Mark Bloom

BOSTON – A Veterans Affairs cooperative study of epilepsy in the elderly has found that two newer agents are as effective as carbamazepine at controlling seizures but are far less likely to cause unpleasant side effects in this age group than the old standby antiepileptic agent.

The newer antiepileptic drugs (AEDs), gabapentin (Neurontin) and lamotrigine (Lamictal), were matched against the enzyme inducer, carbamazepine, in an 18-center randomized double-blind study of 593 patients that lasted 1 year, said A. James Rowan, M.D., a professor of neurology at Mount Sinai School of Medicine, New York.

Of the two newer drugs, lamotrigine was significantly superior to gabapentin in terms of patient retention over the length of the study. Neither of the newer agents was significantly better than carbamazepine in preventing seizures, said Dr. Rowan, who was codirector of the VA study.

The trial also found that optimal doses of AEDs may be lower in elderly patients, he reported at a meeting on epilepsy in the elderly sponsored by Boston University. The mean plasma levels of all three drugs were low “but that seems to be enough for this population,” he said.

The patients were 60 years or older (mean age 72.8 years) with a history of one or more seizures and no previous AED therapy, or inadequate therapy. Aside from patients with medical conditions that suggested they would not survive for a year, “we took all comers, with multiple illnesses and multiple medications–the real world,” Dr. Rowan said.

The patients were titrated to the target doses: 600 mg for carbamazepine, 1,500 mg for gabapentin, and 150 mg for lamotrigine. Clinicians had the flexibility to titrate further for tolerability, and after 12 months the mean doses were 582 mg for carbamazepine, 1,614 mg for gabapentin, and 152 mg for lamotrigine. “It was very much like office practice,” he said.

At the end of 12 months, “carbamazepine had significantly more side effects than lamotrigine or gabapentin,” which led to earlier termination of therapy, according to Dr. Rowan.

In the nursing home world, he added, adverse side effects and drug interactions, which are often promptly noted and reported in younger epilepsy patients, may be unnoticed or underreported among the elderly.

Of the 197 original carbamazepine patients, 72 finished the study (37%). That compared with 95 of 193 gabapentin patients (49%) and 114 of 197 patients in the lamotrigine arm (58%).

Among the neurologic side effects, carbamazepine led to sedation for 51% and cognitive symptoms for 32%. In the gabapentin arm, 46% of patients reported sedation and 29% had cognitive symptoms. Of lamotrigine patients, 40% reported sedation and 23% cognitive symptoms.

BOSTON – A Veterans Affairs cooperative study of epilepsy in the elderly has found that two newer agents are as effective as carbamazepine at controlling seizures but are far less likely to cause unpleasant side effects in this age group than the old standby antiepileptic agent.

The newer antiepileptic drugs (AEDs), gabapentin (Neurontin) and lamotrigine (Lamictal), were matched against the enzyme inducer, carbamazepine, in an 18-center randomized double-blind study of 593 patients that lasted 1 year, said A. James Rowan, M.D., a professor of neurology at Mount Sinai School of Medicine, New York.

Of the two newer drugs, lamotrigine was significantly superior to gabapentin in terms of patient retention over the length of the study. Neither of the newer agents was significantly better than carbamazepine in preventing seizures, said Dr. Rowan, who was codirector of the VA study.

The trial also found that optimal doses of AEDs may be lower in elderly patients, he reported at a meeting on epilepsy in the elderly sponsored by Boston University. The mean plasma levels of all three drugs were low “but that seems to be enough for this population,” he said.

The patients were 60 years or older (mean age 72.8 years) with a history of one or more seizures and no previous AED therapy, or inadequate therapy. Aside from patients with medical conditions that suggested they would not survive for a year, “we took all comers, with multiple illnesses and multiple medications–the real world,” Dr. Rowan said.

The patients were titrated to the target doses: 600 mg for carbamazepine, 1,500 mg for gabapentin, and 150 mg for lamotrigine. Clinicians had the flexibility to titrate further for tolerability, and after 12 months the mean doses were 582 mg for carbamazepine, 1,614 mg for gabapentin, and 152 mg for lamotrigine. “It was very much like office practice,” he said.

At the end of 12 months, “carbamazepine had significantly more side effects than lamotrigine or gabapentin,” which led to earlier termination of therapy, according to Dr. Rowan.

In the nursing home world, he added, adverse side effects and drug interactions, which are often promptly noted and reported in younger epilepsy patients, may be unnoticed or underreported among the elderly.

Of the 197 original carbamazepine patients, 72 finished the study (37%). That compared with 95 of 193 gabapentin patients (49%) and 114 of 197 patients in the lamotrigine arm (58%).

Among the neurologic side effects, carbamazepine led to sedation for 51% and cognitive symptoms for 32%. In the gabapentin arm, 46% of patients reported sedation and 29% had cognitive symptoms. Of lamotrigine patients, 40% reported sedation and 23% cognitive symptoms.

BOSTON – A Veterans Affairs cooperative study of epilepsy in the elderly has found that two newer agents are as effective as carbamazepine at controlling seizures but are far less likely to cause unpleasant side effects in this age group than the old standby antiepileptic agent.

The newer antiepileptic drugs (AEDs), gabapentin (Neurontin) and lamotrigine (Lamictal), were matched against the enzyme inducer, carbamazepine, in an 18-center randomized double-blind study of 593 patients that lasted 1 year, said A. James Rowan, M.D., a professor of neurology at Mount Sinai School of Medicine, New York.

Of the two newer drugs, lamotrigine was significantly superior to gabapentin in terms of patient retention over the length of the study. Neither of the newer agents was significantly better than carbamazepine in preventing seizures, said Dr. Rowan, who was codirector of the VA study.

The trial also found that optimal doses of AEDs may be lower in elderly patients, he reported at a meeting on epilepsy in the elderly sponsored by Boston University. The mean plasma levels of all three drugs were low “but that seems to be enough for this population,” he said.

The patients were 60 years or older (mean age 72.8 years) with a history of one or more seizures and no previous AED therapy, or inadequate therapy. Aside from patients with medical conditions that suggested they would not survive for a year, “we took all comers, with multiple illnesses and multiple medications–the real world,” Dr. Rowan said.

The patients were titrated to the target doses: 600 mg for carbamazepine, 1,500 mg for gabapentin, and 150 mg for lamotrigine. Clinicians had the flexibility to titrate further for tolerability, and after 12 months the mean doses were 582 mg for carbamazepine, 1,614 mg for gabapentin, and 152 mg for lamotrigine. “It was very much like office practice,” he said.

At the end of 12 months, “carbamazepine had significantly more side effects than lamotrigine or gabapentin,” which led to earlier termination of therapy, according to Dr. Rowan.

In the nursing home world, he added, adverse side effects and drug interactions, which are often promptly noted and reported in younger epilepsy patients, may be unnoticed or underreported among the elderly.

Of the 197 original carbamazepine patients, 72 finished the study (37%). That compared with 95 of 193 gabapentin patients (49%) and 114 of 197 patients in the lamotrigine arm (58%).

Among the neurologic side effects, carbamazepine led to sedation for 51% and cognitive symptoms for 32%. In the gabapentin arm, 46% of patients reported sedation and 29% had cognitive symptoms. Of lamotrigine patients, 40% reported sedation and 23% cognitive symptoms.

BOSTON – Epilepsy in the elderly often presents as complex partial seizures that can resemble sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York.

By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said.

Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something did not fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postictal state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

BOSTON – Epilepsy in the elderly often presents as complex partial seizures that can resemble sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York.

By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said.

Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something did not fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postictal state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

BOSTON – Epilepsy in the elderly often presents as complex partial seizures that can resemble sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York.

By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said.

Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something did not fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postictal state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

BOSTON — Keep the risk of osteoporosis and osteopenia in mind when elderly patients are being treated even with the newer antiepileptic drugs, Georgia D. Montouris, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

While drug-to-drug interactions are less common with newer antiepileptic drugs (AEDs), there are no data suggesting they pose less of an osteoporosis risk than the earlier P450 enzyme-inducing versions do.

The diagnosis of new-onset seizures is made in an estimated 68,000 patients over age 60 every year in the United States, said Dr. Montouris, a neurologist at Boston University. All of these patients are at risk for osteoporosis.

“The fastest-growing population with new-onset seizures is over the age of 60, a large population that is in the prime years to develop osteoporosis,” she said.

Dr. Montouris reported that she usually starts elderly patients with new-onset seizures on one of the newer AEDs that don't induce enzymes, to avoid drug-to-drug interactions and liver metabolism.

All of the older P450 enzyme-inducing drugs—carbamazepine, phenytoin, primidone, and phenobarbital—metabolize through the cytochrome P450 system. Phenobarbital, primidone, and phenytoin are most commonly associated with altered bone disease and decreased bone density, said Dr. Montouris. There are conflicting results for carbamazepine.

Lacking data on the effect of newer drugs on bone health, Dr. Montouris said she prefers not to switch older patients with epilepsy to newer AEDs when the older drugs have controlled their seizures for many years. In addition, there is no evidence to support withdrawal of the enzyme-inducing antiepileptic medication to reverse the osteoporotic condition.

The newer drugs, indicated as add-on agents for refractory seizures, include gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine hydrochloride, topiramate, and zonisamide. Oxcarbazepine is approved for monotherapy, lamtorigine is approved for conversion to monotherapy, and topiramate is under Food and Drug Administration evaluation for use in monotherapy. No information is available yet on the effect of these agents on bone health, she added.

“I feel it is more appropriate to keep them on a regimen that works and treat the bone health issues, than risk exacerbating the epilepsy and not improving bone health.”

Seizures in this age group present most often as confusion and mental status changes, putting the patients at risk for falls.

Dr. Montouris said she tries to correct a patient's vitamin D deficiency or insufficiency. She usually prescribes, as preventatives, supplementation with 200 IU of vitamin D twice a day, along with at least 500-600 mg (or more depending on age) of calcium twice per day. If signs of osteoporosis or osteopenia are present, she refers the patient to either an endocrinologist or a rheumatologist for assessment and treatment. She prescribes a calcium-containing diet, weight-bearing exercise, and exposure to sunlight.

A vitamin D deficiency can lead to defects in calcium absorption and sometimes secondary hyperparathyroidism. “It's reported that carbamazepine and phenytoin can affect osteoblast formation,” she said. “Phenytoin can actually reduce the intestinal calcium absorption as well.” In epileptic patients taking AEDs, osteoporosis may occur as a result of the medication and can lead to fractures of the hip and spine. “A tonic-clonic seizure is known to cause thoracic spine fractures,” Dr. Montouris said.

She sends epileptic patients taking AEDs to be tested for baseline levels of 25-hydroxyvitamin D and parathyroid hormone and for a dual-photon absorptiometry scan.

The tests can be repeated 1-2 years later if normal or, if not, the patient should be treated or referred.

BOSTON — Keep the risk of osteoporosis and osteopenia in mind when elderly patients are being treated even with the newer antiepileptic drugs, Georgia D. Montouris, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

While drug-to-drug interactions are less common with newer antiepileptic drugs (AEDs), there are no data suggesting they pose less of an osteoporosis risk than the earlier P450 enzyme-inducing versions do.

The diagnosis of new-onset seizures is made in an estimated 68,000 patients over age 60 every year in the United States, said Dr. Montouris, a neurologist at Boston University. All of these patients are at risk for osteoporosis.

“The fastest-growing population with new-onset seizures is over the age of 60, a large population that is in the prime years to develop osteoporosis,” she said.

Dr. Montouris reported that she usually starts elderly patients with new-onset seizures on one of the newer AEDs that don't induce enzymes, to avoid drug-to-drug interactions and liver metabolism.

All of the older P450 enzyme-inducing drugs—carbamazepine, phenytoin, primidone, and phenobarbital—metabolize through the cytochrome P450 system. Phenobarbital, primidone, and phenytoin are most commonly associated with altered bone disease and decreased bone density, said Dr. Montouris. There are conflicting results for carbamazepine.

Lacking data on the effect of newer drugs on bone health, Dr. Montouris said she prefers not to switch older patients with epilepsy to newer AEDs when the older drugs have controlled their seizures for many years. In addition, there is no evidence to support withdrawal of the enzyme-inducing antiepileptic medication to reverse the osteoporotic condition.

The newer drugs, indicated as add-on agents for refractory seizures, include gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine hydrochloride, topiramate, and zonisamide. Oxcarbazepine is approved for monotherapy, lamtorigine is approved for conversion to monotherapy, and topiramate is under Food and Drug Administration evaluation for use in monotherapy. No information is available yet on the effect of these agents on bone health, she added.

“I feel it is more appropriate to keep them on a regimen that works and treat the bone health issues, than risk exacerbating the epilepsy and not improving bone health.”

Seizures in this age group present most often as confusion and mental status changes, putting the patients at risk for falls.

Dr. Montouris said she tries to correct a patient's vitamin D deficiency or insufficiency. She usually prescribes, as preventatives, supplementation with 200 IU of vitamin D twice a day, along with at least 500-600 mg (or more depending on age) of calcium twice per day. If signs of osteoporosis or osteopenia are present, she refers the patient to either an endocrinologist or a rheumatologist for assessment and treatment. She prescribes a calcium-containing diet, weight-bearing exercise, and exposure to sunlight.

A vitamin D deficiency can lead to defects in calcium absorption and sometimes secondary hyperparathyroidism. “It's reported that carbamazepine and phenytoin can affect osteoblast formation,” she said. “Phenytoin can actually reduce the intestinal calcium absorption as well.” In epileptic patients taking AEDs, osteoporosis may occur as a result of the medication and can lead to fractures of the hip and spine. “A tonic-clonic seizure is known to cause thoracic spine fractures,” Dr. Montouris said.

She sends epileptic patients taking AEDs to be tested for baseline levels of 25-hydroxyvitamin D and parathyroid hormone and for a dual-photon absorptiometry scan.

The tests can be repeated 1-2 years later if normal or, if not, the patient should be treated or referred.

BOSTON — Keep the risk of osteoporosis and osteopenia in mind when elderly patients are being treated even with the newer antiepileptic drugs, Georgia D. Montouris, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

While drug-to-drug interactions are less common with newer antiepileptic drugs (AEDs), there are no data suggesting they pose less of an osteoporosis risk than the earlier P450 enzyme-inducing versions do.

The diagnosis of new-onset seizures is made in an estimated 68,000 patients over age 60 every year in the United States, said Dr. Montouris, a neurologist at Boston University. All of these patients are at risk for osteoporosis.

“The fastest-growing population with new-onset seizures is over the age of 60, a large population that is in the prime years to develop osteoporosis,” she said.

Dr. Montouris reported that she usually starts elderly patients with new-onset seizures on one of the newer AEDs that don't induce enzymes, to avoid drug-to-drug interactions and liver metabolism.

All of the older P450 enzyme-inducing drugs—carbamazepine, phenytoin, primidone, and phenobarbital—metabolize through the cytochrome P450 system. Phenobarbital, primidone, and phenytoin are most commonly associated with altered bone disease and decreased bone density, said Dr. Montouris. There are conflicting results for carbamazepine.

Lacking data on the effect of newer drugs on bone health, Dr. Montouris said she prefers not to switch older patients with epilepsy to newer AEDs when the older drugs have controlled their seizures for many years. In addition, there is no evidence to support withdrawal of the enzyme-inducing antiepileptic medication to reverse the osteoporotic condition.

