Seizures can begin at any age. The highest incidence of newly diagnosed seizures is currently in seniors (generally referring to individuals age 60 and above), which is also the fastest growing segment of our population. This segment of our population poses numerous unique challenges with regard to diagnosis, management, and treatment of seizures and epilepsy.
Diagnosis often is delayed because some of the clinical signs of a seizure, such as confusion, memory loss, abnormal behavior, or wandering, are often thought to be due to other conditions that are more common in this age group, such as dementia, delirium, or memory loss.
Many medical conditions that are risk factors for the development of seizures are seen more frequently in seniors, including stroke, intracranial hemorrhage, subdural hematoma, brain tumor, dementia, and head trauma from falls or other causes. Moreover, seizures do not need to begin immediately after the diagnosis of one of these preceding conditions. The first seizure may occur many months or years later. Neither does there need to be a family history of seizures, and often the cause of epilepsy is not found. Consequently, many older people have a difficult time accepting the diagnosis of seizures or epilepsy.
The diagnosis of seizures can result in significant changes in an individual’s lifestyle. These changes can impact quality of life in all individuals, but can have a relatively greater impact on the older adults. In this age group, individuals try more 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, anti-epileptic drugs (AEDs) are the main form of treatment. Some of the most common side effects of AEDs include fatigue, drowsiness, dizziness, and slowed cognition. Older adults are especially prone to these side effects. Increased side effects can result in decreased compliance, which in turn can lead to break through seizures. Furthermore, breakthrough seizures lead to potential for more injuries and decreased quality of life.
Correspondingly, one of the most important decisions is the choice of AED. Ideally, one should be chosen that has the least likelihood of the above side effects, requires minimal monitoring, does not interact with other medications (many elderly people are already on multiple medications for other medical conditions), and has a low dosing frequency. The best AED dose required in the elderly is often lower than other age groups, and the way the dose is scaled up needs to be slower to minimize side effects. This is in part because older people have decreased metabolism that leads to slower processing and clearance of medication.
The common goal for all people with epilepsy no matter what age is “no seizures and not side effects.” Care of elder people with epilepsy is complicated by the fact that there are very few studies done in this age group and there is no definitive guideline to assist in making the decisions outlined above. Consequently, their care involves a combined emphasis on balancing risks and benefits, along with assessing co-medical problems, patience, and compassion.