|Relevant tool: A.14|
Cerebrovascular disease and Alzheimer's3 disease become more prevalent with increasing age. Both conditions are associated with an increased incidence of epilepsy. Unexplained epilepsy occurring for the first time may be an early presentation of cerebrovascular disease.4,5
The specialist who manages their epilepsy should also have the expertise to manage other comorbid conditions affecting older people. The NICE guidance recommends that the choice of treatment, access to investigations, and the importance of regular monitoring of effectiveness and tolerability are the same for older people as for the general population.6 This is supported by the emphasis in the National Service Framework for Older People on dismissing age discrimination.7
Referral to an epilepsy specialist nurse (ESN) is also desirable, to ensure the patient has access to ongoing support. In the absence of an ESN a referral to a district liaison nurse or a community matron is required. Practice nurses can also be a good source of support.
Epilepsy in older people may pose several additional problems for the provision of services compared with the rest of the population:8
- diagnostic difficulties, due to co-morbidity, cognitive impairment and polypharmacy
- unclear patient and witness accounts: the older patient may live alone (absence of an eye witness)
- susceptibility to AED side-effects and toxicity. AED therapeutic blood levels were established on younger populations and might not apply to older people. For this reason toxicity may occur with levels within or below the traditional therapeutic range
- polypharmacy and drug interaction. Some older people will take medication for other conditions. This poses two potential problems:
- the person may struggle to remember what tablets to take, how many to take and when
- there is an increased likelihood of interaction with medication for other conditions.
- psychosocial and generational difficulties. Increased feeling of stigma; impact on ability to drive and possible loss of confidence can lead to social isolation
- physical restrictions to lifestyle. Seizures that cause falls are more likely to cause injury in older people
- multidisciplinary service requirements may be needed in the community, such as a liaison nurse, social worker, falls specialist and occupational therapist.
Special attention should be paid to the pharmacokinetics and pharmacokinetic issues with polypharmacy; consider using lower doses of AEDs and/or controlled-release formulations.6
1 Joint Epilepsy Council, 2005. Epilepsy prevalence, incidence and other statistics. [online] (Accessed 12/04/2012).
3 Hart YM et al.1990. National General Practice Study of Epilepsy: Newly Diagnosed Epileptic Seizures in a General Population. Lancet. 336: 1267-1271.
4 Hamandi K, 2003. Epilepsy. In: Fillit HM, Tallis RC, Borcklehurst JC eds 2003. Brocklehurst's Textbook of Geriatric Medicine and Gerontology. Oxford: Churchill Livingstone.
5 Taylor PM, 2000. Managing Epilepsy – a Clinical Handbook. Second edition. Oxford: Wiley Blackwell.
6 National Institute for Health and Clinical Excellence (NICE), 2012. The epilepsies: The diagnosis and management of the epilepsies in adults and children in primary and secondary care. [CG137]. London: NICE.
7 Department of Health, 2001. National Service Framework for Older People. London: DOH
8 Shorvon S, Kitson A, 2000. Clinical standards advisory group. Services for patients with epilepsy: a report of a CSAG committee.London: Department of Health.