Skip to main content

Advertisement

SpringerLink
Log in

Seizures and Epilepsy in the Elderly: Diagnostic and Treatment Considerations

  • Neurology of Aging (K Marder, Section Editor)
  • Published:
Current Geriatrics Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this review is to highlight important clinical aspects in diagnosis and management of epilepsy in the elderly and to highlight recent literature and its relevance to current practice.

Recent Findings

Recent studies have shown that elderly patients are under referred for evaluation to epilepsy monitoring units and for epilepsy surgery, which has been demonstrated to be safe and effective in this population.

Summary

The elderly are at increased risk for acute symptomatic seizures and epilepsy. Accurate diagnosis can be challenging in older patients due to limitations in history, atypical symptoms, and medical comorbidities. Inpatient video-EEG monitoring is a valuable tool for the clinician when diagnosis is unclear or patients are unresponsive to medication. Drug resistance rates in the elderly are similar to younger adults with epilepsy, but elderly patients are less likely to be referred for epilepsy monitoring unit admissions and epilepsy surgery, despite evidence of safety and effectiveness.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Trends in aging--United States and worldwide. MMWR Morb Mortal Wkly Rep. 2003/03/21 ed2003. p. 101–4, 6.

  2. Wan H, Goodkind D, Kowal P. An aging world: 2015. U.S. Census Bureau, International Population Reports 2016.

  3. Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet. 1990;336(8726):1267–71. https://doi.org/10.1016/0140-6736(90)92959-l.

    Article  CAS  PubMed  Google Scholar 

  4. Annegers JF, Hauser WA, Lee JR, Rocca WA. Incidence of acute symptomatic seizures in Rochester, Minnesota, 1935-1984. Epilepsia. 1995;36(4):327–33. https://doi.org/10.1111/j.1528-1157.1995.tb01005.x.

    Article  CAS  PubMed  Google Scholar 

  5. Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia. 1993;34(3):453–68. https://doi.org/10.1111/j.1528-1157.1993.tb02586.x.

    Article  CAS  PubMed  Google Scholar 

  6. Mendiratta A, Pedley TA. Seizures and Epilepsy in the Elderly. In: Shorvon S, Pedley TA, editors. The Epilepsies 3. 1st ed. Blue Books of Neurology. Philadelphia: Saunders Elsevier; 2009. p. 177–93.

    Google Scholar 

  7. Kotsopoulos IA, van Merode T, Kessels FG, de Krom MC, Knottnerus JA. Systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures. Epilepsia. 2002;43(11):1402–9. https://doi.org/10.1046/j.1528-1157.2002.t01-1-26901.x.

    Article  PubMed  Google Scholar 

  8. Cloyd J, Hauser W, Towne A, Ramsay R, Mattson R, Gilliam F, et al. Epidemiological and medical aspects of epilepsy in the elderly. Epilepsy Res. 2006;68(Suppl 1):S39–48. https://doi.org/10.1016/j.eplepsyres.2005.07.016.

    Article  PubMed  Google Scholar 

  9. Sidenvall R, Forsgren L, Blomquist HK, Heijbel J. A community-based prospective incidence study of epileptic seizures in children. Acta Paediatr. 1993;82(1):60–5.

    Article  CAS  Google Scholar 

  10. Forsgren L, Bucht G, Eriksson S, Bergmark L. Incidence and clinical characterization of unprovoked seizures in adults: a prospective population-based study. Epilepsia. 1996;37(3):224–9. https://doi.org/10.1111/j.1528-1157.1996.tb00017.x.

    Article  CAS  PubMed  Google Scholar 

  11. Olafsson E, Ludvigsson P, Gudmundsson G, Hesdorffer D, Kjartansson O, Hauser WA. Incidence of unprovoked seizures and epilepsy in Iceland and assessment of the epilepsy syndrome classification: a prospective study. Lancet Neurol. 2005;4(10):627–34. https://doi.org/10.1016/s1474-4422(05)70172-1.

    Article  PubMed  Google Scholar 

  12. de la Court A, Breteler MM, Meinardi H, Hauser WA, Hofman A. Prevalence of epilepsy in the elderly: the Rotterdam study. Epilepsia. 1996;37(2):141–7. https://doi.org/10.1111/j.1528-1157.1996.tb00005.x.

    Article  PubMed  Google Scholar 

  13. Hauser WA, Annegers JF, Kurland LT. Prevalence of epilepsy in Rochester, Minnesota: 1940-1980. Epilepsia. 1991;32(4):429–45. https://doi.org/10.1111/j.1528-1157.1991.tb04675.x.

