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Original article
Epilepsy in elderly patients: does age of onset make a difference?
Epilepsia en el anciano: ¿la edad de inicio marca la diferencia?
A. Suller Martia,
Corresponding author
anasm98@gmail.com

Corresponding author.
, E. Bellosta Diagob, P. Vinueza Buitronb, A. Velázquez Benitob, S. Santos Lasaosab, J.Á. Mauri Llerdab
a Programa de Epilepsia, Departamento de Ciencias Neurológicas, Schulich School of Medicine, Western University, London, Ontario, Canada
b Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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stroke&#44; or brain trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The Royal Spanish Academy defines elderly individuals as &#8220;people of old age&#44;&#8221;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and the World Health Organization considers adults aged 60 years and older to be elderly&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This age may seem young&#59; in fact&#44; due to increased life expectancy&#44; the cut-off age for defining &#8220;elderly individuals&#8221; has changed&#44; with this population now considered to comprise people aged 65 years or older&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The study by Sillanp&#228;&#228; et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> on an epilepsy registry conducted in Finland between 1986 and 2002 revealed a decrease in the incidence of new-onset epilepsy in children and a significant increase in the elderly population&#46; Besocke et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> observed an age-dependent increase in the incidence of epilepsy&#44; with 40 cases per 100&#8239;000 population among individuals aged 40&#8211;45 years&#44; 80 cases per 100&#8239;000 population in those aged 60&#8211;65&#44; and 140 cases per 100&#8239;000 population in individuals aged over 80&#46; These findings have considerable implications in view of population ageing&#44; especially in Europe and Spain&#46; According to demographic estimates&#44; 70&#37; of the Spanish population is expected to be older than 64 years in the following 30 years&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Furthermore&#44; epilepsy management is associated with more limitations in elderly individuals than in younger patients due to the higher incidence of comorbidities and concomitant treatments in the former group&#46; Furthermore&#44; some age-related physiological changes &#40;lower levels of free plasma proteins&#44; decreased kidney or liver function&#44; memory impairment&#41; may have a negative impact on treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Elderly patients with epilepsy may be classified into those developing the condition during old age and those presenting the condition many years before the 65-year mark&#46; The purpose of this study was to analyse the profile of epileptic patients aged &#8805; 65 years and to determine whether it differs from that of elderly patients diagnosed with epilepsy before age 65&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We conducted a retrospective observational study of all patients attended at the epilepsy unit of Hospital Cl&#237;nico Universitario Lozano Blesa between June 2013 and December 2014&#46; We included all patients with an established diagnosis of epilepsy according to the definition of the International League Against Epilepsy<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and aged&#8239;&#8805;&#8239;65 years&#46; Patients not meeting the inclusion criteria were excluded&#46; The study complies with the ethical principles of the Declaration of Helsinki&#59; informed consent was not obtained from the included patients given the retrospective observational design of the study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We gathered demographic data &#40;age&#44; sex&#41;&#44; clinical data &#40;age at diagnosis of epilepsy&#44; type of seizure &#91;focal&#44; focal impaired awareness&#44; focal to bilateral tonic-clonic&#44; generalised tonic-clonic&#93;&#44; seizure frequency over the past 3 months&#44; epilepsy aetiology&#41;&#44; complementary test results &#40;head CT&#44; brain MRI&#44; EEG&#41;&#44; and antiepileptic drug &#40;AED&#41; treatment &#40;active ingredient&#44; dose&#44; treatment duration&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were classified into 2 groups&#58; group A&#44; including all patients who presented epilepsy before the age of 65 years&#44; and group B&#44; with all patients who developed epilepsy at age&#8239;&#8805;&#8239;65 years&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Data were analysed using SPSS statistical software&#44; version 22&#46;0&#46; In the descriptive study&#44; quantitative variables are expressed as means and standard deviations &#40;SD&#41; and qualitative variables as