EPIMART: prospective incidence study of epileptic seizures in newly referred patients in a French Carribean island (Martinique)

The epidemiology of epilepsy in older adults: A narrative review by the ILAE Task Force on Epilepsy in the Elderly

In an aging world, it is important to know the burden of epilepsy affecting populations of older persons. We performed a selective review of epidemiological studies that we considered to be most informative, trying to include data from all parts of the world. We emphasized primary reports rather than review articles. We reviewed studies reporting the incidence and prevalence of epilepsy that focused on an older population as well as studies that included a wider age range if older persons were tabulated as a subgroup. There is strong evidence that persons older than approximately 60 years incur an increasing risk of both acute symptomatic seizures and epilepsy. In wealthier countries, the incidence of epilepsy increases sharply after age 60 or 65 years. This phenomenon was not always observed among reports from populations with lower socioeconomic status. This discrepancy may reflect differences in etiologies, methods of ascertainment, or distribution of ages; this is an area for more research. We identified other areas for which there are inadequate data. Incidence data are scarcer than prevalence data and are missing for large areas of the world. Prevalence is lower than would be expected from cumulative incidence, possibly because of remissions, excess mortality, or misdiagnosis of acute symptomatic seizures as epilepsy. Segmentation by age, frailty, and comorbidities is desirable, because "epilepsy in the elderly" is otherwise too broad a concept. Data are needed on rates of status epilepticus and drug-resistant epilepsy using the newer definitions. Many more data are needed from low-income populations and from developing countries. Greater awareness of the high rates of seizures among older adults should lead to more focused diagnostic efforts for individuals. Accurate data on epilepsy among older adults should drive proper allocation of treatments for individuals and resources for societies.

Status of epilepsy in the tropics: An overlooked perspective

Epilepsy is one of the most common serious chronic neurological diseases affecting people of all ages globally. It is characterized by recurrent seizures. About 50 million people worldwide have epilepsy. Indubitably, people with epilepsy (PWE) may be without access to appropriate treatment. Many studies have examined the molecular mechanisms and clinical aspects of epilepsy; nonetheless, the treatment gap exists in some special areas. In the tropics, the specific geographical and ecological conditions and a lack of medical resources result in neglect or delay of diagnosis for PWE. Herein, we summarized the epidemiology of epilepsy in the tropics and discussed the disease burden and existing problems, aiming to offer a medical environment for patients in need and highlight the importance of reducing the epileptic disease burden in tropical countries.

Factors not considered in the study of drug-resistant epilepsy: Psychiatric comorbidities, age and gender

In basic research and clinical practice, the control of seizures has been the most important goal but it should not be the only one. There are factors that remain poorly understood in the study of refractory epilepsy such as the age and gender of patients and the presence of psychiatric comorbidities. It is known that in patients with drug-resistant epilepsy (DRE), the comorbidities contribute to the deterioration of the quality of life, increase the severity, and worsen the prognosis of epilepsy. Some studies have demonstrated that patients diagnosed with a co-occurrence of epilepsy and psychiatric disorders are more likely to present refractory seizures and the probability of seizure remission after pharmacotherapy is reduced. The evidence of this association suggests the presence of shared pathogenic mechanisms that may include endocrine disorders, neuroinflammatory processes, disturbances of neurotransmitters and mechanisms triggered by stress. Additionally, significant demographic, clinical and electrographic differences have been observed between women and men with epilepsy. Epilepsy affects the female gender in a greater proportion, although there are no studies that report whether refractoriness affects more females. The reasons behind these sex differences are unclear; however, it is likely that sex hormones and sex brain differences related to chromosomal genes play an important role. On the other hand, it has been shown in industrialized countries that prevalence of DRE is higher in the elderly when compared to youngsters. Conversely, this phenomenon is not observed in developing regions, where more cases are found in children and young adults. The correct identification and management of these factors is crucial in order to improve the quality of life of the patients.