    Article  CAS  PubMed  Google Scholar 

  14. Galimberti CA, Magri F, Magnani B, Arbasino C, Cravello L, Marchioni E, et al. Antiepileptic drug use and epileptic seizures in elderly nursing home residents: a survey in the province of Pavia, Northern Italy. Epilepsy Res. 2006;68(1):1–8. https://doi.org/10.1016/j.eplepsyres.2005.09.031.

    Article  PubMed  Google Scholar 

  15. Garrard J, Harms S, Hardie N, Eberly LE, Nitz N, Bland P, et al. Antiepileptic drug use in nursing home admissions. Ann Neurol. 2003;54(1):75–85. https://doi.org/10.1002/ana.10593.

    Article  PubMed  Google Scholar 

  16. Schachter SC, Cramer GW, Thompson GD, Chaponis RJ, Mendelson MA, Lawhorne L. An evaluation of antiepileptic drug therapy in nursing facilities. J Am Geriatr Soc. 1998;46(9):1137–41. https://doi.org/10.1111/j.1532-5415.1998.tb06654.x.

    Article  CAS  PubMed  Google Scholar 

  17. Beagle AJ, Darwish SM, Ranasinghe KG, La AL, Karageorgiou E, Vossel KA. Relative incidence of seizures and myoclonus in Alzheimer's disease, dementia with Lewy bodies, and Frontotemporal dementia. J Alzheimers Dis. 2017;60(1):211–23. https://doi.org/10.3233/JAD-170031.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Hauser WA. Seizure disorders: the changes with age. Epilepsia. 1992;33(Suppl 4):S6–14. https://doi.org/10.1111/j.1528-1157.1992.tb06222.x.

    Article  PubMed  Google Scholar 

  19. Hauser W. Epidemiology of seizures and epilepsy in the elderly. In: Rowan A, Ramsay R, editors. Seizures and epilepsy in the elderly. Boston: Butterworth-Heineman; 1997.

    Google Scholar 

  20. Loiseau J, Loiseau P, Duche B, Guyot M, Dartigues JF, Aublet B. A survey of epileptic disorders in Southwest France: seizures in elderly patients. Ann Neurol. 1990;27(3):232–7. https://doi.org/10.1002/ana.410270304.

    Article  CAS  PubMed  Google Scholar 

  21. Leppik IE, Birnbaum AK. Epilepsy in the elderly. In: Wyllie E, Cascino GD, Gidal BE, Goodkin HP, editors. Wyllie's treatment of epilepsy. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2011. p. 458–68.

    Google Scholar 

  22. Fisher RS, Acevedo C, Arzimanoglou A, Bogacz A, Cross JH, Elger CE, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia. 2014;55(4):475–82. https://doi.org/10.1111/epi.12550.

    Article  PubMed  Google Scholar 

  23. So EL, Annegers JF, Hauser WA, O'Brien PC, Whisnant JP. Population-based study of seizure disorders after cerebral infarction. Neurology. 1996;46(2):350–5. https://doi.org/10.1212/wnl.46.2.350.

    Article  CAS  PubMed  Google Scholar 

  24. Hesdorffer DC, Hauser WA, Annegers JF, Kokmen E, Rocca WA. Dementia and adult-onset unprovoked seizures. Neurology. 1996;46(3):727–30. https://doi.org/10.1212/wnl.46.3.727.

    Article  CAS  PubMed  Google Scholar 

  25. Ramsay RE, Rowan AJ, Pryor FM. Special considerations in treating the elderly patient with epilepsy. Neurology. 2004;62(5 Suppl 2):S24–9. https://doi.org/10.1212/wnl.62.5_suppl_2.s24.

    Article  PubMed  Google Scholar 

  26. Kellinghaus C, Loddenkemper T, Dinner DS, Lachhwani D, Luders HO. Seizure semiology in the elderly: a video analysis. Epilepsia. 2004;45(3):263–7. https://doi.org/10.1111/j.0013-9580.2004.29003.x.

    Article  PubMed  Google Scholar 

  27. Silveira DC, Jehi L, Chapin J, Krishnaiengar S, Novak E, Foldvary-Schaefer N, et al. Seizure semiology and aging. Epilepsy Behav. 2011;20(2):375–7. https://doi.org/10.1016/j.yebeh.2010.12.033.

    Article  PubMed  Google Scholar 

  28. Drury I, Beydoun A. Interictal epileptiform activity in elderly patients with epilepsy. Electroencephalogr Clin Neurophysiol. 1998;106(4):369–73. https://doi.org/10.1016/s0013-4694(97)00158-2.

