Temporal changes in the incidence of epilepsy in Finland: nationwide study

Advances in big data and omics: Paving the way for discovery in childhood epilepsies

The insights gained from big data and omics approaches have transformed the field of childhood genetic epilepsy. With an increasing number of individuals receiving genetic testing for seizures, we are provided with an opportunity to identify clinically relevant subgroups and extract meaningful observations from this large-scale clinical data. However, the volume of data from electronic medical records and omics (e.g., genomics, transcriptomics) is so vast that standardized methods, such as the Human Phenotype Ontology, are necessary for reliable and comprehensive characterization. Here, we explore the integration of clinical and omics data, highlighting how these approaches pave the way for discovery in childhood epilepsies.

Association between pediatric traumatic brain injury and epilepsy at later ages in Finland: A nationwide register-based cohort study

OBJECTIVE

This study was undertaken to examine how pediatric traumatic brain injury (pTBI) correlates with incidence of epilepsy at later ages in Finland.

METHODS

This nationwide retrospective register-based cohort study extended from 1998 to 2018. The study group consisted of 71 969 pediatric (<18 years old) patients hospitalized with TBI and a control group consisting of 64 856 pediatric patients with distal extremity fracture. Epilepsy diagnoses were gathered from the Finnish Social Insurance Institution. Kaplan-Meier and multivariable Cox regression models were conducted to analyze the probability of epilepsy with 95% confidence intervals (CIs).

RESULTS

Cumulative incidence rates (CIRs) for the first 2 years were .5% in the pTBI group and .1% in the control group. The corresponding rates after 15 years of follow-up were 1.5% in the pTBI group and .7% in the control group. Due to proportional hazard violations, the study population was split to the first 2 years and in subgroup analysis 4 years. During the first 2 years of surveillance, the hazard ratio (HR) for the pTBI group was 4.38 (95% CI = 3.39-5.66). However, between years 2 and 20, the HR for the pTBI group was 2.02 (95% CI = 1.71-2.38). A total of 337 patients (.47%) underwent neurosurgery, and 36 (10.7%) patients subsequently developed epilepsy. The CIR for the first year after TBI was 4.5% (95% CI = 2.3-6.7) in operatively managed patients and .3% (95% CI = .3-.4) in nonoperatively managed patients. Corresponding figures after 15 years were 12.0% (95% CI = 8.2-15.8) and 1.5% (95% CI = 1.4-1.6). During the first 4 years of surveillance, the HR for the operative pTBI group was 14.37 (95% CI = 9.29-20.80) and 3.67 (95% CI = 1.63-8.22) between years 4 and 20.

SIGNIFICANCE

pTBI exposes patients to a higher risk for posttraumatic epilepsy for many years after initial trauma. Children who undergo operative management for TBI have a high risk for epilepsy, and this risk was highest during the first 4 years after injury.

[Epilepsy in the elderly]

The incidence rate of epilepsy has importantly increased during the last decades due to the rising expectation of life. Special clinical aspects have to be considered for the correct diagnosis and differential diagnosis of epileptic seizures in the elderly: On one hand, the etiology of epilepsy in the elderly is different from epilepsies of younger people with a higher rate of symptomatic epilepsies compared to younger people. On the other hand, seizures are more often clinically inconclusive as they frequently appear without motor symptoms and therefore require an accurate diagnostic differentiation from other attacks of unconsciousness. The most accurate diagnostic tool for the correct diagnosis of such seizures is the registration of the seizures by longtime-video-EEG-monitoring (LTVEM). If LTVEM cannot be performed also home-video-registration could be useful. Medical treatment of epilepsies in the elderly has to be done with special consideration of comorbidity and metabolic changes in this age group.

Epilepsy in elderly patients: does age of onset make a difference?

INTRODUCTION

Epilepsy is most frequent in children and elderly people. Today's population is ageing and epilepsy prevalence is increasing. The type of epilepsy and its management change with age.

METHODS

We performed a retrospective, observational study comparing patients aged ≥ 65 years with epilepsy diagnosed before and after the age of 65, and describing epilepsy characteristics and comorbidities in each group.

RESULTS

The sample included 123 patients, of whom 61 were diagnosed at < 65 years of age (group A), 62 at ≥ 65 of age (group B). Sex distribution was similar in both groups, with 39 men (62.9%) in group A and 37 (60.7%) in group B. Mean age was 69.97 ± 5.6 years in group A and 77.29 ± 6.73 in group B. The most common aetiology was cryptogenic in group A (44.3%, n = 27) and vascular in group B (74.2%, n = 46). History of stroke was present in 12 patients from group A (19.7%) and 32 (51.6%) in group B. Antiepileptic drugs were prescribed at lower doses in group A. Statistically significant differences were found between groups for history of ischaemic stroke, cognitive impairment, psychiatric disorders, and diabetes mellitus; degree of dependence; and number of antiepileptic drugs.

CONCLUSION

Age of onset ≥ 65 years is closely related to cardiovascular risk factors; these patients require fewer antiepileptic drugs and respond to lower doses. Some cases initially present as status epilepticus.

Epilepsy in elderly patients: does age of onset make a difference?

INTRODUCTION

Epilepsy is most frequent in children and elderly people. Today's population is ageing and epilepsy prevalence is increasing. The type of epilepsy and its management change with age.

METHODS

We performed a retrospective, observational study comparing patients aged ≥ 65 years with epilepsy diagnosed before and after the age of 65, and describing epilepsy characteristics and comorbidities in each group.

RESULTS

The sample included 123 patients, of whom 61 were diagnosed at <65 years of age (group A), 62 at ≥ 65 of age (group B). Sex distribution was similar in both groups, with 39 men (62.9%) in group A and 37 (60.7%) in group B. Mean age was 69.97±5.6 years in group A and 77.29±6.73 in group B. The most common aetiology was unknown in group A (44.3%, n=27) and vascular in group B (74.2%, n=46). History of stroke was present in 12 patients from group A (19.7%) and 32 (51.6%) in group B. Antiepileptic drugs were prescribed at lower doses in group A. Statistically significant differences were found between groups for history of ischaemic stroke, cognitive impairment, psychiatric disorders, and diabetes mellitus; degree of dependence; and number of antiepileptic drugs.

CONCLUSION

Age of onset ≥ 65 years is closely related to cardiovascular risk factors; these patients require fewer antiepileptic drugs and respond to lower doses. Some cases initially present as status epilepticus.

