Scientists who study Alzheimer’s disease have mostly ignored the role of seizures, but that is beginning to change, and new research suggests they may provide insight into the progression of the disease and pave the way for treatments.
It’s no surprise to neurologists that some people experience convulsive seizures in the later stages of the disease. In fact, the second patient ever to receive an Alzheimer’s diagnosis more than a century ago suffered from them. But because brain damage can cause seizures, they were long thought to be just one more casualty of a deteriorating brain.
Now evidence is accumulating that such abnormal electrical activity is far more common and occurs much earlier — and perhaps even precedes obvious signs of memory loss. This raises the possibility that seizures may be intimately tied up with the progression of the disease.
New research that lends credence to this hypothesis was shared at the Alzheimer’s Association International Conference in Los Angeles this week. One study looked at 55 patients between the ages of 50 and 69 who were admitted to an Israeli medical center with their first known seizure. A quarter of them went on to develop dementia — with a mean time to the diagnosis of eight and a half years. Another study of nearly 300,000 U.S. veterans over the age of 55 found that seizures were associated with twice the risk for developing dementia between one and nine years later.
It’s been notoriously difficult to tease out the causes of Alzheimer’s, which is complex, progresses slowly, and may have many different triggers. Finding an association between seizures and dementia is by no means proof of causality, but the new studies excluded people with known risk factors for both epilepsy and Alzheimer’s, such as cerebrovascular disease and traumatic brain injury.
“We had to design a very conservative study that takes these participants out, said Ophir Keret, a neurologist at the University of California, San Francisco who was a researcher on both studies, “because we wanted to isolate the effect that epilepsy would have.”
Michela Gallagher, a professor of psychology and neuroscience at Johns Hopkins University, said the researchers used “good criteria for defining unprovoked seizures independent of things that could be causing [epileptic activity],” and pointed to the large sample size and long time period for tracking each veteran’s health trajectory as two of the study’s strengths. One weakness she noted is that the Veterans Affairs health data used in the study did not allow researchers to differentiate between Alzheimer’s or other types of dementia. Neither the veterans study or the smaller one has been published yet in a peer-reviewed journal.
Two additional studies presented during a poster session at the conference found that people with Alzheimer’s had more seizures than normal controls. However, one of those studies, which is also unpublished, looked for evidence of seizures before a diagnosis of Alzheimer’s, and failed to find such an association. The lead researcher of that work, neurologist Jonathan Vöglein of the German Center for Neurodegenerative Diseases and LMU Munich, nevertheless called Keret’s research “very, very interesting,” and said the results could be in keeping with previous research showing that seizures can occur before the onset of dementia in some people with Alzheimer’s disease.
Lennart Mucke, director of the Gladstone Institute of Neurological Disease and a professor at UC San Francisco, has been examining the relationship between epilepsy and Alzheimer’s in both animal models and people since the early 2000s. He noted in an interview that one reason study results may differ is that some types of seizures are easy to miss. “When we looked at patients who had come to UCSF with both epilepsy and Alzheimer’s disease, it became clear that a lot of the epilepsy they had was non-convulsive,” said Mucke.
Patients with these so-called partial seizures might stop and stare, or experience psychic phenomena like deja vu. Seizures that can be detected on EEG during an overnight testing session are often missed during standard daytime tests that may be as short as 20 minutes.
In a 2016 paper, Mucke, who was not involved in the research presented this week, reported that more than 40 percent of the patients with Alzheimer’s he studied had epileptic activity. Mucke said that he and his colleagues also found in an earlier study that “the onset of the seizures wasn’t late in the game but could happen shortly before the cognitive decline became manifest.”
Research with mouse models supports the hypothesis that seizures or other epileptic events may sometimes be an early feature of Alzheimer’s disease. Scientists have recorded such abnormal electrical activity in the brains of mice before they went on to accumulate amyloid plaques or tau tangles, both hallmarks of Alzheimer’s. Many of these events had no outward manifestation, suggesting again that the prevalence of epileptic activity may be going unrecognized and therefore underestimated.
Seizures are an extreme example of an imbalance in brain function. Normally, a class of cells called inhibitory neurons, which have received scant attention until recently, act much like the bouncers at a night club. Their job is to manage the timing and flow of brain signals and keep excitatory neurons under control. As we age, inhibitory neurons appear to become less effective, resulting in chronic hyperactivity. Low-level hyperactivity has been detected in the hippocampus — a brain region critical to memory — of both rodents and older people with mild cognitive impairment.
Researchers once assumed that hyperactivity was a compensatory mechanism to make up for a brain that couldn’t keep up with cognitive demands. Now many believe the reverse is true — that hyperactivity is pathological and interferes with memory — and that this imbalance is a core feature of Alzheimer’s disease.
“I think there is a recognition it’s not just seizures which are a real abnormality in the brain,” said Gallagher, “but greater excitability in the earliest stages.”
Gallagher has been putting this theory to the test in clinical trials. A short phase 2 trial completed in 2017 used a common anti-seizure drug called levetiracetam and measured reduced activity in the hippocampus of test subjects coupled with improved performance on memory tests.
Gallagher started a company, AgeneBio, that is now recruiting 830 subjects for a phase 3 clinical trial using a specially formulated low-dose version of the drug. Patients with the type of mild cognitive impairment that precedes Alzheimer’s will take the drug for a year and a half to “crank down the neural activity,” said Gallagher, and see whether the disease progresses more slowly. Three smaller phase 2 trials using a similar strategy are also underway, sponsored by the Medical College of Wisconsin, University of Minnesota, University of San Francisco, and Oxford University Hospitals.
