Seizures and Epilepsy in the Elderly

Electrophysiological and Imaging Calcium Biomarkers of Aging in Male and Female 5×FAD Mice

BACKGROUND

In animal models and tissue preparations, calcium dyshomeostasis is a biomarker of aging and Alzheimer's disease that is associated with synaptic dysfunction, neuritic pruning, and dysregulated cellular processes. It is unclear, however, whether the onset of calcium dysregulation precedes, is concurrent with, or is the product of pathological cellular events (e.g., oxidation, amyloid-β production, and neuroinflammation). Further, neuronal calcium dysregulation is not always present in animal models of amyloidogenesis, questioning its reliability as a disease biomarker.

OBJECTIVE

Here, we directly tested for the presence of calcium dysregulation in dorsal hippocampal neurons in male and female 5×FAD mice on a C57BL/6 genetic background using sharp electrodes coupled with Oregon-green Bapta-1 imaging. We focused on three ages that coincide with the course of amyloid deposition: 1.5, 4, and 10 months old.

METHODS

Outcome variables included measures of the afterhyperpolarization, short-term synaptic plasticity, and calcium kinetics during synaptic activation. Quantitative analyses of spatial learning and memory were also conducted using the Morris water maze. Main effects of sex, age, and genotype were identified on measures of electrophysiology and calcium imaging.

RESULTS

Measures of resting Oregon-green Bapta-1 fluorescence showed significant reductions in the 5×FAD group compared to controls. Deficits in spatial memory, along with increases in Aβ load, were detectable at older ages, allowing us to test for temporal associations with the onset of calcium dysregulation.

CONCLUSION

Our results provide evidence that reduced, rather than elevated, neuronal calcium is identified in this 5×FAD model and suggests that this surprising result may be a novel biomarker of AD.

New-onset epilepsy in the elderly

People who are 60 years old and older have the highest incidence of developing new-onset epilepsy. The increase of the ageing population has resulted in a greater number of patients with new-onset epilepsy or at risk of developing the condition. Previously published review articles regarding epilepsy in older patients have had a broad focus, including people who were diagnosed with epilepsy in their childhood or middle age. The present review focuses on the causes, treatment, prognosis and psychosocial impact of new-onset epilepsy in people aged ≥60 years. Following a search of the medical electronic databases and relevant references, we identified 22 studies overall that met the inclusion criteria. Only four randomized clinical trials (RCTs) were identified that compared different antiepileptic drug treatments in this population, demonstrating that newer-generation antiepileptic drugs (e.g. lamotrigine and levetiracetam) were generally better tolerated. One uncontrolled study provided promising evidence of good outcomes and safety for surgical resection as a treatment for people with uncontrolled seizures. Five studies reported that people ≥60 years with new-onset epilepsy have significant cognitive impairments (e.g. memory loss) and psychological issues including depression, anxiety and fatigue. We found that there is limited evidence to guide treatment in people with Alzheimer's disease and epilepsy. The specific features of new-onset epilepsy in this target population significantly influences the choice of treatment. Cognitive and psychiatric screening before treatment may be useful for management. Two studies with proposed guidelines were identified but no formal clinical practice guidelines exist for this special population to assist with appropriate management. There is a need for more RCTs that investigate effective treatments with limited side effects. More research studies on the psychosocial effects of new-onset epilepsy, and long-term outcomes, for people aged ≥60 years are also required.

Poststroke epilepsy following transient unilateral middle cerebral and common carotid artery occlusion in young adult and aged F344 rats

The mechanisms of injured brain that establish poststroke seizures and epilepsy are not well understood, largely because animal modeling has had limited development. The main objective of this study was to determine whether an arterial occlusion model of cortical stroke in young adult and aged rats was capable of generating either focal or generalized epileptic seizures within 2 months of lesioning. Four- and 20-month-old male Fischer 344 (F344) sham-operated controls and those lesioned by transient (3 h) unilateral middle cerebral artery (MCA) and common carotid artery (CCA) occlusion (MCA/CCAo) were studied by video-EEG recordings up to 2 months post-procedure. The main findings were: 1) seizures (grade 3 and above) were recorded within 2 months in both young (4-month; 0.23/h) and aged (20-month; 1.93/h) MCA/CCAo rat groups; both MCA/CCAo rat groups had more seizures recorded than the respective control groups, i.e., no seizures in young controls and 0.52/h in old controls; 2) both age and infarction independently had effects on seizure frequency; however, there was no demonstrated interaction between the two factors; and 3) there was no difference in infarct volumes comparing 4- to 20-month-old MCA/CCAo animals. In addition, all lesioned and sham-operated animals demonstrated intermittent solitary myoclonic convulsions arising out of sleep. Morbidity and mortality of animals limited the extent to which the animals could be evaluated, especially 20-month-old animals. These results suggest that transient unilateral MCA/CCAo can result in poststroke epileptic seizures in both young adult and aged F344 rats within a relatively brief period of time following lesioning.

