Epilepsy Research 139 (2018) 107–112

Contents lists available at ScienceDirect

Epilepsy Research
journal homepage: www.elsevier.com/locate/epilepsyres

An update on the prevalence and incidence of epilepsy among older adults T

a,⁎ a b c,d b,e
Queeny Ip , Daniel C. Malone , Jenny Chong , Robin B. Harris , David M. Labiner
a
Department of Pharmaceutical Sciences, College of Pharmacy, University of Arizona, 1295 N. Martin Ave, Campus PO Box: 210202, Tucson, AZ, 85721, USA
b
Department of Neurology, College of Medicine, University of Arizona, 1501 N Campbell Ave, Tucson, AZ, 85724-5023, USA
c
Epidemiology and Biostatistics Department, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave, Campus PO Box: 245211
Drachman Hall, Tucson, AZ, 85724, USA
d
Arizona Cancer Center, University of Arizona, 1515 N. Campbell Ave, Tucson, AZ, 85724, USA
e
Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, 1295 N. Martin PO Box 210202, Tucson, AZ, 85721, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To estimate the prevalence and incidence of epilepsy among beneficiaries of Arizona Medicare aged
Epilepsy 65 and over.
Incidence Methods: An analysis of Medicare administrative claims data for 2009–2011 for the State of Arizona was con-
Prevalence ducted. Epilepsy was defined as a beneficiary who had either ≥ one claim with diagnostic code of 345.xx
Comorbidities
(epilepsy) or at least two claims with diagnosis code of 780.3x (seizure) ≥30 days apart. Stroke-related and
Medicare
psychiatric comorbidities were determined by diagnostic codes. Average annual prevalence and incidence were
calculated and stratified by demographic characteristics and comorbidities. Odds ratios (OR) and 95% con-
fidence intervals (CI) were calculated as measures of effect for prevalence and incidence and the chi-square
statistic was calculated to compare the proportions of epilepsy cases with and without comorbidities
(alpha = 0.05).
Results: The overall average annual prevalence and incidence over the study period was 15.2/1000 and 6.1/
1000, respectively. Relative to the 65–69 age group and White beneficiaries, the highest prevalence was ob-
served for beneficiaries 85 years or older (19.8/1000, OR 1.66, 95% CI 1.53–1.81) and Native Americans (21.2/
1000, OR 1.42, 95% CI 1.25–1.62). In contrast, the highest incidence rates were observed for beneficiaries 85
years and older (8.5/1000, OR 1.82, 95% CI 1.60–2.07) and for Black beneficiaries (8.7/1000, OR 1.44, 95% CI
1.12–1.86). The incidence rate for Native Americans was not significantly different from that for White bene-
ficiaries (6.2/1000, OR 1.02, 95% CI 0.81–1.29). More than one quarter of all cases (25.7%) and 31% of incident
cases had either stroke-related and/or psychiatric comorbidities (all p-values < 0.001).
Conclusions: Epilepsy is a significant neurological disease among Medicare beneficiaries 65 years and older.
Beneficiaries aged 85 and older and Black and Native Americans experienced higher rates of epilepsy than other
demographic subgroups compared to White beneficiaries.

1. Introduction
Epilepsy is one of the more common neurologic disorders in the
United States (US) and is the third most common for older age groups
(Hirtz et al., 2007; Werhahn 2009). The risk for developing epilepsy is
high in the very young (< 1 year), decreases by age 20, and drastically
increases starting at the age of 60 (Hesdorffer et al., 2011). Across the
lifespan, epilepsy is most common among individuals aged 75 and older
(Cloyd et al., 2006). As a chronic disease, epilepsy is associated with
substantial morbidity and mortality.
A previous study of older Medicare beneficiaries from 2001 to 2005
reported the average annual prevalence to be10.8 per 1000 and
incidence rate to be 2.4 per 1000 (Faught et al., 2012). More recent
estimates seem to indicate an increase in the prevalence of epilepsy.
Among low-income elderly, the 2009 prevalence of epilepsy was esti-
mated to be 19.3 per 1000 (Tang et al., 2015). Using data from the US
National Health Interview Survey (NHIS) 2010 for 65 years and over,
the prevalence of epilepsy was reported to be 13 per 1000 (CDC 2012).
Another study among the commercially insured US population, in-
cluding those with Medicare supplemental insurance paid by em-
ployers, reported lower prevalence estimates but did note a rise in
prevalence from 2007 to 2011 from 2.7 per 1000 (95% CI 2.65–4.82) to
4.8 per 1000 (95% CI 4.77–4.82) (Helmers et al., 2015). The purpose of
this study is to estimate the prevalence and incidence of epilepsy among

