 Research shows that the incidence of epilepsy is higher in the elderly .

 Epilepsy was believed to be predominantly a childhood disorder.  Epilepsy is the most common serious neurological disorder in the elderly after stroke and dementia.

US census projections  147 percent increase in the over 65 years old population between 2000-2050  Only 49 percent in population over the same period.

 Elderly people with epilepsy are a large but neglected group.  In a postal survey 25% of general practitioners were unaware that epilepsy commonly manifests for first time in elderly.

 The prevalence and incidence of epilepsy are highest in later life!!

 Approximately 7% of seniors have epilepsy.

 25% of new cases occur in elderly

 5·15 per 1000 people.

 Children   5–9 years: 3·16 10–14 years: 4·05  Elderly      65–69 years : 6·01 70–74 years : 6·53 75–79 years : 7·39 80–84 years : 7·54 85 years and older : 7·73

 80·8 per 100 000 people  children   5–9 years: 63·2 10–14 years : 53·8  Elderly      65–69 years: 85·9 70–74 years: 82·8 75–79 years: 114·5 80–84 years: 159 ⩾ 85 years: 135·4

 PROVOKED SEIZURES  UNPROVOKED SEIZURES.

 Stroke is the leading cause of new-onset epilepsy in elderly   8% of patients will hemorrhagic stroke will develop seizures within two weeks 5% of patients with ischemic stroke will develop seizures with in 2 weeks.

 Post-stroke epilepsy usually develops within 3–12 months  However, can still occur many years later

 10–20% of all epilepsy in older people.

 Less appreciated is the evidence suggesting that dementia may develop with greater frequency elderly with chronic and established epilepsy.

 Post-traumatic epilepsy is common in elderly  Head injury, mostly from falls, causes up to 20% of epilepsy in the elderly.  Increased risk of subdural hemorrhage, especially with anticoagulants or platelet inhibitors.  Factors that increase risk of post-traumatic epilepsy  Loss of consciousness   Post-traumatic amnesia > 24 hrs. Skull fracture, brain contusion and subdural hematoma.

 Seizures may be the presenting feature of tumors at any age.  The most common tumors causing seizures are gliomas, meningiomas and metastases.

 Seizures may be the first presentation of metastatic disease  In one study 43% of those presenting with seizures from metastases had no previous systemic diagnosis of cancer.

 Acute symptomatic seizures.

 Often a reversible cause.

 By definition, these are not epilepsy.

     Common causes acute alcohol withdrawal    metabolic and electrolyte disturbances Hyponatremia Hypocalcemia Hypomagnesemia Infections   systemic CNS.

Drugs - commonly prescribed to elderly.

     Tramadol Antipsychotics Antidepressants (particularly tricyclics) Antibiotics(quinolones and macrolide) Theophylline, levodopa, thiazide diuretics and even the herbal remedy, ginkgo biloba

 The presentation of epilepsy in old age is often less specific.

 It may take time before a firm diagnosis can be reached.

 Under diagnosis and misdiagnosis common.

are

 70% of seizures are of focal onset.

     Focal or complex partial seizures Memory lapses, Episodes of confusion Periods of inattention Apparent syncope.

 Late onset idiopathic generalized epilepsy cases are occasionally seen.

Status epilepticus (SE) is a serious condition of prolonged or repetitive seizures.

 The annual incidence is 86/100,000 > 60 Yrs.

 It is almost twice that of the general population.



Over half of patients with SE do not have a diagnosis of epilepsy and often it is precipitated by an acute illness.

              Cerebrovascular accident (CVA) 21% Remote symptomatic (mainly previous CVA) 21% Low anticonvulsant drug concentrations 21% Hypoxia Metabolic 17% 14% Alcohol 11% Tumor 10% Infection Anoxia 6% Hemorrhage Idiopathic Other 1% 6% 5% CNS infection 5% Trauma 1% 1%

 NCSE SE .

accounts for about 4-20  High mortality of about 50%. % of all cases of  Only one third of the patients with NCSE had a history of epilepsy.

 Veterans Affairs studies found that 65% of the patients with NCSE died within 30 days of an episode compared to 27% of patients with GCSE.

 Impairment of cognition, Behavioral change.

 Psychomotor retardation  Agitation or excitation  Subtle facial or limb twitches  Aphasia, echolalia, confabulation  Head or eye deviation  Automatisms  Autonomic disturbance

SEIZURE

OR

NOT A SEIZURE



Neurological

     Transient ischemic attack Transient global amnesia Migraine Narcolepsy Restless legs syndrome 

Cardiovascular

     Vasovagal syncope Orthostatic hypotension Cardiac arrhythmias Structural heart disease Carotid sinus syndrome



Endocrine/metabolic

   Hypoglycaemia Hyponatraemia Hypokalaemia 

Sleep disorders

 Obstructive sleep apnea   Hypnic jerks Rapid eye movement sleep disorders 

Psychological

 Non-epileptic psychogenic seizures

 Diagnosing epilepsy can be more difficult and more time consuming in elderly.

