EPILEPSY IN ELDERLY
NEELIMA THAKUR MD.
EPILEPSY IN ELDERLY
Research shows that the incidence of epilepsy is higher in the elderly.
Epilepsy was believed to be predominantly a childhood disorder.
Epilepsy is the most common serious neurological disorder in the elderly after stroke and dementia.
EPILEPSY IN ELDERLY
US census projections
147 percent increase in the over 65 years old population between 2000-2050
Only 49 percent in population over the same period.
EPILEPSY IN ELDERLY Elderly people with epilepsy are a large
but neglected group.
In a postal survey 25% of general practitioners were unaware that epilepsy commonly manifests for first time in elderly.
HOW COMMON IS EPILEPSY IN SENIORS?
The prevalence and incidence of epilepsy are highest in later life!!
Approximately 7% of seniors have epilepsy.
25% of new cases occur in elderly
PREVALENCE( TOTAL CASES -OLD & NEW CASES)OF EPILEPSY1995-UK STUDY
5·15 per 1000 people. Children
5–9 years: 3·16 10–14 years: 4·05
Elderly65–69 years :6·01 70–74 years :6·53 75–79 years : 7·3980–84 years : 7·54 85 years and older : 7·73
INCIDENCE (NEW CASES) OF EPILEPSY 1995-UK STUDY
80·8 per 100 000 people children
5–9 years: 63·210–14 years :53·8
Elderly65–69 years: 85·970–74 years: 82·875–79 years: 114·580–84 years: 159⩾85 years: 135·4
CAUSES / ETIOLOGY
PROVOKED SEIZURES
UNPROVOKED SEIZURES.
ETIOLOGY
C
ereb
ral i
nfar
ctio
n(29
.9%
)
Arte
riosc
lero
sis(
15.7
%)
Head
traum
a(7.
1%)
Other
s(24
%)
STROKE
Stroke is the leading cause of new-onset epilepsy in elderly 8% of patients will hemorrhagic stroke will develop
seizures within two weeks 5% of patients with ischemic stroke will develop seizures
with in 2 weeks.
Post-stroke epilepsy usually develops within 3–12 months
However, can still occur many years later
DEMENTIAS AND NEURODEGENERATIVE DISEASES
10–20% of all epilepsy in older people.
Less appreciated is the evidence suggesting that dementia may develop with greater frequency elderly with chronic and established epilepsy.
TRAUMA
Post-traumatic epilepsy is common in elderly
Head injury, mostly from falls, causes up to 20% of epilepsy in the elderly.
Increased risk of subdural hemorrhage, especially with anticoagulants or platelet inhibitors.
Factors that increase risk of post-traumatic epilepsy Loss of consciousness Post-traumatic amnesia > 24 hrs. Skull fracture, brain contusion and subdural hematoma.
TUMORS
Seizures may be the presenting feature of tumors at any age.
The most common tumors causing seizures are gliomas, meningiomas and metastases.
TUMORS
Seizures may be the first presentation of metastatic disease
In one study 43% of those presenting with seizures from metastases had no previous systemic diagnosis of cancer.
PROVOKED SEIZURES
Acute symptomatic seizures.
Often a reversible cause.
By definition, these are not epilepsy.
PROVOKED SEIZURES Common causes
acute alcohol withdrawal metabolic and electrolyte disturbances
Hyponatremia Hypocalcemia Hypomagnesemia
Infections systemic CNS.
Drugs - commonly prescribed to elderly. Tramadol Antipsychotics Antidepressants (particularly tricyclics) Antibiotics(quinolones and macrolide) Theophylline, levodopa, thiazide diuretics and even the
herbal remedy, ginkgo biloba
CLINICAL PRESENTATION
The presentation of epilepsy in old age is often less specific.
It may take time before a firm diagnosis can be reached.
Under diagnosis and misdiagnosis are common.
CLINICAL PRESENTATION 70% of seizures are of focal onset.
Focal or complex partial seizuresMemory lapses, Episodes of confusionPeriods of inattentionApparent syncope.
Late onset idiopathic generalized epilepsy cases are occasionally seen.
STATUS EPILEPTICUSStatus epilepticus (SE) is a serious condition of prolonged or repetitive seizures.
The annual incidence is 86/100,000 > 60 Yrs.
It is almost twice that of the general population.
Over half of patients with SE do not have a diagnosis of epilepsy and often it is precipitated by an acute illness.
STATUS EPILEPTICUS
CAUSES OF STATUS EPILEPTICUS
Cerebrovascular accident (CVA) 21% Remote symptomatic (mainly previous CVA) 21% Low anticonvulsant drug concentrations 21% Hypoxia 17% Metabolic 14% Alcohol 11% Tumor 10% Infection 6% Anoxia 6% Hemorrhage 5% CNS infection 5% Trauma 1% Idiopathic 1% Other 1%
NONCONVULSIVE STATUS EPILEPTICUS(NCSE).
NCSE accounts for about 4-20% of all cases of SE.
Only one third of the patients with NCSE had a history of epilepsy.
High mortality of about 50%. Veterans Affairs studies found that 65%
of the patients with NCSE died within 30 days of an episode compared to 27% of patients with GCSE.
FEATURES THAT MAY INDICATE NCSE
Impairment of cognition, Behavioral change.