⁎
Corresponding author at: University of Arizona College of Pharmacy, Pharmaceutical Sciences, 1295 N. Martin Ave, Campus PO Box: 210202, Drachman Hall, Tucson, AZ, USA.
E-mail addresses: queenyip@pharmacy.arizona.edu (Q. Ip), malone@pharmacy.arizona.edu (D.C. Malone), jchong@neurology.arizona.edu (J. Chong),
rbharris@email.arizona.edu (R.B. Harris), labinerd@neurology.arizona.edu (D.M. Labiner).

https://doi.org/10.1016/j.eplepsyres.2017.11.022
Received 12 December 2016; Received in revised form 23 October 2017; Accepted 30 November 2017
Available online 05 December 2017
0920-1211/ © 2017 Elsevier B.V. All rights reserved.
Q. Ip et al.
older Medicare beneficiaries using the State of Arizona Medicare claims
data (2009–2011) and to evaluate the impact of comorbidities on these
prevalence and incidence estimates.
2. Material and methods
This study was approved by the Institutional Review Board of the
University of Arizona.
2.1. Data source
Medicare administrative data for the state of Arizona were obtained
from the Centers for Medicare and Medicaid Services. The data con-
tained claims made by Arizona Medicare beneficiaries enrolled in fee-
for-service Medicare from 2009 to 2011. Diagnostic information from
inpatient and outpatient files, along with demographic information
from the master summary files, were extracted since the use of both
inpatient and outpatient administrative claims have been shown to
enhance the validity of epilepsy case ascertainment (Reid et al., 2012;
Thurman et al., 2011).
2.2. Inclusion criteria
Similar to a previous study by Faught et al., the following inclusion
criteria were used: 1) enrolled in fee-for-service (FFS), and 2) enrolled
in Medicare as a result of being age-qualified (≥65 years of age), and 3)
enrolled in Medicare Part A and Part B for 12 consecutive months in the
year of enrollment. These criteria excluded Medicare Advantage (MA)
beneficiaries and those who qualified for Medicare due to disability or
end-stage renal disease. Encounter data for Medicare Advantage (MA)
beneficiaries were not captured in the Medicare utilization files and
those with disability or end-stage disease may have very different dis-
ease burden and other characteristics comparing to Medicare bene-
ficiaries enrolled strictly by age.
2.3. Definition of epilepsy cases
The International League Against Epilepsy’s “Practical Clinical
Definition of Epilepsy” defined epilepsy as a condition characterized by
any of the following conditions: (1) diagnosis of epilepsy; (2) at least
two unprovoked seizures occurring > 24 h apart; (3) one unprovoked
seizure with at least 60% probability of further seizures over the next
ten years (Fisher et al., 2014). In this current study, epilepsy cases were
identified as having any of the following International Classification of
Disease-Version 9-Clinical Modification (ICD 9-CM) diagnostic codes
recorded on encounter claims: At least one ICD 9-CM 345.xx (epilepsy),
or at least two ICD 9-CM 780.3x (seizure) claims occurring at least
30 days apart. The 30-day minimum eliminated those with acute
symptomatic seizures caused by transient conditions (Faught et al.,
2012). Cases with two ICD 9-CM 780.3x claims that crossed over two
calendar years were not included because these cases were expected to
be captured by an eventual ICD 9-CM 345.xx (epilepsy) code. Referring
back to the first two definitions of epilepsy, if two unprovoked seizures
occurring > 24 h apart characterize an epilepsy diagnosis, one would
expect an ICD 9-CM 345.xx (epilepsy) code to follow two ICD 9-CM
780.3x (seizure) codes. Beneficiaries with the third definition of epi-
lepsy were not included because the determination of the probability of
further seizures over the next ten years was not feasible due to the
limited data.
2.4. Prevalent case definition
A prevalent case was identified as an eligible beneficiary having a
diagnostic code definition for epilepsy during the study time period.
Prevalent cases were identified for each of the individual years,
2009–2011.
108
Epilepsy Research 139 (2018) 107–112
2.5. Incident case definition
Incident cases were subsets of the prevalent cases with the addi-
tional requirement for evidence of the event being a new diagnosis of
epilepsy. With the limited timeframe, 2009–2011, incident cases were
identified only for 2010 and 2011. For 2010 incident cases, there must
have been at least one previous epilepsy-free year. For 2011 incident
cases, at least two previous epilepsy-free years were required; in-
dividuals with only one diagnosis of ICD 9-CM 345.xx were excluded
from the incident count for the following reasons. Hauser et al. con-
cluded from their study of recurrent seizure risk that about one-third of
patients with a first unprovoked seizure will have further seizures
within five years compared to approximately 75% of those with two or
three unprovoked seizures will have further seizures within four years
(Hauser et al., 1998). Hauser et al.’s discovery of exponential increase
in seizure risk starting from the second seizure indicates that a new case
would first present as a seizure episode coded as ICD 9-CM 780.3x and
the diagnosis of epilepsy coded as ICD 9-CM 345.xx eventually follows.
Furthermore, not all patients with epilepsy seek medical follow-up, a
single diagnostic code of epilepsy of ICD 9-CM 345.xx would not be an
accurate representation of a new case unless there is a very long pre-
ceding period of enrollment with no recorded seizure (ICD 9-CM
780.3x) or epilepsy (ICD 9-CM 345.xx) (Thurman et al., 2011).
2.6. Identification of other risk factors
Presence of stroke-related comorbidities of cerebral thrombosis,
transient cerebral ischemia, and cerebrovascular disease were identified
by claims for ICD 9-CM codes, 434.xx, 435.xx, and 436.xx respectively.
The term, stroke can be used interchangeably with stroke syndrome,
cerebral vascular accident, and cerebrovascular accident (Keane, 2003)
and can be indicated by numerous ICD 9-CM codes. Our choice of ICD
9-CM codes for defining stroke-related comorbidities was selected to
identify specific conditions associated with epilepsy. Psychiatric co-
morbidities included depression, anxiety, psychosis, and mood disorder
and were identified by the ICD-9-CM codes of 311.xx, 300.xx, 295.xx,
and 296.xx respectively. Demographic and geographic characteristics of
the beneficiaries were obtained from the Medicare beneficiary files age,
sex, race, and county of residence.
2.7. Analysis
Prevalence was estimated for each specific year as the number of
prevalent cases per 1000 eligible beneficiaries. The denominator for
each year was the number of beneficiaries who met inclusion criteria in
that year. The average annual prevalence was calculated from the
average prevalence of the three specific years. Incidence was estimated
as the number of incident cases per number of beneficiaries at risk of
being diagnosed with epilepsy for the first time. This population at risk
excluded beneficiaries previously identified as cases. Incidence rates for
2010 and 2011 were separately calculated as well as the average annual
incidence rate. Both incidence and prevalence estimates were calcu-
lated for the total population and various demographic subgroups.
Because epilepsy is a rare disease in this population, the odds ratios
(ORs) were used to estimate relative risk for both incidence and pre-
valence comparisons between the demographic characteristics. The
frequency estimates (i.e. percentage of cases with comorbidities) were
compared using the chi square statistic.
To contrast the association of the presence of comorbidities with
incidence and prevalence of epilepsy, we pooled the prevalence popu-
lation for years 2009–2011 and incidence cohorts of 2010 and 2011.
The proportions of epilepsy cases and non-cases with stroke-related and
psychiatric comorbidities were compared separately for both popula-
tion groups using the Chi-square test. Odds ratios (OR) and 95% con-
fidence intervals (CI) were calculated to estimate the effect between the
prevalence and incidence of epilepsy among demographic groups and
Q. Ip et al. Epilepsy Research 139 (2018) 107–112

