Abstracts

Rationale:
To understand the clinical decision making for epilepsy surgery in older adults and elderly with drug-resistant epilepsy (DRE) undergoing epilepsy monitoring unit (EMU) evaluation.
Method:
We used our prospectively maintained EMU database to identify consecutive 60 years or older patients admitted between January 2015 and December 2019. Subsequently, electronic medical records (EMR) were reviewed for identification of the study population: confirmed focal epilepsy with DRE per ILAE criteria at the time of EMU evaluation. The indication for EMU admission, the recommendation from multidisciplinary patient management conference (PMC), and the patient decision-making were reviewed. Patients undergoing presurgical workup was compared to the rest of the study population.
Results:
A total of 379 of the admitted 692 (54.8%) patients 60 years or older were diagnosed with focal epilepsy. Among them, 115 (30.3%) had DRE and were included in the study. The indication for EMU evaluation in study population included presurgical evaluation in 78 (67.8%) patients, diagnosis in 16 (13.9%) patients, and seizure burden assessment/anti-seizure medication (ASM) adjustment in 21 (18.3%) patients. Table 1 provides data on the study population as well as compares presurgical patients with the rest of study population. The latter group was older, less often employed, with more comorbidity [Charlson comorbidty index (CCI)], less often had aura and an abnormal MRI (p< 0.05). They were not evaluated for surgery until the last clinical follow-up. Of the 78 patients undergoing presurgical evaluation, 12 patients declined considering surgery during EMU admission and were not presented in the PMC, 2 are scheduled for PMC, and 1 patient was lost to follow-up. Among the 63 patients discussed in the PMC, the recommendations were: epilepsy surgery in 42 patients (66.7%), further non-invasive testing in 6 (9.5%), invasive EEG evaluation in 5 (7.9%) patients, and continuation of medical management in 10 (15.9%) patients.  A total of 35 out of 63 (55.6%) underwent epilepsy surgery, including 3 neuromodulation procedures (1 VNS, 2 RNS), or are scheduled for it. Twenty-three patients (29.5% of 78 patients undergoing presurgical evaluation) declined epilepsy surgery or invasive EEG evaluation. The reasons for not recommending surgery at PMC or for patients declining it are detailed in Table 2.
Conclusion:
Close to one-third of patients 60 years or older with DRE who underwent EMU evaluation were never considered for epilepsy surgery. They had significant differences compared to patient undergoing presurgical evaluation. Among the latter, another one-third (29.5%) end up not undergoing surgery, mostly due to reluctance at the patient level. Combined, there seems to be physician as well as patient related factors that prevent presurgical evaluation, and eventual surgery in older adults and the elderly. With rapidly aging population, further research is required to improve access of older adults and elderly to an effective management therapy for DRE. 
Funding:
:no