ReviewEpilepsy, surgery, and the elderly
Introduction
A variety of issues need to be taken into consideration when treating a patient with epilepsy: medication adverse events (AEs), co-morbid conditions, and physiologic abnormalities. For the treatment of an elderly patient with epilepsy, these issues become more pronounced. In addition, aging, as well as other medical conditions that affect the elderly, can increase their risk for developing epilepsy (Hauser, 1997). More consideration will be given to treatment options for the elderly as this cohort of the population grows.
The idea of surgically separating the epilepsy patient from his or her disease is not a new concept, yet many practitioners are reluctant to employ this approach with elderly patients, even when potentially curative. Unfortunately, the increased incidence of co-morbid conditions and medication use among the elderly complicates therapies dependent on drugs alone. Thus, as a treatment regimen is developed, it seems prudent to give surgical intervention early consideration.
Section snippets
Therapeutic choices
Elderly patients who are medically intractable and have key features, such as lateralization and precise localization of a seizure focus, are appropriate surgical candidates. A patient should be thoroughly evaluated to determine the extent of the epileptogenic focus by means of surface cortical digital electroencephalograph (EEG), computed tomography (CT), magnetic resonance imaging, positron emission tomography, video EEG, and single photon emission CT. A favorable prognosis can be expected if
Vagus nerve stimulation
Much has been learned since Zabara (1985) first reported the effects of VNS on epilepsy. After a number of randomized clinical human trials, the US Food and Drug Administration approved VNS use in the late 1990s. An assessment of post-surgical VNS patients compiled in a registry maintained by Cyerbonics® Inc. offers clues to the efficacy of this procedure when applied to an elderly population. Although the data are non-scientific and company sponsored, they nevertheless report reduced seizure
Deep brain stimulation
Few studies of DBS as another potential, currently palliative, treatment for epilepsy are available (Medtronic International, personal communication). A few controlled investigations are under way, but results are not yet available (Dr. N. Graves, personal communication). Choosing the proper target, or epileptogenic zone in deep brain nuclei, has been the most challenging hindrance to effective DBS therapy.
The identities of target brain structures for effective seizure control, as well as the
Conclusion
Treatment of elderly patients with epilepsy presents unique challenges to physicians, which will only become more unwieldy as the general population ages. The higher incidence of co-morbid medical conditions and their associated drugs can make elucidation of safe and effective drug therapy problematic. Such complications may make surgical intervention more attractive, particularly for medically intractable patients with precisely localized epileptic foci and other key features. When
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(1980) - Cyerbonics® Inc. National Patient Registry. Personal communication and date on file w/ CYBERONICS. Not...
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Who should be considered a surgical candidate?
Cited by (10)
Drug-resistant epilepsy: Definition and treatment alternatives
2015, NeurologiaPerceptions of epilepsy surgery: A systematic review and an explanatory model of decision-making
2015, Epilepsy and BehaviorCitation Excerpt :Furthermore, advancing age should not discourage referral [12]. Comprehensive evaluation for older patients is an important consideration since drug therapy in this age group presents many challenges, including risks of adverse drug interactions, cognitive side effects, dizziness, imbalance, and falls [39]. Although published series are few, surgery is safe and effective in patients over sixty [40], and outcomes are comparable with those of younger patients [41].
Epileptic fits and epilepsy in the elderly: General reflections, specific issues and therapeutic implications
2007, Clinical Neurology and NeurosurgeryCitation Excerpt :Vagal nerve stimulation (VNS) is an established treatment option for medically refractory epilepsy. Although data are limited in elderly patients, VNS has been reported to reduce seizure rates and improve quality of life [163]. In the overall population, one third of patients show a >50% reduction of seizure frequency; one third show a 30–50% seizure reduction, and one third shows no response.
Elders with Epilepsy
2006, Medical Clinics of North AmericaCitation Excerpt :More studies are needed, but data show VNS offers an alternative that avoids complications from drug interactions and cognitive side effects while giving the patient some aspect of control and alleviating concerns of compliance [15]. There are few controlled studies underway using deep brain stimulation for epilepsy in adults and results are not yet available [39]. Controversies currently exist as to the proper target for localization of epileptogenicity.
Epilepsy in the older patient
2007, Reviews in Clinical Gerontology