Poverty Tied to Poor Cognition in Patients With Epilepsy

ORLANDO — Older people with epilepsy who live in deprived neighborhoods with lower socioeconomic status, fewer educational opportunities, and less access to health care have poorer memory, executive function, and processing speed than those living in more affluent areas, early research suggests.

Dr Anny Reyes

Seniors with epilepsy present with multiple comorbidities, including, for example, hypertension and diabetes, and they're at increased risk of developing dementia, study investigator Anny Reyes, PhD, University of California at San Diego, told Medscape Medical News.

Past research has shown neighborhood disadvantage is associated with numerous adverse health outcomes, including an increased risk for developing Alzheimer's disease and related dementias (ADRD).

"We already know epilepsy on its own increases risks for dementia, and when you add disadvantaged to that, it's going to increase the risk even more," said Reyes.

Neurologists should ask their older epilepsy patients, many of whom live alone, about food insecurity and access to resources "not just within the hospital system but also within their community," she said.

The findings were presented at the American Epilepsy Society (AES) 2023 annual meeting.

Proxy Measure of Disadvantage

The incidence and prevalence of epilepsy increases with age. Older adults represent the fastest growing segment of individuals with epilepsy, said Reyes.

The new study included 40 patients with focal epilepsy, average age 67 years, from three areas: San Diego, California; Madison, Wisconsin; and Cleveland, Ohio.

Researchers collected clinical and sociodemographic information as well as vascular biomarkers. They also gathered individual-level data, including income, parental education levels, details on childhood upbringing, etc.

Using residential addresses, investigators determined the area deprivation index (ADI) value for study participants. The ADI is a proxy measure for neighborhood-level socioeconomic disadvantage that captures factors such a poverty, employment, housing, and education opportunities.

ADI values range from 1 to 10, with a higher number indicating greater neighborhood disadvantage. About 30% of the cohort had an ADI decile greater than 6.

Researchers divided subjects into Most Disadvantaged (ADI greater than 7) and Least Disadvantaged (AD 7 or less). The two groups were similar with regard to age, education level, and race/ethnicity.

But those from the most disadvantaged areas were younger, taking more anti-seizure medications, had fewer years of education, lower levels of father's education, less personal and family income, and were less likely to be diagnosed with hypertension.

Study subjects completed neuropsychological testing, including:

Measures of learning (Rey Auditory Verbal Learning Test [RAVLT] Learning Over Trials; Wechsler Memory Scale 4th Edition [WMS-4] Logical Memory [LM] Story B immediate; and WMS-4 Visual Reproduction [VR] immediate)
Memory (RAVLT delayed recall, WMS-4 LM delayed recall, and WMS-4 VR delayed recall)
Language (Multilingual Naming Test, Auditory Naming Test, and animal fluency)
Executive function/processing speed (Letter fluency and Trail-Making Test Parts A and B)

The study found a correlation between higher ADI (most disadvantaged) and poorer performance on learning (Spearman rho: -0.433; 95% CI -0.664 to -0.126; P = .006), memory (r = -0.496; 95% CI -0.707 to -0.205; P = .001), and executive function/processes speed (r = -0.315; 95% CI -0.577 to 0.006; P = .048), but no significant association with language.

Looking at individual-level data, the study found memory and processing speed "were driving the relationship, and again, patients had worse performance when they were coming from the most disadvantaged neighborhoods," said Reyes.

The investigators also examined mood, including depression and anxiety and subjective complaints of cognitive problems. "We found those patients residing in the most disadvantaged neighborhoods complained more about memory problems," she said.

The results underscore the need for community-level interventions "that could provide resources in support of these older adults and their families and connect them to services we know are good for brain health," said Reyes.

Alzheimer's disease experts "have done a really good job of this, but this is new for epilepsy," she added. "This gives us a great opportunity to kind of bridge the worlds of dementia and epilepsy."

Novel Research

Commenting for Medscape Medical News, Rani Sarkis, MD, assistant professor of neurology, Brigham and Women's Hospital, Boston, said the study is "very useful" as it ties social determinants of health to cognition.

"We have not been doing that" in people with epilepsy, he said.

The study, one of the first to look at the link between disadvantaged neighborhoods and cognitive impairment, "has very important" public health implications, including the need to consider access to activities that promote cognitive resilience and other brain health initiatives, said Sarkis.

Another larger study that looked at neighborhood deprivation and cognition in epilepsy was also presented at the AES meeting and published earlier this year in the journal Neurology.

That study included 800 patients with pharmaco-resistant temporal lobe epilepsy being evaluated for surgery at the Cleveland Clinic, mean age about 38 years. It examined numerous cognitive domains as well as depression and anxiety in relation to ADI generated by patient addresses and split into quintiles from least to most disadvantaged.

Dr Robyn Busch

After controlling for covariants, the study found scores for all cognitive domains were significantly worse in the most disadvantaged quintile except for executive function, which was close to reaching significance (P = .052), lead author Robyn M. Busch, PhD, a clinical neuropsychologist in the Epilepsy Center, Department of Neurology, Cleveland Clinic, told Medscape Medical News.

The study also found people in the most disadvantaged areas had more symptoms of depression and anxiety compared with people in the least disadvantaged areas, said Busch.

A Complex Issue

Although the exact mechanism tying disadvantaged areas to cognition in epilepsy isn't fully understood, having less access to healthcare and educational opportunities, poor nutrition, and being under chronic stress "are all things that affect the brain," said Busch.

"This is super complex and it's going to be really difficult to tease apart, but we'd like to look at imaging data to see if it's something structural, if there are functional changes in the brain or something that might help us understand this better."

But it's also possible that having epilepsy "might be pushing people into environments" that offer fewer employment and educational opportunities and less access to resources, she said.

The study authors and Sarkis report no relevant financial relationships.

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