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Epilepsy in the Elderly · UK HealthCast

• 0:05
  Gina (Host): Welcome to UK Health Cast, a podcast presented by UK healthcare.
• 0:09
  I'm Gina Kay, and joining me today is Sally Mattias, MD neurologist
• 0:15
  and epileptologist at the Kentucky Neuroscience Institute.
• 0:20
  Today we are going to be talking about epilepsy in older people.
• 0:24
  Dr.
• 0:24
  Mattias, welcome to the podcast.
• 0:27
  Sally Mathias, MD: Hello Gina, and thank you so much, for inviting me
• 0:30
  to discuss this very important topic.
• 0:33
  Gina (Host): Let's start in with question number one.
• 0:35
  What is the prevalence of seizures in elderly patient's?
• 0:39
  Sally Mathias, MD: sure.
• 0:40
  you know, for a long time it was thought.
• 0:43
  That seizures and epilepsy affected children and younger adults,
• 0:49
  but we now know it is not true.
• 0:52
  when asking about statistics and numbers, I like to kind
• 0:55
  of break it up into two parts.
• 0:57
  First of all, we can look into, nuance at seizures in our older people.
• 1:03
  So what studies have shown is that after age 65.
• 1:08
  about one in 1000 people each year are diagnosed with new onset epilepsy,
• 1:16
  but as age advances, like patient's over the age of 80, that number
• 1:21
  goes up to almost two per 1000.
• 1:25
  Now, when it comes to prevalence, meaning how many people right
• 1:30
  now are living with epilepsy?
• 1:33
  In our older adults, several longitudinal studies have shown a prevalence of five
• 1:41
  to six per 100 that live with epilepsy.
• 1:47
  And in patient's who live in nursing homes who are institutionalized, that
• 1:53
  number is actually seven to eight fold higher than their counterparts
• 1:58
  who live in independent dwelling.
• 2:02
  So bottom line is that seizures are very common in the elderly, and,
• 2:09
  it is an important topic because it is not well recognized and
• 2:13
  therefore, you know, understanding that makes it very important.
• 2:17
  I,
• 2:18
  Gina (Host): how do seizures differ in older patient's
• 2:20
  when compared to the young?
• 2:22
  Sally Mathias, MD: There are several differences actually.
• 2:24
  Now when we think about a seizure, most of the time we think someone having
• 2:30
  whole body shaking or convulsions.
• 2:33
  In fact, That is very seldom seen in our older patient's.
• 2:38
  Most elderly present with subtle confusion, memory lapses, staring, um.
• 2:46
  Sort of reduced or impaired awareness.
• 2:50
  Now, younger patient's have a classic or a distinct warning before seizures that
• 2:56
  can happen before some types of seizures, but That is not there in the elderly.
• 3:03
  and therefore, you know, a lot of times that senior moments
• 3:07
  or memory lapses, what are thought, to be could be seizures.
• 3:13
  and the recovery phase after a seizure in younger people is very brief.
• 3:20
  It's usually short, but in our elderly folks, the recovery phase
• 3:26
  could last hours or days, and it is all thought to be memory lapses.
• 3:31
  And in fact, that may not be the case.
• 3:35
  Gina (Host): So, it sounds like what we're dealing with is maybe
• 3:37
  a lot of misdiagnosis, which.
• 3:39
  Sally Mathias, MD: Absolutely.
• 3:40
  or under recognition that these could be seizures.
• 3:45
  Gina (Host): to that point, what are the most common causes
• 3:47
  of epilepsy in elderly people?
• 3:50
  Sally Mathias, MD: Sure.
• 3:50
  Stroke number one.
• 3:52
  Cause, for seizures in the elderly, the bleeding type of stroke can
• 3:57
  cause more seizures compared to the ischemic type of stroke.
• 4:02
  And within first year after stroke, studies have shown
• 4:05
  a 23 fold higher increase of
• 4:09
  Gina (Host): Wow, that's incredible.
• 4:10
  Sally Mathias, MD: So yes, and some other things, memory problems or
• 4:13
  dementia carries a tenfold higher risk, of developing seizures and,
• 4:20
  Early onset Alzheimer's, so familial Alzheimer's that carries over
• 4:26
  80% risk of developing seizures.
• 4:29
  Some other things are, traumatic brain injury or head injury and brain tumors.
• 4:34
  Now what I like to discuss about is vascular risk factors that most of our
• 4:40
  elderly patient's have, like hypertension.
• 4:44
  Now high blood pressure is thought to be an independent risk
• 4:49
  factor to developing seizures.
• 4:51
  And how many of our elderly folks have high blood pressure?
• 4:54
  Several.
• 4:55
  but it's not known and it is not advertised as such.
• 5:00
  Gina (Host): This is really fascinating information.
• 5:03
  so why do you think epilepsy then gets overlooked in elderly patient's
• 5:07
  knowing all of those risk factors that may or may not be the cause?