   Atypical presentation.

Potential mimics Higher prevalence of comorbidities



Only 24% of patients were initially diagnosed with epilepsy when they presented to their health care providers.



It took a mean of 19 months was correctly diagnosed.

from the time the seizures began to the time epilepsy

   History Clinical Exam Investigations:  Blood work  full blood count, renal function testing, serum electrolytes, and random blood glucose.

1  EKG, Holter monitoring and tilt table in some cases.

  Chest X ray

EEG



Neuroimaging studies

 Provoked seizures - treat the underlying cause.

 Unprovoked Seizures - antiepileptic drug treatment.

 Start treatment after a single unprovoked seizure ?

Remains controversial.

 Older people who present with a first unprovoked seizure are more likely to develop seizure recurrence than are younger adults.

 Cause identified in more than 60% of elderly people with epilepsy.

Epilepsy in elderly people generally responds well to treatment. Up to 80% of patients with onset in old age can be expected to remain seizure-free with anti-epileptic drug treatment

 Treatment decisions have to be made Cautiously.

   Elderly are more susceptible to the adverse effects of drugs than their younger counterparts The pharmacokinetics and pharmacodynamics of antiepileptic drugs differ in old age Drug-drug interactions

Pharmacokinetic and pharmacodynamic alteration of aging.

 Decreased Drug absorption     Delayed esophageal emptying Altered gastric pH Delayed gastric emptying Increased intestinal transit time  Drug distribution   Decreased albumin and decreased of protein binding Decreased body fat Metabolism and excretion.

  Decreased hepatic metabolism Decreased renal clearance

 Reasonable to assume that antiepileptic treatment will be life-long.

      Ideal AED choice Most likely achieves seizure freedom with the fewest side effects. Be well tolerated, have a limited side-effect profile.

Easy dosing.

Free of troublesome drug–drug interactions.

‘Start low and go slow'

 Very narrow evidence based data is available for managing newly-diagnosed epilepsy in the elderly  Even less information is available on newer drugs, such as levetiracetam or oxcarbazepine, in elderly populations.

Older AEDs      Benzodiazepines    Acute use Status epilepticus Idiosyncratic reactions, psychosis and sedation Phenobarbital    Broad spectrum Once-daily dosing Significant adverse event profile Requires very slow dose titration Phenytoin  Acute use     Status epilepticus 'Zero-order' kinetics, so care is needed in making dose changes Enzyme inducer Interacts with digoxin and warfarin Carbamazepine  Effective in partial-onset seizures  Enzyme inducer so interacts with other AEDs, some antibiotics and warfarin  Hyponatremia can occur, especially with diuretics Sodium valproate     Effective in generalized-onset seizures Enzyme inhibitor. .

Few interactions Ataxia and tremor may be troublesome in elderly Reversible extrapyramidal symptoms

NEWER AEDS      Lamotrigine (Lamictal)    Effective in partial-onset seizures and generalized seizures. Mood stabilizer Requires slow-dose titration to avoid serious allergic rash.

Very slow titration especially in patients already taking sodium valproate Oxcarbazepine (Trileptal)   Few interactions. Well tolerated Hyponatremia can occur, especially with diuretics Levetiracetam (Keppra)    Inert metabolites Lack of drug interactions Mood and behavioral disturbances occur occasionally Topiramate (Topamax)    Seizures and migraine prophylaxis.

Requires slow dose titration Can cause weight loss and cognitive problems . Zonisamide (Zonegran)  Better side effect profile compared to Topamax.

NEWER AEDS    Gabapentin (Neurontin)  Also used for neuropathic pain. Limited efficacy in epilepsy.

  Can be used in liver dysfunction Can cause dizziness, sedation and weight gain Pregabalin (lyrica)  Also Used for neuropathic pain    Can be used in liver dysfunction Lack of drug interactions Can cause dizziness and weight gain, motor and cognitive slowing Lacosamide (Vimpat)    Partial Epilepsy Increased risk of PR interval elongation on electrocardiogram.

Contraindicated in second- and third-degree AV block

 Comorbidities of in elderly patients add to the diagnostic challenge and also complicate the treatment options  Polypharmacy interactions.

make them susceptible to drug  A survey of elderly nursing home residents found that 49% of residents receiving AEDs were prescribed six or more medications.

 Adherence may not be as good in elderly patients with epilepsy.



Surgery



VNS

    Development of epilepsy is common in later life.

The number of elderly with epilepsy will rise further. placing an increasing burden on healthcare resources Epilepsy can have a profound physical and psychological impact in old age, with a substantial negative effect on quality of life Be aware of Mimics   Most elderly people with epilepsy can remain seizure free with appropriate treaments.

Attention should be paid to side effects and potential for drug-drug interactions