The room suddenly looks different…or you “space out” for 30 seconds or longer, staring vacantly into space unaware of your surroundings…or black out and fall to the floor. You may even smell, see or hear something that isn’t there.
Do not ignore it. You could be having an epileptic seizure—a hallmark of epilepsy, a widely misunderstood and life-threatening condition that affects one of every 26 people in their lifetimes.
Most people associate epilepsy with lost consciousness, convulsing limbs and twitching—but these generalized tonic-clonic seizures (once known as “grand mal” seizures) are actually less common than more subtle partial seizure episodes, such as those described above.
That’s especially true in adults. While epilepsy often starts in childhood, risk progressively increases starting at about age 55.
Why it goes undetected: Because adult-onset seizures are rarely dramatic, most doctors don’t think of epilepsy very often—if at all—when evaluating their older patients.
Many things can cause a seizure—for example, acute infection, fever, low blood sugar, poisoning and medication side effects. What generally makes it epilepsy is repetition—the same experience, reflecting the same abnormal brain activity, unprovoked by outside stimulus, over and over.
Why does it happen? Much of the time, epilepsy in older adults is the result of more generalized brain disease. Stroke is responsible in one-third of the cases with an identifiable cause. When there’s an underlying cause, such as stroke, a single seizure can be labeled epilepsy (see below).
Alzheimer’s and Parkinson’s disease account for a total of 11% of cases. Head trauma is responsible for 2% of epilepsy in older adults. Tumors—including metastases of cancer originating elsewhere—also may be involved. But often, no underlying cause can be found.
If you think that you may have had a seizure, discuss this with your internist, who may refer you to a neurologist. Diagnosing epilepsy is not always easy. An electroencephalogram (EEG), a test that records electrical activity in the brain, may show abnormal brain activity only when a seizure is occurring, and brain scans, such as an MRI, can look normal.
That’s why it takes an expert to identify epilepsy based on the patient’s description of the episodes and other aspects of a person’s medical history, such as stroke.
Important update:Traditionally, the diagnosis of epilepsy has required at least two seizures. But the International League Against Epilepsy, a prestigious group of researchers and clinicians, recently broadened the definition to include a single seizure when tests and/or history suggest a high risk for recurrence. Examples: An MRI shows evidence of a prior stroke…or an EEG finds brain wave patterns typical of epilepsy.
Treatment is essential: Epilepsy is a life-threatening condition that requires treatment. With untreated epilepsy, abnormal brain activity can actually stop the heart—a complication that occurs in roughly 1% of epilepsy patients each year.
A diagnosis of epilepsy should prompt further investigation—the seizures may be the first warning of another serious brain condition. For example, a study in The Lancet found that the risk for stroke nearly tripled among older adults who had started having seizures without prior strokes, suggesting undetected brain artery disease.
Medication is effective in quelling seizures two-thirds of the time. In older people, epilepsy is more likely to respond to drug treatment, often at a lower dose than a younger person would require. But some side effects of commonly used medications, such as sedation, bone loss and difficulty concentrating, can be particularly problematic in older adults. Also, most older adults take medication for other chronic medical problems, which can interact with certain antiepileptic drugs.
What often works best: Several of the newer antiseizure medications—lamotrigine (Lamictal), gabapentin (Neurontin) and levetiracetam (Keppra)—appear to be as effective as tried-and-true standbys like phenytoin (Dilantin) in older patients, but with fewer side effects and less interaction with other prescriptions. Side effects can include liver problems, thinning hair, dizziness and loss of balance. Medication is usually taken for at least two years. Note: People with epilepsy can drive as long as they have not experienced seizures within a certain amount of time (which varies by state).
When seizures persist despite medication, surgery should be considered. The most effective procedure, resective surgery, removes the usually tiny segment of the brain where abnormal activity originates.
A study presented at the 2013 annual meeting of the American Epilepsy Society found good results in nine out of 10 patients ages 60 to 74 (one patient died of a brain tumor) who received resective surgery—seven becoming seizure free—with no postoperative complications.
Breakthrough treatment: When the part of the brain responsible for seizures can’t be removed—it is too large or too close to critical structures or multiple brain areas are involved—a device can be permanently implanted to modify brain activity electrically. One device, approved by the FDA late last year, functions as a kind of pacemaker for the brain. The Neuropace RNS System detects seizure activity as it starts and produces a mild shock to abort the episode.
In a trial of nearly 200 people whose partial seizures couldn’t be controlled with medication, the device reduced episode frequency by more than half, after two years of use. There is a small risk for brain bleeding and infection.
A seizure results from abnormal brain activity—a group of neurons firing at once without provocation. Depending on the location in the brain where the discharge occurs and how widely it spreads, the form the seizure takes can vary widely. These “brainstorms” typically last seconds to minutes.