[Specificity of epileptic seizures in the elderly: A proposed electro-clinical scale]

Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis... and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia...). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.

Population pharmacokinetic modelling of carbamazepine in epileptic elderly patients: implications for dosage

BACKGROUND

Proper use of antiepileptic drugs in the elderly involves knowledge of their pharmacokinetics to ensure a patient-specific balance between efficacy and toxicity. However, populations of epileptic patients on chronic carbamazepine (CBZ) therapy which have been studied have included data of relatively few elderly patients.

AIMS

The aim of the present study was to evaluate the population pharmacokinetics of CBZ in elderly patients on chronic monotherapy.

METHODS

We have used the non-parametric expectation maximization (NPEM) program in the USC*PACK collection of PC programs to estimate individual and population post-induction pharmacokinetics of CBZ in epileptic elderly patients who received chronic CBZ monotherapy. Age-related changes of CBZ population pharmacokinetics were evaluated from routine therapeutic drug monitoring (TDM) data of 37 elderly and 35 younger patients with epilepsy. As a 'historical control' we used previously published population modelling results from 99 young epileptic patients on chronic CBZ monotherapy. In that control group, TDM was performed in the same pharmacokinetic (PK) laboratory, using the same sampling strategy as in the present study, and the same PK population modelling software was used for data analysis.

RESULTS AND CONCLUSIONS

A poor correlation was found between daily CBZ dose and serum concentrations in the elderly patients (r=0.2, P=0.25). Probably statistically significant difference in the median values of the CBZ metabolic rate constant (P<0.001) between elderly and relatively young epileptic patients was found. Our results showed that age-related influences in CBZ pharmacokinetics in elderly patients should be considered in the optimal planning of CBZ dosage regimens. Most elderly patients with epilepsy will usually need CBZ dosages lower than those based on the median population PK parameter values obtained from younger patients. The present population model is also uniquely well suited for the new 'multiple model' design of dosage regimens to hit target therapeutic goals with maximum precision.

Seizures in the elderly: Video/EEG monitoring analysis

OBJECTIVE

Recently there has been a remarkable increase in the number of elderly people with epilepsy due to the growing size of this segment of the population. The literature provides little information on the characteristics of epileptic and nonepileptic events in the elderly. Therefore we report the results of video/EEG recordings in patients aged 60 or older admitted over 2 consecutive years to an epilepsy monitoring unit (EMU).

METHODS

We examined the records of all elderly patients admitted to our EMU between December 1999 and December 2001. Fifty-eight patients were older than 60, constituting 17% of the total admissions to the EMU. All patients underwent continuous video/EEG monitoring. On the basis of reasons for admission, video/EEG reports were categorized into (1) diagnosis of events, (2) characterization and localization of seizures, (3) adjustment of medication, and (4) status epilepticus (nonconvulsive).

RESULTS

There were 26 women between the ages of 60 and 91 and 32 men between the ages of 60 and 84. The main reasons for admission were diagnosis of events (57% of patients), followed by characterization and localization of events (36% of patients). There were 6 patients with psychogenic nonepileptic seizures (PNES); 5 were women and 4 of them were >70 years of age. All PNES patients presented with motor symptoms, except for an 87-year-old man who presented with abdominal spasm. Two of these six patients were suspected of having PNES before admission. Two patients were admitted with suspicion of status epilepticus, but neither proved to have status epilepticus. The most frequent diagnosis was physiologic nonepileptic seizures (26 patients; 45%), and 27% of these patients were on antiepileptic drugs, which were discontinued after the diagnosis of nonepileptic seizures. Complex partial seizure was the most frequent seizure type, occurring in 23 patients, 6 of whom (27%) had both complex partial seizures and secondarily generalized seizures.

CONCLUSION

In the elderly, video/EEG results in a definitive diagnosis in the majority of cases and can assist in the decision whether antiepileptic drugs are necessary. PNES can occur in the elderly, and video/EEG monitoring can facilitate their recognition and management.