frequencies and percentages&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Quantitative variables were analysed with the <span class="elsevierStyleItalic">t</span> test or with the Mann-Whitney U test&#44; in the case of variables not following a normal distribution&#46; Qualitative variables were analysed with the chi-square test&#59; when the number of cases was less than 5&#44; we used the Fisher exact test&#46; The Bonferroni correction was applied to minimise the risk of type 1 errors&#46; Finally&#44; a multivariate logistic regression analysis was performed&#46; Values of <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;05 were considered to indicate statistically significant differences&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 123 patients were included in our study&#58; 61 in group A and 62 in group B&#46; Both groups included a similar number of patients and presented similar age and sex distributions&#44; with men accounting for 60&#46;7&#37; &#40;n&#8239;&#61;&#8239;37&#41; of the sample in group A and 62&#46;9&#37; &#40;n&#8239;&#61;&#8239;39&#41; in group B&#46; As expected&#44; mean age and age at diagnosis were lower in group A than in group B &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding clinical data&#44; focal impaired awareness seizures were the most frequent type in both groups &#40;41&#37; in group A and 53&#37; in group B&#41;&#44; with no statistically significant differences between groups&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Head CT was performed in 96&#46;7&#37; of patients &#40;59 from group A and 60 from group B&#41; and brain MRI was performed in 80&#46;3&#37; &#40;n&#8239;&#61;&#8239;49&#41; of patients from group A and 61&#46;3&#37; &#40;n&#8239;&#61;&#8239;38&#41; of patients from group B&#46; Brain MRI findings were normal in 32&#46;8&#37; &#40;n&#8239;&#61;&#8239;16&#41; of patients from group A and 11&#46;3&#37; &#40;n&#8239;&#61;&#8239;4&#41; of patients from group B&#46; MRI revealed encephalomalacia secondary to stroke or other lesions &#40;eg&#44; brain trauma&#41; in 24&#46;6&#37; &#40;n&#8239;&#61;&#8239;12&#41; of patients from group A and 64&#46;5&#37; &#40;n&#8239;&#61;&#8239;25&#41; of patients from group B&#46; Mesial temporal sclerosis was found in one patient from group A &#40;1&#46;6&#37;&#41; and in none of the patients in group B&#46; Statistically significant differences &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&#41; were observed between groups in neuroimaging results&#46; Temporal lobe involvement was observed in 25&#46;6&#37; &#40;n&#8239;&#61;&#8239;13&#41; of patients in group A and 18&#37; &#40;n&#8239;&#61;&#8239;17&#41; of patients in group B&#46; Only 10&#46;3&#37; &#40;n&#8239;&#61;&#8239;5&#41; of patients in group A presented parietal lobe involvement&#44; as compared to 24&#37; &#40;n&#8239;&#61;&#8239;9&#41; of patients in group B&#46; Basal ganglia involvement was observed in 28&#46;2&#37; of group A patients and 38&#37; of group B patients&#46; Again&#44; the differences between the 2 groups were statistically significant &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;003&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Awake EEG revealed no alterations in 27&#46;9&#37; &#40;n&#8239;&#61;&#8239;17&#41; of group A patients and 40&#46;3&#37; &#40;n&#8239;&#61;&#8239;25&#41; of group B patients&#46; Abnormalities were generalised in 8&#46;2&#37; &#40;n&#8239;&#61;&#8239;5&#41; of group A patients and 6&#46;5&#37; &#40;n&#8239;&#61;&#8239;4&#41; of group B patients&#44; and focal in 26&#46;2&#37; &#40;n&#8239;&#61;&#8239;16&#41; of group A patients and 14&#46;5&#37; &#40;n&#8239;&#61;&#8239;9&#41; of group B patients&#44; although these differences were not statistically significant&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The aetiology of epilepsy was unknown in 44&#46;3&#37; &#40;n&#8239;&#61;&#8239;27&#41; of group A patients and 11&#46;3&#37; &#40;n&#8239;&#61;&#8239;7&#41; of group B patients&#46; The most frequent aetiology in group B was vascular&#44; accounting for 74&#46;2&#37; &#40;n&#8239;&#61;&#8239;46&#41; of patients&#44; vs 18&#37; &#40;n&#8239;&#61;&#8239;11&#41; of patients in group A&#46; Interestingly&#44; post-anoxic epilepsy and epilepsy secondary to lesions compatible with intraparenchymal tumour were observed in 9&#46;8&#37; and 14&#46;8&#37; of group A patients&#44; respectively&#44; but were rarely observed in group B patients &#40;0&#37; and 4&#46;8&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&#41;&#46; <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> present detailed information on epilepsy aetiology in our sample&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The main comorbidities observed in both groups were arterial hypertension &#40;42&#46;6&#37; in group A vs 74&#46;2&#37; in group B&#41;&#44; history of ischaemic stroke &#40;19&#46;7&#37; vs 