Blog #166: POST-TRAUMATIC EPILEPSY IS ASSOCIATED WITH HIGHER RISK FOR DEMENTIA

 

 

 

 

As I have written in earlier monthly blogs, most people are surprised to learn that the commonest onset of epilepsy is in the older age-group and not in the pediatric population Why? We are living longer.

 

The epilepsy population is one percent of all people. In only half of these people can a cause for their epilepsy be identified. In the other half no cause can be found, in other words, these people have idiopathic epilepsy. In those for whom a cause can be identified, they have what is called symptomatic epilepsy. Usually, the cause is a structural abnormality in the brain associated with scars from trauma, scars from strokes, brain tumors, brain infections, abnormal blood vessels etc.

 

This blog highlights a summary edited by Susan Kreimer in the Neurology Today April 4, 2024, issue. It addresses the higher incidence of dementia in those with post-traumatic epilepsy¹. Post-traumatic epilepsy (PTE) is associated over a 25-year follow-up of developing dementia compared with epilepsy without a history of head trauma. A combination of epilepsy and head injury places the person at an increased risk of developing dementia.

 

Although some patients experiencing significant head injury are placed on anticonvulsant medications even before a seizure occurs, usually for short periods, as seizure prophylaxis, this has not been found to alter the risk of eventually developing PTE. Even mild traumatic brain injury can result in PTE up to a year after the head injury.

 

Researchers collected 12,558 individuals aged 45-64. The average age at baseline was 54 years. Nearly 58% were female and 28% were Black. Of this group 14.4 reported past head injury, 5.1% had seizure/epilepsy and 1.2 % had PTE. After follow-up spanning a median of 25 years, 19.9 of the participants developed dementia. Dementia risk factors may vary among population subgroups. The researchers adjusted for vascular and genetic risk factors.

 

Approximately 5-8% of the American population over 65 has dementia. Neurologists are encouraged to have a lower threshold to suspect cognitive impairment and dementia in their patients with PTE. Screen the patients themselves rather than rely on reports of caregivers to identify such patients for greater diagnostic accuracy. Have them undergo neuropsychological testing to confirm dementia if it appears.

 

We conclude that being aware of this group of PTE patients and of assessing them periodically for their higher risk of developing dementia can lead to better health outcomes.

 

 

1)     Schneider KCA, Law CA, Gottesman RF et. al.  Post-traumatic Epilepsy and dementia risk. JAMA Neurol 2024; Epub 2024 Feb 26

 

 Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School

of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is

told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation

on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review,

DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles

Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now

available in eBook, audiobook, soft and hard cover editions.

Blog # 165: COMMUNICATIONS WITH YOUR EPILEPSY DOCTOR

     

     You understand that your decisions for your epilepsy care are critical to the quality of your life. A study was published examining in-office patient-neurologist conversations that focus on identifying your type of epilepsy, sharing decisions about your care and continuing plans for your condition.

     A study of transcripts and audio recordings of conversations between patients and neurologists were analyzed focusing on epilepsy diagnosis, treatments, and prognostic considerations. The strategies for eliciting this information were assessed for strategies of information elicitation, word-level information, identification of topics discussed, quantification of questions probed, and types of questions asked.1

     Neurologist-patient interactions were analyzed in the United States, in Spain and in Germany. Neurologists tended to utilize event-based language. They referred to seizures in patient-friendly vocabulary. In the United States the term “epilepsy” tended to be avoided. This is cultura-based like Americans avoiding saying someone died. Rather, we say they “passed away.”

    In all three countries it was the neurologist who were unilaterally responsible for the treatment decision and choice of medication. A team effort is sometimes appropriate in medication decisions. When new medicines were described neurologists most often discussed potential side effects but did not review potential benefits. “Seizure control” rarely was defined. Patients were not asked what seizure control meant to them. Did I mean absolutely seizure-free or a very infrequent seizure may be acceptable to be “free” of seizures because “My last seizure was 8 months ago, or a year ago”. I would not consider this to be seizure-free.

