Epilepsy in the elderly

Global trends and burden of idiopathic epilepsy: regional and gender differences from 1990 to 2021 and future outlook

BACKGROUND

Idiopathic epilepsy (IE) remains a significant neurological disorder, contributing to substantial global morbidity and mortality. This study aims to comprehensively evaluate the global burden of IE from 1990 to 2021, focusing on trends in incidence, mortality, and disability-adjusted life years (DALYs) across different geographic regions. Additionally, the study projects IE burden trends through 2036, providing insights for future public health interventions.

METHODS

Data were extracted from the Global Burden of Disease Study 2021 (GBD 2021). IE incidence, mortality, and DALYs were analyzed by age, sex, year, and geographic location. Age-standardized rates were computed to facilitate comparisons across countries and regions. Temporal trends in IE burden were evaluated using Joinpoint regression, while future trends were projected using the Bayesian age-period-cohort (BAPC) model.

RESULTS

In 2021, there were approximately 3.27 million new cases of IE globally (95% uncertainty interval [UI]: 2.4 to 4.13 million) and 140,000 deaths (95% UI: 120,000 to 150,000). Total DALYs reached 13.88 million (95% UI: 10.73 to 17.62 million). The global age-standardized incidence rate increased from 38.12 per 100,000 in 1990 to 42.82 per 100,000 in 2021. The Andean and Central Latin American regions exhibited the highest incidence rates, while East Asia and Oceania reported the lowest. Despite a decrease in the global age-standardized mortality rate from 2.07 per 100,000 in 1990 to 1.74 per 100,000 in 2021, mortality rates remained elevated in low- and middle-income countries, particularly in sub-Saharan Africa. Male patients showed consistently higher incidence, mortality, and DALY rates compared to females, with the highest burden observed in children under 5 years and adults over 60 years.

CONCLUSION

Over the past three decades, global IE incidence has steadily increased, while mortality and DALY rates have declined, especially in high-income countries. However, low- and middle-income regions continue to face significant challenges due to limited access to healthcare. Public health efforts must prioritize enhancing early diagnosis and treatment capabilities in these resource-limited areas.

[Influence of neurological diseases on mobility and ability to drive]

Neurology deals with organic diseases of the muscles, the peripheral nerves of the trunk and extremities, and the central nervous system (spinal cord, brain, stem, cerebellum, and cerebrum). Diseases that lead to dysfunction of these structures can cause both physical and cognitive problems. Therefore, neurological diseases can particularly impair personal mobility through both physical limitations and cognitive deficits. Many of the diseases show a significant increase in frequency with age.Physical impairments in mobility primarily manifest as gait disorders. These are found to a relevant extent in two-thirds of people older than 80 years of age and are a common cause of falls, often with considerable sequelae. Driving a car can have negative effects, for example, on reaction speed, braking power, and looking over the shoulder. Parkinson's disease as well as paralysis and sensory disorders in the context of polyneuropathies can be responsible for this.Driving a car is an obvious compensatory mechanism with respect to impaired walking ability. However, the cause of many diseases that affect the fitness to walk lies in the central nervous system, often in the area of the cerebrum. Consequently, cognitive deficits manifest themselves in addition to physical ones, which further restrict mobility through the loss of the fitness to drive. Neurological diseases typical of old age that limit mobility in this way include Parkinson's disease and circulatory disorders of the brain. In addition, epileptic seizures occur more frequently in old age as a symptom of other diseases.

Tackling seizures in patients with Alzheimer's disease

INTRODUCTION

In past years, a possible bidirectional link between epilepsy and Alzheimer's disease (AD) has been proposed: if AD patients are more likely to develop epilepsy, people with late-onset epilepsy evidence an increased risk of dementia. Furthermore, current research suggested that subclinical epileptiform discharges may be more frequent in patients with AD and network hyperexcitability may hasten cognitive impairment.

