Epilepsy and the Elderly - Mark Spitz

8/6/2019 Epilepsy and the Elderly - Mark Spitz

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Epilepsy in the Elderly

Mark C. Spitz, M.D.

Anschutz Center for Advanced MedicineDenver Veterans Administration Medical Center


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76- year -old manStroke age 74GT

C 3 months laterPhenytoin 300 mg/day startedBreak through seizure -- phenytoinincreased to 300/ 4 00 alternating days

Doesn t feel too bad on the days hetake 300 mg


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Epilepsy in the ElderlyNot rare

Often misdiagnosedCerebrovascular etiology underratedBrain tumors overrated

Usually easy to controlNewer meds may be better thantraditional drugs


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I ncidence of Epilepsy


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Elderly (> 65 years)I ncidence of Alzheimer's 123/100,000Incidence of Epilepsy 13

4 /100,000

Olmsted County Data


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Etiology Of Epilepsy, Age 65 +Idiopathic 51%

Stroke 38 %

Degenerative 12 %

Tumor 5 %

Trama 2 %Infection 2 %

Hauser et. al.


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I ncidence Annual I ncidence of Stroke(Williams, 2001) 75 0,000 in U.S. (199 6 )Seizures after Stroke Cooperative Study(Bladin, 2000) Prospective, 9 -month follow -up, n=2021 Seizures in 8.9% 2.3% recurrent seizures


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Seizures in Alzheimers Autopsy verified, n=8 6

10% had seizures

Hauser, 198 6


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DemographicsDifferent for younger people withepilepsy


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Epilepsy in the Elderly:Seizure Type

Complex Partial 38%Generalized Tonic -Clonic 27 %Simple Partial 1 4 %Mixed 20%

VA Co-op 2003

n=593


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Epilepsy in the Elderly:Concurrent diseases

Hypertension 64 %Stroke 5 3%Cardiac Disease 4 9%Diabetes 2 7 %

History of Cancer 22%

VA Co-op 2003

n=593


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Epilepsy in the Elderly:I maging

Normal 18%CVA 44 %Small vessel disease 4 0%Diffuse atrophy 3 5 %

Encephalomalacia 9%

VA Co-op 2003

n=593


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Epilepsy in the Elderly:EEG

Normal 31%Epileptiform 39%Focal Slow 4 0%Generalized Slow 1 6 %

VA Co-op 2003

n=593


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Epilepsy in the ElderlyEpilepsy in the elderly is oftenmisdiagnosed


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Delay I n Diagnosis VA Co-op, 2003, n= 5 93

9 months to seek medical attention1.7 years to correct diagnosisGT C: immediate diagnosis in 67 % Less dramatic seizures often ignored

Concomitant cardiac or cerebrovasculardisease caused delays in diagnosis


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Diagnosis of Epilepsy:Elderly compared to younger people

Higher percentage of partial seizuresMore extra - temporal onset complexpartial seizures (missing classic auras)More prominent post - ictal symptomsWeaker historiansEEG less helpfulMore concomitant illnesses


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Ocham s RazorExplain all of the patient s complaints bya single diagnosis


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Some diagnostic dilemmasGT C vs. syncopeComplex partial seizure vs. T I ATransient G lobal Amnesia


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GT C compared to SyncopeGT C Syncope

History of Cardiac Disease Common CommonPositional Variable Orthostatic

Warning Variable Pre-syncopeTongue biting Common UnlikelyColor Normal Pale

After Event Confused, sleepy Alert Movements Tonic -clonic Loss of tone,

brief clonic

movementsDuration 1 -2 minutes seconds to

then post - ictal minutesI ncontinence varies varies


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Complex partial seizures compared to T I A

CPS T I AHx of CV Disease Common Common

Anatomic disibration Not Vascular VascularConfusion, unresponsiveness Present Absent (may be aphasic)Frequency Can be frequent Rarely frequent

Amnesia Common Absent Aura Common Absent

Automatisms Common Absent


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Transient G lobal AmnesiaEtiology is controversial I schemic Venous Stasis Epileptic (post - ictal)

Multiple etiologies are likelyEpileptic cause is underdiagosed


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TG A Diagnostic CriteriaProposed by Caplan, Hodges, and Warlow

An attack must be witnessed by an observer who canprovide additional information

Anterograde amnesia must be present No clouding of consciousness or loss of personalidentityCognitive impairment is limited to amnesia, noapraxia, or aphasia

No recent history of head trauma, no history of seizures in the preceding 2 yearsThere are no focal neurologic signs, and no epilepticfeatures


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Transient G lobal Amnesia Are many of these cases a one - timeexpression of transient epilepticamnesia?


