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.     

Epidemiological and medical aspects of epilepsy in the elderly

Both the incidence and prevalence of epilepsy are high among the elderly. Cerebrovascular disease is the most common underlying cause, although as many as 25-40% of new epilepsy cases in the elderly have no obvious underlying etiology. Status epilepticus appears to occur more frequently in individuals greater than 60 years, and the morbidity and mortality of status epilepticus are significantly greater in this age group. Elderly patients with seizures, particularly complex partial seizures, present differently than younger adults, which can lead to misdiagnosis. Post-ictal confusion may last as long as 1-2 weeks in an elderly patient, as opposed to minutes in younger individuals. Adverse events are similar in symptomatology, but are more common in elderly patients and occur at lower doses and plasma drug concentrations. Neuropsychiatric disorders, such as depression and anxiety, are common in elderly patients with epilepsy, although often under-diagnosed and inadequately treated. The risk of osteoporosis is high among elderly women taking antiepileptic drugs, which underscores the importance of assessing bone health and treatment in this group. Management of the older patient with epilepsy requires an understanding of the etiologies and the medical and psychological aspects unique to this age group.     

Treatment and management of epilepsy in the elderly demented patient

Epilepsy and seizures are more frequent in the elderly population than in any other age group. The number of individuals older than 65 is constantly increasing, and dementia is a process that predominantly affects this age group. Several studies have shown that dementia is an important risk factor for developing seizures and epilepsy. Seizure semiology in the elderly demented might differ from that of younger age groups and diagnosis can be complicated further by the variety of other causes of transient changes of alertness and behavior that affects these patients. The pharmacokinetic changes of antiepileptic drugs in the elderly make this group a major therapeutic challenge. Side effects and drug interactions play a major role in the choice of antiepileptic agents. This review intends to summarize the existing data to see whether this can help guide the clinician in the treatment and management of epilepsy in the elderly patient with dementia. Nonpharmacologic therapeutic options are also briefly considered.     

Epilepsie im Alter

Abstract The elderly are the most rapidly growing section of the population in modern industrialized countries. The incidence of single unprovoked seizures reaches 150–200 at the age of 80 years and the prevalence of active epilepsy in the elderly is around 1–1.5%. Yet, the burden of epilepsy in the very old is not well characterized. Elderly patients often have concomitant neurodegenerative, cerebrovascular, or neoplastic disease, for which they might take multiple drugs. The clinical features of the epileptic seizures and those of syncope in the elderly might differ from younger people, and the EEG might be less sensitive for epileptiform discharges hindering diagnosis. However, seizure semiology is largely unknown and syndrome diagnosis too rarely achieved in this age group. In particular, the frequency of nonepileptic, psychogenic seizures might be underestimated. With advancing age there are drastic changes in drug absorption, disposition, and binding in addition to an increased drug sensitivity hampering antiepileptic treatment. This review examines the epidemiology, clinical appearance, pitfalls of diagnosis, and management of epilepsy in the elderly.      

Epilepsy Characteristics and Clinical Outcome in Patients With Mitochondrial Encephalomyopathy,Lactic Acidosis,and Stroke-Like Episodes (MELAS)

