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Epilepsy in the Elderly

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76-year-old man. Stroke age 74. GTC 3 months later. Phenytoin 300 mg ... Annual incidence of 3.4 to 5.2 per 100,000 each year, 23.5 per 100,000 50 years old ... – PowerPoint PPT presentation

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Title: Epilepsy in the Elderly


1
Epilepsy in the Elderly
  • Mark C. Spitz, M.D.
  • Anschutz Center for Advanced Medicine
  • Denver Veterans Administration Medical Center

2
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

3
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

4
Incidence of Epilepsy
5
Elderly (65 years)
  • Incidence of Alzheimer's 123/100,000
  • Incidence of Epilepsy 134/100,000

Olmsted County Data
6
Etiology Of Epilepsy, Age 65
Hauser et. al.
7
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

8
Seizures in Alzheimers
  • Autopsy verified, n86
  • 10 had seizures

Hauser, 1986
9
Demographics
  • Different for younger people with epilepsy

10
Epilepsy in the Elderly Seizure Type
  • Complex Partial 38
  • Generalized Tonic-Clonic 27
  • Simple Partial 14
  • Mixed 20

VA Co-op 2003 n593
11
Epilepsy in the ElderlyConcurrent diseases
  • Hypertension 64
  • Stroke 53
  • Cardiac Disease 49
  • Diabetes 27
  • History of Cancer 22

VA Co-op 2003 n593
12
Epilepsy in the ElderlyImaging
  • Normal 18
  • CVA 44
  • Small vessel disease 40
  • Diffuse atrophy 35
  • Encephalomalacia 9

VA Co-op 2003 n593
13
Epilepsy in the ElderlyEEG
  • Normal 31
  • Epileptiform 39
  • Focal Slow 40
  • Generalized Slow 16

VA Co-op 2003 n593
14
Epilepsy in the Elderly
  • Epilepsy in the elderly is often misdiagnosed

15
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

16
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

17
Ochams Razor
  • Explain all of the patients complaints by a
    single diagnosis

18
Some diagnostic dilemmas
  • GTC vs. syncope
  • Complex partial seizure vs. TIA
  • Transient Global Amnesia

19
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

20
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

21
Transient Global Amnesia
  • Etiology is controversial
  • Ischemic
  • Venous Stasis
  • Epileptic (post-ictal)
  • Multiple etiologies are likely
  • Epileptic cause is underdiagosed

22
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

23
Transient Global Amnesia
  • Are many of these cases a one-time expression of
    transient epileptic amnesia?

24
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

25
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

26
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

27
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

28
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

29
Further testing
  • When seizures continue despite treatment the
    diagnosis may be wrong
  • Consider further testing

30
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)

31
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

32
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
33
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
34
Epilepsy in the ElderlyPharmacologic Problems
  • Reduced hepatic clearance
  • Reduced renal clearance
  • Reduced protein binding
  • Increased pharmacodynamic sensitivity
  • Taking multiple medications

35
Epilepsy in the Elderly Number Of Drugs
Prescribed
36
Veterans Administration databaseFiscal Year 1999
  • 80 with epilepsy 65 years old prescribed
    phenytoin

Berlowitz, 2003
37
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
38
Only 2 double-blind control studies of AEDs in
the elderly
  • Brodie, 1999
  • VA Coop, 2003

39
Lamotrigine vs Carbamazepinein newly diagnosed
elderly
  • retention
  • at 168 days
  • LTG 71
  • CBZ 45
  • p

Brodie, Epilepsy Research 1999
40
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

41
Thoughts on Specific Drugs
  • First Line
  • Lamotrigine
  • Gabapentin
  • Levetiracetam
  • Topiramate
  • Zonisamide
  • Second Line
  • Phenytoin
  • Carbamazepine
  • Oxcarbazepine
  • Valproate
  • Phenobarbital

42
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
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