Elderly with Epilepsy

Incidence of epilepsy makes two peaks throughout lifespan, one peak is during first few years of life and second peak is during elderly years. Someone older than age 85 years old has significantly higher risk of having seizures than someone younger. The increased risk may be higher than 3 fold increase. As the population gets older, new onset epilepsy in elderly becomes an important problem.

The Most Common Causes of Epilepsy in Elderly

  • Stroke
  • Brain tumors
  • Neurodegenerative diseases such as Alzheimer’s disease
  • Head trauma

The epilepsy syndrome in elderly is usually localization related epilepsy with the seizure type of partial seizures and secondarily generalized tonic clonic seizures. Generalized epilepsy syndromes are infrequent since they start at younger ages, usually at age of 18 or younger.

Diagnosis of epilepsy in elderly can be challenging. It takes longer time to diagnose epilepsy in elderly due to presence of coexistent medical conditions. Usually they are initially diagnosed as syncope, transient ischemic attacks or considered as change in behavior due to underlying dementia.

Most Common Differential Diagnosis of Epilepsy in Elderly

  • Stroke /Transient ischemic attacks
  • Transient global amnesia
  • Syncope
  • Confusion or change in behavior due to underlying dementia
  • Movement disorder
  • Sleep disorders
  • Toxic or metabolic derangements or medication side effects

Tests to Diagnose Epilepsy in Elderly

  • Rule out underlying medical etiologies
  • Routine electroencephalogram to catch interictal abnormalities to support diagnosis and classification of epilepsy
  • Video electroencephalogram to catch the spells and diagnose and classify epilepsy
  • Magnetoresonance imaging (MRI) of Brain to rule out underlying structural etiologies such as tumor, stroke, scar tissue or brain malformations.  It should be performed with and without gadolinium.
  • PET scan and SPECT to localize the seizure focus if surgical resection is considered as option.

Treatment

The risk of seizure recurrence after an unprovoked seizure is high in elderly since there is usually identifiable lesion as the cause.  Elderly usually responds to antiepileptic drugs well in terms of seizure control.

Selection of the appropriate antiepileptic drug is very important. The physician needs to take many factors into account in deciding the most appropriate antiepileptic drug. The ideal drug would be the one with the least side effect profile, minimal possible interaction with other medications, low cost and high safety and tolerability.

Antiepileptic drug (AEDs) with side effect of ataxia or gait disturbance should not be considered. Similarly AEDs which may cause sedation, lethargy, and tremor should not be used in elderly. Also AEDs with high potential for drug-drug interaction need to be avoided. If possible one drug should be initiated for treatment. Almost all AEDs can be used in treatment of epilepsy in elderly. An important VA trial 428 study compared three antiepileptic drugs, carbamazepine, lamotrigine and gabapentin in elderly with epilepsy. This study showed that these three drugs are similar in efficacy in seizure control. Carbamazepine caused more drop outs due to side effects in this study.

For the information about antiepileptic drugs please see the section under treatment.

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