The newer drugs, indicated as add-on agents for refractory seizures, include gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine hydrochloride, topiramate, and zonisamide. Oxcarbazepine is approved for monotherapy, lamtorigine is approved for conversion to monotherapy, and topiramate is under Food and Drug Administration evaluation for use in monotherapy. No information is available yet on the effect of these agents on bone health, she added.

“I feel it is more appropriate to keep them on a regimen that works and treat the bone health issues, than risk exacerbating the epilepsy and not improving bone health.”

Seizures in this age group present most often as confusion and mental status changes, putting the patients at risk for falls.

Dr. Montouris said she tries to correct a patient's vitamin D deficiency or insufficiency. She usually prescribes, as preventatives, supplementation with 200 IU of vitamin D twice a day, along with at least 500-600 mg (or more depending on age) of calcium twice per day. If signs of osteoporosis or osteopenia are present, she refers the patient to either an endocrinologist or a rheumatologist for assessment and treatment. She prescribes a calcium-containing diet, weight-bearing exercise, and exposure to sunlight.

A vitamin D deficiency can lead to defects in calcium absorption and sometimes secondary hyperparathyroidism. “It's reported that carbamazepine and phenytoin can affect osteoblast formation,” she said. “Phenytoin can actually reduce the intestinal calcium absorption as well.” In epileptic patients taking AEDs, osteoporosis may occur as a result of the medication and can lead to fractures of the hip and spine. “A tonic-clonic seizure is known to cause thoracic spine fractures,” Dr. Montouris said.

She sends epileptic patients taking AEDs to be tested for baseline levels of 25-hydroxyvitamin D and parathyroid hormone and for a dual-photon absorptiometry scan.

The tests can be repeated 1-2 years later if normal or, if not, the patient should be treated or referred.

BOSTON — Epilepsy in the elderly often presents as complex partial seizures that can resemble sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York.

By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said.

Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something didn't fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postictal state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

In most cases, epilepsy in the elderly develops secondary to cerebrovascular disease, said Dr. Rowan, with infarctions accounting for nearly 40% of cases. Multivessel atherosclerosis, cerebral hemorrhage, and subarachnoid hemorrhage make up another 10%. Approximately 30% of cases are of unknown etiology. About 20% of cases were Alzheimer's patients. Drugs such as theophylline lower the seizure threshold.

BOSTON — Epilepsy in the elderly often presents as complex partial seizures that can resemble sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York.

By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said.

Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something didn't fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postictal state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

In most cases, epilepsy in the elderly develops secondary to cerebrovascular disease, said Dr. Rowan, with infarctions accounting for nearly 40% of cases. Multivessel atherosclerosis, cerebral hemorrhage, and subarachnoid hemorrhage make up another 10%. Approximately 30% of cases are of unknown etiology. About 20% of cases were Alzheimer's patients. Drugs such as theophylline lower the seizure threshold.

BOSTON — Epilepsy in the elderly often presents as complex partial seizures that can resemble sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York.

By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said.

Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something didn't fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postictal state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

In most cases, epilepsy in the elderly develops secondary to cerebrovascular disease, said Dr. Rowan, with infarctions accounting for nearly 40% of cases. Multivessel atherosclerosis, cerebral hemorrhage, and subarachnoid hemorrhage make up another 10%. Approximately 30% of cases are of unknown etiology. About 20% of cases were Alzheimer's patients. Drugs such as theophylline lower the seizure threshold.

Every 15 minutes, every day, every tidbit of medical and health news from thousands of the world's newspapers streams by computer into a small room at the Canadian Centre for Emergency Preparedness and Response.

There, seven analysts sift the most relevant of the fresh articles in a ceaseless hunt for hints of a newly emerging disease epidemic or the subtle signs of a spreading bioterror attack.

The worldwide computer network that brings articles from 10,000 public news sources into the nerve center of the Global Public Health Intelligence Network (GPHIN) is ever alert, seeking suggestions of an outbreak of SARS or avian influenza in Asia, a sign of Ebola in Africa or anthrax in Florida, or an indication of excessive radiation anywhere. It looks for the barest hints of an illness no one has seen before. It looks for a known disease to pop up for the first time in a continent where it is unknown—much like the West Nile virus's appearance in North America.

Most of the reports are trashed by the computer out of hand, but a few stay on the system for human analysis. Once or twice a day, the computer spots something so ominous or so important, in the view of the automated program, that it e-mails an alert to the World Health Organization and other GPHIN users, Peter Uhthoff, M.D., said in an interview. He is chief of counterterrorism coordination and health information networks for the Public Health Agency of Canada. GPHIN is one of his networks.

The automatic alerts have usually involved infectious disease but have also focused on chemical spills and radionuclear accidents. As for bioterrorism, Dr. Uhthoff added, “our purpose is to give an advance notice, as early as possible, and get the information as soon as possible to our users. The sooner they know, the better. Whether it is bioterrorism or an accidental nuclear event, it makes little difference, because the initial stages of reaction are the same.”

GPHIN was inaugurated in 1998 to screen the English-language newspaper literature. Last November, GPHIN was relaunched as GPHIN II, and it now sifts reports in Arabic, French, Russian, Spanish, and both simplified and traditional Chinese. Each language has an analyst fluent in the language and familiar with public health issues.

The GPHIN II upgrade was funded with $560,000 Canadian by the Nuclear Threat Initiative, a Washington-based group founded by Sam Nunn, the former U.S. senator, and Ted Turner. It is dedicated to reducing the worldwide threat of nuclear, biological, and chemical weapons.

The articles that are not trashed immediately or that don't merit an automatic e-mail are the ones that need to be reviewed by a language analyst for public health implications. The analyst also edits the computer's translation to English, going back to the source language if necessary; each sees about 200 articles a day, Dr. Uhthoff said.

Articles that pass muster are retained after editing on the GPHIN system and passed on to the GPHIN subscribers, such as the WHO and the U.S. Centers for Disease Control and Prevention.

Some reports might be of local interest with national implications; the arrival of West Nile virus in New York City would have been such a story. Others could have global implications, such as a worsening or spread of the avian flu outbreak in Asia.

U.S. reports with immediate patient implications are relayed to primary care physicians in the standard way, by state public health authorities. Yet with its active surveillance, GPHIN II allows authorities to rapidly connect the dots of isolated incidents in an outbreak.

Mark Smolinski, M.D., senior program officer of biological programs at the Nuclear Threat Initiative, cited the hantavirus outbreak a few years ago in the southwestern United States as a regional but isolated pattern. “Doctors are going to benefit by better, earlier detection of epidemic disease throughout the world and subsequently getting [the information] to the physician much earlier than if we didn't have such a system in place,” he said.

Every 15 minutes, every day, every tidbit of medical and health news from thousands of the world's newspapers streams by computer into a small room at the Canadian Centre for Emergency Preparedness and Response.

There, seven analysts sift the most relevant of the fresh articles in a ceaseless hunt for hints of a newly emerging disease epidemic or the subtle signs of a spreading bioterror attack.

The worldwide computer network that brings articles from 10,000 public news sources into the nerve center of the Global Public Health Intelligence Network (GPHIN) is ever alert, seeking suggestions of an outbreak of SARS or avian influenza in Asia, a sign of Ebola in Africa or anthrax in Florida, or an indication of excessive radiation anywhere. It looks for the barest hints of an illness no one has seen before. It looks for a known disease to pop up for the first time in a continent where it is unknown—much like the West Nile virus's appearance in North America.

Most of the reports are trashed by the computer out of hand, but a few stay on the system for human analysis. Once or twice a day, the computer spots something so ominous or so important, in the view of the automated program, that it e-mails an alert to the World Health Organization and other GPHIN users, Peter Uhthoff, M.D., said in an interview. He is chief of counterterrorism coordination and health information networks for the Public Health Agency of Canada. GPHIN is one of his networks.

