Overview.
Epilepsy that starts in adulthood is called late-onset epilepsy. Clinically, 20 years of age is often chosen as its age starting point, while those with epilepsy occurring over 60 years of age are called late-onset epilepsy of old age or senile epilepsy. Epilepsy in the elderly is mostly secondary, and its etiology, diagnosis, and treatment are different from those of other age groups.
Causes
1. Idiopathic epilepsy
These patients have no structural changes or metabolic abnormalities in the brain that can explain the symptoms. It is closely related to heredity, and the proportion of patients with this type of epilepsy in the elderly is extremely low.
2. Secondary epilepsy
The vast majority of epilepsy in the elderly is secondary, and the causes can mostly be found, the more common causes are as follows:
(1) Cerebrovascular disease All kinds of cerebrovascular disease can occur epilepsy, accounting for 30% to 40% of the causes of epilepsy in the elderly, mainly ischemic vascular disease. In hemorrhagic cerebrovascular disease, epilepsy mostly occurs in the acute phase or as the first symptom; while in ischemic cerebrovascular disease, in addition to the acute phase, about 33% of the epilepsy occurs afterwards.
(2) Brain tumor is also a common cause of epilepsy in the elderly, among which meningiomas, brain metastases, and gliomas are the most common, especially meningiomas that increase with age. Epilepsy can often be the first symptom of brain tumor, which appears earlier than the symptom of increased intracranial pressure.
(3) Traumatic brain injury It is not uncommon for people to suffer from traumatic brain injury. Craniocerebral trauma, such as skull fracture, intracranial hematoma, and cerebral contusion, can be accompanied by epileptic seizures.
(4) Brain atrophy
(5) metabolic diseases ① non-ketotic hyperglycemia, ketoacidosis, hyperosmolar coma can be combined with epilepsy. ② uremia advanced due to severe water and electrolyte disorders often appear epilepsy.
(6) Chronic ethanol poisoning
Symptoms
In 1981, the International League Against Epilepsy (ILAE) classified epileptic seizures according to clinical manifestations and electroencephalographic (EEG) changes during seizures, which is still in use today.
1. Partial seizures (seizures with localized onset)
(1) Simple partial seizure (without consciousness disorder) ① with motor symptoms; ② with somatosensory or special sensory symptoms; ③ with autonomic symptoms; ④ with mental symptoms.
(2) Complex partial seizures (with impaired consciousness) ① simple partial seizures, followed by impaired consciousness; ② impaired consciousness at the beginning: only impaired consciousness, automatisms.
2. Generalized seizures (symmetrical seizures on both sides, no local symptoms at the onset of the seizure)
(1) Loss of consciousness seizure.
(2) Myoclonic seizures.
(3) Clonic seizures.
(4) Tonic seizures.
(5) Tonic-clonic seizures.
(6) atonic seizures.
3. Unclassified seizures
Since epilepsy in the elderly is mostly secondary, most of the clinical seizure forms of elderly epilepsy are partial seizures, in which simple partial seizures predominate, and a very small number of people exhibit complex partial seizures. The occurrence of elderly epilepsy is not necessarily parallel to the size of the lesion and the severity of the disease, but is related to the location of the lesion, with the highest incidence in the frontal, parietal, and temporal lobes. After a seizure in the elderly, the blinded state can last for a long time, more than 24 hours in some patients, and even up to 1 week in some patients. Post-ictal paralysis is also relatively common and is particularly likely to occur in patients with post-stroke epilepsy and may be confused with re-stroke.
Examination
1. Laboratory tests
Blood white blood cell count may be elevated in the presence of infection.
2. Cranial X-ray
Cranial radiography is an important method of X-ray examination of central nervous system diseases, which can provide an important diagnostic basis for the diagnosis of some of the diseases in the brain, and can provide the following clues for the diagnosis of epilepsy.
(1) Increased intracranial pressure In patients with epilepsy secondary to intracranial space-occupying lesions, cranial radiographs can show various manifestations of increased intracranial pressure, such as: (1) separation of the cranial sutures: the separation of the cranial sutures is more pronounced in infants, young children, and children; (2) increase in the gyrus pressure traces; (3) pterosyndrome changes: manifested by bone resorption and enlargement of the pterosyndrome, disappearance of the dorsal part of the pterosyndrome, blurring of the cortex, and disruption of the pterosyndrome.
(2) Pathologic calcification Many structural lesions that produce epilepsy may show different degrees of pathologic calcification. Tumor calcification is more common. According to the location of calcification and the characteristics of calcification, it helps to locate the tumor and has important reference value for qualitative diagnosis of the tumor. For example, meningiomas are sandy or lumpy, craniopharyngiomas are mostly arcuate, and calcifications of oligodendroglioblastomas mostly occur in the cerebral hemispheres and alternate with each other in the form of strips. Arteriovenous malformation 15% may present calcification, some infectious diseases such as cysticercosis calcification is more common, tuberculosis may present non-specific nodular calcification, chronic brain abscess may present linear calcification.
(3) Cranial bone changes Certain structural changes that lead to epilepsy can cause changes in the bone quality of the skull. For example, tumor invasion leads to bone destruction, long-term stimulation of the lesion can lead to local bone hyperplasia, increased intracranial pressure in the late stage can lead to thinning of the bone plate, decreased bone density, and blurring of the inner plate.