     This paper identified opportunities related to vocabulary, decision making, and treatment goal setting. All these facets can improve communication about epilepsy.

     I recommend that you as the patient bring along your significant other to attend your meetings with your neurologist. That person should participate in all the discussions and ask pertinent questions along with you. Certainly, “two or more heads are better than one” in your doctor’s office. When I was in practice, I would often create the scenario after complex discussions I had with the patient who had come alone, “So, when you get home and your wife/ husband asks, “What did the doctor say?” I often heard the patient respond, “Nothing” or “nothing new” or something completely off the mark.

     I urge you all to bring someone along to be in the office/treatment room, if appropriate, whenever you visit a physician/clinic. You’re bound to get more for “your buck.” 

1) Stern JM, Cendes F, Gilliam F, et.al. Neurologist-Patient communication about epilepsy in the Unites States, Spain, and Germany. Neurology Clinical Practice. 2018; vol 8 (2), pg 93-101. 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

Blog #164: MEMORY: SUBJECTIVE COMPLAINTS VS ACTUAL OBJECTIVE DEFICITS IN EPILEPSY

 

 

Who amongst us doesn’t find fault with our own memory? But are memory concerns and complaints due to actual brain pathology or are they within the normal age-spectrum? Over half of patients with epilepsy complain of impaired memory. Are they actual memory deficits, though? We know that anticonvulsant medications commonly have deleterious effects on memory as can depression, other medications and illnesses.

Exploring memory researchers recruited patients with Temporal Lobe Epilepsy (TLE).¹ TLE diagnosis was based on abnormal EEG and clinically typical seizures. Our temporal lobes are where memory is generated and preserved. Damage there does affect memory whereas damage to other parts of the brain does not have as serious effects on memory. Generalized epilepsy, which does not focus on temporal lobes, seems to have less deleterious effects on memory as compared with TLE.

Researchers recruited 47 patients with TLE. Age and sex-matched 35 healthy controls were similarly studied. Self-evaluation memory questionnaires were used to assess the magnitude of memory complaints. All were then studied with neuropsychological examinations. A surprise recall testing 3 weeks later occurred. No significant differences on standard testing were found between the performance of patients and controls.

The two groups were then brought back three weeks later. The surprise recall tests 3 weeks later revealed significant differences between the two groups. They were assessed if they recalled simple events that occurred during that original testing 3 weeks before. For example, was there a memory of a water glass being offered? Did the examiner leave the room and change what they wore? Did the subject recall the phone ringing twice during the visit, or recall being asked to retrieve a questionnaire from a shelf, etc.? In the absence of spontaneous recall without cues, cues were then provided by the researchers followed by recognition questions such as “did the phone ring once or twice? Were you offered water etc.? Scores were generated.

The standard neuropsychological battery we have relied on to test cognition and memory has some blind spots; an adequate assessment of autobiographical memory and our “long term” memory assessments occur 10 to 30 minutes after the information is encoded. Traditionally these tests haven’t been performed. It is these blind spots that have been addressed in this study. People with subjective memory complaints that were corroborated by family members had normal performance on standard neuropsychological testing. But scores 3 weeks later were significantly lower in the epilepsy group.

This information is another reminder that we need to listen closely to our patients’ complaints, and that our gold standards need to be updated as our understanding of memory evolves.

1)     Lemesle B, Barbeau EJ, Milongo Rigal E, et al. Hidden objective memory deficits behind subjective memory complaints in patients with temporal lobe epilepsy. Neurology. 2022;98(8): E818-E828

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

 

Blog #163 February: ALZHEIMER'S DISEASE AND EPILEPSY

Articles are ubiquitous in the media on Alzheimer's Disease (AD). It is estimated that Alzheimer's currently affects 5 million Americans. In 2050 ten percent of us will be affected according to Harvard.edu.

