provided new ideas or information I expect to use .............................................................................................................................. 1 2 3 4 5

13. Addressed competencies identified by my specialty.............................................................................................................................. 1 2 3 4 5

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