EPIlepsy in elderly Neelima Thakur MD.

1. EPIlepsy in elderlyNeelima Thakur MD.

2. EPIlepsy in elderly • Research shows that the incidence of epilepsy is higher in the elderly. • Epilepsywas believed to be predominantly a childhood disorder. • Epilepsyis the most common serious neurological disorder in the elderly after stroke and dementia.

3. 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.

4. 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.

5. How common is epilepsy in Seniors?

6. The prevalence and incidence of epilepsy are highest in later life!! • Approximately 7% of seniors have epilepsy. • 25% of new cases occur in elderly

7. 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 • 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

8. incidence (New cases) of epilepsy 1995-UK study • 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

9. Causes / Etiology • PROVOKED SEIZURES • UNPROVOKED SEIZURES.

10. Etiology

11. 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

12. 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.

13. 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.

14. Tumors • Seizures may be the presenting feature of tumors at any age. • The most common tumors causing seizures are gliomas, meningiomas and metastases.

15. 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.

16. Provoked SeizurEs • Acute symptomatic seizures. • Often a reversible cause. • By definition, these are not epilepsy.

17. 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

18. 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.

19. Clinical Presentation • 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.

20. Status epilepticus 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.

21. Status epilepticus

22. 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%

23. 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.

24. 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

25. SEIZURE ORNOT A SEIZURE Differential Diagnoses

26. 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

27. Differential Diagnoses • Endocrine/metabolic • Hypoglycaemia • Hyponatraemia • Hypokalaemia • Sleep disorders • Obstructive sleep apnea • Hypnic jerks • Rapid eye movement sleep disorders • Psychological • Non-epileptic psychogenic seizures

28. Diagnosis

29. Diagnosis • Diagnosing epilepsy can be more difficult and more time consuming in elderly. • Atypical presentation. • Potential mimics • Higher prevalence of comorbidities

30. 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.

31. 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 • EEG • Neuroimaging studies

32. Treatment of Epilepsy • Provoked seizures - treat the underlying cause. • Unprovoked Seizures - antiepileptic drug treatment.

33. Treatment Algorithm

34. Treatment of Epilepsy • Start treatment after a single unprovoked seizure ? Remains controversial.

35. 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.

36. 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

37. 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

38. 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

39. 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'

40. 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.

41. 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

42. 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.

43. 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

44. 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.

45. Other Management Options • Surgery • VNS

46. 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

47. Happily seizure free ever after!!