the proportion of cases with comorbidities. The ORs were crude (un- Table 1
adjusted) and were generated from contingency table analysis while the Characteristics of Medicare Epilepsy Prevalence and Incidence population (2009–2011).
95% CIs were estimated using the standard formula (Plichta et al.,
Prevalence Incidence
2013). An alpha value of 0.05 was the significance level considered for
all statistical tests. Analyses were generated using SAS software 9.4. Total Cases Total Cases
Copyright, SAS Institute Inc. SAS and all other SAS Institute Inc. pro- (n) 456,363 11,967 425,056 4895
duct or service names are registered trademarks or trademarks of SAS
Age (%)
Institute Inc., Cary, NC, USA. 65–69 31.7 21.0 27.2 18.7
70–74 24.4 23.0 26.1 23.8
2.8. Sensitivity analyses 75–79 17.8 20.0 18.8 19.7
80–84 13.4 17.5 14.2 18.0
85 and over 12.7 18.5 13.7 19.9
To determine robustness of the results, a series of sensitivity ana-
lyses were conducted. The first analysis examined the approach for Sex (%)
Female 53.6 55.1 53.8 55.0
calculating the prevalence of epilepsy. The original beneficiary dataset
Male 46.4 44.9 46.2 45.0
included individuals identified as residents and individuals who po-
Race (%)
tentially moved into or out of Arizona during a beneficiary year. We
White 91.9 91.1 91.9 91.7
determined the number of beneficiaries registered within counties of Black 1.8 2.4 1.8 2.5
residence outside of Arizona (i.e. if the beneficiary’s address was in Other 1.0 0.6 1.0 0.7
Arizona in 2009, the beneficiary would be included in the 2010 data Asian and Unknown 0.7 0.4 0.7 0.4
even if the beneficiary had moved out of Arizona by 2010) and ex- Hispanic 1.8 1.8 1.7 1.7
Native American 2.8 3.7 2.9 2.9
cluded them in our estimates. This analysis would estimate the degree
of influence on the original average annual prevalence estimate. County of residence (%)
Apache 1.3 1.2 1.3 1.1
Secondly, we evaluated the impact of having only three years of
Cochise 3.3 3.0 3.4 3.0
data. A previous study using Ohio Medicaid data concluded that a Coconino 2.6 2.3 2.7 2.2
minimum of 3-year epilepsy-free interval is required to identify incident Gila 2.1 1.9 2.1 2.0
cases in administrative data. Their study found a decrease of 10.8% in Graham 0.6 0.5 0.6 0.5
incidence rate from estimates using 2-year epilepsy-free interval com- Greenlee 0.2 0.1 0.2 0.2
La Paz 0.7 0.7 0.7 0.6
pared to estimates using a 1-year epilepsy-free period (4.54–4.05 per Maricopa 47.3 43.7 46.4 42.5
1000 person-years). Using a 3-year epilepsy-free interval resulted in a Mohave 7.0 8.1 6.8 7.7
5.2% decrease in incidence rate from the estimate using a 2-year epi- Navajo 2.3 1.9 2.3 1.7
lepsy-free interval (4.05–3.84 per 1000 person-years) (Bakaki et al., Pima 16.0 16.5 15.6 15.5
Pinal 4.1 4.6 4.0 4.6
2013). Extrapolating a similar loss as shown in the Ohio Medicaid
Santa Cruz 0.6 0.5 0.6 0.4
study, we calculated the possible over-estimation of the average annual Yavapai 7.6 6.8 7.5 6.9
incidence rate. Yuma 3.9 6.0 3.8 6.5
Other (outside of Arizona) 0.5 2.3 2.0 4.5
3. Results

