Seizure Semiology in the Elderly: A Video Analysis

EEG and semiology in the elderly: A systematic review

INTRODUCTION

The prevalence and incidence of epileptic seizures and epilepsy increases among the elderly. Epileptic seizures in older people remain often unreported and undiagnosed, contributing to incorrect or delayed treatment. The goal of our review paper is to increase awareness of seizures in the elderly, to improve the diagnostic process in this growing population.

METHODS

We present a systematic review of the literature on EEG findings and seizure semiology among the elderly according to the PRISMA statement. One hundred and two original studies were included and findings were divided in four groups: EEG among elderly without seizures, EEG among elderly with seizures or epilepsy, semiology, and status epilepticus.

CONCLUSIONS

EEG abnormalities are found in approximately half of the geriatric population referred to routine EEG. Slowing (both focal and diffuse) is the most common finding among seniors with and without seizures. Interictal epileptiform discharges (IEDs) are likewise seen among healthy seniors, which reduces their specificity as biomarker for epilepsy. Focal onset seizures prevail among the aged. Generalized seizures are uncommon, starting usually earlier in life but exacerbating in later years. Motor phenomena are less frequently seen than among younger individuals. Seizures are mainly characterized by impairment of awareness, disturbed cognition and confusion, both ictally and postictally. Unresponsiveness may occur during non-epileptic events too, which further challenges seizure recognition. Epilepsy and dementia are bi-directionally related: dementia carries an increased risk of developing epilepsy and vice versa. Up to 45 % of the aged with new onset seizures present with status epilepticus (SE). SE among the elderly is more often focal motor; non-convulsive status epilepticus (NSCE) constitutes 10-25 %.

Diagnosing epileptic seizures in patients with Alzheimer's disease and deciding on the appropriate treatment plan

INTRODUCTION

Alzheimer's disease (AD) is the predominant cause of dementia and a significant contributor to morbidity among the elderly. Patients diagnosed with AD face an increased risk of epileptic seizures.

AREAS COVERED

Herein, the authors review the challenges in the diagnosis of seizures in patients with AD, the risks of seizures related to medications used in AD and the pharmacological treatment of seizures in AD. The authors also provide the reader with their expert opinion on the subject matter and future perspectives.

EXPERT OPINION

Healthcare professionals should maintain a vigilant approach to suspecting seizures in AD patients. Acute symptomatic seizures triggered by metabolic disturbances, infections, toxins, or drug-related factors often have a low risk of recurrence. In such cases, addressing the underlying cause may suffice without initiating antiseizure medications (ASMs). However, unprovoked seizures in certain AD patients carry a higher risk of recurrence over time, warranting the use of ASMs. Although data is limited, both lamotrigine and levetiracetam appear to be reasonable choices for controlling seizures in elderly AD patients. Decisions should be informed by the best available evidence, the treating physician's clinical experience, and the patient's preferences.

Seizures provoked by over-the-counter cough and cold medications in an elderly patient: a case report

BACKGROUND

Seizures are common neurological emergencies in the elderly that are frequently provoked. Geriatrics have higher rates of neurological disorders and other comorbidities that could affect seizure threshold.

CASE PRESENTATION

An 83-year-old male Arabic patient presented to the emergency department with an acute confusional state and urinary incontinence followed by a witnessed tonic-clonic seizure in the hospital. Thorough investigations and imaging were positive only for nonspecific magnetic resonant imaging findings with a negative electroencephalogram. The patient was diagnosed with provoked seizure due to over-the-counter cold medications that included pseudoephedrine and caffeine. He was not prescribed antiepileptic medications at discharge and did not develop subsequent seizures up to this date.

CONCLUSION

Over-the-counter cough and cold medications with sympathomimetic ingredients can be associated with provoked seizures in the elderly. Physicians should be aware of the potentially serious adverse events associated with commonly used nonprescription sympathomimetics such as pseudoephedrine and caffeine in elderly patients.