Secular Trends in the Incidence, Prevalence, and Medications for Epilepsy from 2007 to 2015 in Taiwan: A Nationwide Population-Based Study

BACKGROUND

Patients with epilepsy have a higher mortality rate than the general population. Up-to-date estimates of epilepsy incidence, prevalence, and medication use are critical to assist policymaking.

METHODS

Using the National Taiwan Insurance Research Database, the standardized incidence and prevalence of epilepsy were estimated in each calendar year from 2007 to 2015. We used the incident cases of epilepsy to analyze the change in prescribing patterns from 2007 to 2015. Joinpoint regression was used to estimate secular trends.

RESULTS

From 2007 to 2015, the age- and sex-standardized incidence decreased from 0.72 (95% confidence interval [CI] 0.70-0.73) to 0.54 (95% CI 0.53-0.55) per 1,000 person-years, giving an annual percentage change (APC) of -2.73 (p < 0.05). Among patients younger than 20 years, the incidence did not change significantly. The age- and sex-standardized prevalence decreased from 6.94 (95% CI 6.90-6.98) to 6.86 (95% CI, 6.82-6.89) per 1,000 people, giving an APC of -0.31 (p < 0.05). However, the prevalence increased in the 35- to 49- and 50- to 64-year age-groups. The most common first-line anticonvulsant was phenytoin in 2007 and valproate in 2015. The use of levetiracetam, clobazam, and valproate increased during the study period, with APCs of 25.48% (95% CI 19.97-31.24), 6.41 (3.09-9.85), and 2.83 (1.51-4.16), respectively. The use of carbamazepine, phenytoin, and topiramate decreased; the APCs were -23.86% (95% CI -25.25 to -22.44), -6.61 (-8.40 to -4.79), and -4.29% (-7.87 to -0.57), respectively.

CONCLUSIONS

The overall prevalence and incidence of epilepsy decreased slightly from 2007 to 2015. The prescribed first-line anticonvulsant also changed over time.

Adult onset epilepsy incidence in Finland over 34 years: A nationwide registry study

Background and purpose

The incidence of epilepsy is decreasing among the working‐aged in high‐income countries, but previous studies have reported conflicting results in Finland.

Methods

A nationwide population‐based cross‐sectional analysis was made of annual epilepsy drug reimbursement rights frequency data from the Social Insurance Institution of Finland, the national authority, between 1986 and 2019. All persons at least 20 years of age living in Finland during the study period were included.

Results

Based on the analysis of 77,939 new reimbursement rights, crude incidence was 57.4/100,000 (95% confidence interval [CI] = 57.0–57.8) person‐years, and age‐standardized (to the European Standard Population 2013) incidence was 51.6/100,000 person‐years. Both crude (r = 0.62, p = 0.00009) and standardized (r = 0.65, p = 0.00003) incidence increased over time. Incidence increased in both men (from 66.4 to 71.6/100,000, r = 0.51, p = 0.002) and women (from 51.5 to 55.3/100,000, r = 0.68, p < 0.00001). The mean male to female incidence rate ratio was 1.28 (95% CI = 1.26–1.30, range = 1.15–1.41), but decreased during the study period (r = −0.47, p = 0.006). Incidence decreased in those 20–59 years old but increased in all older age groups. This development was similar between sexes.

Conclusions

The incidence of adult onset epilepsy in Finland increased in people older than 60 years and decreased in the 20–59‐year age group during the study period. These trends were similar between sexes. Therefore, etiological epilepsy trends in the elderly need to be studied further to plan public health measures to prevent epilepsy in this age group.

Genetic Diagnosis in Children with Epilepsy and Developmental Disorders by Targeted Gene Panel Analysis in a Developing Country

Background and Purpose

In childhood epilepsy, genetic etiology is increasingly recognized in recent years with the advent of next generation sequencing. This has broadened the scope of precision medicine in intractable epilepsy, particularly epileptic encephalopathy (EE). Developmental disorder (DD) is an integral part of childhood uncontrolled epilepsy. This study was performed to investigate the genetic etiology of childhood epilepsy and DD.

Methods

In this study, 40 children with epilepsy and DD with positive genetic mutation were included retrospectively. It was done in a tertiary care referral hospital of Bangladesh from January 2019 to December 2020. Genetic study was done by next generation sequencing. In all cases electroencephalography, neuroimaging was done and reviewed.

Results

In total, 40 children were enrolled and the average age was 41.4±35.850 months with a male predominance (67.5%). Generalized seizure was the predominant type of seizure. Regarding the association, intellectual disability and attention deficit hyperactivity disorder was common. Seventeen cases had genetically identified early infantile EE and common mutations observed were SCN1A (3), SCN8A (2), SLC1A2 (2), KCNT1 (2), and etc. Five patients of progressive myoclonic epilepsy were diagnosed and the mutations identified were in KCTD7, MFSD8, and CLN6 genes. Three cases had mitochondrial gene mutation (MT-ND5, MT-CYB). Some rare syndromes like Gibbs syndrome, Kohlschütter-Tönz syndrome, Cockayne syndrome, Pitt-Hopkins syndrome and cerebral creatine deficiency were diagnosed.

Conclusions

This is the first study from Bangladesh on genetics of epilepsy and DD. This will help to improve the understanding of genetics epilepsy of this region as well as contribute in administering precision medicine in these patients.

Incidence and prevalence of epilepsy in the Republic of North Macedonia: Data from nationwide integrated health care platform

PURPOSE

This study aimed to evaluate the incidence and period prevalence of epilepsy in the Republic of North Macedonia, an upper-middle-income country with universal access to healthcare, based on a nationwide healthcare platform (NHP).

METHODS

NHP contains reports from all inpatient and outpatient medical encounters and procedures, and all electronic medical records are linked together with a unique patient number. We performed the analysis of the data maintained at the Macedonian Ministry of Health, concerning the five years of the study (2014 through 2018). Population and demographic data for each year were obtained from the State Statistical Office.

RESULTS

The period prevalence was 6.67 per 1,000 inhabitants. There were 6383 (46.2%) females and 7435 (53.8%) males; the gender difference was significant: 6.17 per 1,000 females and 7.16 per 1,000 males (p = 0.0000). Between 2015 and 2018 the median annual incidence of epilepsy was 68 new epilepsy patients per 100,000, with an upward trend over time. The age-specific incidence was high in childhood and adolescence, was constant (and low) in the adult years, and gradually increased in each successive age group after the age of 50 years. The greatest incidence was found in group 70-79 years of age. The incidence in childhood and adolescence tends to gradually decrease from 2015 to 2018, while it progressively increased in population over 50 years of age, which may explain a rise in overall incidence. We found a statistically significant higher incidence in males than in females, a ratio consistently being 1.2: 1.