Sex Differences in the Epilepsies and Associated Comorbidities: Implications for Use and Development of Pharmacotherapies

The epilepsies are common neurologic disorders characterized by spontaneous recurrent seizures. Boys, girls, men, and women of all ages are affected by epilepsy and, in many cases, by associated comorbidities as well. The primary courses of treatment are pharmacological, dietary, and/or surgical, depending on several factors, including the areas of the brain affected and the severity of the epilepsy. There is a growing appreciation that sex differences in underlying brain function and in the neurobiology of epilepsy are important factors that should be accounted for in the design and development of new therapies. In this review, we discuss the current knowledge on sex differences in epilepsy and associated comorbidities, with emphasis on those aspects most informative for the development of new pharmacotherapies. Particular focus is placed on sex differences in the prevalence and presentation of various focal and generalized epilepsies; psychiatric, cognitive, and physiologic comorbidities; catamenial epilepsy in women; sex differences in brain development; the neural actions of sex and stress hormones and their metabolites; and cellular mechanisms, including brain-derived neurotrophic factor signaling and neuronal-glial interactions. Further attention placed on potential sex differences in epilepsies, comorbidities, and drug effects will enhance therapeutic options and efficacy for all patients with epilepsy. SIGNIFICANCE STATEMENT: Epilepsy is a common neurological disorder that often presents together with various comorbidities. The features of epilepsy and seizure activity as well as comorbid afflictions can vary between men and women. In this review, we discuss sex differences in types of epilepsies, associated comorbidities, pathophysiological mechanisms, and antiepileptic drug efficacy in both clinical patient populations and preclinical animal models.

Long-term risk of seizures in adult survivors of sepsis

OBJECTIVE

To examine the association between sepsis and the long-term risk of seizures.

METHODS

We conducted a retrospective population-based cohort study using administrative claims data from all emergency department visits and hospitalizations at nonfederal acute care hospitals in California, Florida, and New York from 2005 to 2013. Using previously validated diagnosis codes, we identified all adult patients hospitalized with sepsis. Our outcome was any emergency department visit or hospitalization for seizure. Poisson regression and demographic data were used to calculate age-, sex-, and race-standardized incidence rate ratios (IRR). To confirm our findings, we used a matched cohort of hospitalized patients without sepsis for comparison and additionally assessed claims data from a nationally representative 5% sample of Medicare beneficiaries.

RESULTS

We identified 842,735 patients with sepsis. The annual incidence of seizure was 1.29% (95% confidence interval [CI] 1.27%-1.30%) in patients with sepsis vs 0.16% (95% CI 0.16%-0.16%) in the general population (IRR 4.98; 95% CI 4.92-5.04). A secondary analysis using matched hospitalized patients confirmed these findings (IRR 4.33; 95% CI 4.13-4.55), as did a separate analysis of Medicare beneficiaries, in whom we found a similar strength of association (IRR 2.72; 95% CI 2.60-2.83), as we did in patients ≥65 years of age in our primary statewide data (IRR 2.83; 95% CI 2.78-2.88).

CONCLUSIONS

We found that survivors of sepsis faced a significantly higher long-term risk of seizures than both the general population and other hospitalized patients. Our findings suggest that sepsis is associated with pathways that lead to permanent neurologic sequelae.

Epidemiology of First Epileptic Seizures in the Northern Aegean Island of Lesvos, Greece

We aimed at establishing the epidemiologic profile of first epileptic seizures (FES) in the Greek island of Lesvos. During a 1-year period (01/06/2010 to 31/05/2011), cases of FES admitted to the Lesvos General Hospital/addressed by general practitioners/private neurologists were prospectively identified. A total of 45 cases (30 males and 15 females; mean age ± SD of 59.4 ± 28.4 and 58.9 ± 26.8 years, respectively), were collected. The FES incidence rate was 52.1 (95% CI 37-67) per 10⁵ persons. Provoked and unprovoked FES had an incidence of, 16.2 and 35.9 cases per 10⁵ persons, respectively. Following age-adjustment to the 2000 US census population, incidence rates of FES (all types combined) were, 40.5 (95% CI 28-56) per 10⁵ persons. Cerebrovascular disease (CVD) was the most prevalent etiologic factor. The present findings indicate a low-ranking incidence of FES in the studied population and highlight CVD as a leading causative factor.

Clinical profile and neurodevelopmental outcome of new-onset acute symptomatic seizures in children

PURPOSE

To study clinical profile, neurodevelopmental outcome and its predictors in children with acute symptomatic seizures (ASS).

