So with respect to cause of epilepsy or cause of the seizure, absolutely thinking about it a little bit differently in young adults versus older adults. Although the workup is always pretty similar, but you know, the things that we're looking at in younger adults, would be of course, you know, medications, illicit, drug use, and specifically anything that's activating to the brain. So things like cocaine and methamphetamine especially that can provoke alcohol use, unfortunately. And then also, I mean, we're thinking much more along the lines of, you know, genetic and generalized epilepsy in those types of patients as opposed to the patients over 50 and 60. We're thinking along the lines of, you know, post stroke epilepsy, is there any stroke? A brain tumor? Actually, you know, amongst the top three causes of epilepsy is neurodegenerative diseases. So things like Alzheimer's, as it progresses, and usually not in the early stages, but in the later stages, can actually cause enough injury in the brain that it can provoke seizures.
So with respect to causes or risk factors for epilepsy. Again, that is something that sort of changes a little bit with age. But in general, what we're looking for is major head trauma associated with skull fracture, loss of consciousness, any history of brain infection, meningitis, encephalitis. In older adults, we are certainly looking for a prior history of stroke. It's interesting, about 20% of all strokes can lead to seizures later on. The seizures that occur with strokes, they don't occur at the time of the stroke. That's actually unusual. This is months or years later as the scar tissue forms. So it's not one of these things that happens immediately and it depends on the type of stroke itself.
You know, as far as causes, it's tough because it's not uncommon that we can't find the cause. There is a large percentage of patients who we just don't have a perfect answer for why exactly they have seizures. And that's something that we always have to sort of recognize and be vigilant about reevaluating every so often because sometimes things change over time.
The other population that's uniquely affected by epilepsy are women. And the interesting thing is that women have a couple of things that affect them differently. One, your, your hormones have a specific effect on epilepsy. And the sort of, the way that I think about it is that estrogen is proconvulsant and progesterone is anticonvulsant. And so anytime you either have a spike in estrogen, which is sort of observation or a relative increase in estrogen and decrease in progesterone, which is right around the menses, your period, that seizures can be more frequent. And the majority of women, 60%, some may say more, but in that range notice a variation in their seizure frequency with their cycle. And, you know, it used to be a fallacy in the past that women with epilepsy shouldn't have children, which is absolutely silly, but women with epilepsy do have to sort of face the fact that they do have a higher rate of having children with birth defects. This is, we think more related to medication than anything else. And I often sort of preface my description to women saying, and this is, I give a statistic that sounds really scary, and then try to explain why it shouldn't sound quite so scary.
Seizures have a big impact on someone's life. And this is one of these underrecognized undertreated sort of areas in epilepsy. And it's important to sort of recognize two specific things. One is the occurrence, the co-occurrence, of psychiatric disease with epilepsy. So and it sort of makes sense if you think about it. I mean epilepsy does is a disease of neurochemicals and electrical discharges that change the neurotransmitters in the brain and those same neurotransmitters which are involved in seizures and thinking clearly are involved in your emotions. And so, with epilepsy we see a high rate double the incidents of depression and anxiety and triple the rate of suicide. And so it is an important thing to recognize that depression is something that is very common in people with epilepsy, that we don't ignore it and that we treat it aggressively and often it requires an antidepressant. I will point out that a lot of people sort of don't want to go on antidepressants or they fear them because if you look at the side effect of any antidepressant, it'll say seizures as a potential side effect. And they sort of say, "Wait a minute, doc, I've got seizures. Why did you put me on a drug they can cause seizures?" And the answer is that by and large, most, but not all, most antidepressants are perfectly safe in people with epilepsy. It's something that you should talk to your doctor about If you're experiencing depression and very seriously consider being on an antidepressant.
What types of problems in the brain can cause seizures? And the answer is there's a lot. First of all in adults, especially people over the age of 55 who develop seizures, the most common cause is a stroke. But really it's not the stroke that causes the seizure. It's the scar tissue that's formed around there and the way that I tend to think of this is that any scar in the brain, the brain itself, every cell in the brain has a function. You know, the neurons function to make the brain work. But every other supporting cell has an important function to keep sort of the environment there just right so that your brain works well. When there is scar tissue that forms either from a stroke, from trauma, from a brain tumor, and that scar tissue changes that environment and the brain cells aren't happier and can't work as well. And that often, although not always, but that often can cause the cells to become prone to firing. And that misfiring is what ends up causing a seizure.
Women with epilepsy have double the rate of major fetal malformations than the general public. And again, I would point out that this is thought to be probably more related to medication than anything else, although there may be other factors that we don't understand. But I point out that if you know, if you double a small number, it's still a small number. So if the general population, about two to 3% of all women have children with made her major fetal malformations, cleft palate, heart malformations or Spina Bifida. So 2 to 3% of all women in women with epilepsy, it's 4 to 6%. So 94 to 96% of all women have perfectly healthy, normal babies. Things that we need to pay attention to though are the medications that they're on and the doses and how many medications they're on. And we know that there are a couple of medications that are specifically more problematic in women who are going to get pregnant. The first and foremost the drug that is the most problematic is depakote. Highest rate of fetal malformation, specifically Spina Bifida. And so women of childbearing age, generally, we want them off of Depakote, if at all possible. Sometimes it's not possible, but we certainly try our hardest. And there's another one called topiramate. Topiramate is a drug that's been associated with cleft palate. And so that's another one that we try to avoid if we can. Often women of childbearing age are on folic acid. The folic acid is given specifically for prevention of birth defects. Nobody knows how much folic acid is the right amount. Often we'll prescribe two milligrams, but if someone's actually actively trying to get pregnant up it to four milligrams. It's a water soluble vitamin, and whatever you don't need you'll pee right out. And so, specifically hormonal changes, changes with menstrual cycle and pregnancy are two specific issues that have to be addressed with women, and are incredibly important not to forget. And we often do, it just gets brushed over. No one asks, but worth talking about.
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