Increasing knowledge based on multiple studies (meta-analysis) shows a link between AD and epilepsy. People with epilepsy had a 1.8-fold increased risk of AD. Patients with AD had a 3.1- fold higher risk of epilepsy, both generalized and focal seizures with impaired awareness (complex partial epileptic seizures). Temporal lobe epilepsy and AD share some pathologic features such as both show hippocampal sclerosis in the temporal lobe tip. The study populations to confirm this information is interesting but it is inconclusive due to the relatively small populations in the studies.1 

Increased chemical amyloid compounds are found in the brains of patients with AD. Elderly people who may be intellectually normal all have some amyloid in their brains, too, but this chemical compound is more prolific in AD dementia. It appears that amyloid pathology increases the propensity to generalized seizures. There is an association between AD and focal seizures, too, with hippocampal sclerosis (scarring) in the temporal lobes.

1. Fang Y, Xiaoli S, Jial W, et. al. Alzheimer Disease and Epilepsy. Neurology;2023 101:e 399-e409. Doi:10.1212 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions

Blog # 162: The Gamma Knife is Focused Radiation to Treat Epilepsy Without Surgery

               My followers should find this 162^nd of my monthly educational blogs of interest for your own epilepsy and for those whose lives are touched by your epilepsy.

If your epilepsy is drug resistant this is a potential treatment that could benefit you and it is non-surgical. Gamma knife surgery, also known as stereotactic radiotherapy, is not actual surgery. No cutting nor opening of the skull is involved. Radiofrequency beams are painlessly concentrated on the brain area identified as the cause of your epilepsy. This technique originated in the 1950’s. The Gamma Knife can minimize damage to nearby healthy brain tissue. Your seizure frequency may be lessened; your epilepsy may even be cured without opening the skull or damaging normal brain tissue.¹  

The Gamma Knife® is a powerful tool that enables the neurosurgeon to focus many weak beams of radiation energy on any location inside the brain, especially useful to treat areas difficult, or dangerous, to expose surgically. By focusing these intersecting individually weak beams together these many beams can break down tissue. The radiosurgery team can target a region of the brain while limiting damage to surrounding, normal brain tissue. While more commonly used to treat children with brain tumors and collections of abnormal blood vessels arteriovenous malformations, the Gamma Knife is also used to treat some patients with epilepsy.

 

The painless treatment effect of Gamma Knife radiosurgery occurs slowly, depending on these conditions that are often associated epilepsy:

• Benign tumors. Gamma Knife radiosurgery keeps tumor cells from reproducing. The tumor may shrink over a period of months to years. But the main goal of Gamma Knife radiosurgery for noncancerous tumors is to prevent any future tumor growth.
• Malignant tumors. Cancerous tumors may shrink quickly, often within a few months.
• Arteriovenous malformations (AVMs). The radiation therapy causes the atypical blood vessels of brain AVMs to thicken and close off. This process may take two years or more.
• Epilepsy foci. Half of epilepsy patients lack identifiable brain tissue abnormalities or scars which EEGs and brain scans identify where seizures begin. The radiation therapy can be useful in eliminating these abnormal areas.

Consider discussing Gamma Knife treatment on a brain epileptic focus your medical team has identified causing your still poorly controlled seizures with your neurologist.

1.      Lunsford LD, Kondziolka D, Flickinger JC, et al: Stereotactic radiosurgery for arteriovenous malformations of the brain. J Neurosurg 75:512-524, 1991

 

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

 

 

 

Blog # 161: WEEKLY EPILEPTIC SEIZURES REDUCED BY MEDICAL CANNABIS

 

A study was summarized by Robert Herpen, MA and Shenaz Bagha on the American Epilepsy WebSite. The researchers, Xintian Lyn, BS, a student in the department of experimental and clinical pharmacology at the College of Pharmacy at the University of Minnesota and her team reported on their recent poster at the American Epilepsy Society meetings earlier in December 2023 that adults with epilepsy given medical cannabis had a significant decrease in weekly seizure frequency.¹

There is a paucity of data on the effects of THC (Tetrahydrocannabinol, the principal psychoactive constituent of cannabis) on seizure frequency. This researcher group in Minnesota was interested in cannabis’ effects on seizure frequency.

