Other relevant separate articles include: Epilepsy in Adults, Managing Epilepsy in Primary Care, First Seizure and Status Epilepticus Management.
Epilepsy is characterised by the occurrence of at least two unprovoked episodes of periodic disturbance in neurological function, often with altered consciousness, due to abnormal excessive electrical discharge within the brain. Epilepsy in older people poses several additional problems for the provision of services compared with the rest of the population:
- Diagnostic difficulties, especially in differentiating syncope attacks from seizures.
- Susceptibility to anti-epileptic drug (AED) side-effects and toxicity, and increased likelihood of interaction with other medication.
- Social difficulties, eg increased impact of driving restrictions.
- Physical restrictions to lifestyle; seizures that cause falls are more likely to cause injury in older people.
- Multidisciplinary service requirements in the community, including liaison nurse, social worker and occupational therapist.
- After childhood, the incidence of epilepsy increases with age. Epilepsy is the most common serious neurological disorder in the elderly after stroke and dementia.
- Almost a quarter of people with newly diagnosed epilepsy are over 60 years old.
- In one UK study the overall prevalence of epilepsy in people aged over 60 was 11.8 per 1,000 and the overall annual incidence in those over 60 was 117 per 100,000.
- Most new seizures in elderly patients are focal in onset with or without secondary generalisation (focal is now preferred to partial). Idiopathic epilepsy is rarely detected later in life.
- Cerebrovascular disease is the most common cause of seizures in patients over 60 years old who are newly diagnosed with epilepsy.
Aetiology of epilepsy in the elderly
- Underlying factors can be identified in a greater proportion of elderly patients than younger patients, including cerebrovascular disease, dementia and tumours.
- Cerebrovascular disease is the most common underlying factor.
- Dementias of non-vascular origin give rise to seizures that are often easy to control. Alzheimer's disease and epilepsy often co-exist.
- The most common tumours found to produce seizures in later life are gliomas, meningiomas, and metastases. Seizures often have focal features but elderly patients do not always show neurological signs.
- Trauma is common in old age and older people are more likely to develop post-traumatic epilepsy. Subdural haematoma is a potentially treatable cause of epilepsy in elderly people.
- Other possible underlying causes are hypertensive encephalopathy and cerebral vasculitis.
Establishing the diagnosis of epilepsy in old age can be more difficult than in younger patients, due to the extensive range of differential diagnoses and a higher prevalence of concomitant disease. The clinical presentation is different in the elderly. The most common seizures are focal in onset, with or without secondary generalisation. Confusion and memory problems are common presenting symptoms and the postictal phase is often prolonged.
- A reliable history and a witnessed event are generally of more value than investigations.
- There may be a history of trauma with evident bruises, cuts or burns.
- There may be a witness report of pallor, cyanosis, abnormal movements, tongue biting, urinary incontinence, and impaired conscious level, or postictal features, eg confusion, headache, drowsiness, and Todd's paresis.
- Common problems that need to be considered include cardiac arrhythmias, hypoglycaemia, postural hypotension, carotid sinus sensitivity, adverse drug effects and syncope.
- The differential diagnosis of seizures in the elderly includes:
- Neurological: transient ischaemic attack, transient global amnesia, migraine, narcolepsy, restless legs syndrome.
- Cardiovascular: syncope, orthostatic hypotension, cardiac arrhythmias, structural heart disease, carotid sinus syndrome.
- Seizures resulting from anoxic brain injury may occur with respiratory as well as cardiac disease.
- Endocrine/metabolic: renal failure, hypothyroidism, hypoglycaemia, hyperglycaemic non-ketotic states, electrolyte disturbances (eg hyponatraemia, hypokalaemia, hypocalcaemia) and hepatic impairment.
- Sleep disorders: obstructive sleep apnoea, hypnic jerks, rapid eye movement sleep disorders.
- Psychological: non-epileptic psychogenic seizures.
- The peak incidence of first seizures related to alcohol withdrawal occurs in late adult life.
- Drug-induced seizures are most likely to be associated with use of more than one drug, high doses and co-existing illness. Drugs reported to cause seizures include antihistamines, antidepressants, antipsychotics and hypoglycaemic drugs.
- Complex focal seizures presenting as confusion may be misdiagnosed as psychiatric symptoms.
- Transient global amnesia: anterograde amnesia that resolves fully within 24 hours, with no neurological or cognitive sequelae.
- Sleep disorders: patients may only suffer night-time seizures.
- Hypothyroid neuropathy can be confused with focal seizure activity.
- Non-epileptic seizures may present for the first time in later life, but this is unusual.
- Investigations will depend on the presentation but include ECG, ambulatory ECG, carotid and basilar artery ultrasound, orthostatic blood pressure measurement, tilt table testing (see separate Syncope article), and routine biochemical and haematological screening, which can help differentiate between possible underlying causes.
- Initial blood tests should include FBC, ESR, glucose, renal function tests, electrolytes, LFTs, calcium and TFTs.