51&#46;6&#37;&#41;&#44; history of haemorrhagic stroke &#40;4&#46;9&#37; vs 11&#46;3&#37;&#41;&#44; dyslipidaemia &#40;57&#46;4&#37; vs 50&#37;&#41;&#44; diabetes mellitus &#40;8&#46;2&#37; vs 24&#46;2&#37;&#41;&#44; cognitive impairment &#40;8&#46;2&#37; vs 17&#46;7&#37;&#41;&#44; and psychiatric disorders &#40;23&#37; vs 6&#46;5&#37;&#41;&#46; Further information on risk factors is provided in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 3</a>&#46; We observed statistically significant differences between groups in the prevalence of ischaemic stroke &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;003&#41;&#44; cognitive impairment &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;045&#41;&#44; psychiatric disorders &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;027&#41;&#44; and diabetes mellitus &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;016&#41;&#46; However&#44; after application of the Bonferroni correction&#44; we only found significant inter-group differences in hypertension&#44; ischaemic stroke&#44; and age &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients from both groups were classified according to the degree of dependence&#44; as measured with the modified Rankin Scale &#40;mRS&#41;&#58; mRS 0&#8722;2 &#40;no or minimal disability&#44; able to perform daily living activities&#41;&#44; mRS 3&#8722;4 &#40;moderate or moderate-to-severe disability&#41;&#44; and mRS 5 &#40;severe disability&#41;&#59; statistically significant differences were observed between groups &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#61;&#8239;&#46;016&#41;&#44; but the post hoc test did not detect significant differences&#46; Our results are summarised in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 3</a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Regarding seizure frequency&#44; 78&#46;3&#37; &#40;n&#8239;&#61;&#8239;47&#41; of group A patients and 74&#46;2&#37; &#40;n&#8239;&#61;&#8239;46&#41; of group B patients had presented no seizures during the 3 months prior to study inclusion&#46; More group B patients than group A patients presented 2 or fewer seizures during that period &#40;93&#46;5&#37; &#91;n&#8239;&#61;&#8239;58&#93; vs 90&#37; &#91;n&#8239;&#61;&#8239;54&#93;&#41;&#44; although this difference was not significant&#46; History of status epilepticus was more frequent in group A &#40;16&#46;1&#37; &#91;n&#8239;&#61;&#8239;10&#93;&#41; than in group B &#40;1&#46;6&#37; &#91;n&#8239;&#61;&#8239;1&#93;&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Seizures were more easily managed with a single AED in group B &#40;59&#46;7&#37; &#91;n&#8239;&#61;&#8239;37&#93;&#41; than in group A &#40;16&#46;4&#37; &#91;n&#8239;&#61;&#8239;10&#93;&#41;&#46; Similarly&#44; the proportion of patients requiring 3 AEDs was significantly higher in group A &#40;18&#37; &#91;n&#8239;&#61;&#8239;11&#93;&#41; than in group B &#40;16&#46;1&#37; &#91;n&#8239;&#61;&#8239;10&#93;&#41; &#40;<span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&#41;&#46; The AEDs most frequently used in group A were levetiracetam&#44; oxcarbazepine&#44; carbamazepine&#44; and valproic acid&#44; and the best tolerated were lacosamide&#44; levetiracetam&#44; zonisamide&#44; and clobazam&#46; In group B&#44; in turn&#44; the most frequently used AEDs were levetiracetam&#44; valproic acid&#44; lacosamide&#44; and lamotrigine&#44; and the best tolerated were eslicarbazepine&#44; zonisamide&#44; levetiracetam&#44; and lacosamide&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> show data on AED use in each group&#46; Group B patients used lower doses than group A patients&#44; although differences are not significant&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Epilepsy is frequent in adult patients&#59; its incidence increases with age and is linked to increased incidence of other diseases that can cause epilepsy&#44; particularly tumours&#44; ischaemic or haemorrhagic stroke&#44; and dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Our results show that age in itself is a risk factor for epilepsy in old age&#46; In patients developing epilepsy at younger ages &#40;&#60; 65 years&#41;&#44; the condition may be associated with idiopathic generalised epilepsy&#44; malformations of cortical development&#44; post-anoxic episodes during prenatal development or delivery&#44; and mesial temporal sclerosis&#44; among other aetiologies&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Our study compared 2 groups of elderly patients with epilepsy&#58; those presenting epilepsy before the age of 65 years&#44; and those developing the condition at 65 years of age or older&#46; Hesdorffer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> estimate the risk of status epilepticus in elderly patients at 0&#46;4&#37; at age 75 years&#59; subsequent studies report an incidence rate of 86 cases