We fight to improve the lives
of everyone affected by epilepsy

 

Epilepsy in older people

Call for researchers 

The brief:  Literature review (including grey literature) of the service provision and workforce skills needed to effectively diagnose, treat and care for older people with epilepsy.

Deadline: 1pm, 2 August 2019

1. Aim and motivation

Epilepsy Action has a goal to improve the quality and availability of healthcare services for people with epilepsy.  Our research strategy has identified a potential gap in understanding the specific care, services and treatment that meets the needs of older people with epilepsy.

We are aware of several reviews focused on epilepsy in older people, including; the challenges of the pharmacological management, causes of new onset epilepsy, cognition, dementia and the epidemiology of epilepsy in the elderly. This year we would like to identify the key research questions that need to be addressed to find out what Epilepsy Action should focus on to improve health and care services for older people with epilepsy. For example, should we be developing educational resources for key professionals?

With advances in healthcare and an ageing population, the number of older adults with epilepsy is set to rise substantially across the world[1]. This will undoubtedly cause an increased burden on health services and carries the risk of under-diagnosis, if there are not enough professionals trained to recognise epilepsy in older people.

Diagnosis and treatment of this population is complex, yet older people are less likely to be referred to a specialist epilepsy services, for a number of different reasons.[2] Some of the particular issues that need to be considered for this population include:

Causes:

  • The development of seizures correlates with age, not only because several epileptogenic conditions are age- or aging-related, but also because the aging process in itself can be a risk factor for seizures[3]

Diagnosis:

  • Over-diagnosis and under-diagnosis are common.[4] Seizures in older adults can be more difficult to diagnose because their presentation is often subtle and can easily be mistaken for other conditions.
  • Typical age-related problems with diagnosis include:  incomplete or missing medical history, absence of witnesses, dementia, oligo-symptomatic seizures, inconclusive EEG and cerebral imaging results, multiple pathological findings and comorbidity with ambiguous significance, confounding sleep disorders, intake of pro-convulsive drugs, and psychogenic seizures[5] [6]
  • Older patients most often have focal seizures, with less prominent auras and automatisms, and longer duration of postictal confusion compared to younger patients.[7]
  • Older people are less likely to be referred to specialist epilepsy services. Of particular concern are professional assumptions regarding older patients’ willingness to attend appointments.[8]

Treatment:

  • Seizures can be controlled in most patients with low doses of a single anti-epileptic drug (AED). Drug-resistant epilepsy is uncommon[9] [10]
  • Pharmacological management should always take into account the peculiar pharmacokinetics and pharmacodynamics of AEDs, the high rate of comorbidities and the risk of drug interactions.
  • Newer AEDs make the management of epilepsy more complex but also allow a better personalisation of the treatment adapted to a particular patient in this fragile population.[11]
  • For the majority of the old- and new-generation AEDs, a decrease in dose may be needed to maintain concentrations equivalent to those found in young adults[12]
  • Treatment is complicated by the presence of physiological changes related to aging, co-morbidities and cognitive problems as well as concerns regarding drug interactions and medication adherence.[13] [14]

Lifestyle:

  • Status epilepticus is common and has a high mortality rate.[15]
  • There is an association between the use of AEDs and risk of falls and recurrent falls in older people.[16]
  • New-onset epilepsy may have significant cognitive impairments (eg memory loss) and psychological issues including depression, anxiety and fatigue. Cognitive and psychiatric screening before treatment may be useful for management.[17]
 

2. Call for a literature review

Epilepsy Action is now seeking a researcher, or researchers, skilled in analysis and synthesis, to undertake a literature review.  We want to find out how Epilepsy Action could support geriatricians and healthcare professionals who work with older people.

We hope to support the researcher to access communities of practice and relevant literature (although we do not have access to a university library and will assume the researcher can access relevant journals).

We want to understand the evidence base, so that we can work with clinicians and commissioners of services to plan improvements to current practice and services.

 

3. Our broad aims for the literature review

The purpose of this review is to examine the evidence in relation to epilepsy in older people. It is expected that this work will outline what geriatricians and other healthcare professionals who work with older people need to know,  about identifying epilepsy and treating or referring the person to an epilepsy specialist service.

 

4. The research questions and scope

We ultimately want to find out:

  • What is considered to be best practice in the diagnosis, treatment and care of older people with epilepsy?
  • What do geriatricians and healthcare professionals who work with older people need to know about the diagnosis and treatment of older people with suspected epilepsy?
  • When should older people be referred to a specialist epilepsy service?
 

5. The objectives of the literature review

To assist Epilepsy Action and British Geriatric Society Epilepsy special interest group  in developing a strategy to influence service improvement and producing useful resources for healthcare professionals and commissioners of services.

Epilepsy Action will seek to have the results from this piece of research published.