3. CT examination
In patients with epilepsy, the main manifestations of CT abnormalities are as follows:
(1) Brain atrophy Brain atrophy is the most common type of CT scan abnormality in patients with epilepsy, accounting for more than 50% of the abnormality rate, and can be divided into diffuse brain atrophy and limited brain atrophy. Diffuse brain atrophy is mainly characterized by cortical atrophy and enlargement of the sulcus and ventricles, while limited brain atrophy is mainly characterized by enlargement of the ventricles and the sulcus, either unilaterally or locally. It is generally believed that the older the age of onset of epilepsy patients, the longer the duration of the disease, the more common brain atrophy.
(2) Intracranial tumors Intracranial tumors are an important cause of epilepsy, and different tumors have different CT manifestations.
(3) Cerebrovascular disease Cerebrovascular disease is one of the common causes of secondary epilepsy, mainly seen in cerebral infarction, cerebral arteriovenous malformation hemorrhage, arteriovenous malformation and so on. CT of cerebral infarction is characterized by low density shadow in the brain, infarction caused by cortical artery occlusion is wedge-shaped, old infarction can be seen as cystic cavity formation or scarring with focal cerebral atrophy, and occlusion of small blood vessels can cause irregular low-density foci in the deep white matter. Cerebral arteriovenous malformation hemorrhage is manifested as high-density dotted and arcuate vascular clusters on CT imaging.
(4) Traumatic brain injury CT examination has important diagnostic value for intracranial hematoma, skull fracture, limited cortical atrophy and substantial damage to lobes caused by traumatic brain injury.
(5) Intracranial infection Acute brain abscess is often the cause of seizure, CT can see irregular low density shadow and occupying effect.
(6) Brain developmental abnormalities Brain developmental abnormalities are one of the causes of epilepsy. Common brain developmental abnormalities include septal defects, hypoplasia of corpus callosum, hydrocephalus, arachnoid cysts, congenital cysts of brain perforation malformations, ectopic brain tissues, nodular sclerosis, etc. Most of these abnormalities can be diagnosed by CT examination.
Diagnosis
The diagnosis of epilepsy consists of 3 aspects: firstly, to determine whether it is epilepsy, secondly, to clarify the type of seizure, and finally, to identify the cause as far as possible.
A diagnosis of epilepsy in the elderly is made when 2 or more epileptic seizures occur in an individual over 60 years of age. The clinical history is decisive. The EEG and tests related to it are the most critical ancillary tests for the diagnosis of epilepsy.
Since epilepsy in the elderly is almost secondary to epilepsy, it is crucial to search for the etiology of the disease, and its common causes are cerebrovascular disease, brain tumor, and traumatic brain injury. Cranial CT and MRI are very helpful in discovering these causes.
Treatment
1. Treatment of etiology
Since epilepsy in the elderly is mostly secondary, etiologic treatment is important. As the underlying cause is eliminated, seizures tend to improve. Epilepsy secondary to cerebrovascular disease, especially when it occurs during the acute phase of cerebral infarction, suggests a poor prognosis. If the condition can be stabilized and the seizures are controlled, the use of anti-epileptic drugs can be gradually discontinued. If the condition can be stabilized and the seizures are controlled, anti-epileptic drugs can be gradually discontinued. Patients with intracranial tumors should undergo surgical treatment or radiotherapy or chemotherapy depending on their conditions and physical status. Patients with brain parasitic disease should be treated with deworming first.
2. Antiepileptic drug treatment
Once the diagnosis of epilepsy in the elderly is established, antiepileptic drug therapy is needed. There is no significant difference in drug selection with other age groups; there is no significant difference between secondary and primary, and the principle is to select drugs according to the type of seizure.
Questions you may be concerned about
What kind of medication do you take for epilepsy in the elderly
Elderly epilepsy selects drugs orally according to the patient’s condition. First of all, treat the primary disease, epilepsy caused by cerebral infarction give aspirin simvastatin and so on. Cerebral hemorrhage caused by giving the adjustment of blood pressure, such as amlodipine, nifedipine and so on. Secondly, according to the type of epilepsy, choose antiepileptic drugs to be taken orally, such as carbamazepine and phenytoin sodium.
1. Treatment of primary disease. When the acute stage of the disease should actively treat the primary disease, for example, acute cerebral infarction oral aspirin, clopidogrel and other anti-platelet aggregation; atorvastatin, resuvastatin lipid regulation.
Cerebral hemorrhage oral antihypertensive drugs to adjust blood pressure, such as amlodipine, nifedipine and so on. Patients with constipation take oral laxative drugs, such as lactulose, etc., to avoid aggravation of cerebral hemorrhage caused by straining to defecate.
2. Control epilepsy. When epilepsy onset will be based on the patient’s condition using antiepileptic drugs to control epilepsy. In case of grand mal epilepsy, the drugs of choice include sodium valproate, lamotrigine, and so on. Carbamazepine, oxcarbazepine, phenytoin sodium, etc. are taken for minor seizures.
It is recommended that epilepsy patients visit the clinic regularly and use medication under the guidance of professional physicians.