The automatic alerts have usually involved infectious disease but have also focused on chemical spills and radionuclear accidents. As for bioterrorism, Dr. Uhthoff added, “our purpose is to give an advance notice, as early as possible, and get the information as soon as possible to our users. The sooner they know, the better. Whether it is bioterrorism or an accidental nuclear event, it makes little difference, because the initial stages of reaction are the same.”

GPHIN was inaugurated in 1998 to screen the English-language newspaper literature. Last November, GPHIN was relaunched as GPHIN II, and it now sifts reports in Arabic, French, Russian, Spanish, and both simplified and traditional Chinese. Each language has an analyst fluent in the language and familiar with public health issues.

The GPHIN II upgrade was funded with $560,000 Canadian by the Nuclear Threat Initiative, a Washington-based group founded by Sam Nunn, the former U.S. senator, and Ted Turner. It is dedicated to reducing the worldwide threat of nuclear, biological, and chemical weapons.

The articles that are not trashed immediately or that don't merit an automatic e-mail are the ones that need to be reviewed by a language analyst for public health implications. The analyst also edits the computer's translation to English, going back to the source language if necessary; each sees about 200 articles a day, Dr. Uhthoff said.

Articles that pass muster are retained after editing on the GPHIN system and passed on to the GPHIN subscribers, such as the WHO and the U.S. Centers for Disease Control and Prevention.

Some reports might be of local interest with national implications; the arrival of West Nile virus in New York City would have been such a story. Others could have global implications, such as a worsening or spread of the avian flu outbreak in Asia.

U.S. reports with immediate patient implications are relayed to primary care physicians in the standard way, by state public health authorities. Yet with its active surveillance, GPHIN II allows authorities to rapidly connect the dots of isolated incidents in an outbreak.

Mark Smolinski, M.D., senior program officer of biological programs at the Nuclear Threat Initiative, cited the hantavirus outbreak a few years ago in the southwestern United States as a regional but isolated pattern. “Doctors are going to benefit by better, earlier detection of epidemic disease throughout the world and subsequently getting [the information] to the physician much earlier than if we didn't have such a system in place,” he said.

Every 15 minutes, every day, every tidbit of medical and health news from thousands of the world's newspapers streams by computer into a small room at the Canadian Centre for Emergency Preparedness and Response.

There, seven analysts sift the most relevant of the fresh articles in a ceaseless hunt for hints of a newly emerging disease epidemic or the subtle signs of a spreading bioterror attack.

The worldwide computer network that brings articles from 10,000 public news sources into the nerve center of the Global Public Health Intelligence Network (GPHIN) is ever alert, seeking suggestions of an outbreak of SARS or avian influenza in Asia, a sign of Ebola in Africa or anthrax in Florida, or an indication of excessive radiation anywhere. It looks for the barest hints of an illness no one has seen before. It looks for a known disease to pop up for the first time in a continent where it is unknown—much like the West Nile virus's appearance in North America.

Most of the reports are trashed by the computer out of hand, but a few stay on the system for human analysis. Once or twice a day, the computer spots something so ominous or so important, in the view of the automated program, that it e-mails an alert to the World Health Organization and other GPHIN users, Peter Uhthoff, M.D., said in an interview. He is chief of counterterrorism coordination and health information networks for the Public Health Agency of Canada. GPHIN is one of his networks.

The automatic alerts have usually involved infectious disease but have also focused on chemical spills and radionuclear accidents. As for bioterrorism, Dr. Uhthoff added, “our purpose is to give an advance notice, as early as possible, and get the information as soon as possible to our users. The sooner they know, the better. Whether it is bioterrorism or an accidental nuclear event, it makes little difference, because the initial stages of reaction are the same.”

GPHIN was inaugurated in 1998 to screen the English-language newspaper literature. Last November, GPHIN was relaunched as GPHIN II, and it now sifts reports in Arabic, French, Russian, Spanish, and both simplified and traditional Chinese. Each language has an analyst fluent in the language and familiar with public health issues.

The GPHIN II upgrade was funded with $560,000 Canadian by the Nuclear Threat Initiative, a Washington-based group founded by Sam Nunn, the former U.S. senator, and Ted Turner. It is dedicated to reducing the worldwide threat of nuclear, biological, and chemical weapons.

The articles that are not trashed immediately or that don't merit an automatic e-mail are the ones that need to be reviewed by a language analyst for public health implications. The analyst also edits the computer's translation to English, going back to the source language if necessary; each sees about 200 articles a day, Dr. Uhthoff said.

Articles that pass muster are retained after editing on the GPHIN system and passed on to the GPHIN subscribers, such as the WHO and the U.S. Centers for Disease Control and Prevention.

Some reports might be of local interest with national implications; the arrival of West Nile virus in New York City would have been such a story. Others could have global implications, such as a worsening or spread of the avian flu outbreak in Asia.

U.S. reports with immediate patient implications are relayed to primary care physicians in the standard way, by state public health authorities. Yet with its active surveillance, GPHIN II allows authorities to rapidly connect the dots of isolated incidents in an outbreak.

Mark Smolinski, M.D., senior program officer of biological programs at the Nuclear Threat Initiative, cited the hantavirus outbreak a few years ago in the southwestern United States as a regional but isolated pattern. “Doctors are going to benefit by better, earlier detection of epidemic disease throughout the world and subsequently getting [the information] to the physician much earlier than if we didn't have such a system in place,” he said.

Every 15 minutes, every day, around the clock, every tidbit of medical and health news from thousands of the world's newspapers streams by computer into a small room at the Canadian Centre for Emergency Preparedness and Response. There, seven analysts sift the most relevant of the fresh articles in a ceaseless hunt for hints of a newly emerging disease epidemic or the subtle signs of a spreading bioterror attack.

The analysts work a standard 8-hour day, but the worldwide computer network that brings articles from 10,000 public news sources into the nerve center of the Global Public Health Intelligence Network (GPHIN) is ever on the alert. It scans the Web's news sites every 15 minutes, seeking suggestions of an outbreak of SARS or avian influenza in Asia, a sign of Ebola in Africa or anthrax in Florida, or an indication of excessive radiation anywhere. It looks for the barest hints in the news stories of an illness no one has ever seen before. It looks for a disease that is known but pops up for the first time in a continent where it is unknown—much like the West Nile virus's appearance in North America.

Most of the reports are trashed by the computer out of hand. A relatively small percentage stay on the system for human analysis. But once or twice a day, the computer spots something so ominous or so important, in the view of the automated program, that it generates an alert and automatically sends it by e-mail to the World Health Organization and other GPHIN users, said Peter Uhthoff, M.D., in an interview. He is chief of counterterrorism coordination and health information networks for the Public Health Agency of Canada. GPHIN is one of his networks.

Automatic alerts have usually involved infectious disease but have also focused on chemical spills and radionuclear accidents. As for bioterrorism, Dr. Uhthoff added, “our purpose is to give an advance notice, as early as possible, and get the information as soon as possible to our users. The sooner they know, the better. Whether it is bioterrorism or an accidental nuclear event, it makes little difference, because the initial stages of reaction are the same.”

GPHIN was inaugurated in 1998 to screen the English-language newspaper literature. A week before the U.S. Thanksgiving last year, that changed. Now GPHIN has been relaunched as GPHIN II, and it includes several of the world's major languages. So instead of just English-language newspapers, the nerve center is also sifting reports in Arabic, French, Russian, Spanish, and both simplified and traditional Chinese. Each language has an analyst fluent in the language and familiar with public health issues.

The GPHIN II upgrade was funded with $560,000 Canadian by the Nuclear Threat Initiative, a Washington-based group founded by Sam Nunn, the former U.S. senator, and Ted Turner. It is dedicated to reducing the worldwide threat of nuclear, biological, and chemical weapons.