AREAS COVERED

In this narrative review, the authors discuss the recent evidence linking AD and epilepsy as well as seizures semeiology and epileptiform activity observed in patients with AD. Finally, anti-seizure medications (ASMs) and therapeutic trials to tackle seizures and network hyperexcitability in this clinical scenario have been summarized.

EXPERT OPINION

There is growing experimental evidence demonstrating a strong connection between seizures, neuronal hyperexcitability, and AD. Epilepsy in AD has shown a good response to ASMs both at the late and prodromal stages. The new generation ASMs with fewer cognitive adverse effects seem to be a preferable option. Data on the possible effects of network hyperexcitability and ASMs on AD progression are still inconclusive. Further clinical trials are mandatory to identify clear guidelines about treatment of subclinical epileptiform discharges in patients with AD without seizures.

[Non-convulsive status epilepticus manifesting as ictal catatonia: a case report]

A 66 year-old right-handed female was admitted to our hospital presenting with recurrent episodes of catatonic symptoms consisting of stupor, waxy flexibility, and catalepsy lasting about 5-20 minutes. A brain MRI showed no significant abnormalities. An scalp-electroencephalography (EEG) concurrent with the symptoms showed ictal EEG activities arising from the left fronto-central area, which evolved into the bilateral frontal and bilateral parietal areas together. An ¹⁸F-fluorodeoxy glucose positron emission tomography (¹⁸F-FDG-PET) 4 days after improvement of the symptoms showed hypermetabolism in the bilateral frontal and parietal lobes. Her catatonic symptoms are assumed to be due to non-convulsive status epilepticus (NCSE), namely ictal catatonia. The introduction of several anti-epileptic drugs improved the symptoms and normalized the EEG and FDG-PET findings. NCSE must be considered as one of the underlying state of catatonic symptoms because the treatment plan for acute and chronic state is different from that of catatonic syndrome due to psychiatric disorders.

[Epilepsy in old age]

In an aging society, epilepsy in old age will become a more and more relevant disease. The diagnosis is often difficult because of the frequent occurrence of focal seizures in old age, which are easily overlooked. The diagnosis is often delayed, particularly in older patients who, for example also suffer from dementia. The causes of the epilepsy can be manifold in the aging brain. Another challenge for neurologists is the medicinal treatment of geriatric epilepsy, as many anticonvulsive drugs can be associated with serious side effects and interactions. The evidence for the effectiveness and tolerability of anticonvulsive drugs in old age is insufficient, so that the choice of drugs must be made on an individual basis. Status epilepticus is a neurological emergency, which occurs not only more frequently in older than in younger persons but is also associated with a higher mortality, so that immediate diagnosis and adequate treatment is necessary.

Temozolomide and seizure outcomes in a randomized clinical trial of elderly glioblastoma patients

INTRODUCTION

Tumor-related epilepsy may respond to chemotherapy. In a previously-published multi-centre randomized clinical trial of 562 elderly glioblastoma patients, temozolomide plus short-course radiotherapy conferred a survival benefit over radiotherapy alone. Seizure outcomes were not reported.

METHODS

We performed an unplanned secondary analysis of this trial's data. The trial design has been previously reported. Seizures were recorded by clinicians as adverse events and by patients in quality of life questionnaires. A Chi-square test of seizure rates between the two groups (α = 0.05) and a Kaplan-Meier estimator of time-to-first self-reported seizure were planned.

RESULTS

Almost all patients were followed until they died. In the radiotherapy alone group, 68 patients (24%) had a documented or self-reported seizure versus 83 patients (30%) in the temozolomide plus radiotherapy group, Chi-square analysis showed no difference (p = 0.15). Patients receiving radiotherapy alone tended to develop seizures earlier than those receiving temozolomide plus radiotherapy (p = 0.054). Patients with seizures had shorter overall survival than those without seizures (hazard ratio 1.24, p = 0.02).

