Memory and Concentration Problems in Epilepsy Kirsty E. Bortnik, Ph.D. Clinical Neuropsychologist October 29, 2016

Epilepsy and Cognition Significant variation: minimal/no impairment  significant impairment High prevalence of memory problems (20%-50%) Attention/concentration difficulties also frequent 30-40% children with epilepsy Common complaints: Trouble remembering names Forgetting appointments and/or when to take medication Difficulty recalling recent events Trouble paying attention or concentrating Feeling that thinking is “slowed down.” (Lodhi & Agrawal, 2012; Westerveld, 2009)

Factors Affecting Cognition in Epilepsy Multiple epilepsy-related factors contribute towards cognitive difficulties: Seizure etiology Cerebral lesions, cortical malformations Epilepsy-related factors Age of onset/duration of epilepsy Location of epileptogenic/seizure focus (Blackburn et al., 2007.)

Factors Affecting Cognition in Epilepsy Location of seizure onset Frontal lobe: Mental flexibility, problem-solving, attention, processing speed, initiation, inhibition, language functioning Parietal lobe: Visual and spatial abilities Occipital lobe: Integration of visual information, reading Temporal lobe: Memory, language functioning

Factors Affecting Cognition in Epilepsy Seizure-related factors Type Frequency, duration, severity Occurrence of status epilepticus Treatment-related factors Impact of antiepileptic drugs (AEDs) Epilepsy surgery Psychosocial factors Mood/emotional functioning (Park & Kwon, 2008; Lodhi & Agrawal, 2012; Loring et al., 2007.)

All these inter-related factors make complex contributions to cognitive deficits.

Children

Attention/Concentration Problems Very common (30-40%) in children regardless of seizure type/syndrome High co-morbidity with ADHD (esp. ADHD-I) Different from ADHD in general population: boys and girls equally affected. (Dunn et al., 2003; Stucky et al., 2014; Westerveld, 2010)

Attention/Concentration Problems Mechanism of attention/concentration problems varies depending on nature of seizures and underlying pathology Absence seizures more highly associated with attention problems Impaired function in an attention network comprising the anterior insula-frontal operculum and medial frontal cortex Nocturnal seizures impact attention by altered sleep patterns (Stucky et al., 2014; Westerveld, 2010)

Attention/Concentration Problems Structural differences in children with epilepsy and ADHD Increased gray matter volume in sensorimotor, supplementary motor, and prefrontal regions. Decreased brainstem and frontal volumes Treatment with some AEDs may produce attention problems – (side effect; doesn’t fully account for attention/problems). (Hermann et al., 2007; Stucky et al., 2014)

Memory Problems Early-onset seizures (<5 yrs) global nonspecific learning/memory deficits Later seizure onset (>10 yrs) specific deficits in material-dependent learning/memory Particular role of temporal lobes in learning/memory E.g., LTLE associated with worse performance on verbal vs. visual memory tasks But findings mixed; face recognition only lateralizing measure Perhaps location of lesion within temporal lobe? mesial vs. lateral (Cohen, 1992; Lespinet et al., 2002; Gonzalez et al., 2007; Westerveld, 2010)

Memory Problems Childhood Absence Epilepsy Most common epilepsy syndrome of childhood (~15% of childhood seizures) Attention problems adversely affect encoding and storage of new information, with relatively greater impact on nonverbal memory Frontal lobe epilepsy Memory deficits related to poor organization of metacognitive strategies for learning and remembering (Pavone et al., 2001; Stucky, 2014)

Adults

Attention/Concentration Problems 1 in 5 adults with epilepsy have symptoms of ADHD Rarely only attention/concentration difficulties in isolation Widespread neural underpinnings of attentional system Intact attention required to adequately perform variety of cognitive tasks Often seen with other cognitive impairments (word-finding difficulty, forgetfulness, etc.) (Ettinger, 2015; Lee, 2010; Stucky et al., 2014, Westerveld, 2010)

Attention/Concentration Problems Symptomatic epilepsy > idiopathic epilepsy Worsening attention/concentration (along with visuomotor speed) associated with: Early age of onset Long epilepsy duration History of more GTCs (Lee, 2010)

Memory Problems Very frequent in patients with TLE but patients with other epilepsy syndromes also exhibit memory deficits Medial temporal structures crucial for long- term encoding but also network E.g., frontal lobe epilepsy and interconnectivity between frontal and temporal lobes Role of specific areas within the frontal cortex for encoding and retrieval (Centeno et al., 2010; Stucky, 2014).

Memory Problems Memory deficits may be “material specific” depending on side of seizure onset Verbal memory for LTLE (left hemisphere dominance) and visual memory for RTLE * not as robust for visual learning/memory * Patients with TLE and HS degree of memory impairment directly related to degree of cell loss in hippocampus. (Centeno et al., 2010; Stucky, 2014).

Other factors contributing to cognitive difficulties

Mood and Cognitive Functioning Negative impact of depression in patients with epilepsy Perceived cognitive functioning strongly correlated with mood Memory performance scores weakly correlated with perceived cognitive functioning More about depression and anxiety later! (Elixhauser et al., 1999).

Medications and Cognition All AEDs have potential for adverse effects on cognition AEDs decrease neuronal excitability  slowed psychomotor speed, attention and memory probs Significant individual variability Some studies have found that carbamazepine (CBZ) and valproate (VPA) have fewest adverse effects in children and adults But due to individual variability balance between treating seizures and minimizing side effects Keep doctor updated about any cognitive changes you notice (Devinsky, 1995; Loring, 2005; Park & Kwon, 2008).

Neuropsychology

Neuropsychological Assessment Standardized paper-and-pencil measures that assess variety of cognitive functions Cognitive strengths/weaknesses Plays a role in lateralizing/localizing seizure focus Pre-surgical baseline; serial assessments to track cognitive and emotional functioning over time Assesses mood/emotional functioning Assists with treatment planning

Difficulties in memory and concentration can have significant adverse impact on daily functioning:

Use of Compensatory Strategies to Improve Cognitive Functioning Compensatory strategies: patient learns alternative ways to cope with the daily flow of information Training goals tailored to needs of each individual, are realistic, concrete, and modified as needed. External (e.g., environmental modification, calendar, timer, etc.) and internal (e.g., mnemonics, face-name associations, etc.)

Mnemonic?! Rhyme, formula, or other device used to help you remember. Be creative! Some of the best mnemonics are ones that are unusual and have personal meaning.

Common Complaint I ask my child to do something and she doesn’t do it. I ask her later, and she says, “I forgot.”

Strategies to Implement External: use of dry erase board/notebook in central, prominent location to mark down tasks to be completed and timelines for completion. Internal: get into the habit of doing task while still thinking of it, use rehearsal to assist with recall.

Common Complaint tests or assignments My child can’t keep track of upcoming tests or assignments

Strategies to Implement External: use organizer; utilize weekly/monthly planner to keep track of when tests/assignments due, which will help with preparation. Have daily checklist of things to do. Check book bag night before to ensure all assignments are there. Internal: mnemonics Check planner Highlight tasks/assignments Engage/complete the work Check/cross off tasks completed Return folder to book bag

Common Complaints supposed to buy I go to the store and forget what I was supposed to buy I walk into a room and forget why I went in there I keep losing my phone and keys

Strategies to Implement Prospective memory (remembering to remember!) Repeat key pieces of information Use mnemonics Note-taking, use of lists, cell phone apps Make connections to meaningful memories Keep things in the same place Decide what is important (can’t remember everything) Practice, practice, practice Don’t be too harsh on yourself! Give yourself a break at times