The articles that are not trashed immediately or that don't merit an automatic e-mail are the ones that need to be reviewed by a language analyst for public health implications. The analyst also edits the computer's translation to English, going back to the source language if necessary; each sees about 200 articles a day, Dr. Uhthoff said.

Articles that pass muster are retained after editing on the GPHIN system and passed on to the GPHIN subscribers, such as the WHO and the U.S. Centers for Disease Control and Prevention.

Some reports might be of local interest with national implications; the arrival of West Nile virus in New York City would have been such a story. Others could have global implications, such as a worsening or spread of the avian flu outbreak in Asia.

Reports with immediate patient implications in the United States are relayed to physicians in the standard way, by state public health authorities. With its active surveillance, GPHIN II allows those authorities to rapidly connect the dots of isolated incidents in an outbreak.

Every 15 minutes, every day, around the clock, every tidbit of medical and health news from thousands of the world's newspapers streams by computer into a small room at the Canadian Centre for Emergency Preparedness and Response. There, seven analysts sift the most relevant of the fresh articles in a ceaseless hunt for hints of a newly emerging disease epidemic or the subtle signs of a spreading bioterror attack.

The analysts work a standard 8-hour day, but the worldwide computer network that brings articles from 10,000 public news sources into the nerve center of the Global Public Health Intelligence Network (GPHIN) is ever on the alert. It scans the Web's news sites every 15 minutes, seeking suggestions of an outbreak of SARS or avian influenza in Asia, a sign of Ebola in Africa or anthrax in Florida, or an indication of excessive radiation anywhere. It looks for the barest hints in the news stories of an illness no one has ever seen before. It looks for a disease that is known but pops up for the first time in a continent where it is unknown—much like the West Nile virus's appearance in North America.

Most of the reports are trashed by the computer out of hand. A relatively small percentage stay on the system for human analysis. But once or twice a day, the computer spots something so ominous or so important, in the view of the automated program, that it generates an alert and automatically sends it by e-mail to the World Health Organization and other GPHIN users, said Peter Uhthoff, M.D., in an interview. He is chief of counterterrorism coordination and health information networks for the Public Health Agency of Canada. GPHIN is one of his networks.

Automatic alerts have usually involved infectious disease but have also focused on chemical spills and radionuclear accidents. As for bioterrorism, Dr. Uhthoff added, “our purpose is to give an advance notice, as early as possible, and get the information as soon as possible to our users. The sooner they know, the better. Whether it is bioterrorism or an accidental nuclear event, it makes little difference, because the initial stages of reaction are the same.”

GPHIN was inaugurated in 1998 to screen the English-language newspaper literature. A week before the U.S. Thanksgiving last year, that changed. Now GPHIN has been relaunched as GPHIN II, and it includes several of the world's major languages. So instead of just English-language newspapers, the nerve center is also sifting reports in Arabic, French, Russian, Spanish, and both simplified and traditional Chinese. Each language has an analyst fluent in the language and familiar with public health issues.

The GPHIN II upgrade was funded with $560,000 Canadian by the Nuclear Threat Initiative, a Washington-based group founded by Sam Nunn, the former U.S. senator, and Ted Turner. It is dedicated to reducing the worldwide threat of nuclear, biological, and chemical weapons.

The articles that are not trashed immediately or that don't merit an automatic e-mail are the ones that need to be reviewed by a language analyst for public health implications. The analyst also edits the computer's translation to English, going back to the source language if necessary; each sees about 200 articles a day, Dr. Uhthoff said.

Articles that pass muster are retained after editing on the GPHIN system and passed on to the GPHIN subscribers, such as the WHO and the U.S. Centers for Disease Control and Prevention.

Some reports might be of local interest with national implications; the arrival of West Nile virus in New York City would have been such a story. Others could have global implications, such as a worsening or spread of the avian flu outbreak in Asia.

Reports with immediate patient implications in the United States are relayed to physicians in the standard way, by state public health authorities. With its active surveillance, GPHIN II allows those authorities to rapidly connect the dots of isolated incidents in an outbreak.

Every 15 minutes, every day, around the clock, every tidbit of medical and health news from thousands of the world's newspapers streams by computer into a small room at the Canadian Centre for Emergency Preparedness and Response. There, seven analysts sift the most relevant of the fresh articles in a ceaseless hunt for hints of a newly emerging disease epidemic or the subtle signs of a spreading bioterror attack.

The analysts work a standard 8-hour day, but the worldwide computer network that brings articles from 10,000 public news sources into the nerve center of the Global Public Health Intelligence Network (GPHIN) is ever on the alert. It scans the Web's news sites every 15 minutes, seeking suggestions of an outbreak of SARS or avian influenza in Asia, a sign of Ebola in Africa or anthrax in Florida, or an indication of excessive radiation anywhere. It looks for the barest hints in the news stories of an illness no one has ever seen before. It looks for a disease that is known but pops up for the first time in a continent where it is unknown—much like the West Nile virus's appearance in North America.

Most of the reports are trashed by the computer out of hand. A relatively small percentage stay on the system for human analysis. But once or twice a day, the computer spots something so ominous or so important, in the view of the automated program, that it generates an alert and automatically sends it by e-mail to the World Health Organization and other GPHIN users, said Peter Uhthoff, M.D., in an interview. He is chief of counterterrorism coordination and health information networks for the Public Health Agency of Canada. GPHIN is one of his networks.

Automatic alerts have usually involved infectious disease but have also focused on chemical spills and radionuclear accidents. As for bioterrorism, Dr. Uhthoff added, “our purpose is to give an advance notice, as early as possible, and get the information as soon as possible to our users. The sooner they know, the better. Whether it is bioterrorism or an accidental nuclear event, it makes little difference, because the initial stages of reaction are the same.”

GPHIN was inaugurated in 1998 to screen the English-language newspaper literature. A week before the U.S. Thanksgiving last year, that changed. Now GPHIN has been relaunched as GPHIN II, and it includes several of the world's major languages. So instead of just English-language newspapers, the nerve center is also sifting reports in Arabic, French, Russian, Spanish, and both simplified and traditional Chinese. Each language has an analyst fluent in the language and familiar with public health issues.

The GPHIN II upgrade was funded with $560,000 Canadian by the Nuclear Threat Initiative, a Washington-based group founded by Sam Nunn, the former U.S. senator, and Ted Turner. It is dedicated to reducing the worldwide threat of nuclear, biological, and chemical weapons.

The articles that are not trashed immediately or that don't merit an automatic e-mail are the ones that need to be reviewed by a language analyst for public health implications. The analyst also edits the computer's translation to English, going back to the source language if necessary; each sees about 200 articles a day, Dr. Uhthoff said.

Articles that pass muster are retained after editing on the GPHIN system and passed on to the GPHIN subscribers, such as the WHO and the U.S. Centers for Disease Control and Prevention.

Some reports might be of local interest with national implications; the arrival of West Nile virus in New York City would have been such a story. Others could have global implications, such as a worsening or spread of the avian flu outbreak in Asia.

Reports with immediate patient implications in the United States are relayed to physicians in the standard way, by state public health authorities. With its active surveillance, GPHIN II allows those authorities to rapidly connect the dots of isolated incidents in an outbreak.

BOSTON — A Veterans Affairs cooperative study of epilepsy in the elderly has found that two newer agents are as effective as carbamazepine at controlling seizures but are far less likely to cause unpleasant side effects.

The newer antiepileptic drugs (AEDs), gabapentin (Neurontin) and lamotrigine (Lamictal), were matched against carbamazepine in a 1-year, 18-center randomized double-blind study of 593 patients, said A. James Rowan, M.D., professor of neurology at Mount Sinai School of Medicine, New York.