    Article  CAS  PubMed  Google Scholar 

  29. Salinsky M, Kanter R, Dasheiff RM. Effectiveness of multiple EEGs in supporting the diagnosis of epilepsy: an operational curve. Epilepsia. 1987;28(4):331–4. https://doi.org/10.1111/j.1528-1157.1987.tb03652.x.

    Article  CAS  PubMed  Google Scholar 

  30. Dash D, Hernandez-Ronquillo L, Moien-Afshari F, Tellez-Zenteno JF. Ambulatory EEG: a cost-effective alternative to inpatient video-EEG in adult patients. Epileptic Disord. 2012;14(3):290–7. https://doi.org/10.1684/epd.2012.0529.

    Article  PubMed  Google Scholar 

  31. Tolchin B, Lee JW, Pavlova M, Dworetzky BA, Sarkis RA. Diagnostic yield of ambulatory EEGs in the elderly. Clin Neurophysiol. 2017;128(7):1350–3. https://doi.org/10.1016/j.clinph.2017.01.005.

    Article  PubMed  Google Scholar 

  32. • Shih JJ, Fountain NB, Herman ST, Bagic A, Lado F, Arnold S, et al. Indications and methodology for video-electroencephalographic studies in the epilepsy monitoring unit. Epilepsia. 2018;59(1):27–36. https://doi.org/10.1111/epi.13938. This Critical Review and Invited Commentary outlines the rationale and appropriate indications for video-EEG monitoring in the epilepsy monitoring unit, emphasizing this as the gold standard for the definitive diagnosis of epilepsy and seizure-like episodes.

    Article  PubMed  Google Scholar 

  33. Spritzer SD, Riordan KC, Berry J, Corbett BM, Gerke JK, Hoerth MT, et al. Fall prevention and bathroom safety in the epilepsy monitoring unit. Epilepsy Behav. 2015;48:75–8. https://doi.org/10.1016/j.yebeh.2015.05.026.

    Article  PubMed  Google Scholar 

  34. Noe KH, Drazkowski JF. Safety of long-term video-electroencephalographic monitoring for evaluation of epilepsy. Mayo Clin Proc. 2009;84(6):495–500. https://doi.org/10.1016/s0025-6196(11)60580-6.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Benbadis SR, O'Neill E, Tatum WO, Heriaud L. Outcome of prolonged video-EEG monitoring at a typical referral epilepsy center. Epilepsia. 2004;45(9):1150–3. https://doi.org/10.1111/j.0013-9580.2004.14504.x.

    Article  PubMed  Google Scholar 

  36. Drury I, Selwa LM, Schuh LA, Kapur J, Varma N, Beydoun A, et al. Value of inpatient diagnostic CCTV-EEG monitoring in the elderly. Epilepsia. 1999;40(8):1100–2. https://doi.org/10.1111/j.1528-1157.1999.tb00825.x.

    Article  CAS  PubMed  Google Scholar 

  37. McBride AE, Shih TT, Hirsch LJ. Video-EEG monitoring in the elderly: a review of 94 patients. Epilepsia. 2002;43(2):165–9. https://doi.org/10.1046/j.1528-1157.2002.24401.x.

    Article  PubMed  Google Scholar 

  38. Lee SK. Epilepsy in the Elderly: Treatment and Consideration of Comorbid Diseases. J Epilepsy Res. 2019;9(1):27–35. https://doi.org/10.14581/jer.19003.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Benbadis S. The differential diagnosis of epilepsy: a critical review. Epilepsy Behav. 2009;15(1):15–21. https://doi.org/10.1016/j.yebeh.2009.02.024.

    Article  CAS  PubMed  Google Scholar 

  40. Hogl B, Iranzo A. Rapid Eye Movement Sleep Behavior Disorder and Other Rapid Eye Movement Sleep Parasomnias. Continuum (Minneap Minn). 2017;23(4, Sleep Neurology):1017–34. https://doi.org/10.1212/con.0000000000000489.

    Article  Google Scholar 

  41. Brown RJ, Syed TU, Benbadis S, LaFrance WC Jr, Reuber M. Psychogenic nonepileptic seizures. Epilepsy Behav. 2011;22(1):85–93. https://doi.org/10.1016/j.yebeh.2011.02.016.

    Article  PubMed  Google Scholar 

  42. LaFrance WC Jr, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia. 2013;54(Suppl 1):53–67. https://doi.org/10.1111/epi.12106.