CONCLUSIONS

This study was not powered to detect differences in seizure outcomes, but temozolomide seemed to have minimal impact on seizure control in elderly patients with glioblastoma.

CLINICAL TRIAL REGISTRATION

NCT00482677 2007-06-05.

Epilepsy in the Elderly: Treatment and Consideration of Comorbid Diseases

Epilepsy is the third most common neurological disorder affecting older adults after stroke and dementia, and the incidence of epilepsy is increasing rapidly in this population. A further increase in the incidence and prevalence of epilepsy is expected in aging societies. The establishment of a correct differential diagnosis between epilepsy and other seizure disorders that are common in the elderly is crucial. The symptoms of seizures in the elderly may be different from those in younger populations. The diagnosis is difficult, probably because of nonspecific characteristics, short-term symptoms, and absence of witnesses. There are three important issues in the treatment of epilepsy in the elderly: changes in pharmacokinetic parameters, polytherapy (including non-antiepileptic and antiepileptic drugs), and susceptibility to adverse drug effects. Antiepileptic drugs (AEDs) with fewer adverse effects, including cognitive effects, and AEDs without significant pharmacokinetic drug interactions are needed. Several studies found that stroke was strongly associated with a high incidence of early seizures and epilepsy. Stroke is also one of the major causes of status epilepticus. Cortical involvement and large lesions are strongly associated with the development of seizures and epilepsy. The severity of the initial neurological deficit is a strong clinical predictor of seizures after ischemic stroke. The optimal quality of life of dementia patients cannot be achieved without a proper diagnosis of coexisting epilepsy.

New onset epilepsy in the elderly: clinical, radiological and electroencephalographic features and treatment responses

OBJECTIVE

To evaluate new onset epilepsy characteristics, etiology, radiological and electroencephalographic features and to document treatment response in the elderly.

METHODS

This was a retrospective study carried out in King Fahd Medical City, Riyadh, Kingdom of Saudi Arabia, from 2010 to 2013. Medical records were searched to recruit patients. Hundred and nineteen patients were enrolled who fulfill the inclusion criteria. Clinical data with respect to seizure semiology, etiology, electroencephalographic findings, radiological findings, co-morbidities, and anti-epileptic drug (AED) therapy were assessed.

RESULTS

Cerebrovascular disease was the most common etiology, followed by occult cerebrovascular disease (oCVD). Focal onset seizures were the most common clinical presentation in this group of cohort. Electroencephalogram (EEG) showed generalized slowing in majority of patients (45.5%), with 21.8% interictal epileptiform activity. Patients required lower doses of AEDs to control seizures, gain better seizure control. Common co-morbidities were hypertension and diabetes mellitus.

CONCLUSION

Patients presenting with LOE, should have search for any other cerebrovascular risk factors. Further research is needed to determine the prevalence of oCVD in LOE, and to investigate whether addressing cerebrovascular risk factors in this cohort of patients can reduce the incidence of stroke.

Association between ABCB1 genetic polymorphism and the effect on epilepsy following phenytoin treatment

The aim of the study was to analyze the effect of ABCB1 genetic polymorphisms on the efficacy of phenytoin (PHT) treatment in epilepsy patients. In total, 200 epilepsy patients who were administered PHT were divided into the responsive and pharmaco-resistance groups depending on the clinical data of PHT treatment in epilepsy patients. The serum concentration of PHT was detected by high-performance liquid chromatography (HPLC). ABCB1 polymorphisms were analyzed by the polymerase chain reaction restriction-fragment length polymorphism method. The C1236T, C3435T and G2677T/A haplotypes were reconstructed for the ABCB1 gene using SHEsis programs. One-way analysis of variance was used for data analysis. In ABCB1 C1236T, the rate of the CC genotype in pharmaco-resistance (17.5%) was higher than that of the responsive group (2.1%), while the rate of the TT genotype in pharmaco-resistance (41.6%) was lower than that of the responsive group (55.4%) (P<0.05). In ABCB1 G2677T/A, the rate of the GG genotype in pharmaco-resistance (29.6%) was higher than that of the responsive group (9.7%), while the rate of the TT genotype in pharmaco-resistance (4.6%) was lower than that of the responsive group (30.4%) (P<0.05). The rate of the TTC haploid in pharmaco-resistance (24.1%) was higher than that of the responsive group (8.8%) (P<0.05). The PHT serum concentration had no statistical significance in the patients with different genotypes. In conclusion, there was no association between ABCB1 genetic polymorphism and PHT serum concentration, although the polymorphisms affected the efficacy of PHT treatment in patients with epilepsy.