 

6. Methodology

It may be necessary to use a mix of methods to search for relevant evidence.

The appointed researcher must agree the research methodology to be used, with Epilepsy Action and its chosen advisors, BEFORE work commences.  In line with normal protocol, the methodology will be included in the write up of the final literature review.

 

7. Selection criteria and search protocol

The evidence selection criteria and approach to synthesis will be finalised between the researcher and Epilepsy Action (advised by the British Geriatric Society Epilepsy special interest group) prior to the review starting.

 

8. Researcher experience

Experience of completing literature reviews, for example systematic reviews or narrative synthesis that can inform curricular or strategy development.

Experience of epilepsy research is not necessary, provided the researcher is willing to undertake epilepsy awareness training and to seek input from an appropriate clinician.

 

9. Timeframe

The project is expected to start in September 2019 and final reports sent to Epilepsy Action by March 2020.

Completion to publication standard is expected by April 2020.

 

10. Costs

Epilepsy Action has a budget of £30,000 for this work.

 

12. Proposals

Proposals outlining your approach, personnel and costs should be submitted to astoneman@epilepsy.org.uk before 1pm, 2 August 2019.

Proposals should include:

  • A description of your approach to this work
  • A timeline demonstrating completion to publication standard by April 2020
  • CVs demonstrating the experience of the proposed researchers
  • A breakdown of the costs




[1] Cognition and dementia in older patients with epilepsy. Arjune Sen,1 Valentina Capelli,1 and Masud Husain. Brain. 2018 Jun; 141(6): 1592–1608.

[2] Understanding referral patterns to an epilepsy clinic: professional perceptions of factors influencing the referral of older adults. Seizure. 2013 Nov;22(9):698-702.

[3] Aging and the Epidemiology of Epilepsy Beghi E. · Giussani G. Neuroepidemiology 2018;51:216–223

[4] Epilepsy in the elderly: Special considerations and challenges. Acharya JN1, Acharya VJ1. Ann Indian Acad Neurol. 2014 Mar;17(Suppl 1):S18-26

[5] Acute Symptomatic Seizures in Geriatric Patients with Multiple Risk Factors - A Diagnostic Challenge. Curr Aging Sci. 2017;10(4):263-269

[6]Challenges in the pharmacological management of epilepsy and its causes in the elderly. Edoardo Ferlazzoa ,b, Chiara Suerib, SaraGasparinia, b, Umberto Aguglia. Pharmacological Research106 (2016) 21–26

[7] Epilepsy in the elderly: Special considerations and challenges. Acharya JN1, Acharya VJ1. Ann Indian Acad Neurol. 2014 Mar;17(Suppl 1):S18-26

[8] Understanding referral patterns to an epilepsy clinic: professional perceptions of factors influencing the referral of older adults. Seizure. 2013 Nov;22(9):698-702.

[9] Epilepsy in the elderly: Special considerations and challenges. Acharya JN1, Acharya VJ1. Ann Indian Acad Neurol. 2014 Mar;17(Suppl 1):S18-26

[10] Pharmacokinetic Factors to Consider in the Selection of Antiseizure Drugs for Older Patients with Epilepsy.  Anderson GD1, Hakimian S2. Drugs Aging. 2018 Aug;35(8):687-698

[11] Epilepsy treatment in the elderly. Biraben A1, De Clerck L2, Nica A1. Geriatr Psychol Neuropsychiatr Vieil. 2019 Mar 1;17(S1):31-38.

[12] Pharmacokinetic Factors to Consider in the Selection of Antiseizure Drugs for Older Patients with Epilepsy.  Anderson GD1, Hakimian S2. Drugs Aging. 2018 Aug;35(8):687-698

[13]  Epilepsy in the elderly: Special considerations and challenges. Acharya JN1, Acharya VJ1. Ann Indian Acad Neurol. 2014 Mar;17(Suppl 1):S18-26

[14] Challenges in the pharmacological management of epilepsy and its causes in the elderly, Edoardo Ferlazzoa, ChiaraSuerib, SaraGasparinia, UmbertoAguglia PharmacologicalResearch106(2016)21–26

[15] Epilepsy in the elderly: Special considerations and challenges. Acharya JN1, Acharya VJ1. Ann Indian Acad Neurol. 2014 Mar;17(Suppl 1):S18-26

[16] Use of antiepileptic drugs and risk of falls in old age: A systematic review. Haasum Y1, Johnell K2  Epilepsy Res. 2017 Dec;138:98-104

[17] New-onset epilepsy in the elderly. Vu LC1, Piccenna L2, Kwan P1,2, O'Brien TJBr J Clin Pharmacol. 2018 Oct;84(10):2208-221

Event Date: 
Tuesday 27 March 2018

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