• 5:13
  Sally Mathias, MD: Sure.
• 5:14
  Like I said, the presentation is so different, right?
• 5:17
  In medical training, we are thought.
• 5:19
  To have a picture of seizures That is very different, how elderly presents.
• 5:26
  So presentation is different.
• 5:28
  Most of our older patient's live by themselves, so there is no eyewitness,
• 5:32
  to explain what is going on.
• 5:36
  memory lapses itself, like I said, are thought to be more of a dementia process
• 5:41
  because they're elderly and not seizures.
• 5:44
  And then some other things are like e, EG, you know, it is a test
• 5:48
  that we do to diagnose seizures.
• 5:50
  In fact, it is a well-known fact that EEG abnormalities that show epilepsy
• 5:57
  are more robustly seen in children and younger adults and older patient's
• 6:03
  do not have that many abnormalities.
• 6:05
  So even the objective testing that we see does not give us the answer.
• 6:10
  And lastly, it's a sad fact that.
• 6:13
  Oftentimes investigations or workup is not as thorough in the elderly people compared
• 6:19
  to the younger generation especially, maybe because, there is no one to
• 6:24
  advocate for them, no one to be with them in the hospital and, clinic And so on.
• 6:30
  Gina (Host): So we've talked about signs and some symptoms.
• 6:32
  So let's talk about treatment then.
• 6:34
  What does that look like in an elderly person?
• 6:36
  Sally Mathias, MD: Sure.
• 6:37
  So I would discuss about management here, you know, which is, first of all, having
• 6:43
  an open mind to this diagnosis, right?
• 6:46
  keeping seizures high in your differential for physicians and,
• 6:51
  providers, treating these patient's.
• 6:54
  And then, doing investigations like EEG or MRI brain taking a very thorough
• 7:00
  history, that's the first step.
• 7:03
  Once the diagnosis is made, the treatment is actually very simple.
• 7:07
  It's anti-seizure medications.
• 7:09
  And several, anti-seizure medications that have come out
• 7:13
  since the 1990s are excellent in treating seizures in the elderly.
• 7:19
  Lamotrigine has been studied and, you know, very well-tolerated, in the elderly.
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  Levetiracetam is another medication that has a.
• 7:29
  Fantastic pharmacokinetic profile.
• 7:31
  You know, it's, it, it does not have any interactions and you can start
• 7:35
  at a target dose pretty quickly.
• 7:38
  And then there is lacosamide, which also has fewer side effects and,
• 7:44
  helps with seizures significantly.
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  And what studies have shown is that over 80% of our elderly patient's.
• 7:54
  Become very well-controlled with one single medication at a modest dose.
• 8:02
  and if the seizures, do not stop with one medication, then we
• 8:07
  may have to add a second one.
• 8:09
  If still it doesn't work, then we still have epilepsy surgery as an option.
• 8:14
  And that option is also underutilized.
• 8:17
  And, not very commonly thought of in the treatment process.
• 8:23
  Gina (Host): I didn't even realize that that was an option the advancements
• 8:26
  these days are just amazing.
• 8:29
  So we have good news, we have a treatment.
• 8:32
  and it sounds like a really good success rate, so.
• 8:35
  Conversely, what are the dangers of not treating seizures in the elderly?
• 8:40
  Sally Mathias, MD: Yes.
• 8:41
  And This is particularly important to discuss because.
• 8:46
  many of our elderly patient's are already frail due to their medical comorbidities,
• 8:51
  and seizures can cause physical injuries falls, there is an accelerated cognitive
• 8:58
  decline or worsening of memory that happens if seizures are not treated.
• 9:04
  And then of course there is mortality, which studies have shown a very
• 9:09
  high-risk of mortality in patient's with newly diagnosed epilepsy over
• 9:14
  the age of 65 when compared to similar age cohort that do not have epilepsy.
• 9:20
  And the other aspect comes are, you know, emergency of epilepsy,
• 9:25
  which is called status epilepticus.
• 9:27
  That in fact, is related to mortality or death about 40%
• 9:33
  of the times in the elderly.
• 9:35
  So therefore, identifying, sort of spreading awareness about this
• 9:40
  treating patient's with seizures over the age of 65 becomes so important.
• 9:45
  And because of these factors.
• 9:48
  Sometimes even a single unprovoked seizure after the age of 65.
• 9:54
  providers, physicians think about treating this because if not treated,
• 9:59
  the chance of another seizure happening is very high in these patient's.
• 10:04
  Conversely, the risks of treatment with newer anti-seizure
• 10:09
  medications are very few.
• 10:12
  Gina (Host): So, raising awareness with the elderly population
• 10:15
  is obviously very important.
• 10:17
  How do you attack that?
• 10:18
  Sally Mathias, MD: first of all, I think spreading awareness through programs
• 10:22
  like this, knowing that seizures and epilepsy is common in the elderly, knowing
• 10:28
  what are the modifiable risk factors.
• 10:30
  It could be control of high blood pressure that can help.
• 10:35
  Prevent stroke, And that can help prevent seizures.
• 10:39
  keeping an open mind to diagnosis among physicians or providers in
• 10:45
  different settings, that also helps.
• 10:47
  So I, I feel knowing, understanding, enables prevention, early identification
• 10:56
  and of course, helps with a better care model for our patient's.
• 11:01
  Gina (Host): UK Healthcare has a level four epilepsy center.
• 11:05
  Talk to us about that, but that's exciting.
• 11:07
  Sally Mathias, MD: Yes.
• 11:08
  Yes.
• 11:09
  So the University of Kentucky is a level four epilepsy center, which means
• 11:13
  it provides the highest level of care for people with seizures and epilepsy.
• 11:19
  And what our center provides is access to specialists in epilepsy, not just
• 11:26
  that neuropsychologists, you know, who, look into the cognitive side of
• 11:31
  things, neuroradiologist, neurosurgeons.
• 11:33
  So it's a comprehensive care now.
• 11:37
  Our center will help our older adults to get the right diagnosis faster.
• 11:43
  find a true cause for the seizures and see how we can treat that.
• 11:47
  And also, more tailored or more personalized treatment, which
• 11:51
  I think helps significantly.
• 11:54
  Gina (Host): That, that's great.
• 11:55
  I love that.
• 11:56
  so your role at Lexington VA Healthcare System, also another aspect of your,
• 12:02
  job duties there are two epilepsy specialists is what I have on my note.
• 12:06
  So you and a colleague care for elderly veterans with new onset seizures.
• 12:11
  How is that different?
• 12:14
  Or is it.
• 12:15
  Sally Mathias, MD: it is in fact, because veterans are a more vulnerable
• 12:19
  group when it comes to developing epilepsy as age advances, and That
• 12:24
  is because of higher rates of brain injury, higher rates of vascular,
• 12:29
  diseases like hypertension, as well as stroke, and recognizing this risk early.
• 12:36
  Helps us with timely diagnosis and treatment and having
• 12:41
  epilepsy specialists at the va.
• 12:43
  we work closely with UK's level four epilepsy center, And this allows veterans
• 12:49
  to benefit, from advanced expertise without unnecessary delays in care.
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  so you get the expert diagnosis, we get the coordinated care And the
• 12:59
  most advanced treatment options.
• 13:02
  Gina (Host): That's amazing.
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  Really,
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  the fact that those two work hand in hand is, commendable.
• 13:07
  Sally Mathias, MD: absolutely.
• 13:08
  Yes.
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  Most of our neurologists have dual appointments and therefore
• 13:12
  most of the care is so seamless between the two centers.
• 13:16
  Gina (Host): Anything else you'd like to add for the good of the cause?
• 13:19
  Sally Mathias, MD: I would just say recognizing, knowing that seizures
• 13:24
  are very common as age advances And the elderly are the fastest growing
• 13:30
  segment of our epilepsy population.
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  That itself, is eyeopening.
• 13:36
  And then I know all, all providers know what to do from there.
• 13:41
  So that, that would be important.
• 13:42
  And for patient's, I would say.
• 13:45
  seizures can happen.
• 13:46
  They do happen.
• 13:48
  There are risk factors, they're preventable.
• 13:51
  And seizures in the elderly can be easily controlled with a single medication.
• 13:56
  So my suggestion would be do not delay care, accessing care,
• 14:01
  and, work with your doctor and provider, to help control seizures.
• 14:07
  Gina (Host): Nice knowledge really is power.
• 14:09
  Sally Mathias, MD: It is.
• 14:10
  Gina (Host): If you want more information beyond what was received today, please
• 14:14
  visit our website@ukhealthcare.uk.edu.
• 14:20
  Dr.
• 14:20
  Mattias, we very much appreciate your willingness to educate all of us on the
• 14:24
  prevalence of epilepsy in older adults.
• 14:27
  Thank you for all the information you shared.
• 14:30
  Sally Mathias, MD: Thank you so much, Gina.
• 14:31
  It has been a pleasure.
• 14:33
  Gina (Host): That was Dr.
• 14:34
  Sally Mattias, neurologist and epileptologist at the
• 14:37
  Kentucky Neuroscience Institute.
• 14:40
  I'm Gina Kay.
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  Thanks for listening to the UK Health Cast, a podcast from UK Healthcare.
• 14:47
  All content of this podcast is intended for general information purposes only.
• 14:52
  And is not intended or implied to be a substitute for professional medical
• 14:56
  advice, diagnosis, or treatment.
• 14:59
  Please consult a medical professional before adopting any of the suggestions
• 15:03
  discussed on this podcast episode.