Table 1 presents the characteristics of the study population. A total
of 456,363 individuals were enrolled in Arizona Medicare from 2009 to
2011 and 11,967 individuals met the criteria for having epilepsy with
the average annual prevalence of epilepsy of 15.2 cases per 1000
beneficiaries. In 2010 and 2011, a total of 4895 individuals were
identified as new incident cases among the 425,056 eligible bene-
ficiaries at risk during the time period. The average annual incidence
rate of epilepsy in 2010–2011 was 6.1 per 1000 at risk beneficiaries.
As shown in Table 2, the highest prevalence and incidence were
found in the oldest age group (85 years and older). Native American
beneficiaries had the highest prevalence estimate and Black bene-
ficiaries had the highest incidence rate compared to other racial groups.
Although slightly lower than Native American beneficiaries, the pre-
valence estimate for Black beneficiaries was comparatively high. Black
beneficiaries and those who were 85 years of age and older were the
only groups with incidence rate significantly higher than the reference
groups. Both prevalence and incidence rate for Yuma county and
counties outside of Arizona were significantly different from the re-
ference county of Apache. The odds for being a new epilepsy case in
county of Yuma was more than 2 times that for the reference county of
Apache (OR 2.09, 95% CI 1.39–3.13).
Table 3 compares the frequency of stroke-related and psychiatric
comorbidities among epilepsy cases and non-cases within the pooled
beneficiary groups. Over one quarter of prevalent cases had at least one
stroke-related comorbidity compared to about one for every 20 non-
cases. The proportion of incident cases with stroke-related comorbid-
ities was even more prominent at just under one-third compared to
about one for every 20 non-cases. Examining the presence of stroke-
comorbidities in the total population (Table 4), the highest percentage
of cases were for the age range of 65–69 and for Native American
beneficiaries. For the incident population cohort with stroke-co-
morbidities, the highest percentage of cases was among the younger age
group of 65–74 and in Hispanic beneficiaries. No differences were ob-
served by sex or county of residence.
Similar analyses were performed to examine the presence of psy-
chiatric comorbidities. For the total population (Table 3), over one-
quarter of epilepsy cases and over one for every 11 non-cases had
claims for psychiatric comorbidities. The proportions with psychiatric
comorbidities in the incidence cohort were about one for every three
cases and over one for every 12 non-cases. In the stratified analysis of
psychiatric comorbidities (Table 4), the highest proportion of epilepsy
prevalent or incident cases with psychiatric comorbidities was observed
in the age group of 75–79, male, and beneficiaries residing in Yuma
County (total population: 9.7%, incidence cohort: 4.8%). Black pre-
valent cases had the highest proportion with psychiatric comorbidities.
The proportion of incident cases with psychiatric comorbidities was
slightly higher for Hispanic beneficiaries in comparison to Black ben-
eficiaries.
3.1. Sensitivity analyses
Several sensitivity analyses evaluated the robustness of the results.
The first analysis evaluated the effect of inclusion of potential non-
Arizona residents in the analyses. After excluding persons not perma-
nently residing in Arizona from the dataset, the annual prevalence es-
timates per 1000 were 14.9 in 2009, 14.7 in 2010, and 15.7 in 2011.
The adjusted average annual prevalence was therefore 15.1 per 1000
which was a 0.7% decrease from our original estimate of 15.2 per 1000.

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Q. Ip et al. Epilepsy Research 139 (2018) 107–112

Table 2 average incidence rate would be 5.4 per 1000, an 11.5% decrease from
Average annual Prevalence and Incidence of epilepsy (per 1000) in Arizona Medicare the original estimate of 6.1 per 1000.
beneficiaries (2009–2011).