Drug-resistant epilepsy at the age extremes: Disentangling the underlying etiology

The incidence of epilepsy is highest at the extreme age ranges: childhood and elderly age. The most common syndromes in these demographics - self-limited epilepsies of childhood and idiopathic generalized epilepsies in pediatric age, focal epilepsy with structural etiology in older people - are expected to be drug responsive. In this work, we focus on such epilepsy types, overviewing the complex clinical background of unexpected drug-resistance. For self-limited epilepsies of childhood and idiopathic generalized epilepsies, we illustrate drug-resistance resulting from syndrome misinterpretation, reason on possible unexpected courses of epilepsy, and explicate the influence of inappropriate treatments. For elderly-onset epilepsy, we show the challenges in differential diagnosis possibly leading to pseudoresistance and analyze how drug-resistant epilepsy can arise in stroke, neurocognitive disorders, brain tumors, and autoimmune encephalitis. In children and senior people, drug-resistance can be regarded as a hint to review the diagnosis or explore alternative therapeutic strategies. Refractory seizures are not only a therapeutic challenge, but also a cardinal sign not to be overlooked in syndromes commonly deemed to be drug-responsive.

Late-Onset Focal Epilepsy: Electroclinical Features and Prognostic Role of Leukoaraiosis

The aim of this study was to describe the electroclinical and prognostic characteristics, and to investigate the role of leukoaraiosis in outpatients with new-onset elderly focal epilepsy aged ≥60 years, referred to a tertiary epilepsy center between 2005 and December 31, 2020. Among the 720 patients who were referred to the center, we retrospectively selected 162 consecutive outpatients, with a first referral for recent-onset focal epilepsy of unknown cause (UC) or structural cause (SC), and collected a clinical and standard-Electroencephalogram (S-EEG), 24-h ambulatory EEG (A-EEG), and neuroimaging data. We also analyzed the seizure prognosis after titration of the first antiseizure medication (ASM). One hundred and four UC and 58 SC patients, followed up for 5.8 ± 5.3 years (mean ± SD), were included. Compared with the SC group, the patients with UC showed a predominance of focal seizures with impaired awareness (51.9% of cases) and focal to bilateral tonic-clonic seizures during sleep (25%); conversely, the SC group, more frequently, had focal to bilateral tonic-clonic seizures during wakefulness (39.6%) and focal aware seizures (25.8%) (p < 0.0001). Oral or gestural automatisms were prevalent in UC epilepsy (20.2 vs. 6.9% in the SC group, p = 0.04). In UC compared to patients with SC, interictal epileptiform discharges showed a preferential temporal lobe localization (p = 0.0007), low expression on S-EEG, and marked activation during deep Non-Rapid Eye Movement (NREM) sleep (p = 0.003). An overall good treatment response was found in the whole sample, with a probability of seizure freedom of 68.9% for 1 year. The cumulative probability of seizure freedom was significantly higher in the UC compared with the SC group (p < 0.0001). The prognosis was worsened by leukoaraiosis (p = 0.012). In the late-onset focal epilepsy of unknown cause, electroclinical findings suggest a temporal lobe origin of the seizures. This group showed a better prognosis compared with the patients with structural epilepsy. Leukoaraiosis, per se, negatively impacted on seizure prognosis.

Clinical and Instrumental Characterization of Patients With Late-Onset Epilepsy

Epilepsy is classically considered a childhood disease. However, it represents the third most frequent neurological condition in the elderly, following stroke, and dementia. With the progressive aging of the general population, the number of patients with Late-Onset Epilepsy (LOE) is constantly growing, with important economic and social consequences, in particular for the more developed countries where the percentage of elderly people is higher. The most common causes of LOE are structural, mainly secondary to cerebrovascular or infectious diseases, brain tumors, trauma, and metabolic or toxic conditions. Moreover, there is a growing body of evidence linking LOE with neurodegenerative diseases, particularly Alzheimer's disease (AD). However, despite a thorough characterization, the causes of LOE remain unknown in a considerable portion of patients, thus termed as Late-Onset Epilepsy of Unknown origin (LOEU). In order to identify the possible causes of the disease, with an important impact in terms of treatment and prognosis, LOE patients should always undergo an exhaustive phenotypic characterization. In this work, we provide a detailed review of the main clinical and instrumental techniques for the adequate characterization of LOE patients in the clinical practice. This work aims to provide an easy and effective tool that supports routine activity of the clinicians facing LOE.