Lamotrigine was significantly superior to gabapentin from the standpoint of patient retention over the length of the study. Neither of the newer agents was significantly better than carbamazepine in preventing seizures, said Dr. Rowan, who was codirector of the VA study.

Optimal doses of AEDs may be lower in the elderly patients, he reported at a meeting on epilepsy in the elderly sponsored by Boston University. The mean plasma levels of all three drugs were low “but that seems to be enough for this population,” he said.

The patients were 60 years or older (mean age 72.8 years) with a history of one or more seizures and no previous AED therapy, or inadequate therapy.

The patients were titrated to the target doses, 600 mg for carbamazepine, 1,500 mg for gabapentin, and 150 mg for lamotrigine. Clinicians had the flexibility to titrate further for tolerability, and after 12 months the mean doses were 582 mg for carbamazepine, 1,614 mg for gabapentin, and 152 mg for lamotrigine.

At the end of 12 months, “carbamazepine had significantly more side effects than lamotrigine or gabapentin,” which led to earlier termination of therapy, according to Dr. Rowan. In the nursing home world, he added, adverse side effects and drug interactions, which are often promptly noted and reported in younger epilepsy patients, may be unnoticed or underreported among the elderly.

Of the 197 original carbamazepine patients, 72 finished the study (37%). That compared with 95 of 193 gabapentin patients (49%) and 114 of 197 patients in the lamotrigine arm (58%).

Among the neurologic side effects, carbamazepine led to sedation for 51%, cognitive symptoms for 32%, dizziness for 32%, mood alteration for 4%, and gait disturbance for 29%. By contrast, in the gabapentin arm 46% of patients reported sedation, 29% with cognitive symptoms, 28% with dizziness, 26% with mood alterations, and 29% with gait disturbances. In the lamotrigine arm, 40% reported sedation, 23% cognitive symptoms, 27% dizziness, 30% mood alteration, and 28% gait disturbance.

BOSTON — A Veterans Affairs cooperative study of epilepsy in the elderly has found that two newer agents are as effective as carbamazepine at controlling seizures but are far less likely to cause unpleasant side effects.

The newer antiepileptic drugs (AEDs), gabapentin (Neurontin) and lamotrigine (Lamictal), were matched against carbamazepine in a 1-year, 18-center randomized double-blind study of 593 patients, said A. James Rowan, M.D., professor of neurology at Mount Sinai School of Medicine, New York.

Lamotrigine was significantly superior to gabapentin from the standpoint of patient retention over the length of the study. Neither of the newer agents was significantly better than carbamazepine in preventing seizures, said Dr. Rowan, who was codirector of the VA study.

Optimal doses of AEDs may be lower in the elderly patients, he reported at a meeting on epilepsy in the elderly sponsored by Boston University. The mean plasma levels of all three drugs were low “but that seems to be enough for this population,” he said.

The patients were 60 years or older (mean age 72.8 years) with a history of one or more seizures and no previous AED therapy, or inadequate therapy.

The patients were titrated to the target doses, 600 mg for carbamazepine, 1,500 mg for gabapentin, and 150 mg for lamotrigine. Clinicians had the flexibility to titrate further for tolerability, and after 12 months the mean doses were 582 mg for carbamazepine, 1,614 mg for gabapentin, and 152 mg for lamotrigine.

At the end of 12 months, “carbamazepine had significantly more side effects than lamotrigine or gabapentin,” which led to earlier termination of therapy, according to Dr. Rowan. In the nursing home world, he added, adverse side effects and drug interactions, which are often promptly noted and reported in younger epilepsy patients, may be unnoticed or underreported among the elderly.

Of the 197 original carbamazepine patients, 72 finished the study (37%). That compared with 95 of 193 gabapentin patients (49%) and 114 of 197 patients in the lamotrigine arm (58%).

Among the neurologic side effects, carbamazepine led to sedation for 51%, cognitive symptoms for 32%, dizziness for 32%, mood alteration for 4%, and gait disturbance for 29%. By contrast, in the gabapentin arm 46% of patients reported sedation, 29% with cognitive symptoms, 28% with dizziness, 26% with mood alterations, and 29% with gait disturbances. In the lamotrigine arm, 40% reported sedation, 23% cognitive symptoms, 27% dizziness, 30% mood alteration, and 28% gait disturbance.

BOSTON — A Veterans Affairs cooperative study of epilepsy in the elderly has found that two newer agents are as effective as carbamazepine at controlling seizures but are far less likely to cause unpleasant side effects.

The newer antiepileptic drugs (AEDs), gabapentin (Neurontin) and lamotrigine (Lamictal), were matched against carbamazepine in a 1-year, 18-center randomized double-blind study of 593 patients, said A. James Rowan, M.D., professor of neurology at Mount Sinai School of Medicine, New York.

Lamotrigine was significantly superior to gabapentin from the standpoint of patient retention over the length of the study. Neither of the newer agents was significantly better than carbamazepine in preventing seizures, said Dr. Rowan, who was codirector of the VA study.

Optimal doses of AEDs may be lower in the elderly patients, he reported at a meeting on epilepsy in the elderly sponsored by Boston University. The mean plasma levels of all three drugs were low “but that seems to be enough for this population,” he said.

The patients were 60 years or older (mean age 72.8 years) with a history of one or more seizures and no previous AED therapy, or inadequate therapy.

The patients were titrated to the target doses, 600 mg for carbamazepine, 1,500 mg for gabapentin, and 150 mg for lamotrigine. Clinicians had the flexibility to titrate further for tolerability, and after 12 months the mean doses were 582 mg for carbamazepine, 1,614 mg for gabapentin, and 152 mg for lamotrigine.

At the end of 12 months, “carbamazepine had significantly more side effects than lamotrigine or gabapentin,” which led to earlier termination of therapy, according to Dr. Rowan. In the nursing home world, he added, adverse side effects and drug interactions, which are often promptly noted and reported in younger epilepsy patients, may be unnoticed or underreported among the elderly.

Of the 197 original carbamazepine patients, 72 finished the study (37%). That compared with 95 of 193 gabapentin patients (49%) and 114 of 197 patients in the lamotrigine arm (58%).

Among the neurologic side effects, carbamazepine led to sedation for 51%, cognitive symptoms for 32%, dizziness for 32%, mood alteration for 4%, and gait disturbance for 29%. By contrast, in the gabapentin arm 46% of patients reported sedation, 29% with cognitive symptoms, 28% with dizziness, 26% with mood alterations, and 29% with gait disturbances. In the lamotrigine arm, 40% reported sedation, 23% cognitive symptoms, 27% dizziness, 30% mood alteration, and 28% gait disturbance.

BOSTON — Antiepileptic drugs can affect elderly patients quite differently from the ways they do a younger population, Thomas R. Browne, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

Pharmacokinetic principles can shift from the center in a variety of ways for older patients, who have double the rate of partial seizures as middle-aged patients, said Dr. Browne, professor of neurology at Boston University.

With age, body fat content increases, while liver and kidney function decrease. The result may be a decrease in volume of distribution with a corresponding increase in plasma concentration with antiepileptic drugs (AEDs) that are water soluble, such as levetiracetam.

Conversely, with drugs that are lipid soluble, such as phenytoin and carbamazepine, there may be an increase in volume of distribution with a corresponding decrease in plasma concentration.

Also, protein binding decreases, which can lead to a higher free level of drugs. Oxidative metabolism and renal excretion may decrease, leading to increased concentration.

Finally, Dr. Browne said, there are many drug-drug interactions that can either increase or decrease the blood level of the AED, resulting in more toxicity for a given blood level of the AED. Following pharmacokinetic principles, the drug of choice for the elderly would have minimum protein binding, minimal oxydative metabolism, minimal renal excretion or predictable renal effects, and minimal toxicity, especially neurotoxicity, according to Dr. Browne.

