I'D LIKE TO WELCOME YOU ALL TO	OUR FIRST CALL OF FISCAL YEAR	FOR FY14,
EPILEPSY AUDIO CALL SERIES.
MY NAME'S SEAN GAMBILL.
I'M WITH THE EMPLOYEE EDUCATION	SERVICES IN ST. LOUIS,
AND I'M THE PROJECT MANAGER	FOR THIS SERIES.
ALL THE LINES ARE MUTED,
AND WE'LL TRY TO OPEN THEM UP	AT THE END,
BUT IF POSSIBLE,	COULD YOU TYPE A QUESTION
INTO THE LITTLE CHAT BOX,
AND WE CAN ASK THE PRESENTER	QUESTIONS.
PLEASE BE SURE TO COMPLETE	YOUR EVALUATION TO GET CREDIT	FOR THIS PROGRAM.
DIRECTIONS CAN BE FOUND	IN THE BROCHURE AND ON TMS.
NOW LET ME WELCOME OUR SPEAKER	FOR TODAY, DENISE RILEY.
GO AHEAD, DENISE.
- THANK YOU, SEAN.
GOOD AFTERNOON, EVERYONE.
LIKE SEAN SAID,	I'M DENISE RILEY,
AND I'M AN EPILEPSY	NURSE PRACTITIONER
AT THE GAINESVILLE VA	EPILEPSY CENTER OF EXCELLENCE.
I WANT TO THANK THOSE OF YOU	WHO ARE CALLING IN TODAY
TO HEAR THE PRESENTATION	ENTITLED, "TREATMENT OF	THE ELDERLY WITH EPILEPSY."
TODAY'S PRESENTATION	IS FOR PROVIDERS,
AND AS SEAN SAID, WE HOPE	THAT YOU HOLD THE QUESTIONS
UNTIL THE END OF	THE PRESENTATION.
NEXT SLIDE.
THE OBJECTIVE OF	TODAY'S PRESENTATION
IS FOR YOU TO BE ABLE	TO TALK ABOUT THE EPIDEMIOLOGY
OF SEIZURES IN THE ELDERLY;
BE ABLE TO DISTINGUISH	BETWEEN SEIZURES
AND OTHER MEDICAL CONDITIONS	THAT CAN MIMIC SEIZURES;
RECOGNIZE THE RISK FACTORS	OF SEIZURES IN THE ELDERLY;
DEVELOP AND APPROPRIATE	MEDICATION AND TREATMENT PLAN;
AND UNDERSTAND THE IMPACT	AND COMPLICATIONS OF EPILEPSY
IN OLD AGE.
I WANT TO MENTION HERE	THAT MY REFERENCE FOR	TODAY'S PRESENTATION
IS AN EXCELLENT ARTICLE ENTITLED	"EPILEPSY IN THE ELDERLY"
BY ANN JOHNSTON AND PHIL SMITH
FROM A 2010 ISSUE OF "EXPERT	REVIEW OF NEUROTHERAPEUTIC."
NEXT SLIDE.
LET'S BEGIN BY DEFINING EPILEPSY	AS A FUNCTIONAL DISORDER	OF THE BRAIN,
A KIND OF GLITCH	IN THE ELECTRICAL SYSTEM
THAT CONTROLS EVERYTHING WE DO	AND FEEL.
AND THESE BRIEF MALFUNCTIONS	OR SEIZURES
CAN TEMPORARILY BLOCK AWARENESS,	CAUSE UNCONTROLLABLE SHAKING,
CONVULSION, CONFUSION,	OR AFFECT THE SENSES.
AND A SINGLE SEIZURE	IS NOT EPILEPSY
ALTHOUGH THE SYMPTOMS	ARE THE SAME.
AND EPILEPSY IS THE NAME	GIVEN TO SEIZURES
THAT OCCUR MORE THAN ONCE DUE TO	AN UNDERLYING BRAIN CONDITION.
BECAUSE WE'RE TALKING ABOUT	THE ELDERLY,
WE'RE GOING TO FOCUS ON PEOPLE	AGE 60 AND OVER.
THE GROWTH OF	THE 65-AND-OLDER POPULATION
IS INCREASING AT	AN UNPRECEDENTED RATE	IN U.S. HISTORY.
THIS IS BECAUSE OF	IMPROVED MEDICAL CARE
AND PREVENTION EFFORTS	THAT ARE RESULTING IN	OUR LONGER LIFE SPAN.
WE ALSO HAVE THE ONCOMING	OF THE BABY BOOMER
WHO IS THE INDIVIDUAL	BORN BETWEEN 1946 AND 1964
WHO IS ALSO CONTRIBUTING	SIGNIFICANTLY TO THIS	DEMOGRAPHIC TREND.
WE'RE DEFINITELY SEEING IT	HERE IN FLORIDA.