Mortality in Patients With Late-Onset Epilepsy: Results From the Atherosclerosis Risk in Communities Study

OBJECTIVE

To determine the risk of mortality and causes of death in persons with late-onset epilepsy (LOE) compared to those without epilepsy in a community-based sample, adjusting for demographics and comorbid conditions.

METHODS

This is an analysis of the prospective Atherosclerosis Risk in Communities (ARIC) study, initiated in 1987-1989 among 15,792 mostly black and white men and women in 4 U.S. communities. We used Centers for Medicare Services fee-for-service claims codes to identify cases of incident epilepsy starting at or after age 67. We used Cox proportional hazards analysis to identify the hazard of mortality associated with LOE and to adjust for demographics and vascular risk factors. We used death certificate data to identify dates and causes of death.

RESULTS

Analyses included 9090 participants, of whom 678 developed LOE during median 11.5 years of follow-up after age 67. Participants who developed LOE were at an increased hazard of mortality compared to those who did not, with adjusted hazard ratio 2.39 (95% CI 2.12-2.71). We observed excess mortality due to stroke, dementia, neurologic conditions, and end-stage renal disease in participants with compared to without LOE. Only 4 deaths (1.1%) were directly attributed to seizure-related causes.

CONCLUSIONS

Persons who develop LOE are at increased risk of death compared to those without epilepsy, even after adjusting for comorbidities. The majority of this excess mortality is due to stroke and dementia.

Late-onset epilepsy and 25-year cognitive change: The Atherosclerosis Risk in Communities (ARIC) study

OBJECTIVE

To define the association between late-onset epilepsy (LOE) and 25-year change in cognitive performance.

METHODS

The Atherosclerosis Risk in Communities (ARIC) study is a multicenter longitudinal cohort study with participants from four U.S. communities. From linked Medicare claims, we identified cases of LOE, defined as ≥2 seizure-related diagnostic codes starting at age ≥67. The ARIC cohort underwent evaluation with in-person visits at intervals of 3-15 years. Cognition was evaluated 4 times over >25 years (including before the onset of seizures) using the Delayed Word Recall Test (DWRT), Digit Symbol Substitution Test (DSST), and Word Fluency Test (WFT); a global z-score was also calculated. We compared the longitudinal cognitive changes of participants with and without LOE, adjusting for demographics and LOE risk factors.

RESULTS

From 8033 ARIC participants with midlife cognitive testing and Medicare claims data available (4523 [56%] female, 1392 [17%] Black), we identified 585 cases of LOE. The rate of cognitive decline was increased on all measures in the participants who developed LOE compared to those without LOE. On the measure of global cognition, participants with LOE declined by -0.43 z-score points more over 25 years than did participants without epilepsy (95% confidence interval [CI] -0.59 to -0.27). Prior to the onset of seizures, cognitive decline was more rapid on the DWRT, DSST, and global z-scores in those who would later develop LOE than it was in non-LOE participants. Results were similar after excluding data from participants with dementia.

SIGNIFICANCE

Global cognition, verbal memory, executive function, and word fluency declined faster over time in persons developing LOE than without LOE. Declines in cognition preceding LOE suggest these are linked; it will be important to investigate causes for midlife cognitive declines associated with LOE.

Risk factors for seizures after intracerebral hemorrhage: Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) Study

OBJECTIVE

We aimed to identify risk factors for seizures after intracerebral hemorrhage, and to validate the prognostic value of the previously reported CAVE score (0-4 points: cortical involvement, age <65, volume >10 mL, and early seizures within 7 days of hemorrhage).

PATIENTS AND METHODS

Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) was a prospective study of spontaneous intracerebral hemorrhage. We included patients who did not have a prior history of seizure and survived to discharge. Univariate analysis and multiple logistic regression modeling were used to identify risk factors for seizure.

