Epigraph Vol. 25 Issue 2, Spring 2023

Managing epilepsy in older adults: Dr. Loretta Piccenna and Dr. Rebecca O'Dwyer

Reported by Dr. Anca Arbune Edited and produced by Nancy Volkers

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What special considerations must physicians make when managing epilepsy in older adults? Who is considered an “older adult,” anyway? Dr. Anca Arbune interviews two authors of a recent critical review by an ILAE task force.

 

Sharp Waves episodes are meant for informational purposes only, and not as clinical or medical advice.

Podcast Transcript

[00:00:21] Dr. Anca Arbune: Hi, I'm Anca Arbune, a neurologist and researcher in Bucharest, Romania. Today I'm speaking with two of the authors of a critical review on the management of epilepsy in older adults. 

[00:00:33] Dr. Loretta Piccenna: So my name is Dr. Loretta Piccenna, and I've been in research and research support for over 10 years now. 

[00:00:41] Dr. Rebecca O'Dwyer: Hi my name is Dr. Rebecca O'Dwyer. I am an adult epileptologist at the Rush Epilepsy Center, which is in Chicago in the US. I am the director of our comprehensive epilepsy clinic for the elderly. I think it's one of very few within the United States. I'm also currently the chairperson of the geriatric neurology section of the American Academy of Neurology.

[00:01:10] Dr. Anca Arbune: One of the first issues is how to define older adult. At what age is someone considered older or elderly? 

[00:01:21] Dr. Loretta Piccenna: This is actually a topic that has been discussed quite a lot within the field. And not too long ago, a team actually in Canada published a paper looking at the studies. Available and what the different age groups had been used within studies in the elderly.

Unfortunately, there's quite a wide variation, so it can be anything like from the ages of probably mid-forties and upwards. But this is something that we, we need to address within the field and come to a shared understanding of exactly what we can use as a limit to say, okay you know, this is the minimum age that we are, we are trying to consider.

[00:02:07] Dr. Rebecca O'Dwyer: I think that's the challenge of this age group. I think when you treat them clinically, you can have a very spry 92 year old who's like playing rummy with her girlfriends on a Tuesday afternoon, and you can have a 55-year-old who has uncontrolled high blood pressure and maybe Type 2 diabetes who's had a stroke.

And so, you know, to Loretta's point, as a community, we need to figure out what are the criteria. And I think it's one of the challenges of treating and researching this particular age group. 

[00:02:42] Dr. Anca Arbune: Comorbidities comprise a big problem in this age group, although some studies have found that seizures in older adults with epilepsy respond well to anti-seizure medications.

We do have to think in advance. So if we choose a new anti-seizure medication in a newly diagnosed epilepsy, what should we have in mind? Is there an ideal drug we can give them and avoid interactions?

[00:03:10] Dr. Rebecca O'Dwyer: So I think there's no one drug fits all, and I think this is something where you need to use... first of all, you have to look at all the comorbidities, right? And then also you need to look at what seizure medication you're going to choose and use. Not only the negative but also the positive sides of that.

So I'm a great believer in trying to get more bang for your buck. So for instance, when I have an older adult who maybe also is having some signs of depression, I might choose a medication like lamotrigine over a different medication because I know I'll get the benefit of some mood stabilization with that patient.

Likewise, if I look at, somebody may be a patient with Parkinson's disease, I might actually choose low-dose zonisamide, because we know there's many studies out of Japan - the Japanese are actually using zonisamide in patients with Parkinson's disease and to treat the motor symptoms of Parkinson's.

And then I think another medication that I often use clinically is levetiracetam. And again, there is some data both from the experimental realm and murine models but yet now also with that JAMA paper from a couple of years ago that patients with Alzheimer's and seizures actually had an improvement in their Mini Mental scores when they were put on low-dose levetiracetam. So if I have a patient with an underlying dementia, and that isn't showing gross behavioral problems, I might decide to use levetiracetam. 

I think the other point about when choosing a medication, you have to obviously consider the renal function. I think another thing is actually their albumin, right? Depending on how protein bound the medication, the anti-seizure medication is on how much you're going to prescribe.

And as a general rule of thumb, I think going low and starting very slow is a good way to medically manage these patients. 

[00:05:10] Dr. Loretta Piccenna: I think you were also asking what you think the ideal anti-seizure medication is. And I think that we highlighted in the report that we just can't... One doesn't exist.

An ideal anti-seizure medication would have a long half-life, it would permit once per day dosing. It would have stable serum levels with a long peak, but long absorption, no drug interactions and, and have very good anti-seizure properties with minimal, minimal side effects. But from the, the current medications we have available, some have these features but not all of them.

So within the paper, we, we do provide four key practical considerations that clinicians should use when they're selecting an anti-seizure medications. And, you know, they include things like the efficacy of the medication to prevent seizures, the potential of that medication to cause adverse effects, things like memory, cognition coordination, mood, and quality of life.