BackgroundEpileptic seizures in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) are heterogeneous with no pathognomonic features. We reviewed epilepsy characteristics and clinical outcome exclusively in a pediatric population.MethodsTwenty-two children and adolescents (13 males) with confirmed mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes due to mitochondrial DNA A3243G mutation and epilepsy were recruited. Clinical data including seizure semiology, treatment response, neuroimaging findings, and electroencephalography were analyzed. We also examined the effect of the age at seizure onset and initial symptoms on the clinical variables.ResultsSeizure semiology and electroencephalography abnormalities showed no syndrome-specific findings. Focal seizures occurred in 21 of 22 subjects (95.5%), whereas generalized seizures developed in seven of 22 subjects (31.8%). Twenty of 22 subjects (90.9%) achieved partial to complete reduction of clinical seizures for more than one year with a combination of more than two antiepileptic drugs. The subgroup with earlier seizure onset presented significantly earlier and showed significantly higher rates of drug-resistant epilepsy compared with the late onset group, although there were no significant differences in the initial symptoms. The subjects with severe epileptic conditions tended to have more severe clinical dysfunction and more severe organ involvement.ConclusionsBoth focal and generalized seizures occurred in patients with MELAS. Epilepsy in this population is drug resistant, but a certain degree of clinical seizure reduction was achievable with antiepileptic drugs, with more favorable outcomes than historically expected. Close observation and active epilepsy treatment of individuals with MELAS episodes and earlier seizure onset might improve the prognosis.     

Safety and tolerability of oxcarbazepine in elderly patients with epilepsy

Despite the high incidence of seizures and epilepsy in the elderly, the tolerability and safety of anticonvulsants are rarely evaluated in this patient population. We compared the safety and tolerability of oxcarbazepine in a cohort of 52 patients aged 65 years and older and a group of 1574 adult patients ranging in age between 18 and 64 years. There was no significant difference between the two groups with respect to premature discontinuation due to adverse events. The four most common adverse events experienced by patients in the elderly group, irrespective of their causal relationship to oxcarbazepine, were vomiting (19%), dizziness (17%), nausea (17%), and somnolence (15%). Three patients developed an asymptomatic hyponatremia, with at least one serum sodium level below 125mEq/L. Elderly patients on concomitant natriuretic drugs were significantly more likely to develop serum sodium levels below 135mEq/L. The results indicate that oxcarbazepine is safe to use in elderly patients and that its tolerability in this age group is similar to that of younger adult patients.     

Epilepsy in a rural elderly population.

PURPOSE: The first goal of this study was to describe the characteristics of elderly patients with epilepsy and the antiepileptic drugs used to treat them. Next, the factors (such as epilepsy type, seizure frequency, medical comorbidities, etc.) influencing antiepileptic drug choice and living situation were explored. METHODS: Retrospective chart review of patients older than 70 with epilepsy seen in a rural health care system. This yielded 449 patients with epilepsy, 54 patients with isolated seizures and 38 patients with syncope as the primary diagnosis. RESULTS: The most commonly used antiepileptic drug was phenytoin. New generation AED's which had fewer side effects were used much less frequently than old generation AED's but the probability of using new generation AED's was increased in patients with renal failure and congestive heart failure as well as in patients that had seen a neurologist. Patients with acute symptomatic seizures, dementia, chronic obstructive pulmonary disease, frequent seizures and advanced age were less likely to be independent. Patients that had seen a neurologist as an outpatient were more likely to live independently. CONCLUSIONS: The elderly are a vulnerable population because of difficulty communicating their symptoms and their needs. This leads to the suboptimal use of AED's as well as poor outcomes. Careful attention to seizure control and medication side effects is critical in promoting good outcomes in this patient group. This retrospective study suggests that access of elderly patients with epilepsy to specialty care improves outcomes in terms of living status. This important information needs to be confirmed by prospective studies.     

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.     

The value of EEG in the investigation of postapoplectic epilepsy

During the 5 years 1979-1983 61 patients within the county of Frederiksberg developed postapoplectic seizures after the age of 60. Of these patients EEG was performed on 48. These EEG's were compared to the EEG's from 25 patients of the same age with epilepsy due to cerebral tumors 33 patients with acute stroke and 24 patients with stroke sequelae who had not experienced seizures. Slow wave activity and foci were seen more often among patients with acute stroke than among patients with postapoplectic seizures whereas paroxysmal activity occurred less often in patients with acute stroke than among patients with postapoplectic seizures patients with stroke sequelae and patients with seizures due to cerebral tumours. Patients with stroke sequelae with proven hemispheric localization had focal abnormalities more often than patients with postapoplectic seizures but apart from this EEG difference between patients with postapoplectic seizures and patients with stroke sequelae or seizures due to brain tumours were not found. In 12 of the patients with postapoplectic seizures and in 20 of the patients with stroke sequelae without seizures EEG at the time of the acute stroke was available. Differences between patients with and patients without seizures were not found neither at the time of the acute stroke nor at the time of readmission due to stroke sequelae or due to onset of seizures. It is concluded that a routine EEG is without value in the diagnosis of postapoplectic seizures in the elderly.     