RESULTS

From 2010-2015, 3000 cases were recruited, and 2507 patients were included in this study. Seizures after hospital discharge developed in 77 patients 3.1 %). Patients with lobar (cortical) hemorrhage (OR 3.0, 95 % CI 1.8-5.0), larger hematoma volume (OR 1.5 per cm³, 95 % CI 1.2-2.0), and surgical evacuation of hematoma (OR 2.6, 95 % CI 1.4-4.8) had a higher risk of late seizure, and older patients had a lower risk (OR 0.88 per 5-year interval increase, 95 % CI 0.81-0.95). The CAVE score was highly associated with seizure development (OR 2.5 per unit score increase, 95 % CI 2.0-3.2, p < 0.0001). The CAVS score, substituting surgical evacuation for early seizure, increased the OR per unit score to 2.8 (95 % CI 2.2-3.5).

CONCLUSIONS

Lobar hemorrhage, larger hematoma volume, younger age, and surgical evacuation are strongly associated with the development of seizures. We validated the CAVE score in a multi-ethnic population, and found the CAVS score to have similar predictive value while representing the current practice of AED use.

Epilepsy in the elderly: Unique challenges in an increasingly prevalent population

Elderly individuals (aged at least 60 or 65 years) represent a rapidly growing segment of the population. The incidence and prevalence of epilepsy is higher in this age group than in any other. Diagnosing epilepsy in the elderly can be challenging because the causes and clinical manifestations of seizures often differ as compared with younger individuals. Particular differential diagnoses, such as syncope and amyloid spells, are commonly encountered in the elderly population. A diagnosis of epilepsy has important implications in the older adult, many of which already present a variety of concomitant complex medical problems, such as cognitive impairment, comorbid cerebrovascular disease, and frailty. The treatment of epilepsy in the elderly is complicated by a variety of factors related to aging, including physiological changes, medical comorbidities, and polypharmacy. In this narrative review, we will address the descriptive epidemiology, clinical presentation, differential diagnosis, diagnostic evaluation, treatment, and prognosis of epilepsy in the elderly individual.

Recurrent episodes of falls and amnestic confusional states as diagnostic challenge in the elderly

New-onset paroxysmal events in patients over 60 years of age are often diagnostically challenging owing to atypical presentation. Recurrent falls and transient states of confusion are especially common in the elderly population, yet their causes often remain undiagnosed due to concomitant cognitive deficits and motor impairments. We present an elderly patient with newly occurring ‘blackouts’ without obvious triggers and transient states of confusion for which he was amnestic. All neurological exams including brain MRI scan and routine electroencephalography (EEG) were normal. Long-term ECG monitoring using an event recorder captured an asystole during a habitual episode, leading to the diagnosis of syncope and pacemaker implantation. A subsequent video EEG monitoring performed due to ongoing unexplained confusional states revealed both bradycardia and long-lasting confusional states to be caused by unrecognised temporal lobe seizures. Ictal video EEG monitoring may play a crucial role in establishing a diagnosis of atypical temporal lobe seizures in the elderly.

Nonlesional late-onset epilepsy: Semiology, EEG, cerebrospinal fluid, and seizure outcome characteristics

INTRODUCTION

Incidence and prevalence of epilepsy increase with advancing age. Although the majority of late-onset epilepsies are of lesional origin, a considerable proportion of patients present with unknown etiology. The aim of this study was to evaluate the semiological, electroencephalographic (EEG), and cerebrospinal fluid (CSF) characteristics as well as the 12-month seizure outcome in a cohort of patients with nonlesional late-onset epilepsy (≥55 years).

METHOD

A total of 54 patients with newly diagnosed nonlesional late-onset epilepsy (NLLOE) were retrospectively evaluated for seizure type using the most recent International League Against Epilepsy (ILAE) classification of seizure types, EEG characteristics, and CSF profile and followed-up for at least 12 months after epilepsy onset. Results were compared with a gender-matched control group of 58 patients with nonlesional early-onset epilepsy (NLEOE).