Antiepileptic drug use and the occurrence of pressure ulcers among bedridden institutionalized elderly patients: a retrospective chart review

BACKGROUND

Phenytoin (PH) is indicated primarily for the control of grand mal and psychomotor seizures. However, topical PH has been used for the treatment of various types of ulcers, including pressure ulcers.

OBJECTIVE

The aim of this study was to investigate the possibility of a relationship between the use of oral PH and the prevalence of pressure ulcers among bedridden institutionalized elderly patients.

METHODS

This retrospective chart review was conducted in a state-run urban geriatric medical center in Israel and involved long-term bedridden institutionalized patients who were receiving chronic antiepileptic medication during the 7-year period between January 1996 and December 2003. The prevalence of pressure ulcers in patients who received treatment with PH alone or in combination with other antiepileptic drugs was compared with that in patients who received antiepileptic agents other than PH.

RESULTS

The study analyzed data from the medical charts of 153 patients, 72 of whom received PH alone or in combination with other antiepileptic drugs, and 81 of whom received antiepileptic agents other than PH. Patients' mean (SD) age was 78.5 (7.2) years; 106 (69.3%) were women. All patients were totally dependent with respect to activities of daily living (mean Katz score, 2.0 [2.0]) and had severe cognitive decline (mean Mini-Mental State Examination score, 3.5 [3.3]). Pressure ulcers occurred in 9.7% of PH recipients and 27.2% of non-PH recipients (P = 0.006; chi2 = 7.55). In PH recipients, 85.7% of pressure ulcers were of mild to moderate severity (stage I or II), compared with 59.1% of ulcers in non-PH recipients; the difference between groups was not statistically significant. Four (18.2%) non-PH recipients and no PH recipients had stage IV pressure ulcers. In the PH group, 71.4% of patients had a pressure ulcer in only 1 anatomic location, compared with 22.7% of the non-PH group (P = 0.023; chi2 = 5.13); 28.6% of PH recipients and 63.6% of non-PH recipients had pressure ulcers in 2 or 3 anatomic locations; and 3 (13.6%) non-PH recipients and no PH recipients had pressure ulcers in > or = 4 areas.

CONCLUSIONS

In the long-term bedridden institutionalized patients studied, those who received PH had lower rates of pressure ulcers, as well as less severe ulcers. PH may be a useful anticonvulsive agent in frail elderly patients, who are at risk for the development of pressure ulcers.

Experience with topiramate monotherapy in elderly patients with recent-onset epilepsy

OBJECTIVES

To evaluate the effect of topiramate in elderly patients with onset of epilepsy after the age of 60, treatment-naive or non-responding to an initial antiepileptic drug.

METHODS

Analysis of patients with epilepsy diagnosed in the preceding 5 years, aged>/=65 years (n=43), enrolled in a larger open-label trial (n=692). After titration to topiramate 100 mg/day over 4 weeks, the dose was adjusted according to individual response (maximum 400 mg/day). Patients were followed up for at least 7 months.

RESULTS

After 7 months, 79% of patients remained in the study. Seizure frequency decreased significantly vs baseline (P<0.001); >/=50% reduction in seizure frequency was achieved in 87% of patients, 64% remained seizure-free. Both previously treated and naive patients responded. Fourteen per cent dropped out because of insufficient tolerability. No unexpected or unusual adverse events were observed.

CONCLUSIONS

The results indicate that elderly patients respond well to topiramate monotherapy. The high patient retention rate reflects a favourable tolerability profile in this population.

Prevalence of Appropriate and Problematic Antiepileptic Combination Therapy in Older People in the Nursing Home

OBJECTIVES

To determine the prevalence of mono- and poly-antiepileptic drug (AED) therapy in a cohort of nursing home (NH) residents and to describe specific AED combinations used, as well as demographic, clinical, and functional factors associated with poly-AED therapy and the most common AED combination.

DESIGN

Retrospective, point prevalence study.

SETTING

All NHs owned/managed by Beverly Enterprises.

PARTICIPANTS

All residents aged 65 and older residing in one of the study NHs on July 1, 1999, and receiving an AED (N=3,881).

MEASUREMENTS

Data were gathered using two secondary source data sets: physicians' orders (AED use) and the Minimum Data Set (health status indicators).