Prevalence OR 95% CI Incidence OR 95% CI

Average annual 15.2 – – 6.1 – –
4. Discussion

Age This study indicates that both prevalence and incidence of epilepsy
65–69 12.0 1.00 ref 4.7 1.00 ref are much higher than previous estimates among Medicare beneficiaries
70–74 13.7 1.15 1.06–1.24 5.3 1.15 1.01–1.30
aged 65 and over (Faught et al., 2012). An increase in prevalence over
75–79 15.8 1.32 1.22–1.43 6.1 1.32 1.16–1.50
80–84 18.6 1.56 1.44–1.70 7.5 1.60 1.40–1.82 time has been suggested by other studies (Tang et al., 2015; Helmers
85 and over 19.8 1.66 1.53–1.81 8.5 1.82 1.60–2.07 et al., 2015; CDC 2012). Previous studies have shown the incidence of
Sex epilepsy to be higher after the age of 70 (Hesdorffer et al., 2011); this
Female 15.6 1.00 ref 6.2 1.00 ref concurs with our finding that incidence rates increase as age increases,
Male 14.9 0.95 0.91–1.00 6.0 0.96 0.88–1.04 with the highest incidence among the age group of 85 and over.
Race The highest prevalence observed in this study was for Native
White 15.0 1.00 ref 6.1 1.00 ref American beneficiaries, which was higher than estimates from an ear-
Black 20.8 1.39 1.18–1.64 8.7 1.44 1.12–1.86 lier study among the Navajo (9.2 per 1000) (Parko and Thurman,
Other 9.8 0.65 0.47–0.88 4.2 0.69 0.43–1.10
2009). The current study included data from all Native American
Asian and 9.7 0.64 0.44–0.95 3.7 0.61 0.33–1.14
Unknown beneficiaries in Arizona, not only those who lived on the Navajo re-
Hispanic 16.0 1.07 0.88–1.30 6.5 1.07 0.79–1.46 servation. Furthermore, a significant proportion (19.1%, OR 1.87, 95%
Native American 21.2 1.42 1.25–1.62 6.2 1.02 0.81–1.29 CI 1.50–2.32) of Native Americans who had epilepsy also had stroke-
County of related comorbidities compared to White beneficiaries. Other studies
residence have found both prevalence and incidence to be highest among Black
Apache 15.3 1.00 ref 5.1 1.00 ref beneficiaries (Faught et al., 2012; Tang et al., 2015; Haerer et al. 1986;
Cochise 13.4 0.87 0.67–1.13 5.5 1.08 0.69–1.67
Coconino 12.4 0.81 0.61–1.07 5.0 0.98 0.62–1.55
Hollingsworth et al., 1971). In this study, Black beneficiaries also had
Gila 13.1 0.86 0.64–1.14 5.7 1.11 0.70–1.78 high incidence rate and their prevalence estimate was only slightly
Graham and 12.0 0.78 0.53–1.15 4.8 0.94 0.51–1.74 lower than the estimate for Native American beneficiaries. This finding
Greenlee may be associated with the higher risk for Blacks having a first stroke
La Paz 13.5 0.88 0.60–1.30 5.4 1.05 0.56–1.99
twice the risk for Whites (Prevention March 2015; Hussain et al., 2006;
Maricopa 14.4 0.94 0.76–1.18 5.6 1.09 0.75–1.60
Mohave 17.6 1.16 0.91–1.46 7.1 1.38 0.93–2.06 Faught et al., 2012), leading to an incidence rate higher than that for
Navajo 12.8 0.84 0.63–1.11 4.4 0.86 0.53–1.39 White beneficiaries.
Pima 16.1 1.05 0.84–1.32 6.1 1.19 0.81–1.76 Differences between prevalent or incident cases and non-cases with
Pinal 17.5 1.14 0.89–1.47 7.0 1.38 0.91–2.09 respect to either stroke-related or psychiatric comorbidities support
Santa Cruz 10.6 0.69 0.44–1.07 4.5 0.87 0.43–1.75
Yavapai 13.9 0.91 0.72–1.16 5.6 1.10 0.73–1.64
previous studies: 1) a 60% higher risk of subsequent stroke in stroke
Yuma 21.4 1.40 1.10–1.79 10.6 2.09 1.39–3.13 patients with epilepsy than those without epilepsy (HR = 1.60; 95%
Other (outside of 24.5 1.62 1.26–2.08 10.9 2.14 1.41–3.26 CI = 1.42–1.80) (Wannamaker et al., 2015); 2) epilepsy is often the
Arizona)a result of cerebrovascular or neurodegenerative disease in the elderly
(Werhahn, 2009); 3) there are significant associations between pre-
OR = odds ratio; CI = confidence interval; ref = reference group.
a existing psychiatric disorders and new-onset epilepsy (Martin et al.,
Average prevalence and incident rate based on 2010 and 2011 (no epilepsy case
registered in counties outside of Arizona in 2009). 2014).
The prevalence and incidence rate (19.3 and 7.9 per 1000) of epi-
A second analysis evaluated the robustness of these findings based on lepsy reported by Tang et al. for Arizona low-income elderly were based
having only three years of data to estimate incidence. We first deducted on Arizona Medicaid data (Tang et al., 2015) and their estimates were
beneficiaries registered in counties of residence outside of Arizona. The higher than the current data based on Arizona Medicare data that in-
2010 incidence rate based on a one-year epilepsy-free period without cluded all income levels. Examining the low-income population, Tang
non-Arizona residents was 6.2 per 1000. After subtracting the non- et al. found the highest prevalence and incidence rate in Black bene-
Arizona residents, the 2011 incidence rate based on a two-year epi- ficiaries and in beneficiaries with stroke-related and/or psychiatric
lepsy-free period was 5.8 per 1000. Devising from the estimates from comorbidities. They reported the highest prevalence and incidence rate
the Ohio Medicaid study (Bakaki et al., 2013), the adjusted annual in the younger elderly (65–74 years) and in males (Tang et al., 2015).
incidence rates were 5.2 per 1000 in year 2010 and 5.5 per 1000 in year Our study found the highest prevalence in Native Americans while the
2011 if accounting for a three-year epilepsy free interval. The adjusted highest incidence rate was found in Black beneficiaries, even though
the prevalence among Black beneficiaries was also high. In our study,

