Clinical Topics & News

Seizures and New-Onset Epilepsy in the Elderly

Nikesh Ardeshna, MD
Dr. Ardeshna is the Medical Director of Epilepsy Services for the Erlanger Health System in Chattanooga, Tennessee.



Seizures can begin at any age. The fastest-growing segment of people with newly diagnosed seizures is currently seniors (generally referring to patients age 60 and above), who are also the fastest-growing segment of our population. This segment of our population poses numerous challenges with regard to diagnosis, management, and treatment.

To a greater extent than in other age groups, diagnosis can be delayed in seniors because some of the clinical signs of a seizure (eg, confusion, memory loss, abnormal behavior, or wandering) are often thought to be due to other conditions or causes that are more common in this segment of the population (eg, dementia, delirium, memory loss, or medication side effects). Moreover, many seniors live alone. The signs they manifest related to a seizure may only be noticed by friends or family, who are not frequently around. Given the often subtle signs of a seizure, elderly patients are often brought to a medical appointment by their family or friends, often to their dismay because they do not believe that something is wrong.

Many medical conditions that are risk factors for the development of seizures are more common in seniors. This is one of the reasons we are seeing the increase in new-onset epilepsy diagnosis in this age group. Some conditions that increase the risk for seizures include stroke, intracranial hemorrhage, subdural hematoma, brain tumor, and dementia. It is important to note that seizures do not need to begin immediately after the diagnosis of one of these preceding conditions, as the first seizure may occur many months or years afterward. Neither does there need to be a family history of seizures, or a prior history of febrile seizures in childood. Consequently, many elderly patients have a difficult time accepting the diagnosis. This problem, in turn, requires compassion and time on the part of the physician as, for example, extra appointments with family may be needed to explain the diagnosis.

The elderly are also more prone to falls because of increasing instability, balance difficulties, and deteriorating bone health. Falls can result in head trauma, which in turn can cause seizures. Therefore, counseling to minimize the risk of falls is crucial. Moreover, breakthrough seizures could result in injury, which, depending on type, could lead to more seizures.

The diagnosis of a seizure or epilepsy can have significant implications for an individual’s lifestyle and quality of life. Again, these changes can impact quality of life in all individuals, but can have a relatively greater impact on the elderly. In this age group, individuals try more so than ever to preserve their independence and do not want to be a burden to others. For example, seizures may require driving privileges to be restricted. This, in turn, has potential implications on living arrangements.

From a treatment perspective, antiepileptic drugs (AEDs) are the mainstay of treatment. The most common side effects of AEDs include fatigue, drowsiness, dizziness, and slowed cognition. These side effects are of concern in any age group, but even more so in the elderly because, by virtue of age, they are prone to more side effects. Increased side effects can lead to decreased compliance, which can lead to breakthrough seizures.

The first item to be considered is the choice of AED. The ideal AED has the minimal likelihood of the above side effects, requires minimal monitoring, and does not interact with other medications (many elderly patients are already on multiple other medications for other conditions). An AED with a lower dosing frequency should be chosen to maximize compliance. Moreover, the AED dose required in the elderly is often lower than other age groups, and the titration needs to be slower to minimize side effects. Elderly patients have decreased metabolism, which leads to slower processing and clearance of medication.

The common goal for all people with epilepsy, no matter what their age, is no seizures and no side effects. Care of elderly patients with epilepsy is unique. It is complicated by the fact that few studies are done in this population segment, and there is no definitive guideline to assist in making the decisions discussed above. Consequently, their care involves a combination of balancing risks and benefits, assessing comorbidities, monitoring for side effects, patience, and compassion.

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