Psychomotor retardation Agitation or excitation Subtle facial or limb twitches Aphasia, echolalia, confabulation Head or eye deviation Automatisms Autonomic disturbance
DIFFERENTIAL DIAGNOSES
SEIZURE OR NOT A SEIZURE
DIFFERENTIAL DIAGNOSES
Neurological
Transient ischemic attack Transient global amnesia Migraine Narcolepsy Restless legs syndrome
Cardiovascular
Vasovagal syncope Orthostatic hypotension Cardiac arrhythmias Structural heart disease Carotid sinus syndrome
DIFFERENTIAL DIAGNOSES
Endocrine/metabolic Hypoglycaemia Hyponatraemia Hypokalaemia
Sleep disorders Obstructive sleep apnea Hypnic jerks Rapid eye movement sleep disorders
Psychological Non-epileptic psychogenic seizures
DIAGNOSIS
DIAGNOSIS
Diagnosing epilepsy can be more difficult and more time consuming in elderly.
Atypical presentation.Potential mimicsHigher prevalence of comorbidities
DELAYED DIAGNOSIS
Only 24% of patients were initially diagnosed with epilepsy when they presented to their health care providers.
It took a mean of 19 months from the time the seizures began to the time epilepsy was correctly diagnosed.
DIAGNOSIS History Clinical Exam Investigations:
Blood work full blood count, renal function testing, serum
electrolytes, and random blood glucose.1 EKG, Holter monitoring and tilt table in
some cases.Chest X ray
EEGNeuroimaging studies
TREATMENT OF EPILEPSY
Provoked seizures - treat the underlying cause.
Unprovoked Seizures - antiepileptic drug treatment.
TREATMENT ALGORITHM
TREATMENT OF EPILEPSY
Start treatment after a single unprovoked seizure ?
Remains controversial.
TREATMENT OF EPILEPSY
Older people who present with a first unprovoked seizure are more likely to develop seizure recurrence than are younger adults.
Cause identified in more than 60% of elderly people with epilepsy.
Epilepsy in elderly people generally
responds well to treatment. Up to 80% of patients with onset in old age can be expected to remain seizure-free with anti-epileptic drug treatment
TREATMENT OF EPILEPSY
Treatment decisions have to be made Cautiously.
Elderly are more susceptible to the adverse effects of drugs than their younger counterparts
The pharmacokinetics and pharmacodynamics of antiepileptic drugs differ in old age
Drug-drug interactions
TREATMENT OF EPILEPSY Pharmacokinetic and pharmacodynamic alteration of aging. Decreased Drug absorption
Delayed esophageal emptying Altered gastric pH Delayed gastric emptying Increased intestinal transit time
Drug distribution Decreased albumin and decreased of protein
binding Decreased body fat Metabolism and excretion. Decreased hepatic metabolism Decreased renal clearance
GENERAL PRESCRIBING PRINCIPLES
Reasonable to assume that antiepileptic treatment will be life-long.
Ideal AED choice Most likely achieves seizure freedom with
the fewest side effects. Be well tolerated, have a limited side-effect
profile.Easy dosing.Free of troublesome drug–drug interactions. ‘Start low and go slow'
WHICH AED WORKS BETTER?
Very narrow evidence based data is available for managing newly-diagnosed epilepsy in the elderly
Even less information is available on newer drugs, such as levetiracetam or oxcarbazepine, in elderly populations.
THE CLINICAL BENEFITS AND CAUTIONS OF ANTIEPILEPTIC DRUG USE IN THE ELDERLY. Older AEDs
Benzodiazepines Acute use Status epilepticus Idiosyncratic reactions, psychosis and sedation
Phenobarbital Broad spectrum Once-daily dosing Significant adverse event profile Requires very slow dose titration
Phenytoin Acute use Status epilepticus 'Zero-order' kinetics, so care is needed in making dose changes Enzyme inducer Interacts with digoxin and warfarin
Carbamazepine Effective in partial-onset seizures Enzyme inducer so interacts with other AEDs, some antibiotics and warfarin Hyponatremia can occur, especially with diuretics
Sodium valproate Effective in generalized-onset seizures Enzyme inhibitor. . Few interactions Ataxia and tremor may be troublesome in elderly Reversible extrapyramidal symptoms
NEWER AEDS Lamotrigine (Lamictal)
Effective in partial-onset seizures and generalized seizures. Mood stabilizer
Requires slow-dose titration to avoid serious allergic rash.
Very slow titration especially in patients already taking sodium valproate
Oxcarbazepine (Trileptal) Few interactions. Well tolerated Hyponatremia can occur, especially with diuretics
Levetiracetam (Keppra) Inert metabolites Lack of drug interactions Mood and behavioral disturbances occur occasionally
Topiramate (Topamax) Seizures and migraine prophylaxis. Requires slow dose titration Can cause weight loss and cognitive problems .
Zonisamide (Zonegran) Better side effect profile compared to Topamax.
NEWER AEDS
Gabapentin (Neurontin) Also used for neuropathic pain. Limited efficacy in epilepsy. Can be used in liver dysfunction Can cause dizziness, sedation and weight gain
Pregabalin (lyrica) Also Used for neuropathic pain Can be used in liver dysfunction Lack of drug interactions Can cause dizziness and weight gain, motor and cognitive
slowing Lacosamide (Vimpat)
Partial Epilepsy Increased risk of PR interval elongation on
electrocardiogram. Contraindicated in second- and third-degree AV block
TREATMENT CHALLENGES
Comorbidities of in elderly patients add to the diagnostic challenge and also complicate the treatment options
Polypharmacy make them susceptible to drug interactions.
A survey of elderly nursing home residents found that 49% of residents receiving AEDs were prescribed six or more medications.
Adherence may not be as good in elderly patients with epilepsy.
OTHER MANAGEMENT OPTIONS
Surgery
VNS
SUMMARY Development of epilepsy is common in later life. The number of elderly with epilepsy will rise
further. placing an increasing burden on healthcare resources
Epilepsy can have a profound physical and psychological impact in old age, with a substantial negative effect on quality of life
Be aware of Mimics Most elderly people with epilepsy can remain
seizure-free with appropriate treaments. Attention should be paid to side effects and
potential for drug-drug interactions