Seizures and epilepsy increase in prevalence after age 60. For various reasons, elderly patients are more prone to develop epilepsy. And, because of their age, may need modifications in treatment and/or require special attention to issues of independence and safety. This is all the more urgent because the elderly are the most rapidly growing segment of the population.
This is what the pattern of new cases of epilepsy looks like – high on the left, in infancy and early childhood, lower in the middle, which represents adult life, and high again on the right hand side after 60. Approximately 25% of new cases of epilepsy occur in men and women over the age of 60. Seizures are now the third most frequently encountered neurologic problem in the elderly population. The most common is stroke followed by dementia. By age 80, nearly 10 percent of Americans will have experienced at least one seizure.
Even healthy older people have a lower threshold for seizures – that is, their brains are more susceptible to situations that lead to seizures. In younger people, the causes of epilepsy are often unknown. In the majority of cases in older people who develop epilepsy, a cause can be identified. Stroke is the leading cause of new cases of epilepsy in elderly people. Among those developing epilepsy after age 65, the most common causes were cerebrovascular disease (33%), degenerative disorders such as Alzheimer’s (11.7 %) and brain tumors (4.5%) Epilepsy is also common among those with Alzheimer’s disease, occurring in about 10%. It’s much higher in people with Down’s syndrome who develop early Alzheimer’s (after the age of 50), amounting to 75-85% of those individuals.
It’s easy to see from this slide that for nearly 3 out of 4 people over 60 with epilepsy, their seizures are partial seizures – either complex partial which affects awareness and produces episodes of automatic, uncontrolled behavior, or simple partial which may affect movement and sensation. The rest are generalized convulsions (tonic clonic) or massive muscle jerks (myoclonic). All types of seizures pose special challenges in caring for the elderly patient with epilepsy.
Complex partial seizure symptoms often include staring, twitching of the face, chewing movements of the mouth, mumbling, compulsion to move, unresponsiveness and lost time during the seizure. Easy to ascribe these to poor hearing, lack of muscle control, memory loss, diminished intellectual ability – all of which may be misinterpreted as just part of aging or reaction to medications. Because memory is affected during complex partial seizures, the patient is often bewildered by what just took place and cannot explain the symptoms and may deny that anything happened.
If an otherwise alert and aware patient experiences sudden changes in behavior, is unresponsive for a brief time, and then experiences a period of confusion that lasts only a relatively short time, it’s a good idea to consider the possibility that a seizure is the cause. However, it is also possible for an elderly patient to be confused for an extended period of time following a seizure, which can include memory loss, increase in speech difficulties (aphasia), and cognitive decline. Auras, the change in feelings or sensations that precedes a more extensive seizure, may be described by the elderly in various ways, depending on how it’s experienced. The seizure itself is more likely to alter thinking, or produce periods of staring, unresponsiveness or blackouts. Episodic changes and confusion should receive a medical evaluation by a physician with expertise in geriatrics or epilepsy.
A generalized tonic clonic seizure is usually defined as loss of consciousness producing a sudden fall, stiffening, followed by major spasms of all muscles. Elderly men and women with osteoporosis are at increased risk of broken bones due to seizures, both from falls and the stress of muscular contractions. Padding home surfaces and one-floor living can help but not completely avoid these problems. Complex partial seizures affect awareness and produce abnormal behavior not under conscious control. When these or generalized tonic clonic seizures happen near or in water, or near fire, heat, or hot water they can produce serious injuries. An elderly person with seizures may be advised not to use the stove, but to use a microwave instead for heating food, to have the water temperature set at a level that will not produce scalding; to avoid fireplace heating; to put padded carpet in the bathroom; and to have bathroom doors that open outwards not inwards to give family or caretakers access to the bathroom if necessary. An older person with epilepsy living alone may gain greater safety and independence by wearing a device that he or she can use to call for help if a seizure occurs and that person is injured or unable get up afterwards. Finally, a word about status epilepticus (non-stop seizures). Status is a serious medical emergency, and elderly people have the highest mortality rates from this condition (30%). While non-stop convulsions are readily recognized, there is also a type of status in which there is continued confusion. Long periods of confusion also require emergency medical treatment.
Older people metabolize drugs – that is, their bodies process them – more slowly than do younger people. This may mean that a standard dose of an antiepileptic drug, which would be well tolerated by a younger person, may build up to toxic levels in an elderly person. Onset of slurred speech, excessive sleeping, and other signs of toxicity should be reported to the doctor in case the dose needs to be reduced. Studies show the most common side effects of antiepileptic drugs in older people are unsteadiness, tremor, visual disturbance and sedation. Elderly people also take many other medications – typically for high blood pressure and high cholesterol, as well as blood thinners, diuretics, laxatives, painkillers, and anti-anxiety medication. Adding anticonvulsants to that mix may lead to interactions. It is advisable to do a “meds audit” from time to time – that is, putting all the medication containers in a bag and taking it to the doctor to see if interactions may be possible. Checking with the pharmacist and providing the pharmacist with a list of all prescription and non-prescription medications including vitamins and any herbal products can also help. Elderly people with limited vision may need help reading dosing directions on medicine bottles, in removing safety caps, and in loading pill boxes. Taking the right meds on time is difficult for many people, and particularly for elderly people struggling with declining short-term memory and a number of meds. Calendars can help, as can segmented pill boxes in which the caregiver or family member can count out the tablets for a day or even a week at a time. Alarm watches and other reminders may also help. Finally, financial issues – especially cost of drugs and the lack of any prescription plan under Medicare – may lead elderly people to miss doses of medicine, or cut the tablets or otherwise try to stretch out the medicine. Reducing the amount of antiepileptic drugs in this way risks seizures, and it is advisable to help older people understand how important it is to keep their intake steady.