METHODS

Short-term neurodevelopmental outcome and predictors of poor outcomes were prospectively assessed in 105 consecutive children with ASS aged 3 months-12 years RESULTS: Mean age was 51.2+42.2months (3-144 months); 67.2% were males. Central nervous system (CNS) infection in 82%, status epilepticus in 15.2%, abnormal neuroimaging in 62.8% and abnormal electroencephalography in 22.3% were noted. At discharge, 27.6% had poor outcome including death (13%); CNS infections were significantly associated with poor outcome compared to ASS of other aetiologies (32.6% vs 5.2%, p=0.02). Low GCS (OR 4.9, 95%CI 1.2-20.7), abnormal electroencephalograph (OR 4.3, 95%CI 1-16.9) and neuroimaging (OR 12.1, 95%CI 1.4-105.2) were independent predictors of poor outcome. After 6 months, 16% children had delayed neurodevelopment and cognition; 6% had seizure recurrences. Abnormal electroencephalograph (p=0.002; OR 6.8, 95%CI 2.0-23.1), abnormal neuroimaging (p=0.015; OR 9.47, 95%CI 1.18-75.8),>1 anti-epileptic (p=0.00; OR 9.9, 95%CI 2.88-33.9), intubation (p=0.004; OR 6.25, 95%CI 1.79-21.7) and poor outcome at discharge (p=0.02; OR 4.44, 95%CI1.38-14.2) predicted abnormal neurodevelopment.

CONCLUSIONS

CNS infections are the most common cause of ASS in children from developing countries. Abnormal neurodevelopment and seizure recurrences on short-term follow-up are seen in a minority of children.

When is it safe to return to driving following first-ever seizure?

OBJECTIVES

The risk of recurrence following a first-ever seizure is 40-50%, warranting driving restriction during the early period of highest risk. This restriction must be balanced against the occupational, educational and social limitations that result from patients being ineligible to drive. The recommended duration of non-driving after a first seizure varies widely between jurisdictions, influenced by various factors including the community perception of an acceptable relative level of risk for an accident (the accident risk ratio; ARR). Driving restrictions may be based on individualised risk assessments or across-the-board guidelines, but these approaches both require accurate data on the risk of seizure recurrence.

METHODS

1386 patients with first-ever seizure were prospectively analysed. Seizure recurrence was evaluated using survival analysis. The duration of non-driving required for a range of risks of seizure recurrence and ARRs was calculated. Additionally, the actual occurrence of seizures while driving was prospectively determined during follow-up.

RESULTS

For a risk of seizure recurrence to fall to 2.5% per month, corresponding to a monthly risk of a seizure while driving of 1.04 per thousand and an ARR of 2.6, non-driving periods of 8 months are required for unprovoked first-ever seizure, and 5 months for provoked first-ever seizure. Of patients with a seizure recurrence, 14 (2%) occurred while driving, with the monthly risk falling to less than 1/1000 after 6 months.

CONCLUSIONS

Our data provide a quantitative approach to decisions regarding a return to driving in patients with first-ever provoked or unprovoked seizure.

The brain, seizures and epilepsy throughout life: understanding a moving target

The human brain is a tremendously complex and still enigmatic three-dimensional structure, composed of countless interconnected neurons and glia. The temporal evolution of the brain throughout life provides a fourth dimension, one that influences every element of the brain's function in health and disease. This temporal evolution contributes to the probability of seizure generation and to the type and the nature of these seizures. The age-specific properties of the brain also influence the consequences of seizures on neuronal structure and behavior. These, in turn, govern epileptic activity and cognitive and emotional functions, contributing to the diverse consequences of seizures and epilepsy throughout life.

