Clinical Scorecard: Exploring the Relationship Between Epilepsy and Dementia: A Collaborative Approach Needed

At a Glance

Key Highlights

• Active seizures in dementia are associated with increased mortality and younger age at death compared to those with remote or no seizures.
• Active epilepsy correlates with more severe Alzheimer’s disease pathology, cerebral and hippocampal atrophy, and locus coeruleus hypopigmentation.
• No significant differences in vascular co-pathology were found between seizure groups, but older anti-seizure medications may increase cardiovascular risk.

Guideline-Based Recommendations

Diagnosis

• Classify epilepsy status in dementia patients as active (seizures within last year or on ASMs), remote (no recent seizures or ASMs), or no history of seizures.
• Use detailed phenotyping to capture seizure frequency, semiology, and ASM use in dementia datasets.
• Consider prolonged EEG monitoring to detect unrecognized seizures in dementia.

Management

• Optimize seizure control to potentially reduce neurodegeneration and mortality risk in dementia patients.
• Consider substituting enzyme-inducing anti-seizure medications with newer therapies to reduce vascular risk.
• Address modifiable factors such as sleep hygiene and vascular risk reduction.
• Explore potential benefits of anti-seizure medications that stabilize neuronal networks and anti-dementia treatments that may reduce epileptogenesis.

Monitoring & Follow-up

• Implement longitudinal cognitive assessments in epilepsy patients to detect early cognitive decline.
• Use biomarkers, including EEG, to monitor treatment impact on seizure control and neurodegeneration.

Risks

• Active seizures increase mortality and accelerate neurodegenerative pathology in dementia.
• Older anti-seizure medications may elevate cardiovascular risk in older adults.
• Recurrent generalized tonic-clonic seizures, status epilepticus, and seizure-related head injury may worsen outcomes.

Patient & Prescribing Data

Older adults with dementia and active or remote epilepsy

Active seizure control is crucial to reduce mortality and neurodegeneration; newer ASMs may lower vascular risk compared to older enzyme-inducing drugs.

Clinical Best Practices

• Collaborate across epilepsy and dementia specialties to improve phenotyping and management.
• Capture detailed epilepsy characteristics in dementia research datasets and vice versa.
• Educate patients about the risks of ongoing seizures and the importance of seizure control.
• Consider vascular risk factors when selecting anti-seizure medications in older adults.
• Promote research into mechanisms linking seizures and dementia to develop targeted therapies.

References

• The association of seizure control with neuropathology in dementia by Zawar et al.