CONCLUSION

The data from the study provides accurate findings on the prevalence and incidence of epilepsy in the upper-middle-income Southeastern European country.

Seizure-like events leading to hospital referrals in infants: A retrospective population-based study

AIM

To identify the aetiology and outcome of seizure-like events leading to hospital referrals in infants and to identify early predictors of epilepsy and delayed neurodevelopment.

METHODS

This Norwegian population-based study focused on all children born in Sør-Trøndelag county, who were up to one year of age in 2014-2015. They were identified by diagnostic codes for seizure-like events and electroencephalography (EEG) examinations. Hospital records were examined up to 1.5 years of age.

RESULTS

The one-year prevalence of seizure-like events was 1.5% (114/7430). Epilepsy was diagnosed in 17%, 57% had non-epileptic paroxysmal events (NEPE), 16% had febrile seizures, and 10% had other acute symptomatic epileptic seizures. Neurodevelopmental delay occurred in 21%. The cumulative incidence was 0.22% for epilepsy and 0.79% for NEPE. Abnormal brain magnetic resonance imaging, abnormal first EEGs and neonatal care increased the likelihood of epilepsy and delayed development. Identifying situation-related factors decreased the epilepsy risk. Occurrence at a younger age increased the risk of delayed development. Absence of unambiguous motor symptoms was less common in epilepsy than in NEPE.

CONCLUSION

Seizure-like events were common in infants and most were not caused by epilepsy. Specific anamnestic clues, and detailed descriptions of the entire event, helped to predict adverse outcomes.

Risk conditions in children hospitalized with influenza in Norway, 2017-2019

BACKGROUND

Norwegian children are more frequently hospitalized with influenza than adults. Little is known about the characteristics of these children. Our aim was to investigate the presence of pre-existing risk conditions and to determine the duration of influenza hospitalizations in children during two influenza seasons.

METHODS

The Norwegian Patient Registry holds data on all hospitalized patients in Norway. We included all patients younger than 18 years hospitalized with a diagnosis of influenza during the influenza seasons 2017-18 and 2018-19. Pre-existing risk conditions for influenza were identified by ICD-10 diagnoses in the Norwegian Patient Registry. In addition, information on asthma diagnoses were also retrieved from the Norwegian Registry for Primary Health Care. To estimate the prevalence of risk conditions in the child population, we obtained diagnoses on all Norwegian children in a two-year period prior to each influenza season. We calculated age-specific rates for hospitalization and risk for being hospitalized with influenza in children with risk conditions.

RESULTS

In total, 1013 children were hospitalized with influenza during the two influenza seasons. Children younger than 6 months had the highest rate of hospitalization, accounting for 13.5% of all admissions (137 children). Hospitalization rates decreased with increasing age. Among children hospitalized with influenza, 25% had one or more pre-existing risk conditions for severe influenza, compared to 5% in the general population under 18 years. Having one or more risk conditions significantly increased the risk of hospitalization, (Odds Ratio (OR) 6.1, 95% confidence interval (CI) 5.0-7.4 in the 2017-18 season, and OR 6.8, 95% CI 5.4-8.4 in the 2018-19 season). Immunocompromised children and children with epilepsy had the highest risk of hospitalization with influenza, followed by children with heart disease and lung disease. The average length of stay in hospital were 4.6 days, and this did not differ with age.

CONCLUSION

Children with pre-existing risk conditions for influenza had a higher risk of hospitalization for influenza. However, most children (75%) admitted to hospital with influenza in Norway during 2017-2019 did not have pre-existing risk conditions. Influenza vaccination should be promoted in particular for children with risk conditions and pregnant women to protect new-borns.

Psychosis rarely occurs in patients with late-onset focal epilepsy

AIMS

We examined psychosis occurrence in patients with late-onset focal epilepsy.

SUBJECTS AND METHODS

Case records of consecutive patients with focal epilepsy without central nervous system (CNS) disease (n = 873) were retrospectively examined, with gender, age at epilepsy onset, duration of epilepsy, epilepsy type (temporal or extratemporal), and age at the initial examination used as clinical and demographic variables. Patients with onset ≤49 years old (control) were compared with those with late-onset.

RESULTS

In the control group (n = 775), 38 had a history of psychosis, while none in the late-onset group (n = 98) reported that (p = 0.016). Psychosis was only interictal in 32 and predominantly postictal in 6, while 2 patients showed both interictal and postictal psychosis. Duration of illness (p = 0.000001) and temporal lobe epilepsy (p = 0.000343) were significant determinants associated with psychosis. Gender (p = 0.210) and age at examination (p = 0.084) were found to be not contributory to psychosis.

DISCUSSION

The prevalence for a history of psychosis in the present cohort (2.5%) agrees well with that noted in previous studies, and duration of illness proved to be the most powerful determining factor leading to that. A keen awareness of unrecognized underlying CNS or metabolic disease is important when psychosis appears in patients with nonlesional late-onset epilepsy, which should lead to an in-depth investigation of possible underlying and still uncovered CNS disease.

Economic Value of Adjunctive Brivaracetam Treatment Strategy for Focal Onset Seizures in Finland

Introduction

There is an unmet need for well-tolerated antiepileptic drugs (AEDs) that effectively control focal onset seizures. This study aimed to evaluate the economic value of new AEDs in the treatment of focal onset seizure, with or without secondary generalization, in Finnish adults and adolescents with epilepsy, comparing brivaracetam with perampanel as adjunctive AEDs.

Methods

Economic value was assessed using cost-utility analysis. Periods of AED initiation, titration, response assessment (seizure freedom, ≥ 50% reduction, no response), switching in no response or treatment-emergent adverse events (TEAEs), and death were simulated using a discrete-event simulation model. Responses and switching were simulated based on a comprehensive Bayesian network meta-analysis. The primary modeled outcome was the 3%/year discounted incremental cost-effectiveness ratio (ICER). Discounted quality-adjusted life-years (QALYs), payer costs (year 2017 Euro) per patient, and net monetary benefit (NMB) were secondary outcomes. Probabilistic and comprehensive deterministic sensitivity analyses were conducted.

Results

Brivaracetam was more efficacious and had fewer TEAEs than perampanel and other AEDs. Modeled average 5-year QALYs and costs were 3.671 and €28,297 for brivaracetam and 3.611 and €27,979 for perampanel, respectively. The resulting ICER for brivaracetam versus perampanel was only €5345/QALY gained in a deterministic base case scenario. Brivaracetam had a positive NMB and high probability of cost-effectiveness of €1190 and 71% or €1944 and 80% with the assumed willingness to pay of €25,358 or €38,036/QALY gained, respectively. The primary result was robust, with a positive NMB persistent in all sensitivity analysis scenarios. When switching from brivaracetam to perampanel was excluded from the modeling or switching from perampanel to brivaracetam was included, brivaracetam was cost-saving and more effective than perampanel (dominant).