RESULTS

The predominant seizure types in NLLOE were focal to bilateral tonic-clonic seizures (30%) as well as focal onset impaired awareness motor seizures (IAMS) (22%) and focal onset impaired awareness nonmotor seizures (IANMS) (22%). The predominant seizure types in NLEOE were focal to bilateral tonic-clonic seizures (43%) as well as focal onset aware nonmotor seizures (ANMS) (31%) and IAMS (31%). Focal onset impaired awareness nonmotor seizures were found to be more characteristic in patients with NLLOE (p = 0.019; α < 0.05; NLLOE: 22.2% vs. NLEOE: 8.6%). Electroencephalography revealed no significant differences between groups. Of interest, three patients with NLLOE (8%) presented with oligoclonal bands (OCB) in CSF albeit absence of antineuronal antibodies. Seizure-free rate was 70%. Adverse effects from medication leading to antiepileptic drug (AED) change were reported in 12 patients (22%), valproate was the best tolerated AED in patients with NLLOE [adverse effects in 9%, compared with 12% (gabapentin) and 26% (levetiracetam)].

CONCLUSIONS

Using the most recent classification system, different patterns of semiological characteristics were identified: NLLOE more frequently present with IANMS, whereas patients with NLEOE rather have ANMS. Oligoclonal bands were only detected in patients with NLLOE, indicating that careful exclusion of autoimmune encephalitis in this patient group is warranted. Our findings may help to more accurately identify and characterize patients with NLLOE to improve targeted diagnostics and adequate treatment in this challenging group of patients.

[Epileptic seizures and epilepsy after a stroke : Incidence, prevention and treatment]

Following stroke, 3-6% of patients develop acute symptomatic seizures within the first 7 days. The rate is higher after cerebral haemorrhage compared to ischaemia. In 10-12% of patients, after more than 7 days unprovoked seizures occur. Due to these low incidence rates, primary prophylaxis with antiepileptic drugs is generally not necessary. Following one acute symptomatic seizure, recurrence risk within the first 7 days post-stroke is 10-20%, generally arguing against secondary prophylaxis with an antiepileptic drug. In clinical practice however, antiepileptic drug treatment in this constellation is often initiated. If this is done, the antiepileptic drug should be withdrawn soon after the acute phase, as the long-term risk for manifestation of an unprovoked seizure is approximately 30%. Following one post-stroke unprovoked seizure, recurrence risk within the next 10 years is more than 70%, this defines epilepsy. In this case, antiepileptic drug treatment is regularly recommended.

Factors associated with the duration of the postictal state after a generalized convulsion

PURPOSE

Few studies have assessed the duration of the postictal state after a generalized convulsion (GC) in adults. This study aimed to investigate the postictal duration after a GC and the factors associated with it.

METHODS

Patients aged ≥16 years who presented to the emergency department of a community general hospital with an unprovoked GC from January 2015 through December 2016 were evaluated retrospectively. A GC was defined as a bilateral convulsion with apparent impaired consciousness including a generalized tonic-clonic seizure.

RESULTS

We evaluated 209 consecutive GCs (median age, 42 years) with the median postictal duration of 0.75 h. The univariate analyses indicated that the median duration of the postictal state was significantly longer: in elderly patients (aged ≥65 years) than in younger patients (aged <65 years) (2 h vs. 0.7 h, p = 0.0005); in patients with higher modified Rankin scale (mRS) scores (≥3) at baseline than in those with lower scores (≤2) (2.5 h vs. 0.7 h, p <0.0001); in patients with longer seizure duration (≥30 min) than in those with shorter duration (55 h vs. 0.7 h, p <0.0001); in patients who were given emergency antiepileptic drugs than in those who were not (16 h vs. 0.6 h, p <0.0001); and in patients who were intubated than in those who were not (63.5 h vs. 0.75 h, p = 0.0009). Multiple linear regression analyses indicated that older age, higher mRS scores at baseline, longer seizure duration, and administration of emergency antiepileptic drugs were independently associated with longer postictal duration.