There are several neurotransmitter changes with age: some that increase the seizure threshold and some that decrease it. “But there is no overriding picture here,” he said. “The changes in epilepsy in the old are not readily explained by an increase in GABA [gamma-aminobutyric acid] or an increase in AMPA [alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid],” according to Dr. Browne.

Changes in the absorption processes in older patients may occur but with no consistent pattern, Dr. Browne said. They include pH, gastric motility, decreased transit times that enhance absorption, and a decrease in blood flow.

When elderly patients are absorbing drugs by nasogastric tube, there is decreased motility and adsorption of lipid-soluble drugs. One way to solve this is to use a drug in suspension or solution, particularly levetiracetam. But, the absorption may increase so much if they are switched from phenytoin that clinicians have to be alert to toxicity, he added. Among elderly patients, Dr. Browne said, total body water and lean body mass both decrease, whereas fat mass increases.

So the volume of distribution of water-soluble drugs decreases, and the volume of distribution of lipid-soluble drugs increases. Clinicians can remember that the plasma concentration of a drug is equal to the dose divided by the volume of distribution.

Increased protein binding is one reason why patients may experience toxicity on so-called therapeutic levels of drugs, he said.

“The plasma albumin concentration—albumin is the protein that binds drugs—decreases by 5%-10%. Because there is less plasma binding, there is a higher free level of drug.”

In the liver, there is a 40%-50% decrease in blood flow between young adults and the elderly.

There is also a 15%-20% decrease in oxidative metabolism between young and old adults in drugs that use the cytochrome P450 system for oxidization and inactivation.

“Unfortunately, there is no magic formula, no test for exactly how much P450 is reduced, unlike creatinine clearance,” Dr. Browne said.

AED/Drug Interactions Pose Risk in the Aged

Drug interactions are common with antiepileptic drugs taken by elderly patients, and these patients take a lot of medicine, Thomas R. Browne, M.D., said at the meeting.

For instance, some of the drugs will adhere to antacids and will decrease their concentrations. Aspirin will interfere with the protein-binding sites of phenytoin and depakote, decreasing the total concentration while the free level stays the same.

Theophylline, a treatment for chronic asthma, blocks the GABA receptor and can cause seizures. In persons who have seizures, this will lower the seizure threshold, but patients who don't have seizures may develop what appear to be new-onset seizures if they have toxic levels of theophylline.

Phenytoin should be avoided in patients on warfarin. Seizures in the elderly are often due to strokes, and people who have strokes may be taking warfarin. Yet warfarin and phenytoin can have a biphasic interaction, said Dr. Browne, professor of neurology at Boston University.

Gabapentin and levetiracetam, both excreted by the kidney, are better choices for new-onset patients because they don't affect warfarin.

BOSTON — Antiepileptic drugs can affect elderly patients quite differently from the ways they do a younger population, Thomas R. Browne, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

Pharmacokinetic principles can shift from the center in a variety of ways for older patients, who have double the rate of partial seizures as middle-aged patients, said Dr. Browne, professor of neurology at Boston University.

With age, body fat content increases, while liver and kidney function decrease. The result may be a decrease in volume of distribution with a corresponding increase in plasma concentration with antiepileptic drugs (AEDs) that are water soluble, such as levetiracetam.

Conversely, with drugs that are lipid soluble, such as phenytoin and carbamazepine, there may be an increase in volume of distribution with a corresponding decrease in plasma concentration.

Also, protein binding decreases, which can lead to a higher free level of drugs. Oxidative metabolism and renal excretion may decrease, leading to increased concentration.

Finally, Dr. Browne said, there are many drug-drug interactions that can either increase or decrease the blood level of the AED, resulting in more toxicity for a given blood level of the AED. Following pharmacokinetic principles, the drug of choice for the elderly would have minimum protein binding, minimal oxydative metabolism, minimal renal excretion or predictable renal effects, and minimal toxicity, especially neurotoxicity, according to Dr. Browne.

There are several neurotransmitter changes with age: some that increase the seizure threshold and some that decrease it. “But there is no overriding picture here,” he said. “The changes in epilepsy in the old are not readily explained by an increase in GABA [gamma-aminobutyric acid] or an increase in AMPA [alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid],” according to Dr. Browne.

Changes in the absorption processes in older patients may occur but with no consistent pattern, Dr. Browne said. They include pH, gastric motility, decreased transit times that enhance absorption, and a decrease in blood flow.

When elderly patients are absorbing drugs by nasogastric tube, there is decreased motility and adsorption of lipid-soluble drugs. One way to solve this is to use a drug in suspension or solution, particularly levetiracetam. But, the absorption may increase so much if they are switched from phenytoin that clinicians have to be alert to toxicity, he added. Among elderly patients, Dr. Browne said, total body water and lean body mass both decrease, whereas fat mass increases.

So the volume of distribution of water-soluble drugs decreases, and the volume of distribution of lipid-soluble drugs increases. Clinicians can remember that the plasma concentration of a drug is equal to the dose divided by the volume of distribution.

Increased protein binding is one reason why patients may experience toxicity on so-called therapeutic levels of drugs, he said.

“The plasma albumin concentration—albumin is the protein that binds drugs—decreases by 5%-10%. Because there is less plasma binding, there is a higher free level of drug.”

In the liver, there is a 40%-50% decrease in blood flow between young adults and the elderly.

There is also a 15%-20% decrease in oxidative metabolism between young and old adults in drugs that use the cytochrome P450 system for oxidization and inactivation.

“Unfortunately, there is no magic formula, no test for exactly how much P450 is reduced, unlike creatinine clearance,” Dr. Browne said.

AED/Drug Interactions Pose Risk in the Aged

Drug interactions are common with antiepileptic drugs taken by elderly patients, and these patients take a lot of medicine, Thomas R. Browne, M.D., said at the meeting.

For instance, some of the drugs will adhere to antacids and will decrease their concentrations. Aspirin will interfere with the protein-binding sites of phenytoin and depakote, decreasing the total concentration while the free level stays the same.

Theophylline, a treatment for chronic asthma, blocks the GABA receptor and can cause seizures. In persons who have seizures, this will lower the seizure threshold, but patients who don't have seizures may develop what appear to be new-onset seizures if they have toxic levels of theophylline.

Phenytoin should be avoided in patients on warfarin. Seizures in the elderly are often due to strokes, and people who have strokes may be taking warfarin. Yet warfarin and phenytoin can have a biphasic interaction, said Dr. Browne, professor of neurology at Boston University.

Gabapentin and levetiracetam, both excreted by the kidney, are better choices for new-onset patients because they don't affect warfarin.

BOSTON — Antiepileptic drugs can affect elderly patients quite differently from the ways they do a younger population, Thomas R. Browne, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

Pharmacokinetic principles can shift from the center in a variety of ways for older patients, who have double the rate of partial seizures as middle-aged patients, said Dr. Browne, professor of neurology at Boston University.

With age, body fat content increases, while liver and kidney function decrease. The result may be a decrease in volume of distribution with a corresponding increase in plasma concentration with antiepileptic drugs (AEDs) that are water soluble, such as levetiracetam.

Conversely, with drugs that are lipid soluble, such as phenytoin and carbamazepine, there may be an increase in volume of distribution with a corresponding decrease in plasma concentration.

Also, protein binding decreases, which can lead to a higher free level of drugs. Oxidative metabolism and renal excretion may decrease, leading to increased concentration.

Finally, Dr. Browne said, there are many drug-drug interactions that can either increase or decrease the blood level of the AED, resulting in more toxicity for a given blood level of the AED. Following pharmacokinetic principles, the drug of choice for the elderly would have minimum protein binding, minimal oxydative metabolism, minimal renal excretion or predictable renal effects, and minimal toxicity, especially neurotoxicity, according to Dr. Browne.

