Epilepsy in the Elderly

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Epilepsy in the Elderly

• Mark C. Spitz, M.D.
• Anschutz Center for Advanced Medicine
• Denver Veterans Administration Medical Center

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76-year-old man

• Stroke age 74
• GTC 3 months later
• Phenytoin 300 mg/day started
• Break through seizure -- phenytoin increased to
  300/400 alternating days
• Doesnt feel too bad on the days he take 300 mg

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Epilepsy in the Elderly

• Not rare
• Often misdiagnosed
• Cerebrovascular etiology underrated
• Brain tumors overrated
• Usually easy to control
• Newer meds may be better than traditional drugs

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Incidence of Epilepsy
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Elderly (65 years)

• Incidence of Alzheimer's 123/100,000
• Incidence of Epilepsy 134/100,000

Olmsted County Data
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Etiology Of Epilepsy, Age 65
Hauser et. al.
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Incidence

• Annual Incidence of Stroke
• (Williams, 2001)
• 750,000 in U.S. (1996)
• Seizures after Stroke Cooperative Study
• (Bladin, 2000)
• Prospective, 9-month follow-up, n2021
• Seizures in 8.9
• 2.3 recurrent seizures

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Seizures in Alzheimers

• Autopsy verified, n86
• 10 had seizures

Hauser, 1986
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Demographics

• Different for younger people with epilepsy

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Epilepsy in the Elderly Seizure Type

• Complex Partial 38
• Generalized Tonic-Clonic 27
• Simple Partial 14
• Mixed 20

VA Co-op 2003 n593
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Epilepsy in the ElderlyConcurrent diseases

• Hypertension 64
• Stroke 53
• Cardiac Disease 49
• Diabetes 27
• History of Cancer 22

VA Co-op 2003 n593
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Epilepsy in the ElderlyImaging

• Normal 18
• CVA 44
• Small vessel disease 40
• Diffuse atrophy 35
• Encephalomalacia 9

VA Co-op 2003 n593
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Epilepsy in the ElderlyEEG

• Normal 31
• Epileptiform 39
• Focal Slow 40
• Generalized Slow 16

VA Co-op 2003 n593
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Epilepsy in the Elderly

• Epilepsy in the elderly is often misdiagnosed

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Delay In Diagnosis VA Co-op, 2003, n593

• 9 months to seek medical attention
• 1.7 years to correct diagnosis
• GTC immediate diagnosis in 67
• Less dramatic seizures often ignored
• Concomitant cardiac or cerebrovascular disease
  caused delays in diagnosis

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Diagnosis of EpilepsyElderly compared to
younger people

• Higher percentage of partial seizures
• More extra-temporal onset complex partial
  seizures (missing classic auras)
• More prominent post-ictal symptoms
• Weaker historians
• EEG less helpful
• More concomitant illnesses

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Ochams Razor

• Explain all of the patients complaints by a
  single diagnosis

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Some diagnostic dilemmas

• GTC vs. syncope
• Complex partial seizure vs. TIA
• Transient Global Amnesia

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GTC compared to Syncope

• GTC Syncope
• History of Cardiac Disease Common Common
• Positional Variable Orthostatic
• Warning Variable Pre-syncope
• Tongue biting Common Unlikely
• Color Normal Pale
• After Event Confused, sleepy Alert
• Movements Tonic-clonic Loss of tone, brief
  clonic
• movements
• Duration 1-2 minutes seconds to
• then post-ictal minutes
• Incontinence varies varies

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Complex partial seizures compared to TIA

• CPS TIA
• Hx of CV Disease Common Common
• Anatomic disibration Not Vascular Vascular
• Confusion, unresponsiveness Present Absent (may
  be aphasic)
• Frequency Can be frequent Rarely frequent
• Amnesia Common Absent
• Aura Common Absent
• Automatisms Common Absent

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Transient Global Amnesia

• Etiology is controversial
• Ischemic
• Venous Stasis
• Epileptic (post-ictal)
• Multiple etiologies are likely
• Epileptic cause is underdiagosed

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TGA Diagnostic CriteriaProposed by Caplan,
Hodges, and Warlow

• An attack must be witnessed by an observer who
  can provide additional information
• Anterograde amnesia must be present
• No clouding of consciousness or loss of personal
  identity
• Cognitive impairment is limited to amnesia, no
  apraxia, or aphasia
• No recent history of head trauma, no history of
  seizures in the preceding 2 years
• There are no focal neurologic signs, and no
  epileptic features

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Transient Global Amnesia

• Are many of these cases a one-time expression of
  transient epileptic amnesia?