Prevalence and Incidence of Epilepsy in an Elderly and Low-Income Population in the United States

Background and Purpose

The purpose of this study was to estimate the incidence and prevalence of epilepsy among an elderly and poor population in the United States.

Methods

Arizona Medicaid claims data from January 1, 2008 to December 31, 2010 were used for this analysis. Subjects who were aged ≥65 years and were continuously enrolled in any Arizona Medicaid health plans (eligible to patients with low income) for ≥12 months between January 1, 2008 and December 31, 2009 were considered eligible for inclusion in the study cohort. In addition to meeting the aforementioned criteria, incident and prevalent cases must have had epilepsy-related healthcare claims. Furthermore, incident cases were required to have a 1-year "clean" period immediately preceding the index date. Negative binomial and logistic regression models were used to assess the factors associated with epilepsy incidence and prevalence.

Results

The estimated epilepsy incidence and prevalence for this population in 2009 were 7.9 and 19.3 per 1,000 person-years, respectively. The incidence and prevalence rates were significantly higher for patients with comorbid conditions that were potential risk factors for epilepsy and were of younger age than for their non-comorbid and older counterparts (p<0.05). The prevalence rates were significantly higher for non-Hispanic Blacks and male beneficiaries than for non-Hispanic Whites and female beneficiaries, respectively (p<0.05).

Conclusions

This patient population had higher epilepsy incidence and prevalence compared with the general US population. These differences may be at least in part attributable to their low socioeconomic status.

Raised activity of L-type calcium channels renders neurons prone to form paroxysmal depolarization shifts

Neuronal L-type voltage-gated calcium channels (LTCCs) are involved in several physiological functions, but increased activity of LTCCs has been linked to pathology. Due to the coupling of LTCC-mediated Ca²⁺ influx to Ca²⁺-dependent conductances, such as K_Ca or non-specific cation channels, LTCCs act as important regulators of neuronal excitability. Augmentation of after-hyperpolarizations may be one mechanism that shows how elevated LTCC activity can lead to neurological malfunctions. However, little is known about other impacts on electrical discharge activity. We used pharmacological up-regulation of LTCCs to address this issue on primary rat hippocampal neurons. Potentiation of LTCCs with Bay K8644 enhanced excitatory postsynaptic potentials to various degrees and eventually resulted in paroxysmal depolarization shifts (PDS). Under conditions of disturbed Ca²⁺ homeostasis, PDS were evoked frequently upon LTCC potentiation. Exposing the neurons to oxidative stress using hydrogen peroxide also induced LTCC-dependent PDS. Hence, raising LTCC activity had unidirectional effects on brief electrical signals and increased the likeliness of epileptiform events. However, long-lasting seizure-like activity induced by various pharmacological means was affected by Bay K8644 in a bimodal manner, with increases in one group of neurons and decreases in another group. In each group, isradipine exerted the opposite effect. This suggests that therapeutic reduction in LTCC activity may have little beneficial or even adverse effects on long-lasting abnormal discharge activities. However, our data identify enhanced activity of LTCCs as one precipitating cause of PDS. Because evidence is continuously accumulating that PDS represent important elements in neuropathogenesis, LTCCs may provide valuable targets for neuroprophylactic therapy.