Conclusion

These simulated comparisons demonstrated that brivaracetam was more effective and potentially also more affordable than perampanel. Thus, brivaracetam is likely a cost-effective and net beneficial alternative to perampanel for treatment of focal onset seizures.

Plain Language Summary

Plain language summary available for this article.

Electronic supplementary material

The online version of this article (10.1007/s12325-019-01155-6) contains supplementary material, which is available to authorized users.

Overrepresentation of epilepsy in children with type 1 diabetes is declining in a longitudinal population study in Finland

AIM

The aim was to determine temporal changes in increased risk of epilepsy among children with type 1 diabetes.

METHODS

The incidence of epilepsy up to age 15 in children with prior type 1 diabetes was analysed regarding the general Finnish child population using data from the Finnish nationwide hospital register. Type 1 diabetes and epilepsy were identified by the International Classification of Diseases 9th and 10th revision codes. Epilepsy was defined according to ILAE guidelines. The analyses were done using negative binomial regression models.

RESULTS

Preceding type 1 diabetes was diagnosed in 6162 (0.91%) of the 679 375 general children population. Incidence rate of new-onset epilepsy among children with type 1 diabetes was higher than in controls (140 vs 82 per 100 000 person-years at risk, respectively). The excess incidence diminished with time (P = 0.033 for diabetes to birth cohort interaction), from over twofold in birth cohort 1990-1993 [incidence rate ratio 2.2 (95% CI 1.7-2.9)] to 40% in birth cohort 1998-2000 [1.4 (95% CI 1.001-1.9)].

CONCLUSION

In a population study setting, children with type 1 diabetes had an increased, but slowly declining risk of developing epilepsy. Future research may elucidate the underlying mechanisms.

New anti-seizure medication for elderly epileptic patients

Introduction: Epilepsy treatment in older people requires specific consideration owing to more physical co-morbidities, the risk of drug-to-drug interactions through polypharmacy, and differences in pharmacodynamics and pharmacokinetics. There are many 'newer' antiepileptic drugs (AEDs) widely used for various seizure types and seizure disorders. However, there is limited specific evidence for the efficacy, safety, and tolerability of these treatments in the elderly population. Areas covered: This review summarises the current most robust evidence available for the use of the newer AEDs belonging to generation two and three in elderly people with epilepsy. The article provides practical evidenced based clinical information to help prescribers choose the most appropriate AED from the drugs discussed. Expert opinion: Diagnosing new onset epilepsy in the elderly population requires specialist assessment. Treatment plans need to be tailored to accommodate an individual's co-morbidities, concurrent medications, and general health status. To date, few clinical investigations consider the elderly population specifically despite the increased risk factors. There is a need for large quality trial data to assess the impact of the newest AEDs on seizure control and quality of life in this population with complex needs.

An estimation of global volume of surgically treatable epilepsy based on a systematic review and meta-analysis of epilepsy

OBJECTIVE

Epilepsy is one of the most common neurological disorders, yet its global surgical burden has yet to be characterized. The authors sought to compile the most current epidemiological data to quantify global prevalence and incidence, and estimate global surgically treatable epilepsy. Understanding regional and global epilepsy trends and potential surgical volume is crucial for future policy efforts and resource allocation.

METHODS

The authors performed a systematic literature review and meta-analysis to determine the global incidence, lifetime prevalence, and active prevalence of epilepsy; to estimate surgically treatable epilepsy volume; and to evaluate regional trends by WHO regions and World Bank income levels. Data were extracted from all population-based studies with prespecified methodological quality across all countries and demographics, performed between 1990 and 2016 and indexed on PubMed, EMBASE, and Cochrane. The current and annual new case volumes for surgically treatable epilepsy were derived from global epilepsy prevalence and incidence.

RESULTS

This systematic review yielded 167 articles, across all WHO regions and income levels. Meta-analysis showed a raw global prevalence of lifetime epilepsy of 1099 per 100,000 people, whereas active epilepsy prevalence is slightly lower at 690 per 100,000 people. Global incidence was found to be 62 cases per 100,000 person-years. The meta-analysis predicted 4.6 million new cases of epilepsy annually worldwide, a prevalence of 51.7 million active epilepsy cases, and 82.3 million people with any lifetime epilepsy diagnosis. Differences across WHO regions and country incomes were significant. The authors estimate that currently 10.1 million patients with epilepsy may be surgical treatment candidates, and 1.4 million new surgically treatable epilepsy cases arise annually. The highest prevalences are found in Africa and Latin America, although the highest incidences are reported in the Middle East and Latin America. These regions are primarily low- and middle-income countries; as expected, the highest disease burden falls disproportionately on regions with the fewest healthcare resources.

CONCLUSIONS

Understanding of the global epilepsy burden has evolved as more regions have been studied. This up-to-date worldwide analysis provides the first estimate of surgical epilepsy volume and an updated comprehensive overview of current epidemiological trends. The disproportionate burden of epilepsy on low- and middle-income countries will require targeted diagnostic and treatment efforts to reduce the global disparities in care and cost. Quantifying global epilepsy provides the first step toward restructuring the allocation of healthcare resources as part of global healthcare system strengthening.

Valproic acid utilization among girls and women in Stockholm: Impact of regulatory restrictions

Objective

In November 2014, the European Medicines Agency (EMA) strengthened restrictions on the use of valproic acid in girls and women of childbearing potential. The objective of this study was to determine whether there has been a change in initiations of valproic acid treatment to females after the regulatory restrictions and to assess if such changes differed between indications (epilepsy and psychiatric disorder).

Methods

An interrupted time-series analysis was conducted using all initiations of valproic acid in Stockholm, Sweden. from January 2011 to June 2017. Female and male patients aged 0-45 years with a recorded diagnosis of epilepsy and/or a psychiatric disorder were compared.

Results

Before the EMA warning, a decline in trend of valproic acid initiations was seen in patients with epilepsy. After the warning, a significant decrease of valproic acid initiations was seen in women with a psychiatric disorder, but not in women with epilepsy.

Significance

The regulatory warning appeared to have significantly influenced valproic acid initiations in women of childbearing age with a psychiatric disorder. No effect was seen in women with epilepsy, probably because the decline had started long before.