There are several neurotransmitter changes with age: some that increase the seizure threshold and some that decrease it. “But there is no overriding picture here,” he said. “The changes in epilepsy in the old are not readily explained by an increase in GABA [gamma-aminobutyric acid] or an increase in AMPA [alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid],” according to Dr. Browne.

Changes in the absorption processes in older patients may occur but with no consistent pattern, Dr. Browne said. They include pH, gastric motility, decreased transit times that enhance absorption, and a decrease in blood flow.

When elderly patients are absorbing drugs by nasogastric tube, there is decreased motility and adsorption of lipid-soluble drugs. One way to solve this is to use a drug in suspension or solution, particularly levetiracetam. But, the absorption may increase so much if they are switched from phenytoin that clinicians have to be alert to toxicity, he added. Among elderly patients, Dr. Browne said, total body water and lean body mass both decrease, whereas fat mass increases.

So the volume of distribution of water-soluble drugs decreases, and the volume of distribution of lipid-soluble drugs increases. Clinicians can remember that the plasma concentration of a drug is equal to the dose divided by the volume of distribution.

Increased protein binding is one reason why patients may experience toxicity on so-called therapeutic levels of drugs, he said.

“The plasma albumin concentration—albumin is the protein that binds drugs—decreases by 5%-10%. Because there is less plasma binding, there is a higher free level of drug.”

In the liver, there is a 40%-50% decrease in blood flow between young adults and the elderly.

There is also a 15%-20% decrease in oxidative metabolism between young and old adults in drugs that use the cytochrome P450 system for oxidization and inactivation.

“Unfortunately, there is no magic formula, no test for exactly how much P450 is reduced, unlike creatinine clearance,” Dr. Browne said.

AED/Drug Interactions Pose Risk in the Aged

Drug interactions are common with antiepileptic drugs taken by elderly patients, and these patients take a lot of medicine, Thomas R. Browne, M.D., said at the meeting.

For instance, some of the drugs will adhere to antacids and will decrease their concentrations. Aspirin will interfere with the protein-binding sites of phenytoin and depakote, decreasing the total concentration while the free level stays the same.

Theophylline, a treatment for chronic asthma, blocks the GABA receptor and can cause seizures. In persons who have seizures, this will lower the seizure threshold, but patients who don't have seizures may develop what appear to be new-onset seizures if they have toxic levels of theophylline.

Phenytoin should be avoided in patients on warfarin. Seizures in the elderly are often due to strokes, and people who have strokes may be taking warfarin. Yet warfarin and phenytoin can have a biphasic interaction, said Dr. Browne, professor of neurology at Boston University.

Gabapentin and levetiracetam, both excreted by the kidney, are better choices for new-onset patients because they don't affect warfarin.

BOSTON — Just as epilepsy is a disease of those at the start of their lives, it can present for the first time in those whose lives are beginning to draw to a close. Unlike the generalized clonic seizures of children, this treatable condition in the elderly is subtle and may be misdiagnosed as dementia or confusion.

In fact, because the presenting feature of new-onset epilepsy in the elderly is complex partial seizures, the clinical picture may resemble that of sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30 years, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York. By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said. Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something did not fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postical state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

In most cases, epilepsy in the elderly develops secondary to cerebrovascular disease, said Dr. Rowan.

Cerebral infarctions account for nearly 40% of cases of new onset epilepsy. Multivessel atherosclerosis, cerebral hemorrhage, and subarachnoid hemorrhage make up another 10%. Approximately 30% of cases are of unknown etiology. About 20% of cases were Alzheimer's patients. Drugs such as theophylline lower the seizure threshold.

BOSTON — Just as epilepsy is a disease of those at the start of their lives, it can present for the first time in those whose lives are beginning to draw to a close. Unlike the generalized clonic seizures of children, this treatable condition in the elderly is subtle and may be misdiagnosed as dementia or confusion.

In fact, because the presenting feature of new-onset epilepsy in the elderly is complex partial seizures, the clinical picture may resemble that of sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30 years, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York. By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said. Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something did not fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postical state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

In most cases, epilepsy in the elderly develops secondary to cerebrovascular disease, said Dr. Rowan.

Cerebral infarctions account for nearly 40% of cases of new onset epilepsy. Multivessel atherosclerosis, cerebral hemorrhage, and subarachnoid hemorrhage make up another 10%. Approximately 30% of cases are of unknown etiology. About 20% of cases were Alzheimer's patients. Drugs such as theophylline lower the seizure threshold.

BOSTON — Just as epilepsy is a disease of those at the start of their lives, it can present for the first time in those whose lives are beginning to draw to a close. Unlike the generalized clonic seizures of children, this treatable condition in the elderly is subtle and may be misdiagnosed as dementia or confusion.

In fact, because the presenting feature of new-onset epilepsy in the elderly is complex partial seizures, the clinical picture may resemble that of sudden-onset dementia, A. James Rowan, M.D., said at a meeting on epilepsy in the elderly sponsored by Boston University.

The incidence of new-onset seizures begins to climb when patients are in their 50s after a decline that begins in childhood and reaches a nadir around age 30 years, said Dr. Rowan, professor of neurology at the Mount Sinai School of Medicine in New York. By age 60, the incidence of epilepsy reaches 40 new cases per 100,000 per year, Dr. Rowan said, citing data from W. Allen Hauser, M.D., professor of neurology and neuroepidemiology at Columbia University, New York. The incidence begins an almost exponential climb to age 75, when it hits 139 new cases per 100,000 per year, which is higher than the incidence of epilepsy in infants and children up to age 3.

“Epilepsy is, in fact, a disease of the very young and the very old,” Dr. Rowan said. Yet epilepsy in elderly patients is often quite different from that in children, who typically have generalized tonic-clonic seizures. In the elderly, complex partial seizures are the norm.

Dr. Rowan described the case of a 72-year-old woman whose treatable epilepsy was misdiagnosed as worsening dementia. She was about to be sent to a nursing home.

The woman was admitted to the hospital for a dementia evaluation. She reported having “fuzzy” periods. Her past medical history was unremarkable. A CT scan showed atrophy. ECG and lab results were negative. But in a neurologic consult, she said the “fuzzy” periods were intermittent. She kept asking, “What am I doing here?”

The neurologist felt that something did not fit, Dr. Rowan said.

A video EEG revealed a complex partial seizure. In the elderly the postictal state following a complex partial seizure may last up to 2 weeks. When she was treated with phenytoin, the symptoms resolved, and she went home. “It was a remarkable turnaround,” he said.

If such patients are recognized as having seizures, they can be treated and may enjoy a vastly improved quality of life. Often, he added, they are misdiagnosed with altered mental status, confusion, dizziness, syncope, memory disturbance, or dementia.

Dr. Rowan noted that 50% of all new-onset seizures occur in patients 60 years or older. Although in younger patients the diagnosis of epilepsy is reserved for those who have had at least two seizures, the diagnosis can be made in the elderly after just one seizure; 90% of elderly patients who have had one seizure will have a second unless they are treated.

Among the other differences between epilepsy in the young and the elderly, he added, is that epilepsy in the elderly, while extremely common, is manifested by a low rate of seizures. Yet in the elderly the postical state after complex partial seizures tends to be prolonged. The period of confusion can last up to 2 weeks, compared with a minute or so in infants and youngsters.

In most cases, epilepsy in the elderly develops secondary to cerebrovascular disease, said Dr. Rowan.

Cerebral infarctions account for nearly 40% of cases of new onset epilepsy. Multivessel atherosclerosis, cerebral hemorrhage, and subarachnoid hemorrhage make up another 10%. Approximately 30% of cases are of unknown etiology. About 20% of cases were Alzheimer's patients. Drugs such as theophylline lower the seizure threshold.