Gender-specific psychosocial outcome for women with epilepsy

The objective of the study described here was to compare gender-specific differences of the personal impact of juvenile myoclonic epilepsy (JME) and temporal lobe epilepsy (TLE). We interviewed consecutive men and women with JME or TLE attending a tertiary epilepsy center to characterize their clinical and psychological profiles and details of employment and marriage. We recruited 150 persons with JME (74 males) and 150 with TLE (80 males). There were no gender-specific differences between men and women with respect to age at onset or semiology or frequency of seizures. Antiepileptic drug usage was comparable for both sexes except that fewer women with JME were prescribed valproate. Comorbidities, lower employment, and higher anxiety state were more frequent for women with epilepsy than for men with epilepsy. Females had more difficulty finding life partners compared with males. Women with epilepsy were at increased risk of divorce. Women with epilepsy have more problems with, marriage, mood, and employment as compared with men, even when the clinical profiles of their epilepsy syndromes are comparable.

The descriptive epidemiology of epilepsy-a review

Epilepsy is a chronic disease experienced by millions and a cause of substantial morbidity and mortality. This review summarizes prevalence and incidence studies of epilepsy that provided a clear definition of epilepsy and could be age-adjusted: requirements if comparisons across studies are to be made. Although few exceptions, age-adjusted prevalence estimates from record-based studies (2.7-17.6 per 1000), are lower than those from door-to-door surveys (2.2-41.0 per 1000). Age-adjusted incidence ranged from 16 to 51 per 100,000, with one exception in Chile, where incidence was 111 per 100,000. Variation in reported prevalence and incidence may be related to factors such as access to health care, regional environmental exposures, or socioeconomic status. A higher proportion of epilepsy characterized by generalized seizures was reported in most prevalence studies. Epilepsy characterized by partial seizures accounted for 20-66% of incident epilepsies. Virtually all prevalence and incidence studies report a preponderance of seizures of unknown cause. Additional prevalence studies are needed in regions where data does not exist, and additional incidence studies in all regions. Interpretation of differences in prevalence and incidence will require understanding of the role of cultural, social and economic factors influencing epilepsy and its care.

The incidence rate of seizures in relation to BMI in UK adults

A retrospective cohort study using the data from The Health Improvement Network (THIN) database in the United Kingdom was conducted to examine the incidence rates of seizures across different BMI levels in the adult population aged > or = 18 years. Poisson regression was used to examine the relationship between BMI and seizures. The overall incidence rate of seizures was found to be 31.2 cases per 100,000 person-years. The incidence rate of seizures (cases per 100,000 person-years) in obese patients (BMI > or = 30 kg/m2) was 34.8 (95% confidence interval (CI), 23.1, 46.4), comparable to that in patients with normal weight (BMI between 18.5 and 24.9 kg/m2) (35.8, 95% CI (26.6, 44.9)). In contrast, underweight patients (< 18.5 kg/m2) or extremely obese (> or = 40 kg/m2) patients tended to have higher incidence rates than those with normal weight. After adjustment for age, gender, and smoking status, compared to patients with normal weight, those who were underweight or extremely obese had a rate ratio (RR) for seizures of 1.6 (95% CI (0.7, 3.8)) and 1.7 (95% CI (0.7, 3.9)), respectively. To date, we have not found any study that examines the associations between BMI or obesity and seizures. In this study, the incidence rates of seizures in the extremely obese and underweight patients tended to be higher than that in the normal-weight patients.

Incidence and prevalence of epilepsy in Denmark

PURPOSE

To estimate the occurrence of epilepsy in Denmark between 1977 and 2002, taking gender, age, and secular trends into consideration.

METHODS

We used the Danish Civil Registration System to identify all persons born in Denmark and the Danish National Hospital Register to identify persons registered with epilepsy between 1977 and 2002.

RESULTS

Between 1977 and 2002 the average incidence of epilepsy was 68.8 new epilepsy patients per 100,000 person-years at risk. However, the incidence changed with calendar time and increased steeply from 1990 to 1995, probably due to changes in diagnostic system and inclusion of outpatients. From 1995 to 2002 the incidence rate was reasonable constant with an average of 83.3 new cases per 100,000 person-years at risk, except for patients over 60 years of age where we observed an increase in incidence with calendar time. The age-specific incidence rates declined from a high level in children to a low level between 20 and 40 years of age, and thereafter a gradual increase was seen. The incidence rate was slightly higher in men than in women except for the age range 10-20 years. About 2% of the population was diagnosed with epilepsy at some point during the first 25 years of life. The overall 5-year prevalence proportion of epilepsy was 0.6% with a slight variation with age and gender between 0.4 and 0.8% of the population.