    Article  PubMed  Google Scholar 

  43. Duncan R, Oto M, Martin E, Pelosi A. Late onset psychogenic nonepileptic attacks. Neurology. 2006;66(11):1644–7. https://doi.org/10.1212/01.wnl.0000223320.94812.7a.

    Article  PubMed  Google Scholar 

  44. Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. First Seizure Trial Group (FIR.S.T. Group). Neurology. 1993;43(3 Pt 1):478–83. doi:https://doi.org/10.1212/wnl.43.3_part_1.478.

    Article  Google Scholar 

  45. Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology. 1991;41(7):965–72. https://doi.org/10.1212/wnl.41.7.965.

    Article  CAS  PubMed  Google Scholar 

  46. Lhatoo SD, Johnson AL, Goodridge DM, MacDonald BK, Sander JW, Shorvon SD. Mortality in epilepsy in the first 11 to 14 years after diagnosis: multivariate analysis of a long-term, prospective, population-based cohort. Ann Neurol. 2001;49(3):336–44.

    Article  CAS  Google Scholar 

  47. Carlson C, Anderson CT. Special Issues in Epilepsy: The Elderly, the Immunocompromised, and Bone Health. Continuum (Minneap Minn). 2016;22(1 Epilepsy):246–61. https://doi.org/10.1212/con.0000000000000273.

    Article  Google Scholar 

  48. Pack AM. Treatment of epilepsy to optimize bone health. Curr Treat Options Neurol. 2011;13(4):346–54. https://doi.org/10.1007/s11940-011-0133-x.

    Article  PubMed  Google Scholar 

  49. Italiano D, Perucca E. Clinical pharmacokinetics of new-generation antiepileptic drugs at the extremes of age: an update. Clin Pharmacokinet. 2013;52(8):627–45. https://doi.org/10.1007/s40262-013-0067-4.

    Article  CAS  PubMed  Google Scholar 

  50. Werhahn KJ, Trinka E, Dobesberger J, Unterberger I, Baum P, Deckert-Schmitz M, et al. A randomized, double-blind comparison of antiepileptic drug treatment in the elderly with new-onset focal epilepsy. Epilepsia. 2015;56(3):450–9. https://doi.org/10.1111/epi.12926.

    Article  CAS  PubMed  Google Scholar 

  51. Werhahn KJ. Epilepsy in the elderly. Dtsch Arztebl Int. 2009;106(9):135–42. https://doi.org/10.3238/arztebl.2009.0135.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Kanner AM, Ashman E, Gloss D, Harden C, Bourgeois B, Bautista JF, et al. Practice guideline update summary: efficacy and tolerability of the new antiepileptic drugs I: treatment of new-onset epilepsy: report of the guideline development, dissemination, and implementation Subcommittee of the American Academy of neurology and the American Epilepsy Society. Neurology. 2018;91(2):74–81. https://doi.org/10.1212/wnl.0000000000005755.

    Article  CAS  PubMed  Google Scholar 

  53. Kanner AM, Ashman E, Gloss D, Harden C, Bourgeois B, Bautista JF, et al. Practice guideline update summary: efficacy and tolerability of the new antiepileptic drugs II: treatment-resistant epilepsy: report of the guideline development, dissemination, and implementation Subcommittee of the American Academy of neurology and the American Epilepsy Society. Neurology. 2018;91(2):82–90. https://doi.org/10.1212/wnl.0000000000005756.

    Article  CAS  PubMed  Google Scholar 

  54. Beerhorst K, van der Kruijs SJ, Verschuure P, Tan IY, Aldenkamp AP. Bone disease during chronic antiepileptic drug therapy: general versus specific risk factors. J Neurol Sci. 2013;331(1–2):19–25. https://doi.org/10.1016/j.jns.2013.05.005.

    Article  CAS  PubMed  Google Scholar 

  55. Brodie MJ, Overstall PW, Giorgi L. Multicentre, double-blind, randomised comparison between lamotrigine and carbamazepine in elderly patients with newly diagnosed epilepsy. The UK Lamotrigine elderly study group. Epilepsy Res. 1999;37(1):81–7. https://doi.org/10.1016/s0920-1211(99)00039-x.

    Article  CAS  PubMed  Google Scholar 

  56. Rowan AJ, Ramsay RE, Collins JF, Pryor F, Boardman KD, Uthman BM, et al. New onset geriatric epilepsy: a randomized study of gabapentin, lamotrigine, and carbamazepine. Neurology. 2005;64(11):1868–73. https://doi.org/10.1212/01.Wnl.0000167384.68207.3e.