CONCLUSION

Age, baseline functional disability, and seizure duration were factors associated with the duration of the postictal state after a GC.

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.

Outcome of newly-diagnosed epilepsy in older patients

INTRODUCTION

The annual incidence of seizure disorders rises sharply after the age of 60. Treatment is complicated by the normal physiological changes of aging, comorbid diseases, and polypharmacy. Despite this, approximately 80% of the patients become seizure-free.

OBJECTIVES

The objectives of this study were to (1) analyze the outcome of a cohort of patients with newly-diagnosed epilepsy over the age of 65, (2) describe epilepsy etiology and seizure type, and (3) classify the outcome according to the latest ILAE classification proposal for drug-resistant epilepsy (2010).

METHODS

All patients with newly-diagnosed epilepsy over the age of 65 who were evaluated in two different institutions were included. Seizures and epilepsy syndromes were classified according to the International League Against Epilepsy proposal (2010). Epilepsy outcomes were also analyzed according to the proposal of the ILAE Commission on Therapeutic Strategies (2010).

RESULTS

One hundred and twenty-two patients were included with a median follow-up time of 15 months. Median age of diagnosis was 78 years. Seventy-seven patients (55%) had epilepsy of unknown cause, and 55 (45%) had structural-metabolic epilepsy. The proportions of seizure-free patients at 6, 12, 18, and 24 months were 90%, 77%, 74%, and 67%, respectively. Thirty percent of patients experienced adverse effects (AEs). We found a statistically significant trend toward a higher frequency of AEs as the number of concomitant medications rose and in younger patients. According to the 2010 ILAE classification proposal for drug-resistant epilepsy criteria, 55.8% of the patients were seizure-free, 12.3% had treatment failure, and 32% had undetermined seizure outcome.

CONCLUSION

Patients with newly-diagnosed epilepsy after the age of 65 have very good chances of achieving seizure control with AED treatment. It seems that fulfilling the ILAE classification proposal for drug-resistant epilepsy (2010) criteria for seizure freedom was more difficult in our cohort. Older patients also seem to be more prone to suffering from AEs.

Status epilepticus in the elderly: epidemiology, clinical aspects and treatment

The aim of the study was to review the epidemiology, clinical profile and discuss the etiology, prognosis and treatment options in patients aged 60 years or older presenting with status epilepticus. We performed a systematic review involving studies published from 1996 to 2010, in Medline/PubMed, Scientific Electronic Library on line (Scielo), Latin-American and Caribbean Center of Health Sciences Information (Lilacs) databases and textbooks. Related articles published before 1996, when relevant for discussing epilepsy in older people, were also included. Several population studies had shown an increased incidence of status epilepticus after the age of 60 years. Status epilepticus is a medical and neurological emergency that is associated with high morbidity and mortality, and is a major concern in the elderly compared to the general population. Prompt diagnosis and effective treatment of convulsive status epilepticus are crucial to avoid brain injury and reduce the fatality rate in this age group.

Epilepsy with onset at over 50 years of age: clinical and electroencephalographic characteristics

Epilepsy in older individuals has an elevated incidence. The objective of the present work was to evaluate the clinical, EEG and brain imaging aspects in patients showing late-onset epilepsy. Fifty-five patients with late-onset epilepsy (older than 50 years) were evaluated. They were composed of two groups according to the onset age of the epilepsy seizure (ES): 51-60 (G51-60) and over 60 (G60+) years. Focal ES predominated although they were less frequent in G60+. The occurrence of status epilepticus was high and more frequent in G60+ whereas seizures in series predominated in G51-60. Symptomatic epilepsy was more frequent and the vascular etiology predominated. Epileptiform activity was associated with a greater number of ES, and background activity abnormalities were more frequent in G60+. In conclusion, epilepsy with onset at over 50 was predominantly focal and symptomatic, with a high occurrence of status epilepticus and of seizures in series.

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.