From 2016 to 2019 one-hundred-twelve adults with epilepsy, 70% of whom were aged 18-64 (54.5 % were male) were studied. The participants had at least four visits for treatment for at least 6 months. They may or may not have had antiseizure medications prescribed, too. The outcome of the study was that 57 participants reported fewer weekly seizures, 47 enrollees reported no change—including 34 with zero frequency seizures during the study period—while 10 patients reported an increase in their seizure frequency. In all three of these groups, participants were dispensed both CBD (cannabis) and THC. The study found a significant difference reported in CBD total daily dose among those who recorded either a decrease or no change in seizure frequency. CBD is a chemical found in marijuana. CBD doesn't contain tetrahydrocannabinol (THC), the psychoactive ingredient found in marijuana that produces a high.

Thirty patients relied on only CBD cannabis to manage their epileptic seizures. Most of this study population were also taking one to five antiseizure medications.

If your epilepsy is poorly controlled discuss adding CBD (cannabis) to your treatment with your physicians. Additionally, explore the potential of brain surgery as your epilepsy treatment if no other treatments benefit you. Several of my previous 160 monthly blogs on my website: LanceFogan.com dealt with brain surgery as a chance to improve your epilepsy when medications fail (See Blog # 89 December 26, 2017: Surgical Removal of Seizure Foci in Your Brain to Cure Poorly Controlled Epilepsy is Safe!; Blog # 103 February 26, 2019: Epilepsy—fit to drive?; Blog # 114 January 26, 2020: Epilepsy surgery in childhood and long-term employment is encouraging.; Blog # 121 August 25, 2020: If your seizures aren’t controlled epilepsy surgery is safe and really can help).

 

1.      Lyu X. et al. Medical cannabis and seizure control in Minnesota medical cannabis program. Presented at AmericanEpilepsy Society annual meeting Dec. 1-5, 2023: Orlando, FL.

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.

Blog #160: Life Expectancy Varies by Epilepsy Type

 

Overall, life expectancy is comparable to the general population.¹ But in certain types of epilepsy, the risk of premature death is higher than that of the general population. Most of the increased risk is directly related to what causes your epilepsy.

Only a small number of deaths in the epilepsy patient population are epilepsy related. These are deaths caused by a seizure or accidents during or immediately after the seizure, as well as sudden unexpected death for which no cause of the death can be identified. SUDEP (see below) is one example of this. Sudden unexpected deaths are more common in patients with poorly controlled, intractable epilepsy. Improved seizure control, medical advice and avoiding the hazards that occur during a seizure are key. Regular medical follow-up care and supervision may help reduce the risks of epilepsy-related death occurring.

What causes epilepsy?

Epilepsy can be categorized into three broad groups:

Idiopathic epilepsy

Common among children, idiopathic epilepsy is an inherited type of epilepsy with a strong genetic component and no structural brain abnormalities. Provoked seizures (for example, from flashing lights) are often seen in idiopathic epilepsy.

Cryptogenic epilepsy

Cryptogenic epilepsy is the type with no known cause and often involves unprovoked seizures. This accounts for approximately 20% of seizure cases.

Symptomatic epilepsy

Symptomatic epilepsy is caused by an injured brain. Common causes: head injuries, central nervous system infections, loss of oxygen to the brain, strokes, brain tumors and brain surgery.

How can your epilepsy result in premature death?

Premature deaths in people living with epilepsy: failure to take antiseizure medications as prescribed; the seizures themselves; collateral damage related to a seizure; reduced quality of life that comes with living with epilepsy; fatal unintentional injuries (for example, falls and burns), or through aspiration pneumonia during a seizure.

Additionally:

Serious transportation accidents: Seizures — which can result in impaired awareness and uncontrolled motor activity — put people living with epilepsy at increased risk of serious transportation accidents. This increased risk doesn’t apply to just car accidents but to the increased risk of pedestrian accidents and increased risk of bicycle accidents.

Drowning: because seizures can lead to a loss of consciousness or uncontrolled motor activity, people living with epilepsy are at increased risk of drowning. The risk of drowning is much higher in people with epilepsy. Despite my warnings, one of my young surfer patients ignored this warning and continued surfing. I don’t know his current condition While cases of drowning often occur in the bathtub (Mark Twain’s adult daughter had epilepsy; she drowned in her bath, for example), less frequently patients die in the shower; the body, face-down, blocks the drain resulting in drowning in just inches of water.

Status epilepticus: status epilepticus is a condition in which a person experiences abnormally prolonged seizures (longer than five minutes in the case of generalized tonic-clonic seizures; they usually last under 2 minutes) that can lead to long-term consequences, including brain damage and death.

Psychiatric illness: people with epilepsy commonly have depression, which increases the risk of suicide. The high incidence and prevalence of psychiatric illness (including impulsivity, psychosis, and substance abuse) correlates with the duration and severity of epilepsy. Depression is also associated with not taking medications as recommended, which can increase mortality.

What is a sudden unexpected death in epilepsy (SUDEP)? Premature mortality in people with epilepsy can also be attributed to a sudden unexpected death in epilepsy (SUDEP): Blog #108: SUDEP—Sudden Death in Epilepsy—Occurs in All Types of Epilepsies; Blog #74: New Studies Reveal High SUDEP Risk of Death in Poorly Controlled Epilepsy. In the US, there are at least 2,750 cases of SUDEP per year. SUDEP refers to deaths among people with epilepsy that cannot be attributed to other known causes. Studies suggest that for every 100,000 people with epilepsy, there will be approximately 116 cases of SUDEP. While the causes of SUDEP are not yet fully understood, most cases occur during or immediately after a seizure and generally during sleep. Possible seizure-related factors contributing to SUDEP include breathing and/or heart rhythm disruptions.

Does epilepsy shorten your life expectancy? People with epilepsy are two to three times more likely to die early than those without the condition. This suggests that epilepsy can shorten life expectancy by ten years for those living with symptomatic epilepsy and by two years for those with idiopathic/cryptogenic epilepsy where no serious brain pathology can be identified. While life expectancy is reduced in cases of symptomatic epilepsy (by approximately seven years), people with cryptogenic epilepsy had an almost normal life expectancy.

SUMMARY: While epilepsy can increase your risk of premature death, it is possible, in most cases, to manage these risks with anti-epileptic drugs, appropriate mental healthcare, and lifestyle changes. Mortality in patients with newly diagnosed epilepsy is higher than in patients with chronic epilepsy due mainly to the underlying epilepsy cause.

MY ADVICE: making family, friends, and colleagues aware of the risks and how they might be able to help you reduce these risks can go a long way to keeping you safe. Be certain that you have follow-up care and observation by your physician for your best chance of thriving with epilepsy.

1.     Granbichler CA, Zimmerman G, Oberaigner W, et. al. Potential years lost and life expectancy in adults with newly diagnosed epilepsy. Epilepsia. 2017;58(11): 1939-1945.

 

 

Lance Fogan, M.D. is Clinical Professor of Neurology at the David Geffen School of Medicine at UCLA. His hard-hitting emotional family medical drama, “DINGS, is told from a mother’s point of view. “DINGS” is his first novel. Aside from acclamation on internet bookstore sites, U.S. Report of Books, and the Hollywood Book Review, DINGS has been advertised in recent New York Times Book Reviews, the Los Angeles Times Calendar section and Publishers Weekly. DINGS teaches epilepsy and is now available in eBook, audiobook, soft and hard cover editions.