Pathogenesis of epileptic seizures and epilepsy after stroke

Stroke is an important cause of seizures and epilepsy in adults, particularly among the elderly. The incidence of stroke increases yearly as life expectancy increases and the number of patients with post-stroke seizures and epilepsy is also rising. Post-stroke epilepsy accounts for nearly 50% of newly diagnosed epilepsy among patients over 60 years of age. With increasing stroke awareness and advanced treatments, increased attention is paid to post-stroke seizures and epilepsy including its diagnosis and treatment. There has been a plethora of research on the pathogenesis of seizures and epilepsy after stroke. And thus, the research advances in the pathogenesis and related therapeutic targets of post-stroke seizures and epilepsy will be reviewed in this article.     

Epilepsy in the Elderly: The Use of Tiagabine

Summary: The incidence of epilepsy increases sharply in patients older than 60 years. There is a clear need for clinical trials designed specifically for this age group, as elderly patients differ from younger patients with epilepsy with respect to seizure etiology, coexisting diseases, concomitant drug therapy, and drug disposition. The new antiepileptic drugs (AEDs) are often associated with fewer side effects than are the traditional AEDs and may be particularly useful in the elderly. The pharmacokinetics of tiagabine (TGB) are not significantly modified in elderly patients, although elimination is more rapid in the presence of enzyme-inducing AEDs. Efficacy and tolerability data on TGB in elderly patients is currently limited, and a formal trial of TGB monotherapy in this age group is needed.     

Is epilepsy in the elderly overlooked? An investigation in a home for the aged

The symptoms of epileptic seizures in old patients differ from those in younger patients. Therefore, these seizures may be misinterpreted as symptoms of other "typical" diseases in old people. In an old people's home, we assessed whether a standardized questionnaire is able to reveal undiagnosed epilepsy in the elderly. Reported sudden falls, loss of consciousness, and cramps were the criteria for further diagnostic procedures. We found epilepsy in 11 of 389 study participants. In four of them (1% of the total sample), the epilepsy was newly diagnosed; five more cases remained unclear. Therefore, the total number of epileptic patients might have been even higher. Most of the reported sudden falls and unconsciousness (89%) were due to internal medical or other neurological or orthopaedic causes. Once these have been excluded, the diagnosis of epilepsy should be considered. The results of our pilot study suggest that epilepsy in old people's homes is often unrecognised. Early diagnosis and treatment of epilepsy in the elderly is important to improve prognosis and social consequences for affected persons.     

Prevalence and Prognosis of Epilepsy in Patients with Multiple Sclerosis

An analysis of 599 clinically definite multiple sclerosis (MS) patients including all known cases of the southern province of Finland in January 1, 1979 revealed epileptic seizures in 21 (3.5%) patients. On that date, 12 patients needed treatment (2.0%). The age-adjusted prevalence of active epilepsy was significantly higher than that in the general population. The percentage of partial seizures (67%) was significantly increased in proportion to a series of 100 adult epilepsy patients, with a comparable age distribution. In 10 patients (including three patients with symptomatic epilepsy), the attacks appeared before the MS symptoms. The mean follow-up after the first seizures was 19.3 years. In 10 patients, the seizures disappeared totally during the surveillance until September 1985. Our results show an increased comorbidity between MS and epilepsy. In most cases, however, the prognosis of epilepsy was good and there seemed not to be any clear correlation between the severity of MS and epilepsy.     