[Epilepsy in the elderly]

BACKGROUND

Diagnostic work-up and treatment of patients who have developed epilepsy after the age of 65 can both be difficult. Epilepsy is one of the most common neurological conditions in the elderly, and the incidence of de novo geriatric epilepsy is rising. The aim of this review is to provide guidance on the management of epilepsy in this patient group.

METHOD

The review is based on a discretionary selection of original articles and reviews found in PubMed using the search term combination 'epilepsy' and 'elderly', and the authors' personal experience.

RESULTS

The seizures, which are most commonly of the focal type, are not infrequently overlooked or misdiagnosed. Cerebrovascular disease is the underlying cause of about half of the cases. When selecting an anticonvulsant, it is important to take age-related physiological changes and comorbidities into consideration. Because elderly patients have a narrower therapeutic window than younger persons and greater susceptibility to cognitive and other side effects, a low starting dose and slower dose titration are particularly important.

INTERPRETATION

The results of studies of young epilepsy patients cannot be extrapolated to apply to elderly patients. More studies directly targeting this patient population are therefore needed. As a general rule, we do not recommend starting on enzyme-inducing drugs such as phenytoin, phenobarbital and carbamazepine, partly because of their high interaction potential.

Seizures in Alzheimer disease: clinical and epidemiological data

Alzheimer disease (AD) and epilepsy are disorders commonly seen in the elderly. Many studies have shown that patients with AD are at increased risk for developing seizures and epilepsy. Whereas, patients with specific types of epilepsy, such as temporal lobe epilepsy (TLE), experience some degree of cognitive dysfunction, questions have been raised as to whether these disorders share some underlying pathophysiologic mechanisms or whether one is an epiphenomenon of the other. In this report, we review some of the available clinical and epidemiologic literature on various aspects of the topic of seizures in AD, including seizure rates and types, risk factors for seizures, electroencephalographic findings, treatment options, limitations, and methodological issues. Overall, multiple aspects of the literature on seizures and epilepsy in AD, including diagnosis, risk factors, the role of EEG in diagnosis, and the response to treatment are not clear and suffer from many methodological limitations and gaps.

Oxidative stress and epilepsy: literature review

Backgrounds. The production of free radicals has a role in the regulation of biological function, cellular damage, and the pathogenesis of central nervous system conditions. Epilepsy is a highly prevalent serious brain disorder, and oxidative stress is regarded as a possible mechanism involved in epileptogenesis. Experimental studies suggest that oxidative stress is a contributing factor to the onset and evolution of epilepsy. Objective. A review was conducted to investigate the link between oxidative stress and seizures, and oxidative stress and age as risk factors for epilepsy. The role of oxidative stress in seizure induction and propagation is also discussed. Results/Conclusions. Oxidative stress and mitochondrial dysfunction are involved in neuronal death and seizures. There is evidence that suggests that antioxidant therapy may reduce lesions induced by oxidative free radicals in some animal seizure models. Studies have demonstrated that mitochondrial dysfunction is associated with chronic oxidative stress and may have an essential role in the epileptogenesis process; however, few studies have shown an established link between oxidative stress, seizures, and age.

Lewy body and parkinsonian dementia: common, but often misdiagnosed conditions

BACKGROUND

Dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) are the two most common types of dementing neurodegenerative disease after Alzheimer's disease (AD). Both of these conditions are often diagnosed late or not at all.

METHODS

Selective literature review.

RESULTS

The severe cholinergic and dopaminergic deficits that are present in both DLB and PDD produce not only motor manifestations, but also cognitive deficits, mainly in the executive and visual-constructive areas, as well as psychotic manifestations such as visual hallucinations, delusions, and agitation. The intensity of these manifestations can fluctuate markedly over the course of the day, particularly in DLB. Useful tests for differential diagnosis include magnetic resonance imaging and electroencephalography; in case of clinical uncertainty, nuclear medical procedures and cerebrospinal fluid analysis can be helpful as well. Neuropathological studies have revealed progressive alpha-synuclein aggregation in affected areas of the brain. In DLB, beta-amyloid abnormalities are often seen as well.

