AEDs and Seniors
Unfortunately, it may take as long as 19 months after seizure onset before a correct diagnosis of epilepsy is made in seniors and appropriate drugs are prescribed http://professionals.epilepsy.com/page/ar_1110476473.html. Further, despite the availability of newer AEDs, Marianne Spanaki, MD, and colleagues at Henry Ford Hospital in Detroit found recently that 95% of primary care physicians were still prescribing older AEDs, as were three out of four neurologists and neurosurgeons, to seniors with epilepsy http://professionals.epilepsy.com/secondary/convnews_newdrugs.html.
We asked two experts in the diagnosis and treatment of seniors with epilepsy -- Ilo Leppik, MD, from MINCEP Epilepsy Care in Minneapolis and Joseph I. Sirven, MD, from Mayo Clinic in Scottsdale -- the following questions:
COMMENTS OF EXPERTS
Ilo E. Leppik, MD, is the Director of Research of MINCEP Epilepsy Care in Minneapolis and Professor of Pharmacy and Neurology at the University of Minnesota. Dr. Leppik is the past President of the American Epilepsy Society and the past Chairman of the American Epilepsy Society Guidelines Task Force and the Central Society for Neurological Research.
Joseph I. Sirven, MD, is Associate Professor of Neurology at the Mayo Clinic in Scottsdale, Arizona. He did his neurology residency at the University of Minnesota Medical School, Minneapolis, and a fellowship in EEG/Clinical Epilepsy at the University of Pennsylvania in Philadelphia. Dr. Sirven currently chairs the Seniors and Seizure Task Force for the Epilepsy Foundation of America and co –edited the textbook, Clinical Neurology of the Older Adult. He is co-director of the epilepsy program at Mayo Clinic Arizona and is Director of Education for Mayo Clinic Arizona.
Dr. Sirven’s interests are in: Epilepsy and Seizure Treatments in Adults and Children (particularly older adults), Epilepsy Surgery, Electroencephalography, Investigational Antiepilepsy Drugs, Status Epilepticus, Vagal Nerve Stimulator, and the Ketogenic Diet. He has numerous peer-reviewed publications which can be viewed at PubMed.
How do you make the diagnosis of new onset epilepsy in an elderly person?
Joseph Sirven: The biggest problem in diagnosing seizures in this population is that they mimic so many other conditions. As such, doctors do not always think of seizures to begin with because it doesn’t present as it does with children. For example, they may see a patient with vertigo and not think about the possibility of seizures but rather will make a diagnosis based on more traditional causes of vertigo in the elderly.
Essentially, it still requires a clinical diagnosis so it fits the syndrome; that is, the story needs to make sense. Seizures in this population can so easily be misdiagnosed as cerebrovascular disease (transient ischemic attacks), for example. Also we need to rule out infections, metabolic problems, and sodium or glucose intake.
Therefore I take a good history, order lab tests, and do imaging studies to be sure there was no stroke or hemorrhage. Lastly I will do an EEG if the story does not fit with the concept to either confirm the diagnosis of epilepsy or exclude it.
Ilo Leppik: First of all, to make a good diagnosis you need a good observation of the event – so you need a reliable witness who sees it. Most people do not recall this event, therefore, the initial observation is not reliable.
If I have a reliable observer who describes a general tonic-clonic seizure followed by a post-ictal state for 2 to 4 minutes with deep respirations, then it is much easier to diagnosis a seizure. But oftentimes there might be a complex partial seizure and these are hard to observe since they last only about 30 seconds to 2 minutes with the person affected staring into space with poor responsiveness to verbal or visual commands. This can be mistaken for something else.
A third type that we don’t know very much about is called transient global amnesia. All of a sudden the person will say, “What was I doing? Where was I?”
The real problem with a large number of these patients who have a convulsion is that they might be suffering from is a cardiac arrhythmia or micturition syncope rather than epilepsy. An older man with prostate problems might strain to urinate and this affects the vagus nerve. As such the heart slows down, he gets less oxygen and this causes a convulsion.
EEG is a very important tool for diagnosing the presence of epilepsy. But EEGs are hard to interpret and the standard half hour test is not long enough for a clear diagnosis – especially with epilepsy. It takes skill and work. We often refer to the studies by Ramsey and Rowan where each case was reviewed by epileptologists to be certain that each fit the diagnosis of epilepsy.