Table 3
Comparison of Stroke-related Comorbidities and Psychiatric Comorbidities between Epilepsy Cases and Non-cases.

Total population Incidence cohort

n = 456,363 % P-value n = 425,056 % P-value

Overall number of cases 11,967 – – 4895 – –

Overall number of non-cases 444,396 – – 420,161 – –
Number of cases with SRCa 3076 25.7 < 0.001 1517 31.0 < 0.001
Number of non-cases with SRCa 23,552 5.3 – 23,167 5.5 –
Number of cases with PCb 3128 26.1 < 0.001 1464 29.9 < 0.001
Number of non-cases with PCb 51,476 11.6 – 53,078 12.6 –

a
SRC = stroke-related comorbidities.
b
PC = psychiatric comorbidities.

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Q. Ip et al. Epilepsy Research 139 (2018) 107–112

Table 4
Stratified Analysis of Cases with Stroke-related Comorbidities and Psychiatric Comorbidities in Arizona Medicare Beneficiaries (2009–2011)

With stroke-related comorbidities Total population (n = 26,628) Incidence cohort (n = 24,684)

% OR 95% CI % OR 95% CI

Total cases with SRCa 11.6 – – 6.1 – –

Age
65–69 14.2 1.00 Ref 7.5 1.00 ref
70–74 12.5 0.86 0.76–0.97 6.8 0.91 0.77–1.08
75–79 12.4 0.85 0.76–0.96 6.2 0.81 0.69–0.97
80–84 9.9 0.66 0.59–0.75 5.9 0.78 0.66–0.93
85 and over 9.5 0.63 0.56–0.71 5.1 0.66 0.56–0.78

Sex
Female 11.5 1.00 ref 6.1 1.00 ref
Male 11.6 1.01 0.93–1.09 6.3 1.04 0.93–1.15

Race
White 11.2 1.00 ref 6.0 1.00 ref
Black 16.0 1.51 1.20–1.90 8.7 1.49 1.09–2.03
Asian, Other, Unknown 9.6 0.84 0.60–1.18 6.0 1.00 0.63–1.57
Hispanic 16.4 1.54 1.19–2.00 10.0 1.73 1.24–2.41
Native American 19.1 1.87 1.50–2.32 7.5 1.27 0.91–1.78

With psychiatric comorbidities Total population (n = 54,604) Incidence cohort (n = 54,542)

% OR 95% CI % OR 95% CI

Total cases with PC b

5.7 – – 2.7 – –
Age
65–69 5.5 1.00 ref 2.5 1.00 ref
70–74 5.5 1.01 0.91–1.12 2.6 1.04 0.90–1.21
75–79 6.1 1.12 1.01–1.25 3.0 1.20 1.03–1.40
80–84 6.0 1.10 0.98–1.24 2.9 1.18 1.00–1.39
85 and over 5.7 1.04 0.92–1.16 2.6 1.04 0.88–1.23

Sex
Female 5.4 1.00 ref 2.5 1.00 ref
Male 6.5 1.22 1.13–1.32 3.0 1.19 1.07–1.33

Race
White 5.6 1.00 ref 2.7 1.00 ref
Black 9.0 1.67 1.31–2.13 3.8 1.47 1.01–2.12
Asian, Other, Unknown 5.0 0.88 0.61–1.26 2.0 0.74 0.42–1.31
Hispanic 7.1 1.29 0.99–1.67 4.0 1.52 1.05–2.20
Native American 7.1 1.28 1.03–1.58 2.8 1.04 0.74–1.47

a
SRC = stroke-related comorbidities.
b
PC = psychiatric comorbidities.