per 100&#8239;000 population among elderly people&#44; with an upward trend&#44; reaching 100 cases per 100&#8239;000 population among individuals aged 70&#8211;79 years&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In our study&#44; only one patient from group B presented history of status epilepticus&#44; whereas group A included several cases&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The study by Stefan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> established 3 groups according to age of epilepsy onset&#58; onset at ages 50&#8211;65&#44; onset after age 65 years&#44; and onset at ages 18&#8211;50 years&#46; The first 2 groups showed a higher incidence of focal seizures &#40;26&#46;9&#37; and 21&#46;5&#37;&#44; respectively&#41; than groups A and B from our study &#40;10&#37; and 14&#37;&#44; respectively&#41;&#46; The prevalence of focal impaired awareness seizures was 64&#46;2&#37; and 48&#46;1&#37; in the first 2 groups from the study by Stefan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> compared to 41&#37; and 53&#37; in groups A and B from our study&#46; However&#44; the percentage of patients with generalised tonic-clonic seizures was lower in our group B than in the study by Stefan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> &#40;15&#37; vs 46&#46;8&#37;&#41;&#44; in line with the data reported by Hughes and Zialcita<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> in 1999&#46; We recommend classifying patients into 2 single age groups to better assess disease progression and the associated comorbidities&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">As expected&#44; a high percentage of patients from group A showed no alterations on neuroimaging studies&#44; as compared to group B&#46; This finding was associated with a higher frequency of idiopathic epilepsy in group A&#46; Likewise&#44; group B patients more frequently displayed focal lesions &#40;especially due to stroke or trauma&#41;&#44; which may have a direct causal role in the aetiology of epilepsy&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Our results on the frequency of comorbidities in both groups are noteworthy&#46; This information is crucial for better understanding of this type of population with a view to optimising treatment&#46; These patients present a high incidence of cardiovascular risk factors&#44; mainly arterial hypertension&#44; diabetes mellitus&#44; and dyslipidaemia&#59; the latter is the most frequent risk factor among patients with epilepsy onset before the age of 65 years&#46; This may be explained by the AEDs used for epilepsy management in this population&#44; which may increase cardiovascular risk and&#44; as a result&#44; the incidence of brain lesions causing epilepsy&#46; In fact&#44; history of ischaemic stroke was found to be much more prevalent in both groups than history of haemorrhagic stroke&#44; and it was twice as frequent in group B as in group A&#44; representing the most frequent aetiology of epilepsy in the elderly population&#46; We should also mention the large number of patients with cognitive impairment in group B&#46; In contrast&#44; psychiatric comorbidities were more frequent among patients with epilepsy onset before 65 years of age&#46; A small subgroup of patients &#40;more numerous in group A than in group B&#41; were diagnosed with sleep apnoea-hypopnoea syndrome&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">These patients require comprehensive management&#44; considering not only epilepsy and the associated comorbidities but also cognitive function and independence&#46; Previous studies have not analysed patients&#8217; degree of dependence&#46; In our study&#44; group B patients exhibited a higher degree of dependence&#46; The literature includes extensive data on dependence in this population group&#46; Optimising independence and preventing new seizures may help prevent falls&#44; bone fractures&#44; hospitalisation&#44; and early admission to nursing homes&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Regarding epilepsy treatment&#44; marked differences were found between groups in the number of AEDs used&#58; 16&#46;4&#37; &#40;n&#8239;&#61;&#8239;10&#41; of patients in group A received a single AED&#44; compared to 59&#46;7&#37; &#40;n&#8239;&#61;&#8239;37&#41; of patients in group B&#46; Furthermore&#44; doses were lower in group B&#46; However&#44; in a study published by Tanaka et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> in 2013&#44; the doses administered to elderly patients with epilepsy were considerably lower than in our study&#46; Unlike in the study by Phabphal et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and in line with the evidence reported by Stefan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> we found a clear preference for new-generation AEDs to minimise the risk of adverse