The Under-Diagnosis of Epilepsy Posted on Saturday, April 01, 2006
Still Often Not Recognized in Older Adults By Wendy J. Meyeroff THE ERICKSON TRIBUNE “When people hear the diagnosis ‘epilepsy’ they cringe. I try to explain it’s actually very common; one in every three people knows someone with epilepsy,” says Brien Smith, M.D. Smith is chair of the Epilepsy Foundation of America (EFA) advocacy committee and director of Henry Ford Hospital’s Comprehensive Epilepsy Center in Detroit. The EFA estimates 2.7 to 3 million people in the U.S. have epilepsy. Every year 181,000 people develop it for the first time, a situation called new onset epilepsy. You are more at risk if you are over age 60. Latest estimates of new onset epilepsy are about 100 cases per 100,000 in people age 60- plus, and some estimates say it is the leading neurological disorder in older people. (Others say it comes third, behind Alzheimer’s and stroke.) Why Epilepsy Develops Later Epilepsy is a neurological condition that makes people susceptible to seizures. Seizures are a change in sensation, awareness, or behavior brought about by a brief electrical disturbance in the brain. “Almost anything that affects the brain can cause epilepsy,” says Edward Bromfield, M.D., chief of the division of EEG, Epilepsy, and Sleep Neurology at Brigham & Women’s Hospital in Massachusetts. Accidents and head injuries are factors in new onset cases. Research suggests cerebrovascular problems—blood flow problems in the brain— are a factor in older people. “They can cause small strokes we can’t track but which cause damage. People with heart disease and diabetes are among those at risk,” he adds. Once seizures develop, various factors can trigger them. “Sleep deprivation is a common precipitant and many older people suffer from sleep problems, including sleep apnea. Older people often become confused with medications and a missed dosage can instigate seizures,” says Smith. The Misdiagnosis Debate
Many doctors debate the likelihood of epilepsy’s being missed or misdiagnosed, but experts The Erickson Tribune interviewed defend the statement. “Most epilepsy
studies done in adults include those in middle age. We don’t have good records as to how it affects older people,” says Smith. One cause of misdiagnosis is older people don’t always have the better known motor seizures associated with epilepsy. Instead they might present very vague symptoms. “People who are older can have subtler changes. They might look like they are yawning or stretching,” says Smith. “Older people tend to have staring spells,” says R. Eugene Ramsay, M.D., director of the International Epilepsy Center in Miami and a leading expert on epilepsy in older people. Unless someone happened to be hooked to an EEG machine during such episodes, “you would never know they are having a seizure,” Smith says. That is why it’s possible for these kind of seizures to be mistaken as an Alzheimer’s episode in an older person. Misdiagnosis occurs for other reasons. “It’s not unusual for people to not report their symptoms properly. I had a patient who told his doctors he had weakness and tingling in his arm. He was diagnosed with a heart problem called TIA, and put on aspirin. He was actually having a seizure,” says Ramsay. “Very often the person’s memory of the seizure, or the events leading to it, is impaired. Many older people live alone, and don’t have a second pair of eyes to give the doctor a true observation of what has happened,” he adds. For these and other reasons, Ramsay believes epilepsy is five times higher in older people than is generally recognized. Choosing a Medication The treatment of choice for most older people is still medication. Among the side effects of the older antiepileptic drugs (AED)s, including phenobarbitol, Dilantin, Tegretol, and Depakote, are balance problems, depression, and osteoporosis. Because of the latter, anyone on these drugs should get regular bone density tests and recommendations for fighting bone loss. Unfortunately, studies show less than 10 percent of neurologists prescribe calcium and Vitamin D supplements as a preventive measure. The older AEDs can affect the liver and interfere with other drugs’ effectiveness. “They can cause the liver to clear ‘good’ medications—like cholesterol-lowering statins and blood-thinning Coumdin—out of the system too quickly to be effective,” says Bromfield. That means your doctor might have to prescribe more of the other drugs to make them effective. Among other problems, that could increase your drug costs. The good news is that if one of the older drugs doesn’t control your seizures, doctors have newer medication treatments, including Keppra and Neurontin. Many of the newer AEDs are processed through the kidneys, not the liver, so they don’t have the same kind of drug interactions as their older counterparts. The new medications also don’t seem to cause as many balance and bone problems.
Bromfield issues one warning before leaping to the use of a new medication, and uses the worry about bone loss from an older medication as an example. “I’m a great believer in ‘if it ain’t broke, don’t fix it.’ If a person has been doing well on Dilantin, I transfer them to a newer drug if they have bone density tests showing bone loss. Otherwise I keep them on that drug, and recommend regular bone density tests and preventive measures,” he says. Impediments to Treatment Unfortunately experts agree several issues prevent older people from getting newer AEDs. Cost is a factor. Some insurance plans balk at paying for the newer drugs or the brand name older drugs, even if they might prevent more expensive outcomes— like hip fractures—down the road. Even if the doctor wants to try a different medication, many people refuse to transition to another medication once they have been stabilized. “I can prescribe drugs which ultimately will have fewer side effects, but the patient doesn’t want to take the risk of having seizures during the transition period. They say to me, “I’ve been seizure-free, why should I change?” says Smith. That’s mainly because epilepsy still carries many social stigmas, prejudices, and restrictions. For example, it is one of the few chronic conditions that can lead to driving restrictions, and potential legal ramifications if those are not followed. Ultimately it’s not enough for scientists to make advances in fighting epilepsy. Until both doctors and patients are better educated, and society’s attitude changes, people with epilepsy may not always get the best treatment possible.