Drug to drug interactions. So not forgetting things like natural supplements that, that they may be taking or, or particular products as well as the economical and practical factors like cost, dosage, whether the tablets are similar colors to other drugs being used by that person or if they have, you know, things like swallowing difficulties.

So yeah, listening carefully to the patient and asking questions is essential. 

[00:06:39] Dr. Anca Arbune: During the natural aging process, a degree of cognitive decline is expected. One issue would be how can we distinguish between a natural decline and the side effect from anti-seizure medication? 

[00:06:53] Dr. Rebecca O'Dwyer: So usually it's the family that's going to tell you.

I mean, I'm not aware of, and I don't know, correct me if I'm wrong, Loretta, I'm not aware of any good systematic tool or quantitative tool that we have at the moment to actually measure that. There are some tools that have been used in in the literature, but nothing has been validated. And I think that's an area of research that we as a community need to do.

My personal experience, like I said, it's usually the family that will come back and tell you and will be like, “You started that drug and now my granny, she's blunted, she's not as cognitively sharp.” I think the flip side to that though is that if you don't treat the seizures, you can also hasten that cognitive decline.

And so Vossel's group over the last several years has done a lot of work in looking at measuring cognitive decline and seizure frequency and onset of seizures. And that they've actually shown, when people—and when I say people, I mean family, loved ones, caregivers—actually recognize the seizures, that's usually also when they report to their physicians the greatest decline in cognition. And so the idea is that if we treat the seizures, we can actually slow down the hastening of cognitive decline. 

[00:08:16] Dr. Anca Arbune: Okay. And how about people with epilepsy in childhood or early adulthood who go into their older ages and have long-term antiepileptic treatment?

Is their cognitive decline more accelerated? And can the tweaking of the medication improve anything? 

[00:08:37] Dr. Rebecca O'Dwyer: Definitely we're aware of the of other side effects, right? You know, huge declines in bone density. Other side effects that I often encounter where you might have somebody who's been on, for instance, valproic acid for most of their life: As they age, they often develop a tremor.

And I've actually had some of my colleagues in the movement disorders section of my department send me patients who are Parkinsonian. And when I look through their medication list, I see that they're on valproic acid. And if I change them to something else, usually their Parkinsonism, their tremor, usually goes away.

And so again, I think something that we kind of highlighted through the article was just that there are so many questions that need to be answered with this age group and they just haven't been, and we really don't have good data. And I think it, it brings the point of, you know, I'm here in America, so I can only really speak to the FDA, but when new anti-seizure medications are being brought to market or they're going through the initial clinical trials, often this age group is either not included in the initial clinical trials or is grossly underrepresented. And so I think we need more clinical trials that are dedicated to this age group.

[00:10:02] Dr. Loretta Piccenna: I think also speaking to that point, Becky, is for elderly patients who are in residential aged care or nursing homes, it can also be quite difficult for staff who perhaps are not trained in recognizing what to look for in terms of cognitive decline. So I think one thing that we did point out in the report was that monitoring of elderly patients and having routine regular reviews by the actual multidisciplinary team is essential. So that we can then pick up particular behaviors or ask staff or, or as you say, the family, you know, when you're talking in conversation, you're able to tease out little things that perhaps they were, were not you know, cognizant that are actually these particular issues.

[00:10:53] Dr. Rebecca O'Dwyer: And I think to speak to your point too, Loretta, with the cognitive decline, sometimes the manifestation of uncontrolled seizures is this accelerated decline in cognition. And I think it's probably, Anca, an important point to kind of bring forward in this interview is how often seizures in older individuals present very differently to younger working age.

And so that often they don't have the same motor phenomenon that we see or that the public is used to seeing. I had a patient who got a new set of dentures and he was doing well with his new set of dentures, and then his family noticed when they visited him that he would play with his dentures and he was also around this time he also declined quite rapidly cognitively. And actually the playing with his dentures was oral automatisms and he was actually having temporal lobe seizures. You know, making not only the public aware, but also our fellow epileptologists and our fellow neurologists and our fellow GPs, primary care physicians that, that these seizures present quite differently in older adults, but nonetheless have huge ramifications. 

[00:12:07] Dr. Anca Arbune: One of the issues you brought up in in the article was that there was poor education about seizures in older adults. And actually I think this should trigger some response from communities all over the world. So at least not only for the older adults, but also for their families, exactly what to watch for and how to recognize. Do you think we are close to achieving an educational program that's easier or accessible for the families in order to help them in this process? 

[00:12:44] Dr. Loretta Piccenna: Um, I think yes and no. Currently I'm aware of a few organizations such as, particularly in the US, the Epilepsy Foundation, and as well here in Australia as well as some of the ones in the UK.

