Presentation on theme: "Epilepsy in the Elderly:"— Presentation transcript:
1Epilepsy in the Elderly: Why is it Different?Brenda Y. Wu, M.D., Ph.D.
2Incidence of New Diagnosis of Epilepsy > 60y/o, ~25%Epilepsy was once thought to be a disorder of childhoodGrowing management challenge in the elderlyIncrease awareness among MDs that Sz is a significant helth problem in the elderlyIncidence is much higher than previously thoughtElderly are the fastest growing segment of population afflicted with epilepsyEpilepsy is the 3rd most frequently identified neurologic condition seen in the elderly.Pohlmann-Eden B, Acta Neurol Scand 2005(suppl);181:40-46
3Etiology in Patients age 60 Ramsay, et al. Neurology 2004; 62 (5 suppl 2).
4Causes of EpilepsyAnnegers JF. The epidemiology of epilepsy. In: Wyllie E, ed. The treatment of epilepsy: principles and practice.3rd Ed, 2001:165-72
5Seizure Precipitants 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 injuryOne or more precipitating factors can contribute to the patient’s seizure. The discovery of a precipitant does not obviate the need to search for intracranial pathology or a genetic predisposition toward seizures, but may lead to a non-epilepsy diagnosis (e.g., alcohol withdrawal seizure), and is very useful in counseling the patient. Common precipitants include metabolic and electrolyte imbalance (such as low blood glucose, low sodium, low calcium or low magnesium), antiepileptic medication reduction or inadequate AED treatment, hormonal variations, stress, infection, severe sleep deprivation, withdrawal from alcohol or other sedative agents, and administration of drugs with proconvulsant properties, such as central nervous system stimulants including cocaine, anticholinergics (including over-the-counter antihistamines), almost all dopamine blocking agents, newer antipsychotics (particularly clozapine), antidepressants (especially buproprion), immune suppressants such as cyclosporine, and antibiotics such as quinolones or imipenem-cilastatin.
6Seizure Types in Patients age 60 Seizures in older persons are more often extratemporal, usually confined to the frontal lobe.Most elderly Pt present with staring spells, only 35-40% have convulsions.In contrast, 70% of younger patients with epilepsy present with convulsion.Ramsay, R. E. et al. Neurology 2004;62:24-29S
7Under-diagnosed Epilepsy in Elderly Obscured by multiple medical problems‘Atypical’ symptoms from commonly discussed seizure types, often interpreted as caused by aging or depressionLiving alone, not being closely observedHalf 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 physiciansThe mean time to the correct diagnosis was 1.7 years (median 2.5 months).‘Atypical’ symptoms from commonly discussed seizure types, often mimic cardiac events or TIA
8Typical Seizures for All Age Groups Generalized: absence, tonic-clonic, atonicStaring, shaking, incontinence, tongue bite, unresponsivePartial-onset epilepsy: simple or complexAuraConfusion, incoherent speechOral or manual automatismHead turning
9Symptoms in Late-onset Epilepsy Auras are less commonOften non-specific auras: e.g. dizzinessLess automatismProlonged post-ictal confusionCommon 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
10Diagnosis Detailed history Clinical symptoms;Circumstances of eventPast medical, neurological & psychiatric history, medicationsPhysical Exam, lateralizing neurological signs, cognitive functionLab & Diagnostic studies:ECGLaboratory tests: immediately after events, supportive onlyRoutine EEG (short) –low yieldLong-term Video EEG monitoring—especially helpful, “gold-standard”
11Epileptiform Activities on EEG First routine (short) EEGs (> age 60):Only seen in 35% with pre-existing epilepsyOnly seen in 26% with late-onset epilepsy (onset after age 60)Past medical, neurological & psychiatric history, medicationsLong-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.Low yielDrury I. et al. Epilepsia. 1999; 40
12Challenges Clinical Impact on quality of life More severe injuriesMore prolonged postictal confusionImpact on quality of lifeLess impact on employmentDrivingCompetency of living independentlyTreatment: more intolerance issuesTreatmentAge-related pharmacokinetics: clearance, sensitivity,low tolerance, dose-related adverse effects drug-interactions
13Nonlinear pharmacokinetics of Phenytion 1. The therapeutic window for some AEDs is narrow or non-existent in elderly patients.2. Sometimes it is difficult to distinguish btw AED toxicity and age- or disease-related factors.3. The basis of change in the therapeutic window is due to age-related changes in absorption, distribution, and elimination (renal and hepatic), and increased sensitivity to pharmacodynamic effects of AEDs.4. With AEDs that are highly protein bound (PHT, VPA), lower initial doses may be needed in some elderly Pt due to age-related hypoalbuminemia, malnutrition or renal failure5. AEDs primarily excreted via kidneyBirnbaum A., et al. Neurology. 2003; 60.
14Treatment of Epilepsy in Elderly Medication(s)make me sick?Is it the symptoms of the disease?Lower doses of high-protein bound AEDs in hypoalbuminemiaAge-relatedMalnutritionRenal failureLower doses of AEDs in patients with renal failureExcretion 1o via kidney (gabapentin, levetiracetam)Renal and liver (OXC, PB, TPM, ZNS)TreatmentAge-related pharmacokinetics: clearance, drug sensitivity,low tolerance, dose-related adverse effects drug-interactionsMore sensitive to fluctuations in AED blood levels
15Treatment of Epilepsy in Elderly Drug of choiceDrug interactionAdverse effect: imbalance, mood swing, sedation, sleep pattern; weight changes;Co-existing medical problems: liver, kidney failure;DosageSpeech impairment from AED adverse effect versus uncontrolled seizuresComplianceManagement of precipitating factors: Sleep disorder (OSA etc), conditions affecting sleep quality, stress management, chronic infections, hormonal and electrolyte disturbance
16Summary 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.