History
A male patient in his 70s has a prior medical history of hypertension, hyperlipidemia, atrial fibrillation, tachy-brady syndrome and prostate cancer.
Prior to coming to Rush, the patient was seen by an outside neurologist and underwent routine EEG and CTH. His EEG showed intermittent bilateral temporal slowing that at times was sharply contoured (no sleep recorded). His CTH had no acute intracranial abnormalities.
Presentation and Examination
He came with his daughter-in-law to the Rush Epilepsy Center seeking a consultation for his issue with spells.
She reported the onset of these episodes began about two years ago. She says that the patient will make a confused expression and may not know where he is or what he is doing. He is able to talk and communicate during them but will respond with bizarre, off-the-point statements.
During these episodes, he will sometimes open and close his mouth, but there are no other automatisms noticed. His daughter-in-law says he can become frustrated during the episodes, which can last for minutes at a time, but can sometimes endure up to 30 minutes in duration, with relative quick return to baseline. When the patient is asked later in the day about the episode, he is usually unable to recall it. Sometimes he remembers the episodes and admits to feeling embarrassed during an episode, but he denies feeling panic, nervousness or fear. When experiencing an episode, the patient says something doesn’t feel “right” but is unable to elaborate further. His episodes are spontaneous without other identifiable triggers and can occur about once per month in frequency.
The patient also reported poor sleep, including difficulty falling and staying asleep, and may only get two hours of sleep at a time. He denies snoring but reports frequent awakening for urination and has difficulty getting back to sleep. The patient says he does not feel refreshed when waking. He reported experiencing some headaches as recently as six months ago that primarily occurred at night but have now resolved.
His daughter-in-law reports the patient experiences depression, but he denies this.
His physical exam was within normal limits.
For the workup, his EEG showed bitemporal slowing, which could be sharply contoured at times; his CTH was without acute focal abnormalities. These discrete, stereotyped events with the EEG findings are concerning for dyscognitive seizures possibly localizing to the temporal lobes. It may also be that the family is observing the patient in a postictal confusional state and the ictal events are being unwitnessed.
Treatment
Given the results from his workup, I prescribed him low-dose, anti-seizure therapy, Levetiracetam, and obtained a prolonged EEG with sleep for further interictal evaluation.
Outcome
His EEG showed left temporal spikes, which confirmed the diagnosis of left temporal lobe epilepsy. The patient had an improvement in the frequency of his seizures and his memory initially improved on Levetiracetam.
At his last clinic visit, he still experiences shorter seizures, and his overall mood has improved with low dose Citalopram.
Analysis
Epilepsy is often thought of as a disease of youth; however, epidemiological studies consistently show a bimodal incidence over lifespan, with a second peak in incidence occurring after the age of 60 years. Almost 25% of new-onset epilepsy occurs in the elderly. Recent reports cite 1% of the population over 65 years has active epilepsy, adding up to almost 500,000 people. Epilepsy is more likely to develop in older adults than younger because as one ages, the risks for seizures and epilepsy increases.
Seizures are often difficult to identify in older adults because they are less likely to present as a convulsion, but rather as discrete episodes of confusion, lapses in memory, falls, dizziness, brief repetitive movements or nonspecific sensory changes. People are more likely to blame the aging process than to think of a seizure. It is important, however, to be evaluated so the correct treatment can be initiated.
Approximately half of older adults diagnosed with epilepsy do not know the cause. Known causes include stroke, traumatic head injury, neurodegenerative disorder or brain tumor.
These causes and other mimics need to be investigated thoroughly before an appropriate treatment strategy is chosen. Older adults with epilepsy often face greater challenges than younger adults. Finding an antiepileptic medication that does not cause unwanted side effects while also not interacting with a patient’s other medications can be challenging. With the diagnosis of epilepsy comes many lifestyle changes that often challenge an older adult’s ability to live independently. As with younger populations, memory problems, depression and anxiety are more prevalent in older adults with epilepsy.
While the patient continues to have seizures, they are shorter, and he reports improved memory. At the last visit, his Levetiracetam dose was mildly increased, following the adage of starting a medication “low and going slow” with dose increases to minimize unwanted side effects.
At Rush, we offer a comprehensive epilepsy clinic for older adults that not only offers a consultation with an epilepsy specialist but also a pharmacist, social worker and a geropsychiatrist for complete evaluation and management. This clinic is unique in Chicago and the Midwest. The experience of our staff allows patients to come to a more efficient diagnosis and effectively implement care models that encourage cooperation with their other care providers. The clinic is also a member of the International Consortium of Clinics for Elderly with Epilepsy, putting Rush patients at the forefront of clinical care and research initiatives.