Seizure semiology and aging

The incidence of epilepsy is high in older individuals. However, epilepsy in the elderly may be underdiagnosed and undertreated because of diagnostic difficulties. The main goal of this study was to determine whether seizure semiology differs between older and younger adults with epilepsy in the outpatient setting. Fifty patients with focal epilepsy aged 55 years and older and 50 patients aged between 18 and 45 years were included. Review of medical records contained detailed seizure description. There were no differences in seizure semiology between groups, except that subtle perceptions of transient confusion were seen in older patients but not in younger patients (P=0.0028). Older patients had less generalized motor seizures, but the differences between groups did not reach significance (P=0.01). Older patients may present with subtle symptoms of seizures characterized by brief periods of confusion, which may contribute to greater difficulty diagnosing seizures in the elderly.

The postictal state: effects of age and underlying brain dysfunction

There is relatively little information on the underlying parameters that affect clinical features of the postictal period. Age-related physiological changes, including alterations in cerebral blood flow and metabolism, neurotransmitter function, and responses of the brain to seizure activity may affect postictal clinical phenomena. Some conclusions can be drawn. Elderly adults and children, particularly in the presence of diffuse cerebral dysfunction, may have more prolonged postictal confusion. Postictal dysphasia strongly suggests a dominant hemisphere focus, more often temporal, and Todd's paralysis is always contralateral to the epileptogenic zone. Much additional information could be derived from the vast amount of video/EEG monitoring data available.

The yield of routine EEG in geriatric patients: A prospective hospital-based study

STUDY AIM

To study the yield of routine EEG in geriatric patients.

PATIENTS AND METHODS

We examined standard EEG recordings of 701 patients aged 84.6±6.4 years. These were performed over a 15 month-period in a geriatric hospital. The majority of patients were hospitalized and 46.5% suffered from multiple medical problems.

RESULTS

We found EEG abnormalities in 392/701 (56%) patients. These consisted of permanent diffuse slowing, either isolated (17.1%) or with intermixed epileptiform abnormalities (2.4%), focal slowing (15.4%), intermittent diffuse slowing (8.9%), triphasic waves (1.14%), periodic epileptiform discharges (0.57%), flat and inactive tracing (0.14%), status epilepticus (0.99%), seizures (0.42%), interictal epileptiform abnormalities (8.7%). Epileptiform abnormalities (both ictal and interictal) were observed in 92/701 (13.1%) patients. These were focal in the majority of cases (85.9%), most frequent in temporal regions (42%), followed by centroparietal (20.2%) and temporo-parieto-occipital carrefour regions (17.2%), but less frequent in frontal (6.3%) and occipital regions (3.8%). We found sleep activity without other EEG abnormalities in 13.7% of patients and subclinical rhythmic electrographic discharge in adult (SREDA) in 1% of cases.

CONCLUSIONS

In this study, EEG abnormalities were very common, which reflects the high frequency of cerebral dysfunction in geriatric patients. These abnormalities are of various types, often suggestive of different aetiologies, and may be helpful in clinical management.

Epilepsy in later life

Epilepsy is most likely to develop in later life. The burden of this disorder on health-care resources will rise further as the world's population continues to age. Making a secure diagnosis can be challenging because the clinical manifestations of seizures and the differential diagnoses and causes of epilepsy can be different in older individuals compared with younger individuals. Obtaining a reliable account of the events for accurate assessment is particularly important in guiding the appropriate choice and interpretation of investigations to arrive at the correct diagnosis. In older age, unique pharmacokinetic and pharmacodynamic changes occur. The use and selection of antiepileptic drugs is often further complicated by the presence of comorbidities, polypharmacy, and concomitant functional impairment, but there is a paucity of high-level clinical evidence on the effects of these factors as well as on the choice of treatment in the elderly. A comprehensive model of care should combine expertise in the diagnosis and treatment of epilepsy with effective assessment and management of the psychosocial effects to improve the prognosis in this vulnerable and poorly studied group of patients.

Epilepsy outcomes in elderly treated with topiramate

OBJECTIVES

To explore effectiveness, tolerability and quality of life in elderly patients with epilepsy treated with topiramate.

METHODS

One year, open-label, flexible-dosing clinical trial.