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Transient Epileptic AmnesiaClassic literature considers it anuncommon relative of Transient G lobal

AmnesiaFeatures Recurrent Spells

EEG

Additional presence of obvious seizure Responsive to AED


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Transient G lobal Amnesia Annual incidence of 3. 4 to 5 .2 per100,000 each year,23. 5 per 100,000 > 5 0 years oldMiddle-aged or elderly, but otherwisehealthyRecurrent attacks < 2 5 %


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TG A Diagnostic CriteriaProposed by Caplan, Hodges, and Warlow

An attack muscle be witnessed by an observer whocan provide additional information

Anterograde amnesia must be present No clouding of consciousness or loss of personalidentityCognitive impairment is limited to amnesia, noapraxia, or aphasia

No recent history of head trauma, no history of seizures in the preceding 2 yearsThere are no focal neurologic signs, and no epilepticfeatures


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Transient G lobal Amnesia Annual incidence of 3. 4 to 5 .2 per100,000 each year,23. 5 per 100,000 > 5 0 years oldMiddle-aged or elderly, but otherwisehealthyRecurrent attacks < 25%


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Pre -existing DementiaConsider post - ictal phenomenon in ademented person when unexplaineddramatic transient worsening incognitive function is observedDementia is a major risk factor for

epilepsy


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Further testingWhen seizures continue despitetreatment the diagnosis may be wrongConsider further testing


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Special TestingProlonged EE G /Video monitoring 10/23 NES were physiologic

(Kellinghaus, 200 4 ) 14 /2 7 NES were physiologic

(E. Bride, 2002) Ambulatory EE GLoop ECG monitoring for cardiac anythmics

T ilt table 33/128 referrals from a seizure clinic were given a newdefinitive diagnosis(Razvi, 2003)


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Unique Considerations in choosing a medication

Milder epilepsyMore adverse effects More susceptible to cognitive side effects More susceptible to ataxia and falls More prone to hyponatremia Drug/Drug interactions


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Epilepsy in the Elderly is milder

VA Coop 118 (PH T , CB2, PB, PRM)

Seizure freedom at 2 years< 4 0 years old 32%4 0-65 years old 22%> 65 years old 6 2%

VA Co-op 2003


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Age and adverse effects VA Coop 118 (PH T , CB2, PB, PRM) and

VA Coop 2 64 (CB2, VPA) combined

Withdrawal rate due to adverse effects< 4 0 years old 33%4 0-65 years old 4 9%> 65 years old 64 %

VA Co-op 2003


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Pharmacologic Problems

Reduced hepatic clearanceReduced renal clearanceReduced protein bindingI ncreased pharmacodynamic sensitivityT

aking multiple medications


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Number Of Drugs Prescribed

02

4

6

8

10

12

14

1 2 3 4 5 6 7 8 9 10 11 12

# patients


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Veterans Administration database

Fiscal Year 199980% with epilepsy 65 years oldprescribed phenytoin

Berlowitz, 2003


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Expert Consensus Guideline Series:

Treatment of Epilepsy Medically stable elderly man or woman

How would you rate these drugs?scored 1 -9

Lamotrigine 8. 5 0.9Levetiracetam 8.0 0.9Gabapentin 6 .9 2.0Carbamazepine 6 .8 1. 4Oxcarbazepine 6 .7 1. 6Topiramate 5 .9 1. 5

Valproate 5 .9 1. 6Zonisamide 5 .9 1. 7Pregabalin 5 .7 1.9Phenytoin 5 .4 1.9

Survey done 200 4

Karceski et al 200 5


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Only 2 double -blind control studies

of AEDs in the elderlyBrodie, 1999

VA Coop, 2003


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Lamotrigine vs Carbamazepine

in newly diagnosed elderlyretention

at 1 6 8 days

LTG 7 1%CBZ 45 %

p < 0.001

Brodie, Epilepsy Research 1999


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New Onset Epilepsy in the Elderly

VA Coop, 2003retention at 1 year

Carbamazepine 3 6 .6 % *Gabapentin 4 9.2%Lamotrigine 57 .9%

CBZ vs LMG 0.0003CBZ vs GPN 0.01GPN vs LMG 0.10


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Thoughts on Specific DrugsFirst Line

LamotrigineGabapentinLevetiracetamTopiramate

Zonisamide

Second LinePhenytoinCarbamazepineOxcarbazepine

Valproate

Phenobarbital


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ConclusionsNot rareOften misdiagnosedCerebrovascular etiology underratedBrain tumors overratedUsually easy to controlNewer meds may be better thantraditional drugs

Epilepsy and the Elderly - Mark Spitz

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