I know that they all have online education programs as well as outreach programs for the community. I think unfortunately, they're not, they're not something that's, well recognized within the community. And I think this is a, you know, the factor that plays a part with the lack of knowledge that particularly people have in the community about what to recognize.

So, yeah, I don't think we have the ultimate, you know, strategy or approach for ensuring that knowledge is increased, not just within the community, but across that continuum of care to ensure that everyone knows about what to look for what the right approach is in terms of, you know, if, if an individual is actually having a seizure and, you know, instead of ringing for an ambulance and going to the emergency department sometimes all that is really needed is an emergency medication and a treatment plan in place to actually manage the epilepsy.

 We're actually hoping that with this report, that there's an increased momentum within the field. and particularly through the professional international organizations to all come together and, and try to figure out some more educational strategies to ensure that we are making this this population a priority.

[00:14:25] Dr. Anca Arbune: How about status epilepticus in older adults, particularly non convulsive status epilepticus, which can be easily missed. 

[00:14:35] Dr. Loretta Piccenna: We, we noted that there was one study that has actually revealed 16% of elderly patients that were seen in the emergency department were found to have non convulsive status epilepticus.

So unfortunately we weren't able to find any sufficient evidence to indicate how status epilepticus can be better managed in the elderly. And I think due to this lack of evidence, it needs to be treated similarly to what is happening in younger age groups. So we, we noted that was an unmet clinical need that exists.

And hence studies are necessary to, to enable understanding what, what better management can be in the emergency department. 

[00:15:20] Dr. Anca Arbune: Moving on a bit to epilepsy surgery. What are the current views? Is it worth it? Are there any special considerations in this age group? 

[00:15:31] Dr. Rebecca O'Dwyer: So when we looked at the literature and also some of, some of the work that I've done here in Chicago, we saw that really the surgeons are quite good at selecting the patients who are at least risk for bad outcomes just due to going under anesthesia.

So I think if you have a patient who's sufficiently healthy, healthy enough to go for a surgery, I think then you look at their epilepsy and really the predictors of how they're going to do after epilepsy surgery are similar to those of younger working aged adults. So you know, non-lesional cases or people with bilateral interictals don't do as well as people with lesional cases and who have, you know, unilateral and ictal and interictal phenomenon.

So really it's just a question of are they healthy enough to go under? And if they are, I don't think there really is at, at least what the literature is showing us now, that there isn't really a reason not to do the surgery if they have intractable epilepsy. 

[00:16:40] Dr. Anca Arbune: And let's talk about bit about the quality of life in in this age group.

Do we have any available scales that are sufficient to reflect the reality in this age group? Or can we just apply any questionnaire on the quality of life as in any adult. 

[00:16:59] Dr. Loretta Piccenna: We did find that one of the systematic reviews concluded that the QOLIE- 31 tool was the most common scale used with the elderly, but at the same time, they also used other scales in addition.

So, you know that in itself, tells us that maybe it wasn't sufficient enough as a tool. And we know that this particular tool was developed for younger age groups originally, so, we really need to have a scale that takes into account the factors that diversify this population so that we know that the efficacy and tolerability of, of treatments is more accurate.

Also, you know, falls in the elderly are a usual occurrence but there's a, an increased risk that's been found with use of anti-seizure medications. And the current scales don't account for this and could actually put patients at risk. So having a tool that that can enable this will, will be very important part of, treatment.

There's potential as well for utilizing things like qualitative studies, to look at the psychosocial impact of epilepsy in this population. To, to my knowledge, I, I believe there's only one study that's been done that was able to identify eight key themes relating to, the impact. And it's these particular perspectives from patients that you know, in terms of their values, their preferences, their needs, that we can then incorporate into a model of care that is more patient centered.

[00:18:36] Dr. Rebecca O'Dwyer: Absolutely. And just to, to kind of piggyback on what all of Loretta said, I think just, you know, like she talked about the QOLIE-31, it really is, when you look at those questions, a lot of it has to do with employment , in terms of quality of life. So if you have a patient who's retired, right, this really isn't relevant to their life.

And there is a pediatric version of that scale. And I think that was one of our kind of themes at the very end of the article was, you know, we honor children rightly so, as not small adults, but their own separate population. And I think we need to do the same for older adults as well. Although there's increasing interest in this age group, the original research hasn't followed and it was on the strength of this that we came up with the idea to start a consortium.

And so at the last AES in Nashville, just last year, we actually founded the International Consortium of and Clinics for Epilepsy and the Elderly, the ICCEE, and we're an international group of physicians and researchers with this interest in epilepsy in the elderly. And the idea behind this consortium is that we will pool our, our work, our clinical work, our ideas, our data, so that we can maybe do, start some original research as a, as a whole international group. Because I think one person on their own seeing patients isn't going to answer these questions. And so I guess we invite your listeners if they would like to join us to reach out to us.