the highest prevalence and incidence rate were among the oldest age
category (85 years and over) with no difference between males and
females. More research is required to investigate these relationships
more thoroughly to understand the relationship between epilepsy and
socioeconomic status. Our finding of more than a 2-fold odds for epi-
lepsy in the county of Yuma compared to the reference county of
Apache may serve as a starting point for further investigation in de-
mographic and environmental differences at county level.
4.1. Limitations
There are several limitations that should be considered when in-
terpreting the findings. A limitation of this study is that Medicare eli-
gible patients do not always choose to enroll in Medicare or to use
Medicare services even if they are enrolled. Like other administrative
data, Medicare data may not capture all diagnostic information of its
enrollees. Another consideration is the data were limited to three years
and the results of the sensitivity analysis suggests possible over-esti-
mation of the incidence rates. That said, it should be noted that the
over-estimation methods were based on the findings from a Medicaid
study. Medicare and Medicaid populations are substantially different.
Medicaid programs are the insurance of last resort for the indigent and
include a large number of women and children. The number of bene-
ficiaries enrolled in Medicaid fluctuates month to month because of
eligibility criteria are assessed frequently. Both the prevalence (15.1 per
1000) and the incidence rate (5.4 per 1000) after adjusting for possible
over-estimation in the present study are still higher than what were
reported for the 2003–2005 US Medicare population (10.8 and 2.4 per
1000 respectively) (Faught et al., 2012). One reason could be due to the
sensitivity of detecting cases from the full Arizona Medicare adminis-
trative dataset comparing to 5% sample data. Another reason could be
that Medicare population aged 65 and over in Arizona has higher
prevalence and incidence of epilepsy than the national estimates. It is
also possible that the prevalence and incidence of epilepsy in the older
Medicare population have increased since 2005 as suggested by other
post-2005 studies (Tang et al., 2015; CDC 2012; Helmers et al., 2015).
5. Conclusions
Epilepsy is a chronic disease and can cause substantial health care
burden. During times of health care policy changes, current estimations
of its incidence rate and prevalence can assist in resource allocation. A
better understanding of the epidemiology of epilepsy in the elderly
population is important given the expected increase in the population
of older persons United States (Rice and Feldman 1983; Faught et al.,
2012). Furthermore, an understanding of how the presence of co-
morbidity conditions affects the prevalence and incidence of epilepsy is
needed. Data covering a longer timeframe and a wider geographic areas