Mucke, like Gallagher and many other neuroscientists, believes that the phenomenon of hyperactivity “is ripe for the discovery of additional therapeutic entry points that might not only be symptomatically beneficial but also have the potential to be disease-modifying.” He points out that brain rhythms have a strong impact on immune system function in the brain, which is increasingly implicated in the pathogenesis of Alzheimer’s disease.
For now, the question remains whether seizures or low-level hyperactivity are a result of Alzheimer’s, an accelerator, an early warning sign, a risk factor, a trigger, or some complex combination. To try to figure that out, researchers point to the need for more trials using sensitive biomarkers to diagnose both seizures and Alzheimer’s, large numbers of test subjects and controls, and long follow-up times.
At a minimum, knowing whether new seizures in older adults are a harbinger of the disease would be valuable. Keret, a fellow at the Global Brain Health Institute at UCSF, points out that even though there are still no proven drug therapies for Alzheimer’s, some lifestyle changes such as exercise or managing known risk factors for dementia may be helpful for delaying the onset of the disease.
So, “if we do establish that this is an early sign, one thing that I would be very interested in evaluating,” said Keret, is whether “interventions at this stage are successful.”
My wife is in the seventh stage of Alzheimer’s and now for the first time ever a
She has seizures. Since she is at home with me I found it very scary for me. Just wondering what (if anything) I can do for her when they happen.
I’m so sorry. I am sure I have ptsd from finding my husband status epileptus, bleeding profusely, disoriented etc too many times to count. It’s harder on us as we see the loss and fear for them. My hubby acccused me off making the seizures up as he has no memory of them
My wife suffers from Dementia/ Alzheimer’s and Epilepsy. Her dementia improves after her seizures. This happens 100 % of the time and therefore her epilepsy remains untreated. She is cognitively better this year and markedly better than 2 years ago.
Her dementia started 5 years ago but the rapid decline came to a halt after a grand mal seizure at 1 1/2 years.
She still has dementia. But we are maintaining a manageable life.
I believe others have noticed this phenomenon but understandabley they end up having there epilepsy treated in order to control their seizures. I realize this is contrary to what studies show. However it is what it is.
Hi there – very interesting to read this article My mum has Dementia and before this she was experiencing Petit Mal Seizures and we discovered she had a Meningioma Tumor. She has been on anti-seizure medication for last 10 years and has declined rapidly with her condition. However now it seems she has been experiencing more grand mal seizures and she has become more lucid and chatty than she has ever been? Very strange and I agree we are looking into controlling the seizures but does that mean that we will just be dampening her awareness again?
You forget the some compound could induce the seizure of rats. This compound increases its level in blood and started the inhibition of adult hippocampal neurogenesis in MCI. This compound level in blood was extremely relation to MMSE score.
I wonder where I can get the paper from this study presented in Los Angeles.
Thank you very much in advance.
Very interested in latest findings; have partial seizures since I’m 19. I’m 67. Am considering VNS right now. Medication does not work. Mother died of Alzheimer’s.
Psychological stress appears to be an important seizure precipitant, and stress reduction techniques may prevent seizures. Further, as indicated by the following article, psychological stress can play a key role in the development of conditions like Alzheimer’s disease as well as Parkinson disease:
Justice, Nicholas J. (2018). The relationship between stress and Alzheimer’s disease. Neurobiology of stress vol. 8 127-133.
What do you mean. ‘Appears to be?’
You can check out the following articles:
McKee HR, Privitera MD. Stress as a seizure precipitant: identification, associated factors, and treatment options. Seizure. 2017;44:21-26.
Baldin E, Hauser WA, Pack A, et al. Stress is associated with an increased risk of recurrent seizures in adults. Epilepsia. 2017 Apr 18.
Novakova B, Harris PR, Reuber M. Diurnal patterns and relationships between physiological and self-reported stress in patients with epilepsy and psychogenic non-epileptic seizures. Epilepsy Behav. 2017;70(pt A):204-211.
Ge A, Gonzalez E, Lee SW, et al. Seizure triggers in epilepsy patients: a national perspective [abstract]. Neurology. 2017;88(16 suppl):S37.002.
Tang V, Poon WS, Kwan P. Mindfulness-based therapy for drug-resistant epilepsy: an assessor-blinded randomized trial. Neurology. 2015;85:1100-1107.
I think we could begin to understand ‘dementia’ if it were made clear that Alzheimer’s is just another ‘cause’ of dementia. And that it just means no ‘reason ‘ can be found for patient’s neurological symptoms. And that there are many causes of these type symptoms and what matters is what part of brain is affected . A diagnose really makes no difference in treatment of neurological symptoms❗️And if it is called ,it should always be called : Alzheimers dementia. Dementia is dementia. In my book❗️Is there something g I am missing here? My husband who had brain bleeds which led to Hydrocephalus and then dementia appeared same in his symptoms as my twin sister who developed dementia after being on Dilantin and Pheobarb got twenty years?
In what context are you using the word: hyperactivity❓
I am exceedingly happy ,delighted joyful and satisfied with the extent of coverages being reported , discussed .analysis and the method that is used making it much easier for various forms of people to be able to gather the information and there by graft this same knowledge with the conclusion as to how critical , important and urgent .this most deadly heath issue warrants a deep and comprehensive attention and means of the curing there off . I thank you .Trevor Merchant . Bronx , New York City . Friday ., July 19. 2019 at 4.01 p.m day light savings .time
Thanks for this excellent reporting on Alzheimers’ role in seizures. As a non-scientist with friends and family members facing Alzheimers and periodic seizures, I appreciated the clear and thorough reporting on latest developments discussed at the Alzheimers Conference in L.A. Also, I shared the article with our neurologist who specializes in seizures.
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