reactions&#46; We gathered data not only on the AEDs used but also on drug and treatment discontinuation&#46; Although insufficient evidence is available&#44; our data suggest that new-generation AEDs are better tolerated&#44; even at relatively high doses&#44; as they present fewer drug interactions and a better biopharmacokinetic profile&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In the light of the above&#44; presence of comorbidities associated with epilepsy should be assessed before prescribing an AED&#46; A sizeable percentage of patients with epilepsy present cardiovascular risk factors&#59; certain AEDs may directly or indirectly increase the risk of cardiovascular events&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Wherever possible&#44; we should avoid prescribing AEDs that may cause such psychiatric symptoms as depression or psychosis to patients with mental disorders&#44; in order to avoid exacerbating the underlying psychological conditions and to ensure proper adherence to antiepileptic treatment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Our study has several limitations&#46; The patients included were attended at our centre&#8217;s epilepsy unit&#44; which may have resulted in selection bias&#44; as these patients may be particularly refractory to treatment&#46; Furthermore&#44; data were obtained retrospectively by reviewing medical records&#46; Further studies with larger samples should be conducted to gather more information about epilepsy in this population group&#44; as the incidence and the burden of the condition on the healthcare system is increasing&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Funding</span><p id="par0140" class="elsevierStylePara elsevierViewall">This study has received no specific funding from any public&#44; private&#44; or non-profit organisation&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Epilepsy is most frequent in children and elderly people&#46; Today&#8217;s population is ageing and epilepsy prevalence is increasing&#46; The type of epilepsy and its management change with age&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective&#44; observational study comparing patients aged&#8239;&#8805;&#8239;65 years with epilepsy diagnosed before and after the age of 65&#44; and describing epilepsy characteristics and comorbidities in each group&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The sample included 123 patients&#44; of whom 61 were diagnosed at&#8239;&#60;&#8239;65 years of age &#40;group A&#41;&#44; 62 at&#8239;&#8805;&#8239;65 of age &#40;group B&#41;&#46; Sex distribution was similar in both groups&#44; with 39 men &#40;62&#46;9&#37;&#41; in group A and 37 &#40;60&#46;7&#37;&#41; in group B&#46; Mean age was 69&#46;97&#8239;&#177;&#8239;5&#46;6 years in group A and 77&#46;29&#8239;&#177;&#8239;6&#46;73 in group B&#46; The most common aetiology was cryptogenic in group A &#40;44&#46;3&#37;&#44; n&#8239;&#61;&#8239;27&#41; and vascular in group B &#40;74&#46;2&#37;&#44; n&#8239;&#61;&#8239;46&#41;&#46; History of stroke was present in 12 patients from group A &#40;19&#46;7&#37;&#41; and 32 &#40;51&#46;6&#37;&#41; in group B&#46; Antiepileptic drugs were prescribed at lower doses in group A&#46; Statistically significant differences were found between groups for history of ischaemic stroke&#44; cognitive impairment&#44; psychiatric disorders&#44; and diabetes mellitus&#59; degree of dependence&#59; and number of antiepileptic drugs&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Age of onset&#8239;&#8805;&#8239;65 years is closely related to cardiovascular risk factors&#59; these patients require fewer antiepileptic drugs and respond to lower doses&#46; Some cases initially present as status epilepticus&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La epilepsia afecta m&#225;s frecuentemente a ni&#241;os y personas ancianas&#46; La edad media de la poblaci&#243;n est&#225; aumentando al igual que la prevalencia de la epilepsia&#46; El tipo de epilepsia y su manejo cambia con la edad&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Presentamos un estudio observacional retrospectivo en el que comparamos pacientes epil&#233;pticos mayores de 65 a&#241;os&#44; con diagn&#243;stico de epilepsia antes y despu&#233;s de los 65 a&#241;os&#46; Estudiamos las caracter&#237;sticas de la epilepsia de estos pacientes y las comorbilidades&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Incluimos 123 pacientes&#44; 61 fueron diagnosticados de epilepsia antes de los 65 a&#241;os &#40;grupo A&#41; y 62 despu&#233;s de los 65 &#40;grupo B&#41;&#46; La distribuci&#243;n en cuanto al g&#233;nero fue similar en ambos grupos&#44; en el A fueron hombres el 62&#44;9&#37; &#40;N&#8239;&#61;&#8239;39&#41; y 60&#44;7&#37; &#40;N&#8239;&#61;&#8239;37&#41; en el B&#46; La edad media fue 69&#44;97&#8239;&#177;&#8239;5&#44;6 a&#241;os en el A y 