Download Epilepsy in elderly: Neelima Thakur, M.D.

 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.
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.
 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.
 The
prevalence and incidence of epilepsy are
highest in later life!!
 Approximately
 25%
7% of seniors have epilepsy.
of new cases occur in elderly
 5·15
per 1000 people.
 Children


5–9 years: 3·16
10–14 years: 4·05
 Elderly





65–69 years :6·01
70–74 years :6·53
75–79 years : 7·39
80–84 years : 7·54
85 years and older : 7·73
 80·8
per 100 000 people
 children


5–9 years: 63·2
10–14 years :53·8
 Elderly





65–69 years: 85·9
70–74 years: 82·8
75–79 years: 114·5
80–84 years: 159
⩾85 years: 135·4
 PROVOKED
SEIZURES
 UNPROVOKED
SEIZURES.

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
 10–20%
 Less
of all epilepsy in older people.
appreciated is the evidence suggesting
that dementia may develop with greater
frequency elderly with chronic and
established epilepsy.

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.
 Seizures
may be the presenting feature of
tumors at any age.

The most common tumors causing seizures
are gliomas, meningiomas and metastases.
 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.
 Acute
symptomatic seizures.

Often a reversible cause.

By definition, these are not epilepsy.

Common causes


acute alcohol withdrawal
metabolic and electrolyte disturbances




Infections



Hyponatremia
Hypocalcemia
Hypomagnesemia
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
 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.

70% of seizures are of focal onset.

Focal or complex partial seizures





Memory lapses,
Episodes of confusion
Periods of inattention
Apparent syncope.
Late onset idiopathic generalized epilepsy
cases are occasionally seen.
Status 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.














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%
 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.
 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
SEIZURE OR NOT A SEIZURE
 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
 Endocrine/metabolic
Hypoglycaemia
 Hyponatraemia
 Hypokalaemia

 Sleep



disorders
Obstructive sleep apnea
Hypnic jerks
Rapid eye movement sleep disorders
 Psychological
 Non-epileptic psychogenic seizures
 Diagnosing
epilepsy can be more difficult and
more time consuming in elderly.



Atypical presentation.
Potential mimics
Higher prevalence of comorbidities
 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.
 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
 EEG
 Neuroimaging
studies
 Provoked
seizures - treat the underlying
cause.
 Unprovoked
treatment.
Seizures - antiepileptic drug
 Start
treatment after a single unprovoked
seizure ?
Remains controversial.
 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
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
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
 Decreased
 Decreased
 Decreased

albumin and decreased of protein binding
body fat Metabolism and excretion.
hepatic metabolism
renal clearance
 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'
 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.
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
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.

Surgery
VNS






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 seizurefree with appropriate treaments.
Attention should be paid to side effects and potential
for drug-drug interactions