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

2. 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)

3. 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.)

4. 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

5. 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.)

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

7. Children

8. 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)

9. 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)

10. 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)

11. 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)

12. 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)

13. Adults

14. 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)

15. 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)

16. 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).

17. 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).

18. Other factors contributing to cognitive difficulties

19. 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).

20. 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).

21. Neuropsychology

22. 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

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

24. 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.)

25. 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.

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

27. 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.

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

29. 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

30. 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

31. 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