What are the potential pitfalls in the diagnostic process?
Joseph Sirven: You may come up with findings on an MRI which are not related to seizures -- such as white matter lacunar infarcts that confound the data. Or you might obtain a normal EEG which may lead some physicians to mistakenly exclude epilepsy from the differential diagnosis. Again, the picture must fit the story and be confirmed by lab results. If they don’t, sometimes you have to repeat the testing.Ilo Leppik: The biggest pitfall is seeing a clear tonic-clonic convulsion and jumping to a conclusion that it is an epileptic seizure other than looking at other causes, such as a cardiac arrhythmia leading to lack of oxygen to the brain. Another problem occurs when we see a complex partial seizure for 2 to 3 minutes and both patient and family may ignore it.
What considerations do you weigh in recommending and choosing therapy?
Joseph Sirven: Quality of life is key. One of the problems that we always face is that for the most part, approved therapies and medications have been tested in younger persons with epilepsy but not older ones. Older persons may have difficulty with treatment because of interactions with other drugs that they are taking.
We need to make sure that the drugs are tolerable and start with as low a dose as possible because of the potential for drug interactions. Many seniors are on multiple medications.
Ilo Leppik: First and foremost we try to identify what other medications the patient is taking and what other illnesses he or she may have. In this way we avoid giving epilepsy medication that might aggravate other conditions.
For example, we stay away from medication that might affect the metabolism of drugs like Coumadin (warfarin). Carbamazepine and phenobarbital are notorious for affecting metabolism. I look for medications that do not have drug interactions.
What particular age-related issues may affect medication compliance, and how do you monitor this?
Joseph Sirven: Prominent issues specific to older adults are age-related memory problems, as well as mild cognitive impairment and dementia. For older persons, remembering to take pills isn’t always easy.
Another issue is that physicians need to be attuned to the likelihood of side effects. Very often seniors may just stop taking their medication because of side effects.
How do I monitor this? I am often an advocate with regards to having more frequent follow-up visits and even emails if a patient can correspond with me in that way. That’s my approach. With older persons you need closer ties than with your younger patients. Even though some older adults may have caretakers, they don’t always have those caretakers around to help them 24/7. They can be frail with cognitive deficits which make it more challenging for them to be compliant with therapy. Moreover, they are not as resilient as younger people.
Ilo Leppik: I think there are three key age-related issues with regard to compliance.
The biggest problem that we are seeing affecting seniors and compliance is affordability of medication. So many people who are seniors are taking medication for high blood pressure and diabetes. How do you then fit in the epilepsy medication when you are on a limited budget? When this becomes problematic, sometimes the less expensive and older drugs might have a realistic role to play.
The second problem is keeping track of all the pills that one is supposed to take and to remember how and when to take them.
The third issue is one that causes confusion. Seniors go to the drug store for their meds and the pharmacist switches from a brand that they are accustomed to and gives them a generic pill instead. If someone is used to that green pill with black print and they are switched to orange it can be very disconcerting. For example, the generic version of phenytoin is white and purple. The brand is all white with a mandarin band. They see the one that their doctor said they should be taking. The pharmacist gives them another one and they become suspicious.
What concerns do seniors with epilepsy express to you?
Jospeh Sirven: The biggest concerns of seniors are those that mirror concerns of younger adults: driving and the loss of independence.
Once they give up their car, they know they are limited in terms of getting around. Then if they have to move in with someone else, they worry that they will have to give up their keys and all sense of independence.
Ilo Leppik: The first concern that patients express to me is a fear of hurting themselves when they are alone and not being able to get help. The second fear is losing driving privileges. If one spouse can still drive, they seem to adjust. But if both lose driving abilities, then it becomes untenable.
My biggest concern as a physician is getting more funding for research through the National Institutes of Health. I say this over and over again. I am in close contact with my Congressman and Senator and Commissioner for this region. They tell me all of the time that I am one of the only ones talking to them about epilepsy.
What we need in the epilepsy community is a concerted on-going effect to make our presence known in Washington.
Interviews by Rita Watson, MPH
Edited by Steven C. Schachter, MD
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