RESULTS

Of residents taking AEDs, 370 (9.5%) were taking two or more; 268 of those (72%) were taking problematic AED combinations (those with the potential of undesirable pharmacokinetic or pharmacodynamic interactions). Phenytoin (PHT) with phenobarbital (PB) was the most common combination (27.0%). Logistic regression indicated that poly-AED subjects were more likely to have a diagnosis of epilepsy/seizure (epi/sz) and less likely to have a diagnosis of cerebrovascular accident (CVA). Residents taking the PHT/PB combination were more likely to have an epi/sz diagnosis and longer NH stay. The association between CVA and PHT/PB polytherapy differed by presence or absence of aphasia.

CONCLUSION

The overall prevalence of poly-AED therapy is less than 10% in NH residents, but 72% of those residents were receiving problematic polytherapy combinations, thereby exposing them to potential risk of adverse reactions and toxicity.

New-onset mesial temporal lobe epilepsy in a 90-year-old: clinical and EEG features

Although there is a peak in the incidence of epilepsy in the elderly compared with the general population, complex partial seizures represent less than 15% of the seizure types reported. We report on a 92-year-old woman with a 2-year history of daily complex partial seizures. Prolonged video/EEG recording showed bilateral anterior mesial temporal interictal spikes, which predominated on the left, and two typical seizures arising from the left temporal area. Cranial MRI scanning showed multiple lacunar infarcts without temporal lobe involvement or mesial temporal atrophy. Our case appears to be oldest patient in the literature with newly diagnosed mesial temporal lobe epilepsy confirmed by video/EEG recording.

Use of levetiracetam in a population of patients aged 65 years and older: a subset analysis of the KEEPER trial

Levetiracetam (Keppra) was evaluated in a subset of patients aged >/=65 years (n=78) enrolled in a large (n=1030) open-label, phase IV trial (the KEEPER trial). A 4-week dose adjustment was followed by a 12-week evaluation period. An overall median reduction in partial seizures of 80.1% (n=65) was observed. Overall, 76.9% of patients were >/=50% responders, 56.9% were >/=75% responders, and 40.0% were 100% responders. Levetiracetam was well tolerated, with 42.3% of patients reporting one or more adverse events. A total of 15 patients (19.2%) experienced an adverse event that led to discontinuation. Somnolence (n=13,16.7%) and dizziness (n=7,9.0%) were the most commonly reported adverse events. Despite the limitations of the open-label study design, these data provide information regarding the use of levetiracetam as add-on therapy for the treatment of partial-onset seizures in patients >/=65 years of age, including those requiring concomitant medications.

Epilepsy in the elderly

BACKGROUND

Epilepsy is one of the most common neurologic diseases that affect the elderly population. Underlying etiologies as well as diagnostic and treatment issues vary from that of younger adults and deserve special consideration.

REVIEW SUMMARY

The substantially increased risk of seizures and epilepsy in the elderly is associated with medical conditions that affect this group such as stroke, dementia, and metabolic disturbances. In addition, there is an increased incidence and associated mortality of status epilepticus among seniors. Distinguishing epilepsy from paroxysmal nonepileptic events can be a particular challenge. As in the general adult population, EEG and MRI are the cornerstones of diagnostic assessment; however, the clinician must be aware of nonspecific changes associated with aging that do not necessarily indicate an underlying predisposition for epilepsy. Finally, there are unique challenges to the treatment of epilepsy in this population, but fortunately there are multiple treatment options available, including nonpharmacological therapies.

CONCLUSIONS

Knowledge of the unique challenges in identifying and treating the elderly patient with epilepsy is important for effective management as well as maximizing quality of life. However, further studies in this area are still needed to establish optimal treatment strategies.

Video-EEG monitoring in the elderly: a review of 94 patients

PURPOSE

We sought to determine the utility and results of video-EEG monitoring in elderly patients. There is an increased incidence of epilepsy in the elderly population. Few studies have assessed the characteristics of epileptic and nonepileptic seizures in this age group. Diagnostic evaluation with video-EEG monitoring is a means to distinguish these different types of events.

METHODS

The authors reviewed all patients aged 60 years and older who were admitted to the epilepsy monitoring unit at Columbia-Presbyterian Medical Center from January 21, 1991, to April 12, 1999.