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Transient Epileptic Amnesia

• Classic literature considers it an uncommon
  relative of Transient Global Amnesia
• Features
• Recurrent Spells
• EEG
• Additional presence of obvious seizure
• Responsive to AED

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Transient Global Amnesia

• Annual incidence of 3.4 to 5.2 per 100,000 each
  year,
• 23.5 per 100,000 50 years old
• Middle-aged or elderly, but otherwise healthy
• Recurrent attacks

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TGA Diagnostic CriteriaProposed by Caplan,
Hodges, and Warlow

• An attack muscle be witnessed by an observer who
  can provide additional information
• Anterograde amnesia must be present
• No clouding of consciousness or loss of personal
  identity
• Cognitive impairment is limited to amnesia, no
  apraxia, or aphasia
• No recent history of head trauma, no history of
  seizures in the preceding 2 years
• There are no focal neurologic signs, and no
  epileptic features

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Transient Global Amnesia

• Annual incidence of 3.4 to 5.2 per 100,000 each
  year,
• 23.5 per 100,000 50 years old
• Middle-aged or elderly, but otherwise healthy
• Recurrent attacks

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Pre-existing Dementia

• Consider post-ictal phenomenon in a demented
  person when unexplained dramatic transient
  worsening in cognitive function is observed
• Dementia is a major risk factor for epilepsy

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Further testing

• When seizures continue despite treatment the
  diagnosis may be wrong
• Consider further testing

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Special Testing

• Prolonged EEG/Video monitoring
• 10/23 NES were physiologic
• (Kellinghaus, 2004)
• 14/27 NES were physiologic
• (E. Bride, 2002)
• Ambulatory EEG
• Loop ECG monitoring for cardiac anythmics
• Tilt table
• 33/128 referrals from a seizure clinic were given
  a new definitive diagnosis
• (Razvi, 2003)

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Epilepsy in the ElderlyUnique Considerations in
choosing a medication

• Milder epilepsy
• More adverse effects
• More susceptible to cognitive side effects
• More susceptible to ataxia and falls
• More prone to hyponatremia
• Drug/Drug interactions

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Epilepsy in the Elderly is milderVA Coop 118
(PHT, CB2, PB, PRM)

• Seizure freedom at 2 years
• 40-65 years old 22
• 65 years old 62

VA Co-op 2003
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Age and adverse effectsVA Coop 118 (PHT, CB2,
PB, PRM) andVA Coop 264 (CB2, VPA) combined

• Withdrawal rate due to adverse effects
• 40-65 years old 49
• 65 years old 64

VA Co-op 2003
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Epilepsy in the ElderlyPharmacologic Problems

• Reduced hepatic clearance
• Reduced renal clearance
• Reduced protein binding
• Increased pharmacodynamic sensitivity
• Taking multiple medications

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Epilepsy in the Elderly Number Of Drugs
Prescribed
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Veterans Administration databaseFiscal Year 1999

• 80 with epilepsy 65 years old prescribed
  phenytoin

Berlowitz, 2003
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Expert Consensus Guideline SeriesTreatment of
Epilepsy

• Medically stable elderly man or woman
• How would you rate these drugs?
• scored 1-9
• Lamotrigine 8.5 0.9
• Levetiracetam 8.0 0.9
• Gabapentin 6.9 2.0
• Carbamazepine 6.8 1.4
• Oxcarbazepine 6.7 1.6
• Topiramate 5.9 1.5
• Valproate 5.9 1.6
• Zonisamide 5.9 1.7
• Pregabalin 5.7 1.9
• Phenytoin 5.4 1.9

Survey done 2004 Karceski et al 2005
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Only 2 double-blind control studies of AEDs in
the elderly

• Brodie, 1999
• VA Coop, 2003

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Lamotrigine vs Carbamazepinein newly diagnosed
elderly

• retention
• at 168 days
• LTG 71
• CBZ 45
• p

Brodie, Epilepsy Research 1999
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New Onset Epilepsy in the ElderlyVA Coop, 2003

• retention at 1 year
• Carbamazepine 36.6
• Gabapentin 49.2
• Lamotrigine 57.9
• CBZ vs LMG 0.0003
• CBZ vs GPN 0.01
• GPN vs LMG 0.10

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Thoughts on Specific Drugs

• First Line
• Lamotrigine
• Gabapentin
• Levetiracetam
• Topiramate
• Zonisamide

• Second Line
• Phenytoin
• Carbamazepine
• Oxcarbazepine
• Valproate
• Phenobarbital

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Epilepsy in the ElderlyConclusions

• Not rare
• Often misdiagnosed
• Cerebrovascular etiology underrated
• Brain tumors overrated
• Usually easy to control
• Newer meds may be better than traditional drugs