Epilepsy in Older People

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Epilepsy in Older People

• Can We Meet the Challenge?
• Raymond Tallis FRCP FMedSci

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Special Issues

• Common
• Different
• Under-researched
• Service challenges

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Seizures matter

• Unpleasant experience
• Physical consequences
• Psychosocial consequences
• Underlying cause

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Special Issues

• Common
• Different
• Under-researched
• Service challenges

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

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Special Issues

• Common
• Different
• Under-researched
• Service challenges

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Seizures in the aged Whats different

• Presentation
• Type of seizure
• Differential diagnosis
• Aetiology
• Co-morbidity
• Functional consequences
• Clinical pharmacology

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Seizures and cerebrovascular disease

• Pre-stroke seizures
• Post-stroke seizures

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Pre-stroke seizuresKaplan-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
  0.2940.408)
• Cleary, Tallis, Shorvon Lancet 2004

p lt0.0001 
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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)

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Special Issues

• Common
• Different
• Under-researched
• Service challenges

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Percentage of patients remaining in the trial
over time (52 weeks). Rowan et al. Neurology
2005 641868-1873.
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Antiepileptic drugs

• When to start?
• Which drug?
• What dose?
• Adverse reactions?
• Interactions?
• Monitoring?
• Compliance?
• Withdrawal?

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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!

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Special Issues

• Common
• Different
• Under-researched
• Service challenges

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Minimal entitlement of older people with
epilepsy in 2011

• Accurate diagnosis
• Comprehensive management

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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

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Misdiagnosis of seizures

• Muddling non-seizures with seizure
• Muddling seizures with non-seizure

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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

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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) Todds
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
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Diagnosis Conclusion

• Need comprehensive, thoughtful, expert
  assessment AND reassessment

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Overall aim of Management
To make epilepsy the least important thing in the
patients life
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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

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ORGANISATION OF SERVICES

• Shared care
• Role of GPSIs
• The annual review
• Hospital-based epilepsy service
• Specialist epilepsy nurse

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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

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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

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Epilepsy amongst older people experiences and
perceptions of geriatricians

• Research study conducted for Epilepsy Action
• April May 2005

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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

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Findings (2)

• Only ? 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

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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

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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

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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

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Key Message

• Do not settle for second class care.

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Conclusions

• Epilepsy in older adults is
• More common
• More important
• More to gain
• Much to be done