THE OLDER POPULATION IS	PROJECTED TO MAKE A BIG SPIKE
BETWEEN THE YEARS 2010 AND 2030,
THE PERIOD IN WHICH THESE BABY	BOOMERS ARE GOING TO REACH	AGE 65.
SO ACCORDING TO THE CURRENT DATA	PROVIDED BY THE U.S.	CENSUS BUREAU,
THE POPULATION 65 YEARS AND OVER
IS GOING TO INCREASE FROM	35 MILLION IN THE YEAR 2000
TO 40 MILLION IN 2010,
WHICH IS A 15% INCREASE.
AND THEN INCREASE AGAIN	TO 55 MILLION IN THE YEAR 2020,
WHICH IS A 36% INCREASE	FOR THAT DECADE.
BY 2030, THERE ARE GOING TO BE
ABOUT 72.1 MILLION OLDER PERSONS	IN THE U.S.,
WHICH WILL ACCOUNT ROUGHLY	FOR ABOUT 20%
OF THE U.S. POPULATION.
AND THESE NUMBERS ARE GOING	TO RISE FURTHER
WITH THE CONTINUING RISE	IN THE AGING OF POPULATION
AND IS GOING TO PLACE	AN INCREASED BURDEN
ON OUR HEALTH CARE RESOURCES.
NEXT SLIDE. SO WE'RE TALKING	ABOUT EPILEPSY,
AND EPILEPSY SPARES	NO AGE GROUP.
ANYONE AT ANY AGE	CAN HAVE A SEIZURE
IF THE BRAIN IS STRESSED	SUFFICIENTLY BY INJURY	OR DISEASE,
BUT THE OVERALL INCIDENCE	OF EPILEPSY
IS HIGHEST IN THE NEWBORN	AND IN THOSE AGED OVER 60.
WITH OLD AGE THE TIME OF LIFE	WHEN SEIZURES ARE	THE MOST COMMON.
SHOCKING STATEMENT.
IN SENIORS AGE 65-69,
THE INCIDENCE OF EPILEPSY	IS 136 OUT OF EVERY 100,000.
AND IN SENIORS AGE 80 AND OVER,
THE INCIDENCE OF EPILEPSY RISES	TO 150 OUT OF EVERY 100,000.
SO YOU CAN SEE WHY A DISCUSSION	ABOUT EPILEPSY IN THE ELDERLY
IS IMPORTANT AS THE INCIDENCE	AND PREVALENCE
IS ONLY GOING TO INCREASE	FURTHER AS PEOPLE LIVE LONGER.
NEXT SLIDE.
ABOUT 1/4 OF ALL NEW SEIZURES	OCCUR IN PEOPLE OVER THE AGE	OF 65.
AND WHEN THESE ELDERLY PEOPLE	EXPERIENCE THESE	UNUSUAL FEELINGS
SUCH AS THEY LOST SOME TIME,	THEY HAVE A SUSPENDED SENSE	OF AWARENESS,
OR THEY GOT CONFUSED	FOR EXAMPLE,
THEY MAY THINK THAT	THEIR SYMPTOMS ARE CAUSED BY
SOME OF THE PROBLEMS THAT	SOMETIMES ACCOMPANY AGING.
SO LET ME ADD HERE THAT	A SERIOUS CAUSE OF ALTERED	MENTAL STATUS IN THE ELDERLY
IS NON-CONVULSIVE	STATUS EPILEPTICUS,
WHICH CARRIES A VERY HIGH	MORBIDITY RATE.
AND A STUDY BY BOTTARO	AND COLLEAGUES FOUND
THAT MOST OF THE PATIENTS	THEY SAW WITH DIAGNOSES
OF NONCONVULSIVE	STATUS EPILEPTICUS.
DID NOT HAVE A HISTORY	OF EPILEPSY
AND THAT THE USE OF OPIATES	FOR PAIN
WAS ASSOCIATED WITH THE ONSET
OF NONCONVULSIVE	STATUS EPILEPTICUS.
SO SEIZURES IN THE ELDERLY	CAN BE VERY SUBTLE.
THEY'RE NOT THE TYPICAL SEIZURE	WE THINK OF
WHEN WE THINK OF A GRAND MAL	OR CONVULSIVE SEIZURE.
OLDER PATIENTS ARE	ALSO LIKELY TO HAVE
EXTRATEMPORAL EPILEPTIC FOCUSES,
AND THEREFORE THEY REPORT	LESS INSTANCES OF SYMPTOMS
THAT ARE ASSOCIATED	WITH A TEMPORAL FOCUS
SUCH AS DEJA VU	OR A FUNNY SMELL OR TASTE.
THERE AURAS MAY BE DESCRIBED	AS DIZZINESS,
AND HOW OFTEN DO WE HEAR	ABOUT OLD PEOPLE BEING DIZZY?