RESULTS

One hundred and seven patients (mean age 69 years, 53% men) were studied during 273 +/- 141 days. The average final dose in monotherapy was 98 mg/day vs 153 mg/day in adjunctive treatment. Mean monthly cumulative seizure frequency decreased from 3.7 +/- 15 to 1.6 +/- 7.7 (n = 101, P < 0.0001), 78% of patients with seizures at baseline (n = 102) achieved at least 50% reduction in seizure frequency, 44% were seizure-free throughout the trial. Total scores on the quality of life in epilepsy inventory (QOLIE-31) improved from 57 +/- 17 to 68 +/- 18 (n = 64, P < 0.0001). The most frequently reported adverse events included convulsions, dizziness and tiredness.

CONCLUSIONS

Elderly patients treated with topiramate showed marked reductions in seizures, good tolerability and significant improvements in several aspects of quality of life.

Video-EEG monitoring of paroxysmal events in the elderly

OBJECTIVES

To determine the importance of video-EEG monitoring (VEM) in elderly patients with various paroxysmal events.

MATERIAL AND METHODS

We retrospectively identified 16 subjects > or = 60 years old out of 834 (1.9%; 7 females, mean age 67.8 +/- 7.7 years), who were admitted to the Video-EEG Unit between 1997 and 2005 and compared data between those with and without epileptic events.

RESULTS

Epilepsy was confirmed in six patients, psychogenic non-epileptic seizures (NES) were diagnosed in seven, one patient had NES and epilepsy whereas the recorded events were non-conclusive in two. NES patients had a higher predisposition to psychiatric disturbances (P<0.02). Following VEM and management alteration, the frequency of monthly events decreased significantly for the cohort as a whole (P<0.001). VEM directly influenced the diagnosis, treatment and outcome of 14 of 16 (88%) patients.

CONCLUSION

Video-EEM plays a vital role in the evaluation of paroxysmal events in the elderly, but is vastly underutilized in this population group.

Epidemiology and outcomes of status epilepticus in the elderly

Status epilepticus (SE) is a serious condition of prolonged or repetitive seizures. The annual incidence (86/100,000) of SE in the elderly who are aged 60 and greater is almost twice that of the general population and is even higher in those who are 70 years and older. Either acute or remote symptomatic stroke causes approximately 60% of SE seen in the elderly. SE is associated with a high mortality in the elderly (38%), with a rate approaching 50% in patients older than 80 years of age. Etiology is a strong determinant of mortality in the elderly: mortality approaches 100% in patients with anoxia and 30% in patients with either metabolic disorders, hemorrhages, tumors, or systemic infections. Mortality is almost three times higher in SE associated with acute ischemic stroke than in stroke alone, indicating synergistic effects. Duration of SE is also a factor in mortality. Treatment should be initiated for any convulsive seizure that lasts at least 10 min or is repetitive. An electroencephalogram (EEG) should be promptly obtained so that a diagnosis can be made without delay. Because older patients have a greater likelihood of nondiagnostic findings on routine EEGs, prolonged EEG recordings and inpatient video-EEG monitoring significantly increase the rate of establishing a definitive diagnosis. Nonconvulsive status epilepticus in the elderly is especially difficult to diagnose and should be evaluated with an EEG. Treatment of SE is complicated by altered pharmacokinetics in the elderly. Initial treatments, usually the administration of an intravenous benzodiazepine, have overall success rates of 55% for overt convulsive SE and 14.9% for subtle SE. For refractory SE, little is gained by using additional standard drugs, and general anesthesia with continuous EEG monitoring is recommended.

Epilepsy Case Studies

Epilepsy is a common disorder affecting all age groups. Diagnosis depends on accurate eyewitness description and electroencephalography. Many genetic, metabolic, and structural perturbations of cortical function can cause seizures. MRI is the most important test for etiology. Medication selection is based on classification of seizure type and epilepsy syndrome, with consideration of patient age, gender, and comorbidities. Surgery is a good treatment for some patients who have medically refractory partial-onset seizures.

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.