CONCLUSION

The occurrence of epilepsy is age and gender specific. The estimated incidence rate of epilepsy furthermore increased over time for persons older than 60 years of age.

Validation of epilepsy diagnoses in the Danish National Hospital Register

PURPOSE

To validate the diagnosis of epilepsy in the Danish National Hospital Register.

METHODS

We randomly selected 200 patients registered with epilepsy in the Danish National Hospital Register between 1977 and 2002 and validated the diagnosis according to the guidelines developed by the International League Against Epilepsy.

RESULTS

We reviewed the medical records of 188 (94%) persons from 57 departments at 41 hospitals. The epilepsy diagnoses were confirmed in 153 patients, providing a positive predictive value for epilepsy of 81% (95% confidence interval (95% CI): 75-87%). Among the 35 patients who did not fulfill the criteria for epilepsy, 14 were admitted after a single, unprovoked seizure. Among patients registered with epilepsy the positive predictive value of seizure disorder was 89% (95% CI: 83-93%). Among patients classified with epilepsy syndromes, the positive predictive value for syndrome classification was 60% (95% CI: 44-74%) for epilepsy with complex focal seizures and 35% (95% CI: 22-51%) for primary generalized epilepsy.

CONCLUSION

The validity of the epilepsy diagnoses in the Danish National Hospital Register has a moderate to high positive predictive value for epilepsy, but a relatively low predictive value for epilepsy syndromes.

Incidence of epilepsy in a racially diverse, community-dwelling, elderly cohort: results from the Einstein aging study

OBJECTIVE

To determine age-specific incidence and cumulative incidence of epilepsy in a well-defined cohort of elderly people, and to examine how rates of epilepsy are modified by sex, race, stroke, dementia, head injury, and depression.

METHODS

The authors examined data from a reconstructed cohort based on 1919 community-dwelling volunteers, followed as part of a large ongoing prospective aging study.

RESULTS

Age-specific incidence was 10.6 (per 100,000 person-years) between ages 45 and 59, 25.8 between ages 60 and 74, and 101.1 between ages 75 and 89. Cumulative incidence was 0.15% from age 45 to age 60, 0.38% to age 70, 1.01% to age 80, and 1.47% to age 90. In addition, the difference in cumulative incidence among African-American subjects approached statistical significance (57.6/100,000 person-years versus 26.1 in Caucasian, p=0.10), and the difference in incidence among subjects reporting a history of stroke was significantly elevated (p=0.029). Incidence of epilepsy was not statistically elevated among males, those with dementia, or individuals reporting a history of head injury or treatment for depression. Among "healthy" subjects without history of stroke, head injury, or dementia, we observed a cumulative risk of epilepsy with onset after age 60 of only 1.1%.

CONCLUSIONS

The incidence of epilepsy was low in this relatively healthy cohort of elderly people, especially among subjects without known risk factors. In this study we identified African-American race as a risk factor in the elderly for epilepsy independent of stroke.

EFNS guideline on the diagnosis and management of alcohol-related seizures: report of an EFNS task force

Despite being a considerable problem in neurological practice and responsible for one-third of seizure-related admissions, there is little consensus as to the optimal investigation and management of alcohol-related seizures. The final literature search was undertaken in September 2004. Consensus recommendations are given graded according to the EFNS guidance regulations. To support the history taking, use of a structured questionnaire is recommended. When the drinking history is inconclusive, elevated values of carbohydrate-deficient transferrin and/or gammaglutamyl transferase can support a clinical suspicion. A first epileptic seizure should prompt neuroimaging (CT or MRI). Before starting any carbohydrate containing fluids or food, patients presenting with suspected alcohol overuse should be given prophylactic thiamine parenterally. After an alcohol withdrawal seizure (AWS), the patient should be observed in hospital for at least 24 h and the severity of withdrawal symptoms needs to be followed. For patients with no history of withdrawal seizures and mild to moderate withdrawal symptoms, routine seizure preventive treatment is not necessary. Generally, benzodiazepines are efficacious and safe for primary and secondary seizure prevention; diazepam or, if available, lorazepam, is recommended. The efficacy of other drugs is insufficiently documented. Concerning long-term recommendations for non-alcohol dependent patients with partial epilepsy and controlled seizures, small amounts of alcohol may be safe. Alcohol-related seizures require particular attention both in the diagnostic work-up and treatment. Benzodiazepines should be chosen for the treatment and prevention of recurrent AWS.