Epilepsy in an elderly population: Classification, etiology and drug resistance

PURPOSE

To characterize epilepsy in an elderly population and describe the prevalence of drug resistant epilepsy (DRE) using recently validated International League Against Epilepsy (ILAE) criteria.

METHODS

Using a case-control design, 72 patients aged 60 years and older (cases) and 223 patients under age 60 (controls) were identified from the Saskatchewan Epilepsy Program database. Patients' charts were retrospectively reviewed. Bivariate and multiple logistic regression analyses were performed to identify variables that were associated with epilepsy in elderly patients.

RESULTS

Forty-seven elderly patients (65%) had focal epilepsy, while 9 (13%) had generalized epilepsy. The most common etiology in elderly patients with epilepsy was unknown in 30 (48%) patients. Other identified etiologies included brain tumors in 14 (19.4%), genetic in 6 (8%), degenerative disease in 4 (5%), stroke in 6 (8%) and head injury in 3 (4%). Significantly fewer elderly patients met criteria for DRE compared to non-elderly patients (26% vs. 51%, p = 0.001). In the multiple logistic regression analysis, elderly patients with epilepsy were more likely to have the presence of stroke, psychiatric comorbidity and to be on monotherapy.

CONCLUSION

In our sample, elderly patients with epilepsy were more likely to have seizures resulting from brain tumors and stroke, and less likely to have DRE than non-elderly patients. These unique features of elderly patients strongly suggest that clinical practice guidelines are needed to facilitate the highest quality of care in elderly patients with epilepsy.

Incidence and Prevalence of Childhood Epilepsy: A Nationwide Cohort Study

BACKGROUND AND OBJECTIVES

Epilepsy affects 0.5% to 1% of children and is the most frequent chronic neurologic condition in childhood. Incidence rates appear to be declining in high-income countries. The validity of epilepsy diagnoses from different data sources varies, and contemporary population-based incidence studies are needed.

METHODS

The study was based on the Norwegian Mother and Child Cohort Study. Potential epilepsy cases were identified through registry linkages and parental questionnaires. Cases were validated through medical record reviews and telephone interviews of parents.

RESULTS

The study population included 112 744 children aged 3 to 13 years (mean 7.4 years) at end of registry follow-up (December 31, 2012). Of these, 896 had registry recordings and/or questionnaire reports of epilepsy. After validation, 587 (66%) met the criteria for an epilepsy diagnosis. The incidence rate of epilepsy was 144 per 100 000 person-years in the first year of life and 58 per 100 000 for ages 1 to 10 years. The cumulative incidence of epilepsy was 0.66% at age 10 years, with 0.62% having active epilepsy. The 309 children (34%) with erroneous reports of epilepsy from the registry and/or the questionnaires had mostly been evaluated for nonepileptic paroxysmal events, or they had undergone electroencephalography examinations because of other developmental or neurocognitive difficulties.

CONCLUSIONS

Approximately 1 out of 150 children is diagnosed with epilepsy during the first 10 years of life, with the highest incidence rate observed during infancy. Validation of epilepsy diagnoses in administrative data and cohort studies is crucial because reported diagnoses may not meet diagnostic criteria for epilepsy.

Etiology, syndrome diagnosis, and cognition in childhood-onset epilepsy: A population-based study

Objective

To evaluate the prevalence of various etiologies of epilepsies and epilepsy syndromes and to estimate cognitive function in cases of childhood‐onset epilepsy.

Methods

A population‐based retrospective registry study. We identified all medically treated children with epilepsy born in 1989–2007 in Finland's Kuopio University Hospital catchment area, combining data from the birth registry and the national registry of special‐reimbursement medicines. We reevaluated the epilepsy diagnoses and syndromes and gathered data on etiologies and cognitive impairment.

Results

We identified 289 children with epilepsy. The annual incidence rate of epilepsies and epilepsy syndromes was 38 in 100,000, and the misdiagnosis rate was 3%. A specific etiology was identified in 65% of the cases, with a structural etiology accounting for 29% and a genetic or presumed genetic etiology for 32%. Most patients with unknown‐etiology epilepsy had focal epilepsy and were of normal intelligence. Intellectual disability was detected in 35% of cases, and only 17% in this group had an unknown etiology for the epilepsy. Electroclinical syndromes (mainly West syndrome) were recognized in 35% of the patients.

Significance

Epilepsy is a complex disease that encompasses many etiologies and rare syndromes. The etiology and specific epilepsy syndrome are important determinants of the outcome and key factors in treatment selection. Etiological diagnosis can be achieved for the majority of children and syndromic diagnosis for only a third.

Comparative effectiveness of levetiracetam, valproate and carbamazepine among elderly patients with newly diagnosed epilepsy: subgroup analysis of the randomized, unblinded KOMET study

Background

Few clinical trials have evaluated the efficacy and tolerability of antiepileptic drugs (AEDs) as initial monotherapy for elderly patients.

Methods

This post-hoc subgroup analysis of data from an unblinded, randomized, 52-week superiority study (KOMET) compared the effectiveness of levetiracetam (LEV) with extended-release sodium valproate (VPA-ER) and controlled-release carbamazepine (CBZ-CR) as monotherapy in patients aged ≥ 60 years with newly diagnosed epilepsy. The physician chose VPA or CBZ as preferred standard treatment; patients were randomized to standard AEDs or LEV. The primary endpoint was time to treatment withdrawal. Results are exploratory, since KOMET was not powered for a subgroup analysis by age.

Results

Patients (n = 308) were randomized to LEV (n = 48) or VPA-ER (n = 53) in the VPE-ER stratum or to LEV (n = 104) or CBZ-CR (n = 103) in the CBZ-CR stratum. Mean age was 69.6 years, range 60.2–89.9 years (intention-to-treat population n = 307). Time to treatment withdrawal hazard ratio [HR] (95 % confidence interval [CI]) for LEV vs. standard AEDs was 0.44 (0.28–0.67); LEV vs. VPA-ER: 0.46 (0.16–1.33); LEV vs. CBZ-CR: 0.45 (0.28–0.72). Twelve-month withdrawal rates were: LEV vs. standard AEDs, 20.4 vs. 38.7 %; LEV vs. VPA-ER, 10.4 vs. 23.1 %; LEV vs. CBZ-CR, 25.0 vs. 46.6 %. Time to first seizure was similar between LEV and standard AEDs (HR: 0.92, 95 % CI: 0.63–1.35), LEV and VPA-ER (0.77, 0.38–1.56), and LEV and CBZ-CR (1.02, 0.64–1.63). Adverse events were reported by 76.2, 67.3, and 82.5 % of patients for LEV, VPA-ER, and CBZ-CR, respectively. Discontinuation rates due to AEs were 11.3, 10.2, and 35.0 % for LEV, VPA-ER, and CBZ-CR, respectively.

Conclusions

Time to treatment withdrawal was longer with LEV compared with standard AEDs. This finding was driven primarly by the result in the CBZ-CR stratum, which in turn was likely due to the more favorable tolerability profile of LEV. Results of this post-hoc analysis suggest that LEV may be a suitable option for initial monotherapy for patients aged ≥ 60 years with newly diagnosed epilepsy.

Trial registration

ClinicalTrials.gov: NCT00175903; September 9, 2005.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0663-7) contains supplementary material, which is available to authorized users.

Patient perceptions of the referral of older adults to an epilepsy clinic: do patients and professionals agree who should be referred to a specialist?

The aim of this study was to establish whether older patients concurred with previously reported staff perceptions of why older adults may be underrepresented in epilepsy clinics. Fifteen interviews with older patients provided support for four of seven key factors previously suggested by professionals as leading to underreferral of older adults: unclear referral pathway, complex differential diagnosis, gaps in referrer knowledge, and the length of time since onset. However, the patients interviewed did not report that patient difficulties accessing the hospital, patient reluctance to attend clinics, or the particular characteristics of older patients (knowledge, awareness, and willingness to ask for help) made it less likely that older adults would want to attend a specialist epilepsy clinic. While recognizing the limitations of the study, particularly in relation to the number of participants, we believe that it provides valuable further insights into the age-bias apparent in referral patterns to specialist epilepsy services. Of particular concern are professional assumptions regarding older patients' willingness to attend appointments and about the impact of seizures on the life of an older adult.

Epilepsy in the elderly: comparing clinical characteristics with younger patients

The prevalence and incidence of epilepsies in elderly is high. Due to demographic development, the portion of elderly patients with epilepsy will continue to rise over the next decades. In this study, we aimed to investigate seizure semiology, etiology, comorbidity, and therapy in elderly patients dependent on onset of epilepsy and in comparison with younger patients. In a prospective multicentre study, 202 epilepsy patients were included in a consecutive manner and subdivided into three groups (group A1: >65 years, onset of epilepsy after the age of 65 years; group A2: >65 years with early onset epilepsy, seizure onset before the age of 50 years; and group B: <50 years with epilepsy). Clinical data with respect to epilepsy, seizures, comorbidity, etiology, and anti-epileptic drug (AED) therapy were assessed using a questionnaire developed especially for these patient groups and filled out by the physicians. The clinical profile with regard to etiology, postictal conditions, and comorbidities clearly depends on the age of the patients and age of onset of epilepsy. Patients with an epilepsy onset after 65 years need lower doses of AEDs, gain better seizure control and have more concomitant diseases than younger patients or elderly epilepsy patients with early-onset epilepsy.

Epilepsy in the elderly: Special considerations and challenges

The elderly are generally defined as those over 60 or 65 years old, but they are a heterogeneous group and may be subdivided into categories based on age and health status. The incidence of epilepsy is highest in the elderly. With a progressive increase in life expectancy, this is the fastest growing segment of patients with epilepsy. Older patients most often have focal seizures, with less prominent auras and automatisms, and longer duration of postictal confusion compared to younger patients. Status epilepticus is common and has a high mortality. The most common specific etiology is cerebrovascular disease, but the cause remains unknown in many patients. Diagnosis can be challenging because of several patient-related, physician-related and investigation-related factors. Over-diagnosis and under-diagnosis are common. Treatment is complicated by the presence of physiological changes related to aging, co-morbidities and cognitive problems as well as concerns regarding drug interactions and medication adherence. Seizures can be controlled in most patients with low doses of a single anti-epileptic drug (AED). Tolerability is an important factor in selection of an AED, as elderly patients tend to be highly sensitive to side effects. Drug-resistant epilepsy is uncommon. Epilepsy surgery, especially temporal lobectomy, can be performed in older patients with good results. More studies addressing the pathophysiological mechanisms of epilepsy in this age group, and greater inclusion of the elderly in clinical trials, as well as development of comprehensive care models are needed to provide optimal care to these patients.

Temporal lobe surgery in Germany from 1988 to 2008: diverse trends in etiological subgroups

BACKGROUND AND PURPOSE

In the epilepsy community, there is talk that the number of classical patients with early onset temporal lobe epilepsy (TLE) and Ammon's horn sclerosis (AHS) is decreasing. This is counterintuitive, considering the success story of epilepsy surgery, improved diagnostic methods and the current recommendation of early admission to surgery. In order to recognize trends, the development of temporal lobe surgery over 20 years in three major German epilepsy centers was reviewed.

METHODS

Age at surgery and duration of epilepsy, which was differentiated according to histopathology (AHS, developmental, tumor, vascular), year of surgery and center, were evaluated in a cohort of 2812 patients from three German epilepsy centers who underwent temporal lobe surgery between 1988 and 2008. The analysis was carried out for the pooled cohort as well as for each center separately.

RESULTS

Of all patients, 52% showed AHS. Compared with other pathologies, the AHS group had the earliest epilepsy onset and the longest duration of epilepsy. Across five time epochs, the diagnosis of AHS increased in the first epoch, remaining constant thereafter. Contrary to the trends in other pathologies, in the AHS group the mean age of patients at surgery increased by 7 years and the duration of epilepsy until surgery increased by 5 years. This trend could be replicated in all three centers. As initially hypothesized for all groups, age and duration of epilepsy in other pathology groups remained constant or indicated earlier submission to surgery.

CONCLUSIONS

During the first few years studied, most probably due to progress in brain imaging, the proportion of patients with AHS increased. However, despite stable numbers over time, and contrary to the trends in other pathology groups, age and duration of epilepsy in mesial TLE with AHS (mTLE + AHS) increased over time. This supports the hypothesis of a decreasing incidence of AHS. This trend is discussed with respect to disease-modifying factors which have changed the incidence of classical mTLE + AHS or, alternatively, to recent developments in antiepileptic drug treatment, the appraisal of surgery and economic incentives for treatment options other than surgery.

Understanding referral patterns to an epilepsy clinic: professional perceptions of factors influencing the referral of older adults

PURPOSE

The number of older patients with epilepsy has been increasing steadily, however older adults have been shown to be referred less commonly to specialist epilepsy services than younger individuals. The aim of this study was to explore staff perceptions of why older adults may be under-represented in epilepsy clinics.

