Gina Kaye (Host): Welcome to UK HealthCast, a podcast presented by UK HealthCare. I'm Gina Kaye. And joining me today is Sally Mathias, MD neurologist and epileptologist at the Kentucky Neuroscience Institute. Today, we are going to be talking about epilepsy in older people. Dr. Mathias, welcome to the podcast.

Sally Mathias, MD: Hello, Gina. And thank you so much for inviting me to discuss this very important topic.

Host: Let's start in with question number one. What is the prevalence of seizures in elderly patients?

Sally Mathias, MD: Sure. You know, for a long time, it was thought that seizures and epilepsy affected children and younger adults, but we now know it is not true. When asking about statistics and numbers, I like to kind of break it up into two parts.

First of all, we can look into new-onset seizures in our older people. So, what studies have shown is that after age 65, about one in 1000 people each year are diagnosed with new-onset epilepsy. But as age advances, like patients over the age of 80, that number goes up to almost two per 1000.

Now, when it comes to prevalence, meaning how many people right now are living with epilepsy? In our older adults, several longitudinal studies have shown a prevalence of five to six per 100 that live with epilepsy. And in patients who live in nursing homes who are institutionalized, that number is actually seven to eight-fold higher than their counterparts who live in independent dwelling.

So, bottom line is that seizures are very common in the elderly, and it is an important topic, because it is not well recognized; and therefore, you know, understanding that makes it very important.

Host: How do seizures differ in older patients when compared to the young?

Sally Mathias, MD: There are several differences actually. Now, when we think about a seizure, most of the time we think someone having whole body shaking or convulsions. In fact, that is very seldom seen in our older patients. Most elderly present with subtle confusion, memory lapses, staring, sort of reduced or impaired awareness.

Now, younger patients have a classic or a distinct warning before seizures that can happen before some types of seizures, but that is not there in the elderly. And therefore, you know, a lot of times, that senior moments or memory lapses are what are thought to be could be seizures. And the recovery phase after a seizure in younger people is very brief. It's usually short. But in our elderly folks, the recovery phase could last hours or days, and it is all thought to be memory lapses. And in fact, that may not be the case.

Host: So, it sounds like what we're dealing with is maybe a lot of misdiagnosis.

Sally Mathias, MD: Absolutely, or underrrecognition that these could be seizures.

Host: To that point, what are the most common causes of epilepsy in elderly people?

Sally Mathias, MD: Sure. Stroke number one cause for seizures in the elderly. The bleeding type of stroke can cause more seizures compared to the ischemic type of stroke. And within first year after stroke, studies have shown a 23-fold higher increase of seizures.

Host: Wow, that's incredible.

Sally Mathias, MD: Yes, and some other things memory problems or dementia carries a tenfold higher risk of developing seizures. And early-onset Alzheimer's, so familial Alzheimer's, that carries over 80% risk of developing seizures. Some other things are traumatic brain injury or head injury and brain tumors.

Now, what I like to discuss about is vascular risk factors that most of our elderly patients have, like hypertension. Now, high blood pressure is thought to be an independent risk factor to developing seizures. And how many of our elderly folks have high blood pressure? Several. But it's not known and it is not advertised as such.

Host: This is really fascinating information. So, why do you think epilepsy then gets overlooked in elderly patients, knowing all of those risk factors that may or may not be the cause?

Sally Mathias, MD: Sure. Like I said, the presentation is so different, right? In medical training, we are thought to have a picture of seizures that is very different how elderly presents. So, presentation is different. Most of our older patients live by themselves. So, there is no eyewitness to explain what is going on. Memory lapses itself, like I said, are thought to be more of a dementia process because they're elderly and not seizures.

And then, some other things are like EEG, you know, it is a test that we do to diagnose seizures. In fact, it is a well-known fact that EEG abnormalities that show epilepsy are more robustly seen in children and younger adults and older patients do not have that many abnormalities. So even the objective testing that we see does not give us the answer.

And lastly, it's a sad fact that oftentimes investigations or workup is not as thorough in the elderly people compared to the younger generation, especially maybe because there is no one to advocate for them, no one to be with them in the hospital and clinic and so on.

Host: So, we've talked about signs and some symptoms. So, let's talk about treatment then. What does that look like in an elderly person?

Sally Mathias, MD: Sure. So, I would discuss about management here, you know, which is, first of all, having an open mind to this diagnosis, right? Keeping seizures high in your differential for physicians and providers treating these patients. And then, doing investigations like EEG or MRI brain. Taking a very thorough history, that's the first step.

Once the diagnosis is made, the treatment is actually very simple. It's anti-seizure medications. And several anti-seizure medications that have come out since the 1990s are excellent in treating seizures in the elderly. Lamotrigine has been studied and, you know, very well-tolerated in the elderly. Levetiracetam is another medication that has a fantastic pharmacokinetic profile. You know, it does not have any interactions, and you can start at a target dose pretty quickly.

