Keywords: Hypertension; Heart Failure; Epilepsy; Dementia; Brain Tumor; Neuroimage; Atherosclerosis
Abbreviation: CVD: Cerebrovascular Disease; AD: Alzheimer´s Disease; AED: Antiepileptic Drugs
Introduction
Besides the chronical illness like diabetes, arterial hypertension
and heart failure, the geriatric patients have a lot of lacks in other
levels. The neurological system is probably the most affected
through the years. There are a lot of syndromes and illness
because the changes produced by the aging, but in frequencies, it
could be summarized in three: vascular pathology, epilepsy, and
cognitive disorders. Sen et al., explained previously the relationship
between some of this pathologies [1], and also, they show how
these conditions are linked. I explain briefly some considerations
in elderly patients with one of three main neurological conditions,
especially with epilepsy, in a way that could facilitate the approach
in the elderly patient who came to see a doctor. According with the
literature, the elderly people with epilepsy are those >65 years
old of age, and it could be separated in two groups: those who had
epilepsy since the childhood or young adults and aged with the
disease. The second group are those who were diagnosed with
epilepsy in the late life.
Cerebrovascular Disease (CVD) is the most common etiology
of epilepsy in the elderly, according to Acharya [2],the range of
frequency is 20-50 %, followed by dementia, brain tumor and head
injury. For this etiologies, the elderly patient with an episode of
epilepsy, need to be approach with an accurate medical history,
a complete neurological examination, and neuroimage. The
prevalence of seizures in people with Alzheimer´s Disease (AD) is
1-22%, and apparently the risk increases in the late stages, induced
by the accumulation of the amyloid-beta that creates aberrant
networks causing epileptiform activity [3]. Baker et al., found an
accelerated decline in attention, fluency and memory in patients
with suspected epileptic seizures [4]. The elderly with advanced
cognitive disorder could have an episode of epilepsy with a
postictal condition that may be difficult to diagnose, in some cases,
the patient could have a transient focal weakness after seizure, but
days latter the patient recover the movement in the extremities
(Todd´s paralysis) [5]. This condition could be considered for
the physicians like a transient ischemic attack and prescribe the
wrong treatment. Delirium is a common condition in the patients
with cognitive disorder, most of the cases could be a sing of acute
infection, stroke, or dehydration. If none of this conditions are
the factor that triggers the delirium, it must be approached like
a possible epileptic manifestation, type impaired awareness non
motor onset [6]. Patients with epilepsy have an increased risk
to develop cognitive disorders, if the duration of the seizure is
prolonged, the risk of brain injuries that can result in cognitive
impairment increase [7].
The cognitive decline could be explained not only for the
etiology of the epileptic disorder, but the type and frequency, age
of onset, the location, and the epileptogenic region [8].The use of
Antiepileptic Drugs (AEDs) are associated with cognitive deficits
specialy with older AEDs [9]. Recently, Wang et al., showed that
patients with epilepsy had a lower cognitive function in vocabulary, attention, memory, executive function, and psychomotor speed,
affected by educational level, seizure types, seizure frequency,
disease duration, depression, age, and AED´s [10]. All the elderly
patient with epilepsy should have a cognitive assessment, in order
to identify some of the deficits in memory or executive function that
could lead to forget to take the medication or affect directly to their
day living activities.
Finally, there are evidence that patients with epilepsy have
an increased risk of stroke not only for the comorbidities but
also with the use of AED’s for the increase in atherosclerosis
level in common carotid artery [11]. Chang et al. showed a 3-fold
higher incidence for stroke in the epilepsy cohort than in the
comparison cohort and also 6.3-fold higher for the patients aged
60 years than for those aged 20–39 years, with higher risk for
ischemic stroke than hemorrhagic stroke. This was explained by
the harmful effects of recurrent epilepsy and vascular risk factors
contribute to the overproduction of reactive oxygen species and the
oxidation of low-density lipoproteins into atherogenic particles,
leading to atherosclerosis [12]. The elderly patient needs to be
assess for atrial fibrillation and CVD to reduce this risk. As we can
see, the epilepsy could be a challenge to diagnose or treat as age
progresses and the manifestation of the disease becomes more
atypical. If the elderly patient with a neurological condition is not
well approached, the consequences could be harmful and lead the
patient to polypharmacy, frequent hospitalizations and death.
References
- Sen A, Capelli V, Husain M (2018) Cognition and dementia in older patients with epilepsy. Brain 141(6): 1592–1608.
- Jayant N Acharya, Vinita J Acharya (2014) Epilepsy in the elderly: Special considerations and challenges. Annals of Indian Academy of Neurology 17(Suppl 1): S18-S26.
- Nicastro N, Assal F, Seeck M (2016) From here to epilepsy: the risk of seizure in patients with Alzheimer's disease. Epileptic Disorders 18(1): 1-12.
- John Baker, Tina Libretto, William Henley, Adam Zeman A (2019) Longitudinal Study of Epileptic Seizures in Alzheimer’s Disease. Frontiers in Neurology 10: 1266.
- Theodore WH (2010) The postictal state: Effects of age and underlying brain dysfunction. Epilepsy Behavior 19(2): 118-120.
- Pack A M (2019) Epilepsy Overview and Revised Classification of Seizures and Epilepsies. Continuum Lifelong Learning in Neurology 25(2): 306-321.
- Homes G L (2015) Cognitive impairment in Epilepsy: The Role of Network Abnormalities. Epileptic Disorders 17(2): 101-116.
- Carreño M, Donaire A, Sánchez Carpintero R (2008) Cognitive disorders associated with epilepsy: diagnosis and treatment. Neurologist 14(6 Suppl 1): S26-S34.
- Sung Pa P, Soon Hak K (2008) Cognitive Effects of Antiepileptic Drugs. J Clin Neurol 4(3): 99-106.
- Wang L, Chen S, Liu C, Lin W, Huang H (2020) Factors for cognitive impairment in adult epileptic patients. Brain and Behavior 10: e01475.
- Tan TY, Lu CH, Chuang HY, Lin TK, Liou CW et al. (2009) Long‐term antiepileptic drug therapy contributes to the acceleration of atherosclerosis. Epilepsia 50(6): 1579-1586.
- Chang CS, Liao CH, Lin CC, Lane HY, Sung FC et al. (2014) Patients with epilepsy are at an increased risk of subsequent stroke: A population-based cohort study. Seizure 23(5): 377-381.