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Epilepsy in the Elderly: Why is it Different? Brenda Y. Wu, M.D., Ph.D.

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Presentation on theme: "Epilepsy in the Elderly: Why is it Different? Brenda Y. Wu, M.D., Ph.D."— Presentation transcript:

1 Epilepsy in the Elderly: Why is it Different? Brenda Y. Wu, M.D., Ph.D.

2 Incidence of New Diagnosis of Epilepsy Pohlmann-Eden B, Acta Neurol Scand 2005(suppl);181:40-46 > 60y/o, ~25%

3 Etiology in Patients  age 60 Ramsay, et al. Neurology 2004; 62 (5 suppl 2).

4 Causes of Epilepsy Annegers JF. The epidemiology of epilepsy. In: Wyllie E, ed. The treatment of epilepsy: principles and practice.3 rd Ed, 2001:165-72

5  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

6 Ramsay, R. E. et al. Neurology 2004;62:24-29S Seizure Types in Patients  age 60

7  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 1 st seizure, < 50% diagnosed (GTC—usually immediately versus only 20% for CPS)  Only < 73% ultimately diagnosed by primary care physicians Under-diagnosed Epilepsy in Elderly

8  Generalized: absence, tonic-clonic, atonic  Staring, shaking, incontinence, tongue bite, unresponsive  Partial-onset epilepsy: simple or complex  Aura  Confusion, incoherent speech  Oral or manual automatism  Head turning Typical Seizures for All Age Groups

9  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

10  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

11  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

12  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

13 Nonlinear pharmacokinetics of Phenytion Birnbaum A., et al. Neurology. 2003; 60.

14 Treatment of Epilepsy in Elderly Medication(s) make me sick? Is it the symptoms of the disease?

15  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

16  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

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