The Complicated Relationship Between Epilepsy and Dementia
There are many reasons why seizures in older individuals go unrecognized or are misdiagnosed for dementia
When Jack, a sharp, gregarious 74-year-old, did not remember attending his favorite granddaughter Anne's wedding in May, they both knew something was wrong. He showed me a picture of her in her bridal gown as we recently sat in my clinic room.
I asked them about his behavior and how they ended up seeing an epileptologist (a neurologist with additional training in treating epilepsy) in a specialized clinic for older people.
Jack reported he would periodically have days where he did not feel like himself, was much quieter than usual, and was almost confused.
For the past year, Jack reported he would periodically have days where he did not feel like himself, was much quieter than usual, and was almost confused. These were days that he could not recall specifics.
With much trepidation, they sought medical advice starting with their primary care provider, who sent them to a general neurologist in the community. Initially, he was diagnosed with mild cognitive impairment, the precursor to dementia.
Still, Anne was not convinced because his confusion was episodic, and between these episodes, he was "sharp as a tack."
They sought a second opinion with another community neurologist, who repeated the initial lab work and imaging of his brain and came to the same conclusion. Later at a hair salon appointment, Anne learned about her hairdresser's mother, who had been to my clinic and, with low-dose medication, was doing much better cognitively.
After listening to his story and cataloging his symptoms, I admitted him to the epilepsy monitoring unit. Here we recorded and identified a seizure his family thought was an odd tick of him "playing with his dentures."
It was what neurologists call oral automatisms, a common symptom of seizures arising from the temporal lobe, the area of the brain that, among other things, makes memories. Both were relieved that the diagnosis was epilepsy and not dementia.
"But I thought young people had seizures," his granddaughter said after I delivered the diagnosis. Unfortunately, she is not alone in this misconception; one in four newly diagnosed people with epilepsy is aged 65 or older.
However, the idea that epilepsy is a disease of youth is pervasive not only in the community at large but also in the medical community.
The idea that epilepsy is a disease of youth is pervasive not only in the community at large but also in the medical community.
Jack is doing well on a single antiseizure medication at a relatively low dose. His "forgotten days" (as he calls them) have not occurred since starting the medication.
While this patient's journey to the correct diagnosis was relatively quick, an older individual's accurate diagnosis can be delayed up to almost two and a half years.
There are many reasons why seizures in older individuals go unrecognized or are misdiagnosed for dementia.
Seizures in older individuals are less dramatic than in younger individuals. Instead, they tend to be very subtle, often characterized by simple behaviors or confusion that can be easily missed or explained away.
There is a long list of seizure mimickers in this older age group, including mini-strokes and fainting due to heart issues and dementia. The relationship between dementia and epilepsy in older adults is a complicated one. The medical literature documents the decline in memory and mental faculties of older people with frequent seizures.
It also demonstrates, nevertheless, that by controlling the seizures, lost cognitive abilities can be regained. Epilepsy in older adults is a treatable cause of dementia.
Further research is needed to understand this relationship fully. In addition, more patients, clinicians, and health care providers need to be aware of seizures in older people. Currently, almost 1 million adults in the United States aged 55 years or older have active epilepsy.
This number will only increase as the fastest-growing demographic is those over 65. President Joe Biden, 80, is consistently called out for "senior moments."
Without more awareness, more people may have misunderstood and untreated symptoms.
Further, age was a consideration for candidates in the midterms and will also be in the 2024 presidential race. Yet, despite the massive spending on health care after the age of 65, with Medicare spending in 2020 rising to $829.5 billion, accounting for a fifth of the national health expenditure, the United States life expectancy is only 42nd in the world.
To improve health outcomes for this age group, policymakers, funders, research institutions, and family members must address the need for investment in epilepsy and dementia.
Treating seizures leads to a better quality of life for individuals and their families; it can lower health care costs with fewer emergency room visits to get unnecessary brain scans and lab work done, fewer medications, doctors' visits, and hospital admissions, plus more time living independently.
In Jack's case, if he had remained untreated, his memory would have continued to decline, and he might have needed to move into an assisted living facility. He might have gotten lost and injured himself and possibly ended up in the emergency room.
But because he was diagnosed, he takes medication twice a day and lives a healthy and active life independently.
As more Americans age, all parties must be aware of concerns over memory and the possibility of epilepsy as a diagnosis. Without more awareness, more people may have misunderstood and untreated symptoms.
The future is far brighter with more awareness to address an accurate diagnosis.