RESULTS

A total of 94 patients and 99 patient admissions were identified, accounting for 8% of all admissions. The average age was 70 years, and the mean length of stay was 3.8 days. Typical events were recorded in 75 of the 99 patient admissions. A total of 118 seizures was recorded in 46 patients, and 98 nonepileptic events were seen in 27 patients. Of the patients with nonepileptic events, 13 had psychogenic seizures. The majority of patients with nonepileptic events were taking antiepileptic medication. Whereas 76% of the patients with epileptic events had interictal epileptiform discharges, 26% of the patients with nonepileptic events had epileptiform discharges as well.

CONCLUSIONS

Video-EEG monitoring in the elderly leads to a definitive diagnosis in the majority of patients in a relatively short time. Interictal recordings are inadequate in determining the nature of paroxysmal events. Nonepileptic events are common in the elderly, including psychogenic seizures, and these are often misdiagnosed and mistreated as epileptic seizures.

Photothrombotic brain infarction results in seizure activity in aging Fischer 344 and Sprague Dawley rats

This study was designed to determine whether photothrombotic brain infarction could result in epileptic seizures in adult animals. Male Fischer 344 (F344) rats at 2, 6, 12, 24, and 30 months of age and male Sprague Dawley (SD) rats at 2 and 6 months of age underwent photothrombotic brain infarction with the photosensitive dye rose bengal by focusing a wide (6 mm) or narrow (3 mm) diameter white light beam on the skull overlying left hemisphere anterior frontal, midfrontal, frontoparietal, or parietal areas. Animals were monitored with video and EEG recordings. Morphological analysis of infarct size was performed with a computer-assisted image analysis system. The primary finding of this study was that epileptic seizures were recorded in post-mature rats 2 months after lesioning the frontoparietal cortex with large photothrombotic infarcts that extended to the cortical-subcortical interface. These seizures were characterized behaviorally by motor arrest, appeared to originate in the periinfarct area, and could be distinguished from inherited spontaneous bilateral cortical discharges by the morphology, frequency, duration, and laterality of the ictal discharges. Small cortical lesions were ineffective in producing seizures except for one animal that demonstrated recurrent prolonged focal discharges unaccompanied by behavioral change. Stage 3 seizures were observed in a small number of mid-aged and aged animals lesioned with large infarcts in anterior frontal and frontoparietal areas. These results suggest that the technique of photothrombosis can be used to produce neocortical infarction as a means to study mechanisms of secondary epileptogenesis.

Epilepsy in elderly people

The prevalence and incidence of epilepsy are highest in later life with around 25% of new cases occurring in elderly people, many of whom will have concomitant neurodegenerative, cerebrovascular, or neoplastic disease. Difficulties accepting the diagnosis are frequently compounded by its unpredictable nature. Those affected commonly lose confidence and independence. Seizures in older people can result in physical injury, adding to low morale. Complete control is achievable in around 70% of patients with antiepileptic drug treatment. Optimum management requires rapid investigation, accurate diagnosis, effective treatment, sympathetic education, and assured support. The emergence of seizure disorders in old age places an increasing burden on health-care facilities and costs. A coordinated programme among health-care workers is advised to maintain the independence and improve the quality of life of this vulnerable patient population.

Treatment of epilepsy in the elderly

Management of epilepsy in the elderly involves many challenges, including the presence of concomitant diseases, polypharmacy and changes in body physiology. Age-related changes in pharmacokinetics and pharmacodynamics have to be taken into account in order to avoid potentially severe adverse drug reactions in elderly people. The present study reviews the most commonly used antiepileptic drugs (AEDs) in the elderly. Because some AEDs may induce the metabolism of other agents and reduce the effectiveness of several drugs, the physicians have to carefully evaluate concomitant drugs being administered. Moreover, the main problems appear to be when beginning therapy, the first choice drug, the appropriate dosage and pharmacologic compliance. Elderly patients must be screened for hepatic and renal functions before beginning a treatment with an AED, carefully interviewed to reduce complaints for drug side-effects which may negatively influence compliance and monitored for total and free blood levels. Besides the 'classic' AEDs, such as phenytoin, phenobarbital, carbamazepine, valproic acid, primidone and benzodiazepines, the review shows the possible advantages of new AEDs, such as felbamate, gabapentin, lamotrigine, oxcarbazepine and gamma-vinyl-GABA, which may be used in the elderly too for their good tolerability. A careful control of drug assumption is requested in the elderly, especially when it is difficult to achieve seizure control.

