Article In Brief
Seizures in older adults often are more subtle than those experienced by younger people, so patients, caregivers, and even physicians may not detect them. However, diagnosing and treating seizures in older people is imperative because it could stave off cognitive decline. The neurologists interviewed here are developing multidisciplinary approaches to diagnosing and treating seizure in this complex population of patients.
As the incidence of seizures in older adults increases, pioneering neurologists are developing multidisciplinary approaches to diagnosing and treating a population of patients who have complex needs.
“We need specialized clinics for this population and people who are interested in it,” said Rebecca O’Dwyer, MD, an epileptologist who runs a clinic for older adults at Rush University Medical Center in Chicago. “And we also have to educate our general neurology colleagues and our geriatricians, because they may be treating patients for something else when actually they are having seizures.”
One in four newly diagnosed patients with epilepsy in the US is 65 or older, but many patients who have seizures in that age range are not diagnosed. Seizures in older adults often are more subtle than those experienced by younger people, so patients, caregivers, and even physicians may not recognize they are happening.
Diagnosing and treating seizures in older people is important because it could stave off cognitive decline, said Edward Faught, MD, FAAN, professor of neurology at Emory University School of Medicine. “There is evidence that controlling seizures in older people improves memory,” he said. “In fact, if they’re associated with Alzheimer’s disease, controlling the seizures may slow the decline in cognition in Alzheimer’s disease.”
The International League Against Epilepsy’s Epilepsy in the Elderly Task Force, which Dr. Faught chaired from 2017 to 2021, is preparing a report on what is known–and the many unknowns–about epilepsy in older adults. “It’s like a call to arms,” said Dr. O’Dwyer, director of the residency program in the department of neurological sciences at Rush Medical College. “It’s time to start doing original research.”
Challenges at Hand
In interviews with Neurology Today, epileptologists who work with older adults said the key to better treatment for these patients is greater awareness. “Most neurologists are aware that older people can have seizures, but I think there is a misperception that they are not as common as they really are,” Dr. Faught said.
The overlap between seizures and other neurologic problems is significant and complex, said Rohit A. Marawar, MD, assistant professor in the department of neurology and program director of the adult epilepsy fellowship training program at Wayne State University. Stroke, tumors, trauma, and neurodegenerative disorders, including dementias, are common causes of seizures in patients with epilepsy.
While stroke is the most common cause of seizures in older adults, a patient with a new-onset seizure who has not experienced a stroke has a high risk of doing so within four weeks of their first seizure, Dr. O’Dwyer said.
There is some debate among experts about how to treat acute symptomatic seizures that occur shortly after stroke—for example, whether these seizures warrant prescribing antiseizure drugs, which can have a lot of side effects. Clinicians at Rhode Island Hospital, Cleveland Clinic, Massachusetts General Hospital, University of North Carolina, and Yale University are working together as part of the Post-acute Symptomatic Seizure Investigation and Outcomes Network (PASSION), to sort this out. They are tracking outcomes of patients who are prescribed antiseizure medication because they had one seizure soon after a stroke, tumor, or other acute brain injury.
“There is a high rate of prescription of antiseizure medication, but not everybody develops epilepsy,” said Monica Dhakar, MD, MS, assistant professor of neurology at the Warren Alpert Medical School of Brown University. “We are looking at the best practices for the optimal duration of treatment or discontinuation of medication in this specific population who may or may not develop epilepsy.”
Alzheimer’s disease and Lewy body dementia also have a complicated association with seizures. Both are risk factors for seizures but, in some cases, treating the seizures limits the dementia. “I like to think of epilepsy in older individuals as a curable form of dementia,” Dr. O’Dwyer said. “Because we know that when older people have more frequent seizures, they decline cognitively, and they decline faster than younger individuals.”
She and other epilepsy specialists told Neurology Today that older adults who have seizures often experience focal seizures—brief staring spells without muscle movements or convulsions. “So, it’s easy to confuse a brief spell of inattention in an older person with a memory lapse or even a transient ischemic attack,” Dr. Faught said. “Any older person who has periods of inattention should be evaluated for the possibility of seizures.”
Dr. O’Dwyer’s colleagues sometimes refer patients who appear to have dementia but the diagnosis is not confirmed by cognitive testing. If an EEG shows “rhythmic slowing” that indicates neuronal dysfunction in a particular region of the brain, she prescribes an antiseizure medication on a trial basis.
“This has happened to me several times now—the family will come back and say, ‘Hey, my mom is back again. She’s back to herself,’” she said. “The patient was misdiagnosed with dementia, but the problem was actually seizures.”
But EEG is not always a reliable diagnostic tool for older patients. The routine EEG used to diagnose epilepsy may not be useful with older adults because it has low sensitivity to identify interictal epileptiform discharges. One study found that 24-hour ambulatory EEG showed interictal epileptiform dischanges in 50 percent of patients, although routine EEG had noted no discharges. Scalp EEGs are less sensitive for recording interictal abnormalities in patients aged 65 years and older.