111
Q. Ip et al.
are needed to examine: 1) the possibility of geographic variation in
prevalence and incidence in different regions of the United States; 2)
the possibility of over-estimation of epilepsy incidence; 3) the see-
mingly increasing trend of epilepsy prevalence and incidence in the
United States; 4) the temporal relationship between comorbid condi-
tions and epilepsy.
Author disclosures
Queeny Ip, Daniel C Malone, Jenny Chong, Robin B. Harris –
Reports no disclosures David M. Labiner– Received research grants but
no income from Eisai Ltd., Sunovian Pharmaceuticals Inc., Upsher-
Smith Laboratories Inc., Visualase Inc. (Medtronic), and NIH; travel
expenses from American Epilepsy Society and GlaxoSmithKline; hon-
orarium from GlaxoSmithKline donated in its entirety to the University
of Arizona Foundation; less than 10% of his income from the Centers for
Disease Control & Prevention (CDC) research grant
Funding
This work was supported by the grant 1U48DP001925-05S1, funded
by the Centers for Disease Control and Prevention. Its contents are so-
lely the responsibility of the authors and do not necessarily represent
the official views of the Centers for Disease Control and Prevention or
the Department of Health and Human Services.
References
Bakaki, P.M., Koroukian, S.M., Jackson, L.W., Albert, J.M., Kaiboriboon, K., 2013.
Defining incident cases of epilepsy in administrative data. Epilepsy Res. 106,
273–279.
CDC, 2010. Epilepsy in adults and access to care–United States, 2010. MMWR. Morbidity
and Mortality Weekly Report, 909. Centers for Disease Control Prevention.
Cloyd, J., Hauser, W., Towne, A., Ramsay, R., Mattson, R., Gilliam, F., Walczak, T., 2006.
Epidemiological and medical aspects of epilepsy in the elderly. Epilepsy Res.
(Netherlands) 68, 39–48.
Faught, E., Richman, J., Martin, R., Funkhouser, E., Foushee, R., Kratt, P., Kim, Y.,
Clements, K., Cohen, N., Adoboe, D., Knowlton, R., Pisu, M., 2012. Incidence and
prevalence of epilepsy among older U.S. Medicare beneficiaries. Neurology (United
States) 78, 448–453.
Fisher, Robert S., Acevedo, Carlos, Arzimanoglou, Alexis, Bogacz, Alicia, Helen Cross, J.,
Elger, Christian E, Engel, Jerome, Forsgren, Lars, French, Jacqueline A., Glynn, Mike,
2014. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 55,
475–482.
112
Epilepsy Research 139 (2018) 107–112
Haerer, Armin F., Anderson, Dallas W., Schoenberg, Bruce S., 1986. Prevalence and
clinical features of epilepsy in a biracial United States population. Epilepsia 27,
66–75.
Hauser, W.A., Rich, S.S., Lee, J.R., Annegers, J.F., Anderson, V.E., 1998. Risk of recurrent
seizures after two unprovoked seizures. New Engl. J. Med. 338, 429–434.
Helmers, Sandra L., Thurman, David J., Durgin, Tracy L., Kalsanka Pai, Akshatha, Faught,
Edward, 2015. Descriptive epidemiology of epilepsy in the US population: a different
approach. Epilepsia 56, 942–948.
Hesdorffer, D.C., Logroscino, G., Benn, E.K., Katri, N., Cascino, G., Hauser, W.A., 2011.
Estimating risk for developing epilepsy: a population-based study in Rochester,
Minnesota. Neurology 76, 23–27.
Hirtz, D., Thurman, D.J., Gwinn-Hardy, K., Mohamed, M., Chaudhuri, A.R., Zalutsky, R.,
2007. How common are the ‘common’ neurologic disorders? Neurology 68, 326–337.
Hollingsworth, J., Alsikafi, M., Coombs, D., 1971. The Prevalence of the Development
Disabilities in Alabama: Findings from the Research: Mental Retardation, Cerebral
Palsy and Epilepsy in Alabama: A Sociological Analysis. The University of Alabama
Press, Tuscaloosa.
Hussain, S.A., Haut, S.R., Lipton, R.B., Derby, C., Markowitz, S.Y., Shinnar, S., 2006.
Incidence of epilepsy in a racially diverse, community-dwelling, elderly cohort: re-
sults from the Einstein aging study. Epilepsy Res. 71, 195–205.
Keane, Miller, 2003. Encyclopedia and Dictionary of Medicine, Nursing, and Allied
Health. Elsevier, Inc., Saunders.
Martin, R.C., Faught, E., Richman, J., Funkhouser, E., Kim, Y., Clements, K., Pisu, M.,
2014. Psychiatric and neurologic risk factors for incident cases of new-onset epilepsy
in older adults: data from U.S. Medicare beneficiaries. Epilepsia 55, 1120–1127.
Parko, Karen, Thurman, David J, 2009. Prevalence of epilepsy and seizures in the Navajo
Nation 1998–2002. Epilepsia 50, 2180–2185.
Plichta, Stacey Beth, Kelvin, Elizabeth A., Munro, Barbara Hazard, 2013. Munro's
Statistical Methods for Health Care Research. Wolters Kluwer Health/Lippincott
Williams & Wilkins.
Prevention, Centers for Disease Control and. March, 2015. ‘Stroke Facts’, Accessed Nov 3.
www.cdc.gov/stroke/facts.htm.
Reid, Aylin Y, St Germaine-Smith, Christine, Liu, Mingfu, Sadiq, Shahnaz, Quan, Hude,
Wiebe, Samuel, Faris, Peter, Dean, Stafford, Jetté, Nathalie, 2012. Development and
validation of a case definition for epilepsy for use with administrative health data.
Epilepsy Res. 102, 173–179.
Rice, Dorothy P., Feldman, Jacob J., 1983. Living Longer in the United States:
Demographic Changes and Health Needs of the Elderly. The Milbank Memorial Fund
Quarterly. Health and Society, pp. 362–396.
Tang, Derek H., Malone, Daniel C., Warholak, Terri L., Chong, Jenny, Armstrong, Edward
P., Slack, Marion K., Hsu, Chiu-Hsieh, Labiner, David M., 2015. Prevalence and in-
cidence of epilepsy in an elderly and low-income population in the United States. J.
Clin. Neurol. 11, 252–261.
Thurman, David J., Beghi, Ettore, Begley, Charles E., Berg, Anne T., Buchhalter, Jeffrey
R., Ding, Ding, Hesdorffer, Dale C., Allen Hauser, W., Kazis, Lewis, Kobau, Rosemarie,
2011. Standards for epidemiologic studies and surveillance of epilepsy. Epilepsia 52,
2–26.
Wannamaker, B.B., Wilson, D.A., Malek, A.M., Selassie, A.W., 2015. Stroke after adult-
onset epilepsy: a population-based retrospective cohort study. Epilepsy Behav. 43,
93–99.
Werhahn, Konrad J., 2009. Epilepsy in the elderly. Dtsch Arztebl Int. 106, 135–142.