METHOD

We conducted 19 interviews with potential referrers and staff providing services including GPs, geriatricians, neurologists, service and clinical managers and epilepsy nurses. Data were analysed using principles of thematic analysis to identify and examine recurring views and perceptions.

RESULTS

Seven key factors were suggested as leading to under-referral of older adults: patient difficulties accessing hospital; patient reluctance to attend clinics; unclear referral pathway; complex differential diagnosis; gaps in referrer knowledge; the length of time since onset; and particular characteristics of older patients.

CONCLUSION

While recognising the limitations of the study we believe that it provides valuable further understanding of referral patterns to specialist epilepsy services. Future studies will need to determine whether the assumptions made by the interviewees about the thoughts and wishes of older people with epilepsy were correct or not. To understand this issue more clearly, we plan to sample the views of patients directly. Of particular concern are assumptions regarding older patient's willingness to attend appointments and about the impact of seizures on the life of an older adult.

Young adult ischaemic stroke related acute symptomatic and late seizures: risk factors

BACKGROUND AND PURPOSE

After first-ever ischaemic stroke, to assess the risk and baseline factors associated with acute symptomatic seizure (ASS) (occurring within 7 days) and late post-stroke seizure (LPS) (>7 days).

METHODS

All consecutive patients aged 15-49 with first-ever ischaemic stroke between 1994 and 2007 treated at the Helsinki University Central Hospital were included, using Cox proportional hazard models to identify factors associated with seizures. Adjustment was for age, gender, vascular risk factors, admission hyperglycemia (>6.1 mm) and hyponatremia (<137 mm), use of psychiatric medication, stroke severity (NIH Stroke Scale) and anatomical (Bamford criteria) and etiological (Trial of Org in Acute Stroke Treatment) stroke subtype.

RESULTS

ASSs emerged in 35 (3.5%) patients. LPSs (n = 102) occurred at a cumulative rate of 6.1% at 1 year, 9.5% at 5 years and 11.5% at 10 years. In multivariate analysis, anxiolytic use at time of index stroke (hazard ratio 13.43, 95% confidence interval 3.91-46.14), moderate stroke severity (3.95, 1.86-8.41), cortical involvement (3.69, 1.66-8.18) and hyponatremia (3.26, 1.41-7.57) were independently associated with ASSs. Risk factors for LPSs were total anterior circulation infarct (15.94, 7.62-33.33), partial anterior circulation infarct (3.48, 1.52-7.93), history of ASS (3.94, 2.07-7.48), antidepressant use at the time of LPS (3.88, 2.46-6.11), hemorrhagic infarct (1.94, 1.19-3.15), male gender (1.79, 1.10-2.92) and hyperglycemia (1.62, 1.05-2.51).

CONCLUSIONS

In young ischaemic stroke patients, the magnitude of seizure risk and the major risk factors were similar to older ischaemic stroke patients but risk factors for ASSs and LPSs differed.

Infertility treatment and umbilical cord length-novel markers of childhood epilepsy?

Background

Epilepsy is one of the most common neurologic disorders of childhood, affecting about 0.4−0.8% of all children up to the age of 20.

Methodology

A population-based retrospective cohort study. Aim was to determine incidence and identify perinatal and reproductive risk factors of epilepsy in children born between 1989 and 2008 among women (n = 43,389) delivered in Kuopio University Hospital. Risk factors of childhood epilepsy were determined by using logistic regression analysis.

Principal Findings

The incidence of childhood epilepsy was 0.7% (n = 302 of 43,389). Maternal epilepsy, major congenital anomalies and use of assisted reproductive technology (ART) were associated with 4.25-, 3.61-, and 1.67- fold increased incidence of childhood epilepsy. A 10 cm increase in umbilical cord length was associated with a 15% decrease in the incidence of epilepsy (adjusted OR 0.85, 95% CI 0.78−0.94). However, the above reproductive factors accounted for less than 2% of total incidence, whereas maternal epilepsy proved to be the highest risk factor.

Conclusions

Perinatal and reproductive factors were shown to be minor risk factors of childhood epilepsy, implying that little can be done in obstetric care to prevent childhood epilepsy. Infertility treatment and umbilical cord length, independent of gestational age and congenital malformations, may be novel markers of childhood epilepsy.

Prevalence of treated epilepsy in Korea based on national health insurance data

The Korean national health security system covers the entire population and all medical facilities. We aimed to estimate epilepsy prevalence, anticonvulsant utilization pattern and the cost. We identified prevalent epilepsy patients by the prescription of anticonvulsants under the diagnostic codes suggesting seizure or epilepsy from 2007 Korean National Health Insurance databases. The information of demography, residential area, the kind of medical security service reflecting economic status, anticonvulsants, and the costs was extracted. The overall prevalence of treated epilepsy patients was 2.41/1,000, and higher for men than women. The age-specific prevalence was the lowest in those in their thirties and forties. Epilepsy was more prevalent among lower-income individuals receiving medical aid. The regional prevalence was the highest in Jeju Island and lowest in Ulsan city. New anticonvulsants were more frequently used than old anticonvulsants in the younger age group. The total annual cost of epilepsy or seizure reached 0.46% of total medical expenditure and 0.27% of total expenditure on health. This is the first nationwide epidemiological report issued on epilepsy in Korea. Epilepsy prevalence in Korea is comparable to those in developed countries. Economic status and geography affect the prevalence of epilepsy.

Epilepsy in the elderly: facts and challenges

The incidence of epilepsy in the elderly has increased steadily over the last few decades. In some industrialized countries, one-third of the population is expected to be over the age of 65 in 2030. Therefore, we will face a dramatic increase in the number of elderly patients with epilepsy, many of whom will likely present comorbidities. This increase will put a heavy burden on health care and pension systems. This article focuses on epidemiology, diagnosis and treatment in epilepsies in the elderlies and outlines current research as well as future requirements for research. The diagnosis of epilepsy in the elderly can be difficult and may require long-term video-EEG monitoring. Stroke is the most frequent etiology in epilepsies in the elderlies. Status epilepticus in acute symptomatic epilepsies often results in fatality and may become an increasing health problem. The article also describes the current strategies in antiepileptic drug treatment and epilepsy surgery in the elderly. Novel antiepileptic drugs are necessary as current antiepileptics have strong interaction potentials and harmful side effects, making them ill-suboptimal for treating epilepsy in the elderly.

Geriatric epilepsy: research and clinical directions for the future

There is a growing awareness of the need for improved treatment and care of older adults with epilepsy. The present review article highlights key clinical and research issues in the emerging field of geriatric epilepsy. Drs. Martin and Schmidt explore the scope of the problems in the field, outline topic areas including cognitive health/dementia, and diagnostic challenges, and also present important research questions that should be considered for the future. As part of this presentation, we will highlight the work of two promising young investigators whose work holds great promise for the field of geriatric epilepsy. Dr. Roberson will discuss his work focusing on the relationship of epilepsy and cognitive impairment, particularly as it relates to Alzheimer's disease pathology including tau and its role in epileptiform activity. Dr. Hope will outline key issues, as well as her work, relating to defining and measuring quality care in geriatric epilepsy.

Efficacy of new antiepileptic drugs

Regarding efficacy of new antiepileptic drugs (AEDs) for seizure control, there are three important clinical questions. How effective are new AEDs when corrected for the efficacy of placebo? And even more important: How do new AEDs fare in terms of seizure remission compared with established agents? And finally: Have patients seizure-free on new AEDs a better chance for lasting remission after withdrawal versus those withdrawing from older agents? The answers raise concerns. Although add-on therapy with marketed new AEDs is more effective than placebo, as expected, the treatment difference for becoming seizure-free is disappointingly small (6%; 95% CI: 4-8%; z = 6.47; p < 0.001). Although many, but not all, new AEDs have comparable efficacy to old standard drugs in well-controlled trials, none of the new AEDs is superior to old drugs in terms of seizure remission. So far, we have no antiepileptogenic treatments that prevent the development of epilepsy or modify its detrimental course. The sobering results suggest the need for novel experimental and clinical strategies for the development of more effective new AEDs that interrupt ictogenesis more effectively and prevent or abort epileptogenesis. Ideally, we need new drugs that block both ictogenesis and epileptogenesis, resulting in complete cure of epilepsy.

Do older adults have equitable access to specialist epilepsy services?

The number of older patients with epilepsy has been increasing steadily. We assessed whether older adults with epilepsy have equitable access to our regional specialist service, designed to serve all patients regardless of age or their ability to pay. We examined the records of 846 adults under the current care of our epilepsy service and used data from a previous epidemiologic study to estimate the proportion of local patients accessing our service in different age groups. Whereas 43.7% of adults younger than age 20 were using the specialist service, only 2.3% of people with epilepsy who were 85 and older had been referred. The results raise the possibility of inadvertent age discrimination, putting older adults with seizures at greater risk for misdiagnoses and suboptimal management.

Epilepsy in the elderly

The elderly, often defined as those 65 years or older, are the most rapidly growing segment of the population, and onset of epilepsy is higher in this age group than in any other. This paper reviews recent developments, including a new proposed definition of epilepsy, a transgenic mouse model of Alzheimer's disease that exhibits complex partial seizures, evidence that the highest incidence of epilepsy may occur after admission to a nursing home, a challenge to the vitamin D hypothesis of osteoporosis associated with antiepileptic drugs (AEDs), evidence that the genetic complement of hepatic isoenzymes is more predictive of metabolic rate than age, and data showing that there is considerable variability in serum levels of AEDs in many nursing home residents during constant dosing conditions.

A guide to disorders causing transient loss of consciousness: focus on syncope

Episodes of transient loss of consciousness (TLOC) events pose diagnostic difficulties, as the causes are diverse, carry vastly different risks, and span various specialties. An inconsistent terminology contributes to the confusion. Here, we present a classification scheme for TLOC, based on ongoing multidisciplinary efforts including those of the Task Force on Syncope of the European Society of Cardiology. We also discuss the pathophysiology of TLOC and the key clinical features that aid diagnosis. TLOC is defined as an apparent loss of consciousness with an abrupt onset, a short duration, and a spontaneous and complete recovery. Syncope is defined as TLOC due to cerebral hypoperfusion, and is divided into reflex syncope (synonymous with neurally mediated syncope), syncope due to orthostatic hypotension, and cardiac syncope (arrhythmic or associated with structural cardiac disease). The other major groups of TLOC are generalized epileptic seizures, functional TLOC (psychogenic TLOC mimicking either epilepsy or syncope), and a further group of miscellaneous disorders. The management of patients who experience TLOC requires the recognition of the defining features of each of the major groups, and cooperation between different clinical specialties.

10-year research update review: psychiatric problems in children with epilepsy

OBJECTIVE

To critically review literature published from 1996 to 2007 on psychopathology in children with epilepsy (CWE).

METHOD

Using Ovid, we searched Medline and PsychInfo databases for original studies on epidemiology, risk factors, clinical characteristics, treatment, and outcome of psychopathology in CWE, ages 0 to 18 years, using the terms "psychopathology," "emotional and behavioral problems," and "mental health problems." We selectively present the findings of studies that are clinically relevant to mental health professionals.

RESULTS

Psychopathology occurs in 37% to 77% of CWE, and attention, internalizing, and thought problems may be specific to epilepsy. Cognitive and linguistic deficits, as well as family factors, have moderating effects on psychopathology in CWE. The association of epilepsy-related variables, including antiepileptic drugs, with psychopathology is inconsistent in cognitively normal CWE. Children with symptomatic epilepsy and devastating epilepsy syndromes have high rates of global developmental delay, hyperactivity, and autistic symptoms. The treatment of psychopathology in CWE integrates standard psychiatric practices.

CONCLUSIONS

Epilepsy is a neuropsychiatric disorder characterized by seizures, psychopathology, cognitive, and linguistic problems. Improved early identification of CWE at risk for psychopathology, evidence-based psychiatric treatment, and multidisciplinary management strategies would advance clinical practice in this highly complex field of pediatric neuropsychiatry.

Special issues in the management of young children, older adults, and the developmentally disabled

The very young, the very old, and those with developmental disability have an increased risk of both epilepsy and prolonged and repetitive seizures. The special issues that affect their management are reviewed. Polypharmacy that occurs because of comorbid illnesses requiring chronic medication can result in dangerous drug-drug interactions. The antiepileptic drug's pharmacokinetic profile must be factored when treating young children and older adults. Patients who have taken an older enzyme-inducing antiepileptic drug for years may have a markedly induced hepatic enzyme system that may alter drug metabolism. Overdose or toxicity may occur in older adults who may metabolize and clear antiepileptic drugs more slowly than younger patients. Benzodiazepines are the most rapidly effective acute therapy for repetitive or prolonged seizures. It is important to have a plan for management of prolonged and repetitive seizures. Long-term therapy should be managed in a manner that will eliminate the need for rescue therapies and visits to the emergency department.