A comparison of adult onset and "classical" idiopathic generalised epilepsy

OBJECTIVES: To report the characteristics of a population of patients with idiopathic generalised epilepsy (IGE) with age of onset over 20 years, and compare them with patients with "classical" IGE. METHODS: Data were collected from a computerised database of all patients with IGE attending a regional adult epilepsy clinic. Demographic data, epilepsy characteristics, and treatment outcomes were recorded. RESULTS: 72 patients with IGE of a total population of 844 had an age of onset over 20 years (8.5%). There was similar incidence of family history of epilepsy, EEG findings, and remission rates between those with a younger and older age of onset of IGE. There was a lower incidence of previous febrile convulsions in patients with adult onset. There were fewer patients with absence seizures in the adult onset group (15.3% v 46.4% in the "classical" group). CONCLUSIONS: IGE with onset later than the third decade was rare in the population studied. Prolonged EEG in selected patients may be helpful in diagnosing adult onset IGE, but the diagnosis of epilepsy remains clinical. Adult onset IGE shares many features with "classical" IGE, including EEG findings and prognosis, and is likely to represent a genetic epilepsy.     

Epilepsy treatment in adults and adolescents: Expert opinion, 2016

Introduction: There are over twenty anti-seizure medications and anti-seizure devices available commercially in the United States. The multitude of treatment options for seizures can present a challenge to clinicians, especially those who are not subspecialists in the epilepsy field. Many clinical questions are not adequately answered in double-blind randomized controlled studies. In the presence of a knowledge gap, many clinicians consult a respected colleague with acknowledged expertise in the field. Our survey was designed to provide expert opinions on the treatment of epilepsy in adults and adolescents.Method: We surveyed a group of 42 physicians across the United States who are considered experts based on publication record in the field of epilepsy, or a leadership role in a National Association of Epilepsy Centers comprehensive epilepsy program. The survey consisted of 43 multiple-part patient scenario questions and was administered online using Redcap software. The experts provided their opinion on 1126 treatment options based on a modified Rand 9-point scale. The patient scenarios focused on genetically-mediated generalized epilepsy and focal epilepsy. The scenarios first focused on overall treatment strategy and then on specific pharmacotherapies. Other questions focused on treatment of specific patient populations (pregnancy, the elderly, patients with brain tumors, and post organ transplant patients), epilepsy patients with comorbidities (renal and hepatic disease, depression), and how to combine medications after failure of monotherapy. Statistical analysis of data used the expert consensus method.Results: Valproate was considered a drug of choice in all genetically-mediated generalized epilepsies, except in the population of women of child-bearing age. Ethosuximide was a drug of choice in patient with absence seizures, and levetiracetam was a drug of choice in patients with genetic generalized tonic-clonic seizures and myoclonic seizures. Lamotrigine, levetiracetam and oxcarbazepine were considered drugs of choice for initial treatment of focal seizures. Lamotrigine and levetiracetam were the drugs of choice for women of child-bearing age with either genetic generalized epilepsy or focal epilepsy. Lamotrigine and levetiracetam were the drugs of choice in the elderly population. Lamotrigine was preferred in patients with co-morbid depression. Levetiracetam was the drug of choice in treating patients with hepatic failure, or who have undergone organ transplantation. Compared to the 2005 and 2001 surveys, there was increased preference for the use of levetiracetam and lamotrigine, and decreased preference for the use of phenytoin, gabapentin, phenobarbital and carbamazepine.Discussion: The study presented here provides a “snapshot” of the clinical practices of experts in the treatment of epilepsy. The experts were very often in agreement, and reached consensus in 81% of the possible responses. However, expert opinion does not replace the medical literature; instead, it acts to supplement existing information. Using the study results is similar to requesting an expert consultation. Our findings suggest options that the clinician should consider to achieve best practice.     