And then, there is lacosamide, which also has fewer side effects and helps with seizures significantly. And what studies have shown is that over 80% of our elderly patients become very well-controlled with one single medication at a modest dose. And if the seizures do not stop with one medication, then we may have to add a second one. If still it doesn't work, then we still have epilepsy surgery as an option. And that option is also underutilized and not very commonly thought of in the treatment process.

Host: Yeah. I didn't even realize that that was an option. The advancements these days are just amazing. So, we have good news. We have a treatment, and it sounds like a really good success rate. So conversely, what are the dangers of not treating seizures in the elderly?

Sally Mathias, MD: Yes. And this is particularly important to discuss, because many of our elderly patients are already frail due to their medical comorbidities, and seizures can cause physical injuries, falls. There is an accelerated cognitive decline or worsening of memory that happens if seizures are not treated. And then, of course, there is mortality, which studies have shown a very high-risk of mortality in patients with newly diagnosed epilepsy over the age of 65 when compared to similar age cohort that do not have epilepsy.

And the other aspect is, you know, emergency of epilepsy, which is called status epilepticus. That in fact is related to mortality or death about 40% of the times in the elderly. So therefore, identifying, sort of spreading awareness about this, treating patients with seizures over the age of 65 becomes so important. And because of these factors, sometimes even a single unprovoked seizure after the age of 65, providers, physicians think about treating this because, if not treated, the chance of another seizure happening is very high in these patients. Conversely, the risks of treatment with newer anti-seizure medications are very few.

Host: So, raising awareness with the elderly population is obviously very important. How do you attack that?

Sally Mathias, MD: First of all, I think spreading awareness through programs like this, knowing that seizures and epilepsy is common in the elderly, knowing what are the modifiable risk factors. It could be control of high blood pressure that can help prevent stroke, and that can help prevent seizures.

Keeping an open mind to diagnosis among physicians or providers in different settings, that also helps. So, I feel knowing, understanding enables prevention, early identification and, of course, helps with a better care model for our patients.

Host: UK HealthCare has a Level 4 epilepsy center. Talk to us about that.

Sally Mathias, MD: That's exciting. Yes. So, the University of Kentucky is a Level 4 epilepsy center, which means it provides the highest level of care for people with seizures and epilepsy. And what our center provides is access to specialists in epilepsy. Not just that, neuropsychologists, you know, who look into the cognitive side of things, neuroradiologist, neurosurgeons. So, it's a comprehensive care.

Now, our center will help our older adults to get the right diagnosis faster. Find a true cause for the seizures and see how we can treat that. And also, more tailored or more personalized treatment, which I think helps significantly.

Host: That's great. I love that. So, your role at Lexington VA Healthcare System, also another aspect of your job duties, there are two epilepsy specialists is what I have on my note. So you and a colleague care for elderly veterans with new onset seizures. How is that different? Or is it?

Sally Mathias, MD: it is in fact, because veterans are a more vulnerable group when it comes to developing epilepsy as age advances. And that is because of higher rates of brain injury, higher rates of vascular diseases like hypertension, as well as stroke. And recognizing this risk early helps us with timely diagnosis and treatment and having epilepsy specialists at the VA. We work closely with UK's Level 4 epilepsy center. And this allows veterans to benefit from advanced expertise without unnecessary delays in care. So, you get the expert diagnosis, we get the coordinated care and the most advanced treatment options.

Host: That's amazing, really. The fact that those two work hand in hand is commendable.

Sally Mathias, MD: Absolutely. Yes. Most of our neurologists have dual appointments and therefore most of the care is so seamless between the two centers.

Host: Anything else you'd like to add for the good of the cause?

Sally Mathias, MD: I would just say recognizing, knowing that seizures are very common as age advances And the elderly are the fastest growing segment of our epilepsy population. That itself is eye-opening. And then, I know all providers know what to do from there. So, that would be important.

And for patients, I would say, seizures can happen. They do happen. There are risk factors, they're preventable. And seizures in the elderly can be easily controlled with a single medication. So, my suggestion would be do not delay care, accessing care, and work with your doctor and provider to help control seizures.

Host: Nice. Knowledge really is power.

Sally Mathias, MD: It is.

Host: If you want more information beyond what was received today, please visit our website at ukhealthcare.uk.edu. Dr. Mathias, we very much appreciate your willingness to educate all of us on the prevalence of epilepsy in older adults. Thank you for all the information you shared.

Sally Mathias, MD: Thank you so much, Gina. It has been a pleasure.

Host: That was Dr. Sally Mathias, neurologist and epileptologist at the Kentucky Neuroscience Institute. I'm Gina Kaye. Thanks for listening to the UK HealthCast, a podcast from UK HealthCare.

Disclaimer: All content of this podcast is intended for general information purposes only and is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment. Please consult a medical professional before adopting any of the suggestions discussed on this podcast episode.