    Article  CAS  PubMed  Google Scholar 

  57. Kwan P, Brodie MJ. Early identification of refractory epilepsy. N Engl J Med. 2000;342(5):314–9. https://doi.org/10.1056/nejm200002033420503.

    Article  CAS  PubMed  Google Scholar 

  58. Wiebe S, Blume WT, Girvin JP, Eliasziw M. A randomized, controlled trial of surgery for temporal-lobe epilepsy. N Engl J Med. 2001;345(5):311–8. https://doi.org/10.1056/nejm200108023450501.

    Article  CAS  PubMed  Google Scholar 

  59. • Bialek F, Rydenhag B, Flink R, Malmgren K. Outcomes after resective epilepsy surgery in patients over 50 years of age in Sweden 1990–2009--a prospective longitudinal study. Seizure. 2014;23(8):641–5. https://doi.org/10.1016/j.seizure.2014.05.003. This prospective longitudinal study assessed outcomes following resective epilepsy surgery, comparing 67 patients aged ≥ 50 years with 491 patients aged 19–49 years. 61% were seizure free in each group, and major complications were low (3%) in each group.

    Article  PubMed  Google Scholar 

  60. Grivas A, Schramm J, Kral T, von Lehe M, Helmstaedter C, Elger CE, et al. Surgical treatment for refractory temporal lobe epilepsy in the elderly: seizure outcome and neuropsychological sequels compared with a younger cohort. Epilepsia. 2006;47(8):1364–72. https://doi.org/10.1111/j.1528-1167.2006.00608.x.

    Article  PubMed  Google Scholar 

  61. Dewar S, Eliashiv D, Walshaw PD, Engel J Jr, Fried I, Moseley BD. Safety, efficacy, and life satisfaction following epilepsy surgery in patients aged 60 years and older. J Neurosurg. 2016;124(4):945–51. https://doi.org/10.3171/2015.3.Jns142317.

    Article  PubMed  Google Scholar 

  62. Drane DL. MRI-guided stereotactic laser ablation for epilepsy surgery: promising preliminary results for cognitive outcome. Epilepsy Res. 2018;142:170–5. https://doi.org/10.1016/j.eplepsyres.2017.09.016.

    Article  PubMed  Google Scholar 

  63. • Youngerman BE, Oh JY, Anbarasan D, Billakota S, Casadei CH, Corrigan EK, et al. Laser ablation is effective for temporal lobe epilepsy with and without mesial temporal sclerosis if hippocampal seizure onsets are localized by stereoelectroencephalography. Epilepsia. 2018;59(3):595–606. https://doi.org/10.1111/epi.14004. In this series of 30 patients who underwent mesial temporal laser ablation, 6 patients were ≥ 60 years of age. 4/6 patients were seizure free, comparing favorably with the younger group (12/24 patients were seizure free).

    Article  PubMed  Google Scholar 

  64. Kang JY, Wu C, Tracy J, Lorenzo M, Evans J, Nei M, et al. Laser interstitial thermal therapy for medically intractable mesial temporal lobe epilepsy. Epilepsia. 2016;57(2):325–34. https://doi.org/10.1111/epi.13284.

    Article  PubMed  Google Scholar 

  65. Jobst BC, Kapur R, Barkley GL, Bazil CW, Berg MJ, Bergey GK, et al. Brain-responsive neurostimulation in patients with medically intractable seizures arising from eloquent and other neocortical areas. Epilepsia. 2017;58(6):1005–14. https://doi.org/10.1111/epi.13739.

    Article  PubMed  Google Scholar 

  66. Fisher R, Salanova V, Witt T, Worth R, Henry T, Gross R, et al. Electrical stimulation of the anterior nucleus of thalamus for treatment of refractory epilepsy. Epilepsia. 2010;51(5):899–908. https://doi.org/10.1111/j.1528-1167.2010.02536.x.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurology, Comprehensive Epilepsy Center, Neurological Institute of New York, Columbia University Irving Medical Center, 710 West 168th Street, 7th Floor, New York, NY, 10032, USA

    Christopher J. Elder & Anil Mendiratta

Authors
  1. Christopher J. Elder
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Anil Mendiratta
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anil Mendiratta.

Ethics declarations

Conflict of Interest

Christopher J. Elder and Anil Mendiratta each declares no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Neurology of Aging

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Elder, C.J., Mendiratta, A. Seizures and Epilepsy in the Elderly: Diagnostic and Treatment Considerations. Curr Geri Rep 9, 10–17 (2020). https://doi.org/10.1007/s13670-020-00310-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13670-020-00310-0

Keywords

Search

Navigation