Clinical and etiological profile of epilepsy in elderly: a hospital-based study from rural India

To determine the clinical profile and etiology of epilepsy in elderly patients in rural population of India which is in a phase of demographic transition with steadily growing geriatric population. A cross-sectional, prospective, hospital-based clinicoepidemiological study was performed from October 2014 to November 2015. Patients having onset of epilepsy after 60 years were incorporated in the study. We excluded the acute symptomatic seizures. One hundred and ten patients were enrolled and were divided into three standard subgroups: subgroup A (aged 60–70), subgroup B (aged 71–80), and subgroup C (aged 81–90). Out of 110 patients, 72 (65.45%) were male and 38 (34.54%) were female. The most common etiology was cerebrovascular disease (46.36%), followed by focal cerebral calcifications single or multiple (11.81%), tumors (9.09%), trauma (6.36%) dementias (6.36%) and unknown (16.63%). In our study, the frequency of epilepsy decreases with advancing age which was 77.27% in group A (less than 70 years), 16.36% in group B and 6.36% in group C (70–90 years).The most common type of seizure in the group studied was focal 59.09% followed by generalized seizures 37.27%. Hypertension was the most common co-morbidity found in 40 (36.36%) patients. The present study proposes that epilepsy in the elderly patients have etiological relationship with stroke, focal cerebral calcifications, tumors and dementias. CNS infections account for a significant number of cases of remote symptomatic epilepsy in elderly in our region where neurocysticercosis is endemic.     

Epilepsy in a population of 6000 re-examined: secular trends in first attendance rates, prevalence, and prognosis.

It is important to document changes in the vital statistics of epilepsy in the general population so that the success or failure of prevention and treatment can be assessed and health provisions planned. A population of 6000 persons was studied 10 years apart to determine secular trends in the prevalence and prognosis of epilepsy. The lifetime prevalence of all patients with one or more afebrile seizures was 20.3/1000 (95% CI 16.9-24.3) in 1983 and 21.0/1000 (95% CI 17.6-25.1) in 1993. The prevalence of active epilepsy was 5.3/1000 (95% CI 3.6-7.5) in 1983 and 4.3 (95% CI 2.8-6.3) in 1993. To assess trends in incidence rates the annual first attendance rates were measured from 1964 to 1993. Annual first attendance rates in children (age < 20 years) have declined from 152.4/100,000 (90% CI 106.0-212.9) in the years 1974-83, to 60.9/100,000 (90% CI 33.0-103.3) in the years from 1984-93, suggesting that the incidence of epilepsy in children is falling. Also noteworthy was the first attendance rates for epilepsy in elderly people (61-80 years) in the years 1984-93, of 82.0 (90% CI 38.5-154.0), higher than in any other age group. This increase in the number of elderly patients with epilepsy is important, and has health planning implications, especially with the overall increase in the total elderly population. There was, however, no evidence that prognosis has significantly altered in the past 40 years.     

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.     

Epilepsie im Alter

Epilepsies frequently only start in old age and given the current demographic trend the prevalence of epilepsy in the elderly population will increase. This article summarizes the most relevant aspects of diagnosis and therapy in elderly patients with epilepsy. Guidelines, systematic reviews or meta-analyses are lacking and there are only three randomized controlled trials of epilepsy in the elderly. Clinically, seizures in the elderly may be missed since warning signs (auras) and seizure evolution into generalized tonic-clonic seizures are rarer in older people. Sudden loss of consciousness occurs more frequently with increasing age and poses a challenge for the differential diagnosis. Therapy is more complex due to frequent comorbidity and multiple drug therapy necessitating a cautious approach. Therapy is hampered by side effects and drug interactions making a definite diagnosis indispensable and requiring the use of newer generation antiepileptic drugs. In case of doubt, to ensure a safe diagnosis long-term video EEG should be considered even in the elderly before hazarding the negative consequences of a misdiagnosis for years.