THE SEIZURE ITSELF HAS	AN ATYPICAL PRESENTATION,
SUCH AS THEY MAY BE INATTENTIVE	OR HAVE MEMORY LAPSES,
AND THEN THEIR POSTICTAL PERIODS	CAN BE MORE PROLONGED
AND SOMETIMES CAN LAST	FOR SEVERAL DAYS.
NEXT SLIDE.
SO LET'S LOOK AT SOME	PROVOKED SEIZURE CAUSES.
THESE ACUTE SYMPTOMATIC SEIZURES	ARE PROVOKED
AND THEY HAVE A REVERSIBLE CAUSE	AND ARE NOT EXPECTED TO RECUR
IF THAT CAUSE IS CORRECTED.
SO BY DEFINITION, THESE TYPES	OF SEIZURES ARE NOT EPILEPSY.
SOME COMMON CAUSES INCLUDE	ACUTE ALCOHOL WITHDRAWAL,
METABOLIC DISORDER,	INFECTIONS,
ENDOCRINE DISORDERS,	AND TAKING CERTAIN MEDICATIONS.
THESE SEIZURES	DO NOT REQUIRE A TREATMENT,
LET ME SAY AGAIN, OTHER THAN	CORRECTION OR WITHDRAWAL	OF THE PREVENTING TRIGGER.
TWO OF THE MOST COMMON	MEDICATIONS WE SEE IN	OUR PATIENT POPULATION
THAT CAN INSTIGATE SEIZURES	INCLUDE TRAMADOL FOR PAIN
AND WELLBUTRIN FOR SMOKING	CESSATION OR MOOD DISORDER.
THERE ARE ALSO SOME	ACUTE SEIZURES CAUSED BY	ACUTE INTRACRANIAL EVENTS,
SUCH AS A STROKE OR HEAD TRAUMA.
ELDERLY PEOPLE,	AS YOU ARE WELL AWARE,
ARE PRONE TO FALLS	AND APPROXIMATELY 1/3	OF THOSE OVER AGE 65
HAVE BEEN KNOWN TO FALL	AT LEAST ONCE EACH YEAR.
A LOT OF THESE FALLS ARE	ASSOCIATED WITH HEAD INJURY,
WHICH CAN MAKE SEIZURES	MORE LIKELY,
AND ALSO THESE FALLS	AND HEAD INJURY
CAN CONTRIBUTE TO COGNITIVE	AND BEHAVIORAL PROBLEMS.
THESE TYPES OF SEIZURES	ARE TYPICALLY TREATED	FOR A LIMITED TIME,
AND IF THEY DO NOT RECUR,	THE ANTI-EPILEPTIC MEDICATION,
OR A.E.D., CAN BE WITHDRAWN	PENDING OTHER RISK FACTORS
IN THAT ELDERLY PERSON.
NEXT SLIDE.
NOW LET'S LOOK AT SOME OF THE	CAUSES OF UNPROVOKED SEIZURES
IN PATIENTS WITH	LATE-ONSET EPILEPSY.
AS WITH YOUNGER PEOPLE,
THE CAUSE OF EPILEPSY	IN AN ELDERLY PERSON
CANNOT BE DETERMINED	IN ABOUT 1/3 OF THE CASES.
OTHERWISE, THE CAUSES	ARE BROKEN DOWN
TO INCLUDE	CEREBRAL VASCULAR DISEASE,
NEURODEGENERATIVE DISORDERS,	TRAUMA, AND TUMORS.
STROKE IS THE MOST COMMON CAUSE	OF NEW-ONSET EPILEPSY
IN THE ELDERLY POPULATION.
AND ACCOUNTS FOR ABOUT UP TO 75%	OF EPILEPSY CASES SEEN.
POSTSTROKE EPILEPSY USUALLY	DEVELOPS WITHIN THE YEAR
BUT CAN STILL OCCUR	MANY YEARS LATER.
AND EPILEPSY IS MORE COMMON	AFTER A HEMORRHAGIC STROKE
COMPARED TO ISCHEMIC STROKE.
THE REASON FOR THIS IS	DUE TO THE HEMOSIDERIN,
WHICH CONTAINS IRON	AS A BLOOD PRODUCT,
AND IT IRRITATES THE BRAIN.
NEURODEGENERATIVE DISORDERS	SUCH AS ALZHEIMER'S,
PARKINSON'S DISEASE,	AND MULTIPLE SCLEROSIS
ACCOUNT FOR UP TO 20% OF ALL	EPILEPSY IN THE OLDER PERSON.