Developing epilepsy has social effects at any age. With the onset of epilepsy in later life, there are a cluster of effects that the older person is particularly prey to. Loss of self-confidence and embarrassment are primary. The fear of what one may do during a seizure, and the loss of social standing implicit in an episode of strange behavior, perhaps accompanied by incontinence, are then compounded by possible loss of driving privileges and a resulting loss of mobility. Depression, and the often even more stigmatized view of epilepsy among a generation that grew up while it was still a shameful condition, only adds to the social impact and may itself require medical attention. Finally, for many frail elderly trying to continue living independently and living alone, the development of seizures is the last straw, the last blow in a series of health problems that leads to residential care.
Older people, like younger ones, need to know as much as possible about the condition they have and how it is being treated. Older people may hesitate to question the doctor, coming from a generation in which such questioning was not done. In some cases, older people hesitate to ask questions because they do not want to be seen as ignorant or stupid. Family members and caregivers can encourage them to write down or tell someone else about the questions they have. It may be helpful to write these down and make sure they are shared with the treating physician. Family members and caregivers can get a sense of how much the older person understands by simple questions during conversations – regarding medicine names, kinds of seizures the person has, possible causes, effect of the medicines, side effects, and so on. Family members can help older people with epilepsy maintain their independence through checking systems such as phone calls at agreed upon times, installation of a security system, or an electronic alerting system or paging device that can be used by an incapacitated older person to summon help. Meals on Wheels services, access to elder transport and similar elder care services in the community can help. For some residential care is the best solution. One study found that 10.5% of elderly in US residential care receive an antiepileptic drug, along with an average of 5.6 other meds. Currently, 1.5 million people over the age of 65 are in residential care, which means there may be more than 150,000 elderly with epilepsy in residential care. Family members and caregivers can help by working with the staffs of residential centers for the elderly to make them aware of seizure symptoms, understand the special challenges in elder care when epilepsy is present, and are alert to the special needs these people have.
I hope this presentation has provided useful information about epilepsy. Before we go to the question session, I’d like to discuss some of the resources that are available to help people with epilepsy and their families. The Epilepsy Foundation is the national organization that works for people affected by seizures. The national office and a network of affiliated Epilepsy Foundations around the country support many programs, including support of research, community, patient and family education, advocacy, and services such as information and referral, public and professional education, employment assistance, and the Women and Epilepsy Initiative. A variety of other resources are listed on the slide.
Seizures after60 powerpoint
Seizures After Sixty Presenter: Myeshi Briley,MS,HS-BCP
Seizures in Later Life:New Cases by AgeHauser, W.A. and Hesdorffer, D.C. Facts About Epilepsy. Landover, MD: Epilepsy Foundation of America, 1990, p. 1.
Seizures in Later Life: Causes• Stroke • Cardiovascular Disease• Brain Tumor • Head /dementia• Brain Surgery • Toxic /metabolic• Chronic Alcoholism disturbances• Infections • Pre- trauma • Alzheimer’s existing conditions
Seizures in Later Life:Complex Partial SeizuresPrimary challenges:• Symptoms misinterpreted as effects of aging• Symptoms may be linked to other disorders• Lack of awareness during the seizure
Seizures in Later Life:Seizure or Not?Signs that point to epilepsy:• Episodic, not continuous, behavior• Sudden change in awareness• Episode is followed by a period of confusion
Seizures in Later Life:Generalized SeizuresPrimary Challenges:• Injury from falls, increased by brittle bones• Muscle damage• Related safety issues: Burns, scalds, drowning
Seizures in Later Life:TreatmentPrimary Challenges:• Slower metabolism of medication• Possibility of interaction between anticonvulsants and other drugs• Memory Problems• Side effects• Financial issues
Seizures in Later Life:Social Issues• Loss of self-confidence• Embarrassment at effects of seizures• Increased dependency• Loss of driving privileges• Decreased mobility• Depression/stigma• Loss of independence
Seizures in Later Life: Goals• To empower the older person regarding health care• To maintain independence and safety as long as possible• To assure that residential care is effective
National and CommunityResources• The Epilepsy Foundation – Local affiliates – Website: www.epilepsyfoundation.org• MedicAlert Foundation• Social Security Administration• Accreditation Council on Services for People with Disabilities• State Offices – Vocational Rehabilitation – Protection and Advocacy – Aging Services