Understanding the burden of epilepsy in Latin America: A systematic review of its prevalence and incidence

RATIONALE

Epilepsy is the most common serious neurological condition in the world, and an important cause of mortality and disability in developing countries. Because epidemiological and clinical characteristics of epilepsy vary by region, it is important to know the peculiarities of epilepsy in this area of the American continent.

METHODS

We searched MEDLINE, IMBIOMED, and LILACS (The Latin-American and Caribbean biomedical database) to identify community-based studies reporting on the prevalence and incidence of epilepsy in Latin America. Studies were included if a definition of epilepsy was given, if data were obtained through standardized questionnaires and if raw population numbers were available for data confirmation.

RESULTS

Thirty-three studies fulfilled eligibility criteria, 32 reported on prevalence and three on incidence of epilepsy. The median lifetime prevalence in all countries was 17.8 (range 6-43.2) per 1000 people, and the range for incidence was 77.7-190 per 100,000 people per year. There were no differences between rural and urban areas, by gender, age-group (children, adult, all ages), ascertainment method, or year of study.

CONCLUSIONS

Measuring the global burden of disease in Latin America requires adequate epidemiological information. This systematic review of epidemiological studies identifies higher prevalence and incidence rates of epilepsy in the general population of Latin America than in northern hemisphere countries. The remarkable heterogeneity found between and even within countries, could be explained by several factors, importantly, socioeconomic and methodological aspects.

Episousse: Incidence of Newly Presenting Seizures in Children in the Region of Sousse, Tunisia

PURPOSE

To evaluate the incidence of newly presenting seizures in children in the area of Sousse, Tunisia.

METHODS

From June 1, 1998, to May 31, 1999, all children aged 1 month to 15 years with first provoked and unprovoked seizures were included. Children with febrile seizures were excluded. All suspected cases were systematically referred to the Department of Functional Explorations of the Nervous System where a detailed questionnaire was filled out by a neurologist. All the patients underwent an EEG. Only 12 patients had a computed tomography (CT) scan.

RESULTS

A total of 175 patients were included. Eighteen (10.3%) patients had acute symptomatic seizures, and 157 patients had unprovoked seizures. The incidence rate of first unprovoked seizures was 102.1/100,000. In this latter group, some epileptic syndromes were individualized on strict electroclinical criteria.

CONCLUSIONS

However, nearly 75% of the cases remained cryptogenic, one of the major reasons that no predominant risk factor was identified in this population.

Systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures

PURPOSE

To evaluate the methodology of incidence studies of epilepsy and unprovoked seizures and to assess the value of their findings by summarizing their results.

METHODS

A Medline literature search from January 1966 to December 1999 was conducted. In each selected study, key methodologic items such as case definition and study design were evaluated. Furthermore, a quantitative meta-analysis of the incidence data was performed.

RESULTS

Forty incidence studies met the inclusion criteria. There was considerable heterogeneity in study methodology, and the methodologic quality score was generally low. The median incidence rate of epilepsy and unprovoked seizures was 47.4 and 56 per 100,000, respectively. The age-specific incidence of epilepsy was high in those aged 60 years or older, but was highest in childhood. Males had a slightly higher incidence of epilepsy (median, 50.7/100,000) than did females (median, 46.2/100,000), and partial seizures seemed to occur more often than generalized seizures. Developing countries had a higher incidence rate of epilepsy (median, 68.7/100,000) than did industrialized countries (median, 43.4/100,000). Similar results were found for unprovoked seizures. The incidence of epilepsy over time appears to decrease in children, whereas it increases in the elderly.

CONCLUSIONS

The age-specific incidence of epilepsy showed a bimodal distribution with the highest peak in childhood. No definitive conclusions could be reached for the incidence of unprovoked seizures and other specific incidence rates of epilepsy. More incidence studies with an adequate study methodology are needed to explore geographic variations and time trends of the incidence of epilepsy and unprovoked seizures.