A LOT OF RESEARCH	IS BEING DONE ALSO
TO FIND OUT WHY	THE ELDERLY BRAIN
IS MORE SUSCEPTIBLE TO EPILEPSY,
AND THEY FEEL IT COULD BE	AN INTERPLAY OF AGE-INDUCED	CHANGES IN THE BRAIN GENES
THAT ARE ASSOCIATED WITH	THINGS LIKE INFLAMMATION,
OXIDATIVE STRESS,	AND ALTERED PROTEIN PROCESSING.
BUT THE CHALLENGE TO UNRAVEL	WHICH OF THESE INCREASES
SEIZURE SUSCEPTIBILITY	IN THE OLDER BRAIN
IS PRETTY CHALLENGING.
NOW, HEAD INJURY,	MOSTLY FROM FALLS,
CAUSES UP TO 20% OF EPILEPSY	IN THE ELDERLY.
THIS IS NORMALLY CALLED	POST-TRAUMATIC EPILEPSY,
AND THE FACTORS SUGGESTING	A HIGHER RISK OF EPILEPSY
IN THESE HEAD INJURIES	INCLUDE LOSS OF CONSCIOUSNESS,
AMNESIA FOR LONGER	THAN 24 HOURS,
SUSTAINING A SKULL FRACTURE,	A BRAIN CONTUSION,
AND HAVING A SUBDURAL HEMATOMA.
SO HEAD INJURY, THEREFORE,	BECOMES POTENTIALLY MORE SERIOUS
IN THIS ELDERLY POPULATION
ESPECIALLY IN VIEW OF THE	ANTICOAGULANTS THAT THEY USE
FOR THEIR MEDICAL COMORBIDITIES.
TUMORS ARE ALSO CAUSE	OF LATE-ONSET EPILEPSY.
AND IN LATER YEARS,	THIS PATIENT POPULATION
PRESENTS WITH TUMORS	THAT CAUSE SEIZURES
TO INCLUDE GLIOMAS,	MENNINGIOMAS,
AND SOMETIMES METASTASES
WITH SEIZURES ACTUALLY BEING	THE FIRST PRESENTATION	OF AN METASTASIS.
AND INTERESTINGLY	A STUDY BY LYMAN ET AL
SHOWED THAT 43% OF THOSE THAT	PRESENTED WITH SEIZURES WITH	METASTASES AS THE IDEOLOGY
HAD NO PREVIOUS SYSTEMIC	DIAGNOSIS OF CANCER.
NEXT SLIDE.
SOME OF THE COMMON CONDITIONS	THAT CAN MIMIC EPILEPSY
INCLUDE PSYCHOGENIC EVENTS,	MIGRAINE, SLEEP DISORDERS,
SYNCAPE,	TRANSIENT GLOBAL AMNESIA,
TRANSIENT ISCHEMIC ATTACKS.
THESE INCLUDE TRANSIENT LOSS	OF CONSCIOUSNESS
OR LIMB SHAKING THAT'S CAUSED BY	BILATERAL SCLEROTIC SIDEROSIS,
ALSO MOVEMENT DISORDERS	AND SOME CARDIAC ARRHYTHMIAS
THAT CAN CAUSE BLACKOUTS.
SO THE DIAGNOSIS OF EPILEPSY	IN THE ELDERLY IS DIFFICULT
NOT ONLY DUE TO THE GREAT NUMBER	OF DIFFERENTIAL DIAGNOSIS
AND THE HIGH PREVALENCE	OF COMORBIDITY
IN THIS PATIENT POPULATION,
BUT BECAUSE OF	ITS ATYPICAL PRESENTATION
AND THE LIMITED LIKELIHOOD	OF AN EYEWITNESS REPORT.
THIS IS BECAUSE THE ELDERLY	TYPICALLY DO NOT WORK,
THEY'RE LESS SOCIALLY ACTIVE,	AND THEY LIVE ALONE.
SO ACCURATE SELF-REPORTING	BY THE PATIENT HIMSELF
IS PRETTY PITIFUL	DUE TO THEIR POOR MEMORY,
NOT RECOGNIZING SYMPTOMS,
THE SYMPTOMS	THEY'RE EXPERIENCING
SERIOUS ENOUGH TO REPORT TO	THEIR HEALTH CARE PROVIDER.
AND A VA STUDY SHOWED THAT	IT TAKES ABOUT AN AVERAGE	OF 18 MONTHS
FROM THE INITIAL REPORTING	OF SYMPTOMS
TO A DIAGNOSIS OF EPILEPSY	IN THIS PATIENT POPULATION.
NEXT SLIDE.
THE GOAL OF EPILEPSY MANAGEMENT	IN ANY PATIENT POPULATION
IS SEIZURE FREEDOM	USING THE LEAST NUMBER	OF ANTI-EPILEPTIC DRUGS
AND HAVING THE PATIENT	TOLERATE IT
AND EXPERIENCING	NO ADVERSE SIDE EFFECTS
TO THE ANTI-EPILEPTIC DRUG.
THIS IS IMPORTANT IN THE ELDERLY
ESPECIALLY BECAUSE	OF THE INTERACTION
POTENTIALLY POSSIBLE WITH OTHER	CONCURRENTLY TAKEN MEDICATION.
NEXT SLIDE.
ANOTHER DIFFICULT TASK	IN THE TREATMENT AND	MANAGEMENT OF THE ELDERLY
IS PRESENTED BY	THE PHARMACOKINETICS
AND PHARMACODYNAMIC ALTERATIONS	OF AGING
ALONG WITH THE EVER-PRESENT	POLYPHARMACY WE SEE	IN THESE PATIENTS.
STUDIES SHOW THAT PEOPLE	OVER THE AGE OF 60
TAKE AN AVERAGE	OF 6.7 PILLS PER DAY
TO TREAT THEIR MANY	MEDICAL CONDITIONS.
SO WHEN WE TALK ABOUT	PHARMACOKINETICS,
WE'RE TALKING ABOUT	WHAT THE BODY DOES TO A DRUG.
THIS INCLUDES	THINGS LIKE ABSORPTION,
DISTRIBUTION, METABOLISM,	AND ELIMINATION.
AND WHEN WE TALK	ABOUT PHARMACODYNAMICS,
WE ARE TALKING ABOUT	WHAT THE DRUG DOES TO THE BODY,
AND THIS INCLUDES SIDE EFFECTS.
SO THE PHYSIOLOGIC CHANGES	THAT WE SEE IN THE ELDERLY
COMPLICATES THE PICTURE	AND AFFECTS THE DOSING	OF SEIZURE MEDICATIONS.
SO IN FACT BECAUSE	OF THESE CHANGES,
MANY TIMES THE ELDERLY	MAY TYPICALLY RESPOND WELL
TO A SMALLER AND	LESS-FREQUENT DOSING REGIMEN,
WHICH I THINK IS A VERY	IMPORTANT FACT TO REMEMBER.
SOME OF THE PHYSIOLOGIC CHANGES	THAT WE SEE IN THE ELDERLY ARE
DECREASED BLOOD VOLUME	AND BLOOD FLOW,
A DECREASED LIVER MASS
AND DECREASED METABOLISM,	WHICH CAN LEAD TO DRUG TOXICITY,
RENAL FUNCTION DECLINES	AT A RATE OF 10% PER	DECADE AFTER AGE 40.
AND THEY ALSO HAVE DECREASED	CONCENTRATION OF PLASMA,
WHICH LOWERS	THE PROTEIN BINDING,
AGAIN CAUSING	A POTENTIAL FOR TOXICITY.
THERE'S AN INCREASED FAT	TO LEAN BODY MASS RATIO,
WHICH CAN ALTER THE VOLUME	OF DISTRIBUTION,
AND DECREASED GASTRIC MOTILITY	CAN AFFECT ABSORPTION.
AS YOU CAN SEE,	GETTING OLD AIN'T FOR SISSIES.
OUR NEXT SLIDE.
SO CURRENT ANTI-EPILEPTIC	DRUG PRESCRIBING PRACTICE
IS TYPICALLY TO WITHHOLD	TREATMENT UNTIL THERE HAVE	BEEN TWO UNPROVOKED SEIZURES,
BUT BECAUSE OLD AGE IS	A SIGNIFICANT PREDICTOR	OF SEIZURE RECURRENCE,
OUR HEALTH CARE COMMUNITY	CONSIDERS IT REASONABLE
TO PRESCRIBE AND ANTI-EPILEPTIC	DRUG TO AN ELDERLY PATIENT
AFTER ONE UNPROVOKED SEIZURE
ESPECIALLY IF THERE'S	A BRAIN LESION
OR AN ABNORMAL EEG,	IMPORTANT POINT.
NEXT SLIDE.
SO HOW DO WE KEEP THESE ELDERLY	PATIENTS OUT OF TROUBLE?
THE FIRST THING IS TO PRESCRIBE	IN AN INFORMED MANNER.
EDUCATE THEM ABOUT THE POTENTIAL	ADVERSE SIDE EFFECTS
OF THE MEDICATION	YOU'RE PRESCRIBING
AND THE POTENTIAL INTERACTIONS	WITH THEIR PRESENT MEDICATIONS.
TRY AND PRESCRIBE ONE	OF THE NEWER GENERATION	ANTI-EPILEPTIC DRUGS,
AND IF THERE IS	AN ADVERSE SIDE EFFECT,
CONSIDER A DOSE ADJUSTMENT
AS YOU MONITOR	THE CLINICAL RESPONSE
BEFORE SWITCHING THEM	TO ANOTHER MEDICATION.
KEEP IN MIND THAT COMPLIANCE	IN THIS PATIENT POPULATION
MAY ALSO NOT BE VERY GOOD
DUE TO FACTORS SUCH AS	MILD COGNITIVE IMPAIRMENT	AND DEMENTIA,
AND SO LEVELS THAT TYPICALLY	AREN'T DRAWN ON MEDICATIONS
WOULD BEHOOVE	APPROPRIATE TREATMENT	FOR THIS PATIENT POPULATION
TO MAKE SURE THEY ARE IN FACT	TAKING IT.
LET'S LOOK AT SOME	OF THE MOST COMMON	SEIZURE MEDICATIONS
UTILIZED IN TREATING EPILEPSY.
BENZODIAZEPINE, SUCH AS ATIVAN,	KLONOPIN, OR VALIUM
SHOULD ONLY BE USED	IN THE ELDERLY FOR ACUTE CASES
BECAUSE LONG-TERM USE	HAS SHOWN TO CAUSE	BEHAVIORAL SIDE EFFECTS
AND COGNITIVE IMPAIRMENT.
PHENOBARBITAL	UNDERGOES HEPATIC METABOLISM
AND CAN CAUSE SOME VERY	SIGNIFICANT ADVERSE EVENTS.
PHENYTOIN, WHICH IS PROBABLY	THE MOST WIDELY PRESCRIBED	SEIZURE MEDICATION,
IS AN ENZYME INDUCER AND	UNDERGOES HEPATIC METABOLISM.
IT INTERACTS WITH COMMON	ELDERLY MEDICATIONS
SUCH AS COUMADIN AND DIGOXIN.
CARBAMAZEPINE IS ALSO	AN ENZYME INDUCER,
AND IT ALSO UNDERGOES	HEPATIC METABOLISM.
IT INTERACTS WITH ANTIBIOTICS,	COUMADIN,
AND IT CAN ALSO CAUSE	HYPONATREMIA,
THAT'S DECREASED SODIUM LEVEL,
ESPECIALLY WHEN DIURETICS	ARE IN THE PICTURE.
VALPROIC IS HIGHLY PROTEIN BOUND
AND ALSO UNDERGOES	HEPATIC METABOLISM.
ADVERSE SIDE EFFECTS	INCLUDE TREMOR
AND SOME	EXTRAPYRAMIDAL SYMPTOMS
WHICH CAN BE TROUBLESOME	TO THE ELDERLY PATIENT.
LACOSAMIDE, ONE OF	OUR NEWER SEIZURE MEDICATIONS,
UNDERGOES HEPATIC METABOLISM
AND INCREASES THE RISK OF	PR INTERVAL PROLONGATION,
WHICH CAN LEAD TO HEART BLOCK.
OXCARBAZEPINE UNDERGOES	HEPATIC METABOLISM
AND CAN CAUSE HYPONATREMIA,
AGAIN, WHEN DIURETICS	ARE IN THE PICTURE.
TOPIRAMATE IS RENALLY EXCRETED.
IT CAN, HOWEVER,	HAVE ADVERSE SIDE EFFECTS
SUCH AS WEIGHT LOSS,	COGNITIVE PROBLEMS,
KIDNEY STONES ESPECIALLY WHEN	NOT ENOUGH WATER IS DRUNK,
WHICH OLD PEOPLE TEND	NOT TO DRINK TOO MUCH WATER.
AND IT CAN ALSO CAUSE	A FORM A GLAUCOMA.
SO IT REQUIRES	A SLOW DOSE TITRATION
IN ORDER TO MINIMIZE EFFECTS	ON COGNITION.
GABAPENTIN,	WHICH IS USED FOR PAIN,
CAN CAUSE DIZZINESS	AND WEIGHT GAIN,
IT CAN ALSO INTERACT	WITH ANTACIDS.
IT HAS A WEAK PROFILE	FOR USE IN EPILEPSY,
BUT BECAUSE OF	ITS MINIMAL INTERACTIONS
IT'S USED WELL	IN THE ELDERLY POPULATION
AT A DOSE OF APPROXIMATELY	900 TWICE PER DAY.
YOU SEE IT A LOT	FOR ISCHEMIA CONTROL.
AND IT IS RENALLY EXCRETED.
PREGABALIN CAN ALSO CAUSE	DIZZINESS AND WEIGHT GAIN
AND HAS A WEAK PROFILE	FOR USE IN EPILEPSY.
IT'S APPROVED	FOR DIABETIC NEUROPATHY
AND FIBROMYALGIA	AS WELL AS EPILEPSY.
LAMOTRIGINE	BENEFITS MOOD DISORDERS
SUCH AS BIPOLAR DISORDER	AND DEMENTIA.
IT'S GOT A GOOD TOLERABILITY,
BUT IT ALSO REQUIRES	A SLOW DOSE TITRATION
IN ORDER TO MINIMIZE THE RISK	OF A SERIOUS ALLERGIC REACTION.
IT IS ALSO	HEPATICALLY METABOLIZED.
AND LASTLY LEVETIRACETAM,
WHICH CAUSES FEWER ADVERSE	EVENTS THAN ANY OF THE OTHER	ANTI-EPILEPTIC DRUGS
AND HAS A GOOD PROFILE	IN KEEPING COGNITION CLEAR,
AND IT IS RENALLY EXCRETED.
SO IF I WOULD REVIEW THESE,	WHAT WOULD BE MY BEST CHOICES	FOR THE ELDERLY POPULATION?
I WOULD PROBABLY START	WITH LEVETIRACETAM.
MY SECOND ONE	WOULD BE LAMOTRIGINE.
AND THEN DEPENDING	ON COMORBIDITIES,
MORE RISK FACTORS	IN THE PATIENT,
YOU CAN LOOK AT PRESCRIBING	GABAPENTIN, TOPIRAMATE,
OXCARBAZEPINE, AND PREGABLIN.
I WANT TO ADD HERE THAT THERE	ARE TWO IMPORTANT POINTS	TO KEEP IN MIND
WHEN PRESCRIBING TO THE ELDERLY.
FIRST THERE'S A MEDICAL EXPENSE	THAT SOME OF THEM HAVE A	DIFFICULT TIME ABSORBING,
SO YOU MAY WANT TO CONSIDER	GENERIC AS A CHOICE.
BUT THEN YOU HAVE TO KEEP	IN MIND THAT BECAUSE THEY HAVE	A NARROWER THERAPEUTIC WINDOW,
BRAND MAY BE MORE EFFECTIVE DUE	TO THE VARIABILITY OF GENERIC.
OUR NEXT SLIDE.
EPILEPSY CAN HAVE	A PROFOUND PHYSICAL
AND PSYCHOLOGICAL	IMPACT IN OLD AGE
CREATING A NEGATIVE EFFECT	ON QUALITY OF LIFE.
THERE'S A STIGMA THAT'S ALWAYS	BEEN ASSOCIATED WITH EPILEPSY,
AND THIS CAN BE MORE PROFOUND	IN THE ELDERLY,
PARTICULARLY HARD	AT THIS TIME OF LIFE.
THE ELDERLY PEOPLE ARE	MORE VULNERABLE TO INJURIES	DURING THE SEIZURES,
AND THIS CLINICAL SITUATION	IS VERY OFTEN COMPLICATED
BY A RANGE OF	NEURO-DEGENERATIVE,	CARDIOVASCULAR,
NEO-PLASTIC, AND PSYCHIATRIC	[INDISTINCT]
SAFE DRIVING LAWS MUST BE	REVIEWED WITH THE PATIENT.
WHEN DRIVING PRIVILEGES	ARE REVOKED,
THERE IS A LOSS OF INDEPENDENCE,
WHICH IN TURN CAN LEAD	TO SOCIAL WITHDRAWAL,
DEPRESSION, AND ANXIETY,
AND THIS UNPREDICTABLE NATURE	OF SEIZURES,
NOT KNOWING WHEN	YOU'RE GOING TO HAVE ONE,
CAN ALSO LEAD TO	SOCIAL WITHDRAWAL	AND LOSS OF CONFIDENCE.
AND THE IMPACT OF THESE	PSYCHO-SOCIAL IMPLICATIONS
CAN LEAD TO A PREMATURE	ADMISSION TO A NURSING HOME.
NEXT SLIDE.
SO IN EVALUATING	THE ELDERLY PATIENT
WITH NEW ONSET SEIZURES,
IT IS IMPORTANT TO INCLUDE	A THOROUGH ASSESSMENT
FOR CARDIOVASCULAR RISK FACTORS	IN THE ELDERLY.
AN EKG SHOULD BE PERFORMED	FOR ALL ASSESSMENTS
OF ANY UNDIAGNOSED TRANSIENT	LOSS OF CONSCIOUSNESS.
NEUROIMAGING CAN BE BENEFICIAL	IN THIS PATIENT POPULATION
AFTER A HEAD INJURY.
AND I WANT YOU ALL	TO KEEP IN MIND
THAT MRI AGE RELATED CHANGES	SUCH AS DIFFUSE ATROPHY,
PERIVENTRICULAR HYPERINTENSITIES
ARE COMMON	IN THIS PATIENT POPULATION.
THEY'RE DUE TO HYPERTENSION	AND ATHEROSCLEROSIS,
AND THEY ARE NOT THE CAUSES	OF SEIZURES.
WE DON'T CONSIDER	THESE BRAIN LESIONS
TO BE CAUSING SEIZURES.
AND LASTLY,	A VERY IMPORTANT POINT
IS NOT TO OVERLOOK THE	POSSIBILITY OF ALCOHOL	WITHDRAWAL SEIZURES
IN THIS PATIENT POPULATION.
I WANT TO THANK YOU	FOR CALLING IN,
AND I AM NOW OPEN FOR QUESTIONS.
NO QUESTIONS?
- IF YOU GUYS HAVE	ANY QUESTIONS,
GO AHEAD AND TYPE THEM	INTO THE BOX,
AND I CAN ASK HER FOR YOU,	OR SHE CAN JUST READ THEM.
OH, NO, YOU DON'T HAVE ACCESS	TO READ THEM, DO YOU?
- I DON'T. I'M TRYING TO--	NO, I--I DON'T.
- HOLD ON. LET'S SEE IF I CAN...
DOES ANYBODY HAVE ANY QUESTIONS?
PLEASE GO AHEAD	AND TYPE IN THE BOX
OR YOU CAN UNMUTE YOURSELF	AND YOU CAN ASK.
- DENISE, THIS IS JUDY	IN SEATTLE. HI.
YOU KNOW, I JUST CAME IN	ON THE LAST PART OF YOUR TALK,
AND I'M SORRY TO HAVE MISSED IT,	BUT I JUST FORGOT,
BUT SEAN, IS THERE A WAY	YOU CAN GIVE US
THE WHOLE SLIDE PRESENTATION	SO I CAN SEE THE FIRST PART	OF THE SLIDE?
- YES, THE SLIDES	ARE AT THE TOP.
IF YOU LOOK AT THE PAPER CLIP	AT THE TOP,
IT SAYS ATTACHMENTS,
AND YOU CAN JUST DOWNLOAD THEM	RIGHT UP THERE.
PLUS THEY'RE IN TMS.
- GOT YOU.
- AND EVERYBODY'S LINE IS OPEN,
SO IF YOU'VE GOT A QUESTION,	GO AHEAD AND ASK.
- OH, SO I GUESS, DENISE,	I CAN ASK THIS QUESTION.
WHEN YOU MENTIONED THE EKG	SHOULD BE PERFORMED
IN ASSESSMENT OF UNDIAGNOSED	TRANSIENT LOSS OF CONSCIOUSNESS,
ARE YOU BASICALLY SAYING THAT	ARRHYTHMIAS CAN BE THE SOURCE
OF THIS PROBLEM IN THE ELDERLY?
- DENISE, ARE YOU STILL THERE?
- YEAH, I'M STILL HERE.	CAN YOU HEAR ME?
- YEAH, DID YOU HEAR	HER QUESTION?
- I DIDN'T GET THE SECOND HALF	OF HER QUESTION.
SHE ASKED SOMETHING	ABOUT AN EKG.
- SHALL I START OVER?
SO TELL ME, DENISE,	ARE YOU SAYING THAT THE EKG
IS IMPORTANT BECAUSE ARRHYTHMIAS	CAN BE A CAUSE
OF LOSS OF CONSCIOUSNESS	IN THIS POPULATION?
- YES, BECAUSE SOME FORM OF	CARDIOVASCULAR COMORBIDITY
MAY BE PRESENT	AND MAY BE MANIFESTING ITSELF
AS A TRANSIENT LOSS	OF CONSCIOUSNESS,
AND I WANT PROVIDERS TO KEEP	IN MIND THAT NOT EVERY BLACKOUT,
JERK, TWITCH IS A SEIZURE.
THAT'S WHY WE HAVE TO INCLUDE	THIS IN OUR EVALUATION	IN THE ELDERLY PERSON.
- THANK YOU.	- YOU'RE WELCOME.
ANYBODY ELSE?
- I DON'T THINK	THERE'S ANY OTHER QUESTIONS.
- VERY GOOD. WELL, IF ANYBODY	HAS ANY QUESTIONS THAT COME	TO MIND LATER,
FEEL FREE TO SEND ME AN EMAIL,
AND I'LL BE HAPPY TO RESPOND.
- ALL RIGHT.	- THANK YOU FOR JOINING US.
- SEAN? I AM STILL TRYING	TO DOWNLOAD THE SLIDES,
AND I'M HAVING TROUBLE,
SO MAYBE YOU AND I	CAN STAY ON THE LINE,
AND YOU CAN WALK ME THROUGH IT.
- I CAN SEND THEM TO YOU.
- [INDISTINCT]
- OK, EITHER ONE OF YOU,	I APPRECIATE IT.
- SEAN, I'LL TAKE CARE OF IT.
- OK, THANK YOU.	- THANK YOU.
THANKS, DENISE!
- THANKS, DENISE.	- BYE-BYE.
- THANK YOU.	- YOU'RE WELCOME.
NEXT TIME, RYAN.