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Epilepsy in Older People

Epilepsy in Older People. Can We Meet the Challenge? Raymond Tallis FRCP FMedSci. Special Issues. Common Different Under-researched Service challenges. Seizures matter. Unpleasant experience Physical consequences Psychosocial consequences Underlying cause. Special Issues. Common

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Epilepsy in Older People

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  1. Epilepsy in Older People Can We Meet the Challenge? Raymond Tallis FRCP FMedSci SIG Meeting

  2. Special Issues • Common • Different • Under-researched • Service challenges SIG Meeting

  3. Seizures matter • Unpleasant experience • Physical consequences • Psychosocial consequences • Underlying cause SIG Meeting

  4. Special Issues • Common • Different • Under-researched • Service challenges SIG Meeting

  5. Age-specific incidence of treated epilepsy per 100,000 persons(Source: Wallace, Shorvon, Tallis, Lancet: 1998) Incidence/100,000 Age SIG Meeting

  6. EPILEPSY MORE PREVALENT IN OLDER PEOPLE • 456,000 people have epilepsy (based on 2003 census population) • This is equivalent to 1 in 131 people or 7.5 per thousand • People over 65, one in 91 (compared with 1 in 279 in children under 16) Source: ONS 2003 SIG Meeting

  7. Special Issues • Common • Different • Under-researched • Service challenges SIG Meeting

  8. Seizures in the aged: What’s different • Presentation • Type of seizure • Differential diagnosis • Aetiology • Co-morbidity • Functional consequences • Clinical pharmacology SIG Meeting

  9. Seizures and cerebrovascular disease • Pre-stroke seizures • Post-stroke seizures SIG Meeting

  10. Pre-stroke seizures:Kaplan-Meier for stroke-free survival • At any point in time, the relative risk of stroke in the control group is approximately one third of that in the seizure cohort (RR 0.346; 95% CI 0.294–0.408) • Cleary, Tallis, Shorvon Lancet 2004 p <0.0001 SIG Meeting

  11. Post-stroke seizures • Approximately 10% of patients with ischaemic stroke will have developed post-stroke seizures by 5 years (Burn, et al. 1997, Oxford Community Stroke Project) SIG Meeting

  12. Special Issues • Common • Different • Under-researched • Service challenges SIG Meeting

  13. Percentage of patients remaining in the trial over time (52 weeks). Rowan et al. Neurology 2005; 64:1868-1873. SIG Meeting

  14. Antiepileptic drugs • When to start? • Which drug? • What dose? • Adverse reactions? • Interactions? • Monitoring? • Compliance? • Withdrawal? SIG Meeting

  15. In Place of a Conclusion • The drug you choose may be less important than how you and the patient use it. • Be prepared to modify the dose in response to actual but unexpected responses • Be prepared to fine tune with small incremental changes • This has implications for provision of services! SIG Meeting

  16. Special Issues • Common • Different • Under-researched • Service challenges SIG Meeting

  17. Minimal entitlement of older people with epilepsy in 2011 • Accurate diagnosis • Comprehensive management SIG Meeting

  18. Service Challenges • Epilepsy often only part of the problem • Diagnostic challenges • Multiple medical problems • Disability • Who should care: neurologists (who might get the epilepsy right) or geriatricians (who might get everything else right) • Role of ESNA SIG Meeting

  19. Misdiagnosis of seizures • Muddling non-seizures with seizure • Muddling seizures with non-seizure SIG Meeting

  20. Conditions in older people that may be misdiagnosed as seizures • Syncope • Hypoglycaemia • Transient ischaemic attack • Recurrent paroxysmal behavioural disturbances in organic brain disease • Drop attacks and other non-epileptic causes of falls • Transient global amnesia • Sleep phenomena: hypnic jerks; obstructive sleep apnoea • [Non-epileptic attack disorder] SIG Meeting

  21. Seizures in older people that may be misdiagnosed as other conditions Epileptic event Partial motor status Sensory seizures Complex partial seizures Epileptic vertigo (due to temporal lobe attacks) Todd’s Palsy Any kind of seizures Possible misdiagnosis Extra pyramidal movement disorder Transient ischaemic attack Organic or functional psychosis Brain stem vestibular disease/non-specific dizziness Stroke/TIAs ’Falls’ SIG Meeting

  22. Diagnosis: Conclusion Need comprehensive, thoughtful, expert assessment AND reassessment SIG Meeting

  23. Overall aim of Management To make epilepsy the least important thing in the patient’s life SIG Meeting

  24. Services for Older People with Seizures • Need to have expertise in epilepsy • Need to have expertise in special aspects of epilepsy in older people • Need to have expertise in other problems that older people may have SIG Meeting

  25. ORGANISATION OF SERVICES • Shared care • Role of GPSIs • The annual review • Hospital-based epilepsy service • Specialist epilepsy nurse SIG Meeting

  26. Epilepsy Specialist Nurse • Highly qualified general nurse • Very experienced • Training in epilepsy • Working closely with the rest of the clinical team under the supervision of a consultant • May be a ‘nurse prescriber’ • ESNA as trainer SIG Meeting

  27. Role of Epilepsy Specialist Nurse • Building good relationships/rapport • Education, support and advice • Act as resource of information • Monitoring of medication • Telephone helpline • Link between primary and secondary care SIG Meeting

  28. Epilepsy amongst older people: experiences and perceptions of geriatricians Research study conducted for Epilepsy Action April – May 2005 SIG Meeting

  29. Findings (1) • 9 out 10 geriatricians see elderly people with seizures • Most geriatricians think the prevalence of seizures is lower than it in fact is SIG Meeting

  30. Findings (2) • Only ⅔ of geriatricians are aware that NICE guidelines are available • Only 1 in 10 identify that under these guidelines a patient reporting a suspected seizure should be seen by a specialist medical practitioner with training and expertise in epilepsy within 2 weeks • Only 13% of geriatricians have been on an epilepsy related course • Of the 87% that had never been on an epilepsy related course, 85% see patients with epilepsy SIG Meeting

  31. NICE guidelines for epilepsy (5) difficult to manage cases Referral to a specialist centre if: • Epilepsy not controlled with medication within 2 years • Not controlled after two drugs have been tried • There are unacceptable side effects from medication • There is doubt over the diagnosis of seizures SIG Meeting

  32. Some Actions • Training and education (geriatricians, neurologists) [NB National Meeting 2nd March] • Professional bodies: Special Interest Groups • Flag up nationally: DoH (New Commissioning arrangements?) • Voluntary Bodies SIG Meeting

  33. First Class Care • Accurate diagnosis • Full information • Appropriate drug treatment • Ready access to review of diagnosis and treatment • Ready access to further information and advice SIG Meeting

  34. Key Message Do not settle for second class care. SIG Meeting

  35. Conclusions Epilepsy in older adults is: • More common • More important • More to gain • Much to be done SIG Meeting

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