Epilepsy in older adults: causes, consequences and treatment

OBJECTIVES

Seizures and epilepsy are common problems in older adults. Although, the highest incidence of seizures and epilepsy occurs in individuals more than 65 years of age, the magnitude of this public health problem, and its consequences on the quality of life of older adults, are not appreciated. Moreover, there is no consensus on the most appropriate way to diagnose or manage epilepsy in this population. This report reviews the current literature on all aspects of epilepsy in older people.

DESIGN/METHODS

The medical literature was reviewed for all articles pertaining to pathophysiology, diagnosis, and treatment of epilepsy in older people.

RESULTS

Epidemiology, etiology, diagnosis, use of diagnostic tests including EEG and imaging, new medical and surgical treatments, and psychosocial issues as they relate to older epilepsy patient are discussed. Several questions that merit future systematic investigation are presented.

CONCLUSION

Seizures and epilepsy in older people are much more common than is generally known. There are unique issues related to this population with regard to diagnosis and treatment. Several new medical and surgical therapies are now available for all epilepsy patients, some of which may be helpful for the older epilepsy patient.

An evaluation of antiepileptic drug therapy in nursing facilities

OBJECTIVES

To describe the prescribing and use of antiepileptic drug (AED) therapy in nursing facility residents.

DESIGN

A retrospective, multicenter drug use evaluation.

SETTING

A total of 85 nursing facilities (average size, 119 beds) in five states.

PARTICIPANTS

1132 residents of the total 10,168 residents screened were prescribed at least one AED.

MEASURES

Demographic information, primary indication for AED, comorbid conditions, prescribing physician's specialty, concomitant medications, and AED dosage regimen information were collected. Laboratory tests obtained in the most recent 6 months and seizure occurrence and seizure-related diagnostic assessments made in the most recent 3 months were also recorded.

RESULTS

Of 1132 residents receiving AED therapy, 892 (78.8%) were prescribed AED therapy for a seizure-related diagnosis although 86% of seizure types were unspecified. Another 215 residents (19.0%) were prescribed AEDs for nonseizure diagnoses, and 25 (2.2%) had no indication for AED therapy. AEDs most frequently prescribed were phenytoin (56.8%), carbamazepine (23.0%), phenobarbital (15.6%), and valproic acid (13.1%). For residents with a seizure diagnosis, the most frequently prescribed monotherapy agents were phenytoin (52.0%), carbamazepine (12.2%), and phenobarbitol (7.1%). Almost 25% of residents with a seizure diagnosis took a combination of AEDs; more than 50% of all combinations included phenobarbital. About 9% of residents with a seizure diagnosis had one or more documented seizures during a 3-month review period.

CONCLUSION

Among the substantial percentage of residents treated with AEDs, the lack of diagnosis of seizure type has serious implications for the choice of AED therapy. Opportunities exist for prescribing physicians, consultant pharmacists, and nursing staff to improve the medical management of nursing facility residents with seizures and of others receiving AEDs.

Seizures in special populations. Children, the elderly, and patients with coexistent medical illness

Epilepsy management may need to be modified in certain patient groups. The management of epilepsy in all age-groups, and particularly in children, may be best approached from a disease-based model that recognizes specific epilepsy syndromes. Accurate diagnosis of pediatric epilepsy syndromes allows the physician to improve medication selection, estimate duration of treatment, and counsel patients and family members about aggravating factors and prognosis. Epilepsy management in elderly patients requires knowledge of age-related changes in the metabolism and protein binding of anticonvulsants and how these changes affect use of particular antiepileptic drugs. Concurrent medical illness, especially renal and hepatic disease, may alter drug distribution, metabolism, and excretion in some patients. In addition, a number of medications used to treat coexistent medical or psychiatric illness are associated with seizure provocation. Knowledge of these factors can improve epilepsy management in special patient populations.

[Preditive clinical factors for epileptic seizures after ischemic stroke]

Preditive clinical factors for epileptic seizures after ischemic stroke. Clinical features of 35 patients with ischemic stroke who developed epilepsy (Group 1) were compared with those of 35 patients with ischemic stroke without epilepsy (Group 2). The age of the patients did not differ between the groups. There were more men than women and more white than other races in both groups. Diabetes melitus, hypertension, transient ischemic attack, previous stroke, migraine, Chagas disease, cerebral embolism of cardiac origin and use of oral contraceptive did not differ between the groups. Smokers and alcohol users were more frequent in Group 1 (p < 0.05). Most patients of Group 1 presented with hemiparesis; none presented cerebellar or brainstem involvement. Perhaps strokes in smokers have some different aspects, that let them more epileptogenic than in non smokers.