CONCLUSION

DLB should be included in the differential diagnosis of early dementia. If motor manifestations arise within one year (DLB), dopaminergic treatment should be initiated. On the other hand, patients with Parkinson's disease should undergo early screening for signs of dementia so that further diagnostic and therapeutic steps can be taken in timely fashion, as indicated. Cholinesterase inhibitors are useful for the treatment of cognitive deficits and experiential/behavioral disturbances in both DLB (off-label indication) and PDD (approved indication).

Medicolegal assessment of the ability to drive a motor vehicle in persons with epilepsy

BACKGROUND

Determining whether a patient with epilepsy ought to be allowed to drive a motor vehicle is a challenging matter for the physician. This situation is fraught with medicolegal uncertainties, not just for general practitioners, but also for specialists and occupational health physicians.

METHODS

A case is reported and discussed in the light of a selective review of the literature and the German medicolegal assessment guidelines for the determination of the ability to drive a motor vehicle.

RESULTS

The risk associated with driving can be estimated as a function of the type of epilepsy from which the patient suffers and of the frequency of seizures. The expert can then express an opinion on the basis of this assessment, within the framework of the German medicolegal assessment guidelines and the German Driver Licensing Act ("Fahrerlaubnisverordnung"). There is no general duty of physicians to report a patient's unsuitability for driving a motor vehicle, but physicians have a right to report to the authorities that a patient should not be allowed to drive when the patient fails to comply with a recommendation not to drive and when a higher legally protected interest is at risk.

CONCLUSIONS

The drawbacks of secondary prevention, as illustrated by the case presented here, could be minimized if the treating physician took the patient's occupational history and gave the relevant advice early on in the course of the patient's illness. Likewise, early counseling about driving would lessen the need for physicians to tell the authorities that patients should not drive in cases where the public interest overrides the patient's right to confidentiality.

Clinical findings in the chronic phase of traumatic brain injury: data from 12 years' experience in the Cognitive Neurology Outpatient Clinic at the University of Leipzig

BACKGROUND

There are many unresolved issues in the diagnosis and treatment of persons with traumatic brain injury (TBI) in its post-acute and chronic phases. This article deals with two problems of clinical importance: (i) the interrelationships between structural brain damage, brain function, and clinical outcome, and (ii) post-traumatic epilepsy.

METHODS

Exploratory, retrospective analysis of clinical, neuroradiological (MRI), and neuropsychological data of all patients with TBI who were treated in a cognitive neurology outpatient clinic of a German university hospital over a period of 12 years (n=320).

RESULTS

156 patients (48.8%) had brain contusions, 83 of them (25.9%) as the sole neuroradiological abnormality. Traumatic micro-hemorrhages were seen in 148 patients (46.2%) and were the sole neuroradiological abnormality in 79 of them (24.7%). 49 patients (15.3%) had no structural brain lesion. There was no obvious correlation between the neuroradiological findings and the clinical outcome, as measured either by a general outcome parameter such as the extended Glasgow Outcome Scale (GOSE) or by neuropsychological testing. 47 patients (14.7%) had post-traumatic epilepsy; its occurrence was positively correlated with the presence of brain contusions, but not with an isolated diagnosis of diffuse axonal injury (DAI).

CONCLUSION

A comparison of the findings of neuroradiological studies and neuropsychological tests among patients in the chronic phase of traumatic brain injury does not reveal any simple relationship between structural and functional brain abnormalities. Diffuse axonal injury is often present in combination with other findings, and it may well be the only structural abnormality in many cases; therefore, all symptomatic patients should undergo MRI of the brain. Patients with isolated DAI seem to be less prone to post-traumatic epilepsy than those with brain contusions.