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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 complexAura
Confusion, incoherent speech
Oral 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