“Because of the anatomy and the physiology of an older brain, the EEG probably is not the best way to detect seizures and we have a clinical picture that is also not the typical clinical picture for epilepsy in younger adults,” said Dr. O’Dwyer, who is working to develop non-invasive diagnostic methods to identify epilepsy in older adults. “So we have a conundrum right now.”
Lack of Access to Neurologists.
When Ilo E. Leppik MD, FAAN, an epilepsy specialist at UMP Epilepsy Care Minneapolis, and colleagues conducted a study of nursing home residents in the Minneapolis/St. Paul area, they found that nearly 10 percent were taking antiseizure medications. That led to a national study of nearly 1.2 million nursing home residents, revealing that, in 2007, 7.7 percent of residents had been diagnosed with seizures or epilepsy.
Despite that high prevalence, Dr. Leppik is the only neurologist member of the American Medical Directors Association, the professional association for clinicians who treat patients in long-term care facilities.
“In a nursing home setting, you just don’t get neurologist consultations so these diagnoses and decisions regarding treatment are being made by geriatricians, most of whom are general practitioners,” said Dr. Leppik, a professor of pharmacy and neurology at the University of Minnesota.
Lack of Age-Specific Best Practices
The therapeutic dose for seizure control in older adults is much lower than that for younger patients, Dr. Marawar said. “And side effects can lead to falls, hospital admissions, and non-adherence because people might just stop taking their medications because they’re having side effects.”
Clinical trials frequently exclude older people because of comorbidities, so the efficacy and safety of antiepileptic drugs (AEDs) is often unknown. “We found that only 3 percent of all clinical trials for AEDs were specifically designed to study older people with epilepsy,” Dr. Marawar said.
Because of that, clinicians, even epileptologists, who focus on older adults, do not agree about the best drugs or dosages to use, Dr. O’Dwyer said.
“We are still at this level where we’re telling our stories to each other–that’s why we really need clinical trials,” she said. “You can’t just say ‘Oh, old people are just old adults.’ We don’t treat children like ‘little adults’—older adults are their own population, and they need to be treated as such.”
New Clinics Emerge
Patients treated at Rush University Medical Center’s epilepsy clinic for older adults see a three-person team: Dr. O’Dwyer, a pharmacist, and a social worker.
Dr. O’Dwyer, who completed a Donald W. Reynolds Foundation mini-fellowship in geriatrics at the University of California, Los Angeles, developed the clinic four years ago to meet the complex needs of older patients she sees. Many live alone or are dependent on others to help with their care, which can involve frequent medical appointments and many medications.
The social worker visits with the patients to identify and address any barriers to complying with a treatment plan and ensures they have a strong social support system, and the pharmacist reviews all the medications they are taking, looking for possible drug interactions and side effects.
“Then the three of us huddle and we make a game plan,” Dr. O’Dwyer said. “The pharmacist is helpful with suggesting dosing regimens that could minimize side effects. I think the patients like the set-up because they feel like, ‘Oh, she wants me to take this med, but the pharmacist is going to make sure there are no interactions, and the social worker will help me make sure I can get it.”
While few institutions are ready to replicate Rush’s clinic for older adults, many epileptologists who work with older patients recognize the need for a multidisciplinary approach to their care, Dr. Faught said.
“The clinic that she runs is probably unique,” Dr. Faught said. “What we hope to do–here as well as other neurologists around the country–is to develop strong ties with our stroke and cognitive neurology groups, so that we can jointly evaluate people that are at higher risk for seizures.”
In Detroit, Dr. Marawar’s clinic serves patients ages 55 and older. “The population that we serve is predominantly African American and low socioeconomic status with multiple comorbidities and polypharmacy,” he said. “It’s possible that dementia starts earlier in this population, so we needed to pre-empt the usual 65-age cut-off for older adults and start earlier.”
At every visit, a patient meets first with a dedicated pharmacist who reviews medications. Patients often are taking medications that interact with AEDs that, after consulting with their other physicians, might be safely discontinued.
“I realized that, with all of these complex aspects to consider, I needed another expert to guide their pharmaceutical care,” he said.
Dr. Marawar hopes to eventually add a social worker to his clinic and a person to conduct neuropsychological testing. At least 60 percent of his patients have some form of cognitive impairment but have not previously been diagnosed; many of them have dementia. Referring them for neuropsychological evaluation means weeks of delay in getting a diagnosis, and that is if the patient can remember the appointment and overcome transportation and other barriers to keeping it. Therefore, same-day confirmation and diagnosis of cognitive impairment with neuropsychological testing is invaluable, he said.
SOURCE: journals.lww.com, Lola Butcher