77&#44;29&#8239;&#177;&#8239;6&#44;73 en el B&#46; La etiolog&#237;a m&#225;s prevalente fue desconocida en el A &#40;44&#44;3&#37;&#44; N&#8239;&#61;&#8239;27&#41; y estructural en el B &#40;74&#44;2&#37;&#44; N&#8239;&#61;&#8239;46&#41;&#46; Se hallaron antecedentes de ictus en el 19&#44;7&#37; &#40;N&#8239;&#61;&#8239;12&#41; en el A y 51&#44;6&#37; &#40;N&#8239;&#61;&#8239;32&#41; en el B&#46; La dosis de f&#225;rmacos antiepil&#233;pticos fue menor en el grupo B&#46; Se encontraron diferencias estad&#237;sticamente significativas entre los grupos respecto al antecedente de ictus isqu&#233;mico&#44; deterioro cognitivo&#44; enfermedades psiqui&#225;tricas&#44; diabetes mellitus&#44; grado de dependencia y n&#250;mero de f&#225;rmacos antiepil&#233;pticos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La epilepsia que se inicia despu&#233;s de los 65 a&#241;os tiene una estrecha relaci&#243;n con factores de riesgo cardiovascular&#44; precisa para su control un menor n&#250;mero de f&#225;rmacos y dosis m&#225;s bajas&#44; aunque en algunos casos puede iniciarse con estatus epil&#233;ptico&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
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        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Please cite this article as&#58; Suller Marti A&#44; Bellosta Diago E&#44; Vinueza Buitron P&#44; Vel&#225;zquez Benito A&#44; Santos Lasaosa S&#44; Mauri Llerda J&#193;&#46; Epilepsia en el anciano&#58; &#191;la edad de inicio marca la diferencia&#63; Neurolog&#237;a 2022&#59;37&#58;171&#8211;177&#46;</p>"
      ]
    ]
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      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 983
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            "Tamanyo" => 111896
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Number of elderly patients in groups A &#40;disease onset before 65 years of age&#41; and B &#40;onset at or after 65 years&#41; in whom different antiepileptic drugs were tried and who continued treatment with these drugs &#40;results are expressed as absolute numbers&#41;&#46; Mean doses &#40;mg&#47;24&#8239;h&#41; with standard deviations and ranges &#40;mg&#47;24&#8239;h&#41; are also indicated&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CBZ&#58; carbamazepine&#59; CLB&#58; clobazam&#59; ESL&#58; eslicarbazepine&#59; GBT&#58; gabapentin&#59; LCS&#58; lacosamide&#59; LEV&#58; levetiracetam&#59; LTG&#58; lamotrigine&#59; OXC&#58; oxcarbazepine&#59; PB&#58; phenobarbital&#59; PGB&#58; pregabalin&#59; PHT&#58; phenytoin&#59; PRM&#58; primidone&#59; RFN&#58; rufinamide&#59; TPM&#58; topiramate&#59; VPA&#58; valproic acid&#59; ZNS&#58; zonisamide&#46;</p>"
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      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">M&#58; men&#59; mRS&#58; modified Rankin Scale&#59; SAHS&#58; sleep apnoea-hypopnoea syndrome&#59; SD&#58; standard deviation&#59; W&#58; women&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group A &#40;onset before age 65 years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Group B &#40;onset at or after age 65 years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">No&#46; patients&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Sex</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&#58; 37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">60&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">M&#58; 39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">62&#46;9&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;80&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">W&#58; 24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">W&#58; 23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">37&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mean age &#40;SD&#41;&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">69&#46;97 &#40;5&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">77&#46;29 &#40;6&#46;73&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mean age at epilepsy diagnosis &#40;SD&#41;&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">43&#46;79 &#40;20&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">73&#46;05 &#40;6&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;range&#44; 0-64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#40;range&#44; 65-92&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Mean disease duration &#40;SD&#41;&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3-4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Ischaemic stroke</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Haemorrhagic stroke</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Arterial hypertension</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mesial temporal sclerosis&nbsp;\t\t\t\t\t\t\n
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos