Epilepsy in Elderly

Incidence, Nature, Cause, Clinical Characteristic

Use of Anti-epileptic Drugs, Tips to improve AED taking, 

Epilepsy after Stroke, Menopause & Osteoporosis

Preventive Measures

For the elderly, difficulties accepting the diagnosis are frequently caused by its unpredictable nature. It can be a very upsetting experience to be newly-diagnosed with epilepsy as a senior. Those affected commonly lose confidence and independence. And for others who have lived with epilepsy all their lives, new challenges and concerns present themselves in the senior years. 

Seizures in older people can result in physical injury, adding to low morale. High incidence of injury (mostly from seizure-related falls), results in frequent visits to the hospital emergency room; seniors risk wandering away and get hurt in crime or abuse during prolonged periods of confusion following seizures. For some, repeated seizures can even lead to a loss of independent living as a result of repeated seizure. 

Complete control is achievable in around 70% of patients with anti-epileptic drug treatment. Optimum management requires rapid investigation, accurate diagnosis, effective treatment, sympathetic education, and assured support. 

INCIDENCE : Among seniors, epilepsy is the third most common neurological disorder after stroke and dementia. The incidence of epilepsy rises with age, with the highest incidence at the end of life at around 25% of new cases occurring in elderly people (especially older than 85).  Research now show that incidence of epilepsy in people age 75 and over is higher than in the first ten years of life.  The annual incidence reaches 100 per 100,000 people aged over 60 years. 

NATURE : Seizures may be situational and subside quickly, but the prevalence of chronic seizures--epilepsy--is as high as 1% in the elderly.

Causes related to Aging

• Stroke – This is the most frequent cause of epilepsy in seniors. Arteries narrow or clog with age, which results in deprivation of blood and oxygen in some parts of the brain. Sometimes bleeding can occurs in the brain. This can also result in damage that causes seizures.
• Nervous System – The nervous system changes as people grow older, making seniors more susceptible to abnormal electric discharges in the brain (seizures).
• Heart Attacks – Oxygen carried to the brain can be cut off temporarily, resulting in damage which can produce seizures.
• Disease– Alzheimer’s and other brain diseases alter the internal structure of the brain and therefore may be likely to induce seizure activity. Other diseases, such as complications of kidney disease, liver disease, alcoholism and diabetes, increase the likelihood of seizures in seniors.
• Brain Tumours – Any kind of tumour may cause seizures. Sometimes, the removal of a tumour stops seizures.
• Surgery – Scars left from an operation may cause seizures later in life

Most are precipitated by acute symptomatic illnesses such as stroke or systemic disease. Many of the elders with epiepsy have concomitant neurodegenerative (deteriorating function of the nerves), cerebrovascular (disease of the heart), or neoplastic disease (one with abnormal tissue growth). However, the cause of seizures in many patients is unknown. 

Clinical Characteristics

The majority of seizures are of partial onset, especially complex partial. Complex partial seizures at this age may be very subtle and hard to diagnose. Generalised-onset seizures also occur, perhaps as a result of diffuse changes with aging or degenerative disease or to a combination of genetic and environmental factors. The prognosis for complete seizure control in this population is relatively favourable.

In a study out of 190 patients (104 males and 86 females) aged 60 years or older at the time of study, the type of epilepsies classified as generalized was 17.4%, partial was 76.3% and for undetermined was 6.3%. 

Twenty-nine of 33 patients with generalized epilepsy were of no known cause, whereas all patients with partial epilepsy were symptomatic (a cause can be identified). It is also found that symptomatic partial epilepsy (SPE) began at all ages (2 to 81 years). 

Patients with early onset (< 20 years) showed the most unfavorable course in both seizure control and social adaptability.25 of 29 having idiopathic generalized epilepsy (IGE) had early onset, and a family history of epilepsy was found in 31%. Nineteen patients continued to have seizures after 50 years of age, albeit infrequently. Furthermore, 10 of them showed exacerbation around the age of 50.

Patients with late onset (50 years or older) were mostly SPE with a relatively good prognosis and had no family history of epilepsy. However, half of them had a past history of disease of the heart or head injury as a presumed cause.

Use of anti-epileptic drug in Elderly

The elderly differ from the young in that they may have many medical conditions, take numerous drugs in addition to the anti-epileptic drugs (AEDs), have different metabolic characteristics, and are more likely to suffer from neurologic conditions such as stroke. Such physiological and disease-related changes with aging result in complex process of drug handling by the body.

As the body fat content increases and muscle mass decreases with age, the distribution of any drug in the body also changes. As a result, the absorption, distribution, metabolism and excretion of medications are all affected. This is why checking the level of medication in your blood regularly becomes important as you grow older.

The elderly are also more sensitive to adverse effects of prescription drugs and this lead to a need for gentler drug treatment with cautious initiation of drugs at lower dosages. Consideration must be given to the kidney and liver function ( involve in drug removal from the body), the distribution of drug in the body and drug interactions (activity of one drug affecting that of another taken at the same time). The dosage of most drugs is determined basically by careful observation of seizure control and emergence of type of adverse effects. 

Antiepileptic drugs (AEDs) are the primary therapeutic mode in elderly. As available AEDs have roughly equivalent efficacy, the side-effects associated with each drug is a major determinant in its use in therapy. Older AEDs have a well-known collection of undesirable side effects while newer AEDs have potential advantages for the elderly, particularly with respect to tolerability. 

Carbamazepine, valproic acid (sodium valproate), gabapentin and lamotrigine have certain theoretical advantages, but comparative trials of anticonvulsants in the elderly are needed. The ideal drug for older patients would be effective, without neurological toxicity, with low protein binding, a nonparticipant in drug interactions and amenable to once daily administration.

Tips to improve AED taking

• Use divided, labeled pill containers. If you cannot find one that suits your needs, label it yourself.
• Wear a wristwatch with an alarm set to sound when you should take your next dose.
• Try to make a routine: if you need to take a pill when you wake up in the morning, always bring one to the breakfast table with you.
• Post a schedule of what medications you should take and when to take them.
  • Let friends and relatives know medication times and where the medication is stored.
• Schedule more frequent visits to your doctor as a motivator to stick with your drug regimen.
• If these strategies fail, consult your physician. It may be possible to switch to another AED with a simpler dosing regimen.
• Many seniors find it difficult to read small print, as is always found on the label of a pill container. If this keeps you from reading the instructions to take your medication, ask your doctor and pharmacist if it is possible to use large print on the label.
• To avoid confusion, ask for the prescriptions to be fully and clearly labeled. Usually, a pamphlet or information about the drug is given to a patient. Make sure you are given the information you need to know.
• If you have arthritis, ask for a container with a cap that is easy to open.

Seizures following Strokes (Poststroke Epilepsy)

Though there have been many reports on poststroke seizures, there is still much we do not know about them. 

Study confirmed that poststroke seizures are frequent and must be divided into 2 types: early-onset (</=14 days) and late-onset seizures. It demonstrates that a significantly lower rate of patients with early-onset seizures develop another seizure, i.e. epilepsy, than do patients with late-onset seizures. Other factors are involved in recurrence suggesting that poststroke epilepsy probably occurs in a chronically injured brain. The problem of treatment remain unanswered.

Status Epilepticus in Stroke

Status epilepticus is common among patients with seizures occuring after stroke. Although the immediate prognosis of patients with status epilepticus is poor, status epilepticus as the presenting sign did not necessarily predict subsequent epilepsy.

Menopause

What has been reported to happen during menopause (The reasons for these changes are not clear):

• no change in seizures
• a recurrence of previously well-controlled seizures
• a worsening of seizures
• the first-time appearance of seizures
• improvement of seizures.

Most studies show that hormones influence seizures in women. Therefore, menopause has been associated with changes in seizures since hormonal changes occur in menopause.  

Studies show that seizures are less likely to improve noticeably if:

• seizures begin early in your life
• seizures have never been well-controlled
• you have tonic-clonic, or complex partial seizures
• you are early in your menopausal stage. This is due to altered homone estrogen:progesterone ratios at the beginning of menopause. Just before the onset of menopause, there may be an exacerbation of seizures. When you reach menopause itself (at least 1 year of not having periods), the seizures may improve.

Seizures that are most likely to improve are:

• seizures that occur later in life, prior to menopause (therefore in a catamenial pattern);
• seizures that have been well-controlled throughout life.

If you have been prescribed hormone replacement therapy you may want to find out if or how it might affect your seizures. Some antiepileptic drugs may interact with hormone replacement therapy. Some women experience an increase in seizures due to hormone replacement therapy but not the majority. It is important to ask your health practitioner for this information.

Osteoporosis

Antiepileptic drugs are a risk factor for developing osteoporosis. Women who are taking antiepileptic drugs should ask their health care practitioners about this risk and should take preventative measures. These might involve changes in diet, the use of vitamins, and exercise programs. If you are taking antiepileptic drugs, you should be evaluated for osteoporosis as you mature.

Preventive Measures for Seizures in Elderly

1. Maintain a healthy level of blood pressure to reduce the chance of stroke.
2. Eat a diet low in fat, sugar and salt to reduce the chance of heart problems.
3. Use canes and walkers when necessary to avoid accidental falls. (See: Preventing Falls)
4. Avoid drinking excessive alcoholic beverages.
   If you smoke, consider quitting.

Posted on 5th May 2001