- EEG: less specific and sensitive than neuro-imaging in the investigation of epilepsy in elderly people. EEG abnormalities in healthy elderly individuals are common. EEG can occasionally help to identify seizure type. The diagnosis of non-convulsive status epilepticus can be confirmed when continuous epileptiform activity is recorded in a confused patient.
- Neuro-imaging to detect intracerebral lesions. MRI is usually the preferred investigation, being more accurate than CT, with the exception of subarachnoid haemorrhage.
See also separate articles Anticonvulsants used for Generalised Seizures and Anticonvulsants used for Partial Seizures.
Do not discriminate against older people, and offer the same services, investigations and therapies as for the general population (therefore, also see separate Epilepsy in Adults article). Pay particular attention to pharmacokinetic and pharmacodynamic issues with polypharmacy and comorbidity in older people with epilepsy. Consider using lower doses of anti-epileptic drugs (AEDs) and, if using carbamazepine, offer controlled-release carbamazepine preparations.
- An elderly person suspected to have had new-onset seizures should ideally be referred to an epilepsy specialist for rapid assessment and initiation of treatment if indicated.
- Education of patients, carers and relatives about cause, cautions and treatment of seizures.
- Treatment for provoked seizures should be directed towards the underlying cause.
- Whether treatment should be started after a single unprovoked seizure remains controversial.
- Calcium and vitamin D supplements should be considered in view of the increased risk of osteoporosis with AED treatment. Some authorities recommend calcium and vitamin D supplements and regular bone density measurements for elderly patients at particular risk of osteoporosis.
- Low-dose drug regimens can help to keep adverse effects and drug interactions to a minimum. Most elderly patients require smaller doses than younger adults. Adverse effects can be kept to a minimum by starting with a low dose and titrating slowly.
- Elderly patients are more at risk of side-effects and idiosyncratic reactions.
- There is an increased risk of pharmacological interactions due to polypharmacy and the elderly are more sensitive to adverse events of AEDs.
- Long-term AED treatment is an independent risk factor for osteoporosis.
- Drugs with a high risk of neurotoxicity should be avoided.
- Few clinical trials of AEDs have been performed specifically in the elderly.
- The postictal phase is frequently extended in elderly patients and can contribute to physical injury sustained during seizure activity. Falls, burns, fractures, lacerations, strains, and severe bruising can greatly reduce quality of life.
- Those affected often lose confidence and independence. Poor mobility and impaired self-confidence can result in admission to residential care.
- Epilepsy is associated with an increased prevalence of mental health disorders including anxiety, depression and suicidal thoughts.
- Mortality rates in older patients with epilepsy are high, particularly for those who present in status epilepticus. Rates of sudden unexpected death are also higher than average for the elderly.
- The prognosis for an individual presenting with suspected epilepsy is very variable and depends on the epilepsy syndrome, the frequency of seizures and the response to treatment.
- Most older patients will remain seizure-free on anti-epileptic drug (AED) monotherapy. Inadequate seizure control should raise the suspicion of poor adherence or progressive neurodegenerative disease.
- Older people who present with a single seizure are more likely than younger individuals to have a further seizure.
Further reading & references
- Transient loss of consciousness in adults and young people, NICE Clinical Guideline (August 2010)
- Epilepsy, Prodigy (June 2009)
- British National Formulary; 62nd Edition (Sep 2011) British Medical Association and Royal Pharmaceutical Society of Great Britain, London
- Epilepsy Action
- Epilepsy Society
- Epilepsy Scotland
- Epilepsy Wales
- The Role of Primary Care in Epilepsy Management, Epilepsy Action, 2005
- Beghi M, Savica R, Beghi E, et al; Utilization and costs of antiepileptic drugs in the elderly: still an unsolved Drugs Aging. 2009;26(2):157-68. doi: 10.2165/0002512-200926020-00007.
- Johnston A, Smith PE; Epilepsy in the elderly. Expert Rev Neurother. 2010 Dec;10(12):1899-1910.
- Collins NS, Shapiro RA, Ramsay RE; Elders with epilepsy. Med Clin North Am. 2006 Sep;90(5):945-66.
- Brodie MJ, Kwan P; Epilepsy in elderly people. BMJ. 2005 Dec 3;331(7528):1317-22.
- Epilepsy, NICE Clinical Guideline (January 2012)
- Jetter GM, Cavazos JE; Epilepsy in the elderly. Semin Neurol. 2008 Jul;28(3):336-41. Epub 2008 Jul 24.
- Elger CE, Schmidt D; Modern management of epilepsy: a practical approach. Epilepsy Behav. 2008 May;12(4):501-39. Epub 2008 Mar 7.
|Original Author: Dr Colin Tidy||Current Version: Dr Colin Tidy||Peer Reviewer: Dr John Cox|
|Last Checked: 14/03/2012||Document ID: 2109 Version: 23||© EMIS|
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