17 Aug 2018

New-onset epilepsy in an ageing population

Prof Patrick Kwan, one of the study co-authors, with an epilepsy
research study patient in the new clinical trial facility at the Alfred
by Anne Crawford

Epilepsy is often regarded as a disease afflicting the young, but the highest incidence of developing new-onset epilepsy is in fact in people aged 60 years old and older – and their number is increasing with an ageing Australian population. Despite this, there has been limited research into this aspect of the disease, with most studies taking a broad approach that looks at older people who are diagnosed with epilepsy in their childhood or middle age.

Researchers led by the Head of the Monash University Department of Neuroscience, Professor Terence O’Brien, decided to review the literature to update existing evidence about the causes, prognosis, treatment and psychosocial effects of new-onset epilepsy in this cohort.

The review, which surveyed 22 studies, was published in the British Journal of Clinical Pharmacology.

By the end of 2015, half of all new-onset seizures in Australia were estimated to be in patients aged 60 years and older. Studies cited in the review showed that the numbers in this group has been increasing significantly over the years. A recent Finnish study for example found a nearly five-fold rise of new-onset epilepsy among the elderly population from 1973 to 2013, whilst an earlier US study suggested the likelihood of developing epilepsy in people older than 80 years old was three times higher than that in children.

The review found evidence that newly treated epilepsy patients have excess mortality and hospitalisation risks. A US study found rates of hospitalisation of people aged ≥60 years with new-onset epilepsy was three times higher compared to that of people with chronic established epilepsy.

The increasing trend was important in a clinical setting, but also as a significant public health issue, given the increasing proportion of Australian society who are in the >65 year old group in our “ageing society”.

Despite this there were no formal guidelines for the management of the condition and limited high-quality studies of treatments.

The literature showed that the most common type of epilepsy experienced by the group in question was focal seizures, which only affect part of the brain.

The elderly experienced new-onset epilepsy in ways that have key differences to the epilepsy experienced by younger patients. Seizures were generally briefer, with less obvious symptoms than those shown by younger people, making diagnosis more challenging. The most common characteristics of seizures were a blank stare, loss of awareness, confusion and memory problems.

“Postictal confusion”, the haziness felt after a seizure, could last much longer in the elderly, even up to two weeks, compared with a few minutes or a few hours in younger patients. This could make an epilepsy diagnosis more complicated as it could be misdiagnosed as delirium from other causes, fatigue or the patient experiencing a “funny turn”.

Said Professor O’Brien, “Seizures in older patients are often more difficult to diagnose, particularly in people who have cognitive deficits and confusion from dementia and other neurological disorders that are common in older people.”

The most common identifiable causes are stroke and Alzheimer’s disease.

Seizures were only part of the symptoms often experienced in this group. Five studies reported that people ≥60 years with new-onset epilepsy had significant cognitive impairments (e.g. memory loss) and psychological issues including depression, anxiety and fatigue.

The review found that all the available anti-epileptic drugs (AEDs) bar one were effective in treating older patients with new-onset epilepsy and that it was generally easier to achieve seizure-free status in older patients compared with younger age groups. However, older patients with new-onset epilepsy often have poor adherence to AED treatment, possibly due to adverse side effects.

It concludes that more high-quality clinical trials are required to investigate effective treatments with limited side effects. More research on the psychosocial effects of new-onset epilepsy and long-term outcomes was also needed to develop strategies aimed at reducing and/or preventing the incidence of new-onset epilepsy in people with Alzheimer’s disease and stroke, as was management incorporating patient-centred care and outcomes.

Unless preventive therapy can be developed, it is expected that the incidence of new-onset epilepsy in people aged ≥60 years will continue to increase, the paper says.

First author on the paper was Lily Chi Vu from the Departments of Medicine and Neurology, Royal Melbourne Hospital.

Vu LC, Piccenna L, Kwan P, O'Brien TJ. New-onset epilepsy in the elderly. Br J Clin Pharmacol. 2018 Jun 1. doi: 10.1111/bcp.13653. [Epub ahead of print, available online 28 July 2018]

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