Adult epilepsy

The epilepsies are one of the most common serious brain disorders, can occur at all ages, and have many possible

presentations and causes. Although incidence in childhood has fallen over the past three decades in developed

countries, this reduction is matched by an increase in elderly people. Monogenic Mendelian epilepsies are rare. A

clinical syndrome often has multiple possible genetic causes, and conversely, diff erent mutations in one gene can

lead to various epileptic syndromes. Most common epilepsies, however, are probably complex traits with

environmental eff ects acting on inherited susceptibility, mediated by common variation in particular genes.

Diagnosis of epilepsy remains clinical, and neurophysiological investigations assist with diagnosis of the syndrome.

Brain imaging is making great progress in identifying the structural and functional causes and consequences of the

epilepsies. Current antiepileptic drugs suppress seizures without infl uencing the underlying tendency to generate

seizures, and are eff ective in 60–70% of individuals. Pharmacogenetic studies hold the promise of being able to

better individualise treatment for each patient, with maximum possibility of benefi t and minimum risk of adverse

eff ects. For people with refractory focal epilepsy, neurosurgical resection off ers the possibility of a life-changing

cure. Potential new treatments include precise prediction of seizures and focal therapy with drug delivery, neural

stimulation, and biological grafts. 

Epilepsy is a disorder of the brain characterised by an

enduring predisposition to generate epileptic seizures,

and epileptogenesis is the development of a neuronal

network in which spontaneous seizures occur. Epilepsy

aff ects the whole age range from neonates to elderly

people, and has varied causes and manifestations, with

many distinct seizure types, several identifi able

syndromes, but also much that is poorly classifi ed. There

are very many comorbidities that complicate assessment

and treatment planning, including learning disabilities,

fi xed neurological defi cits, progressive conditions,

psycholo gical and psychiatric problems, and, particularly

in the older age group, concomitant medical conditions.

Classifi cation of epileptic seizures and syndromes is

continually evolving. The present proposed classifi cation

is across fi ve axes that consider seizure types, focal or

generalised seizure onset, the syndrome, causation, and

associated defi cits.1 Here, we have defi ned individuals

aged 16 years and older as adults. The UK National

Institute for Health and Clinical Excellence (NICE)

produced in October 2004 detailed evidence-based

guidelines2 for the clinical management of individuals

with epilepsy (panel). Other guidelines include those of

the American Academy of Neurology and the Scottish

Intercollegiate Guidelines Network.

Stigma and prejudice mark epilepsy out from other

neurological conditions. The past decade has seen

considerable progress in epilepsy research, and

improvement in public understanding. Much, however,

remains to be done, especially for people for whom drugs

are ineff ective. An important issue that needs urgent

attention is the fact that most people with epilepsy live in

resource-poor countries where the management of

epilepsy is inconsistent. There is a great diagnostic gap in

large parts of the world because there are too few trained

personnel and medical facilities. The WHO-led Global

Campaign Against Epilepsy with the active support of the

International League Against Epilepsy and International

Bureau for Epilepsy (the two major international

non-governmental organisations in epilepsy) is seeking

to address these issues.3,4 Additionally, there is a large

treatment gap in resource-poor countries, and worldwide,

less than 20% of people with the disorder are estimated to

be treated at any time.5,6 However, resolving these

diffi culties will require tremendous eff ort and will take

time to achieve. Most of what we discuss here relates to

diagnosis and treatment of epilepsy as seen in the

developed world. We hope that before long, the same

standards will be achieved in resource-poor countries.