Treatment of seizures and epilepsy in the elderly patient
- Jane G Boggs, MD
Jane G Boggs, MD
- Associate Professor, Neurology
- Wake Forest University
- Section Editors
- Timothy A Pedley, MD
Timothy A Pedley, MD
- Editor-in-Chief — Neurology
- Section Editor — Epilepsy
- Henry and Lucy Moses Professor of Neurology
- Columbia University College of Physicians and Surgeons
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
A discussion of seizures and epilepsy specific to the elderly patient is important for many reasons. A high proportion (25 percent) of new seizures occur in persons over the age of 65 years, and nearly 25 percent of all people with epilepsy are elderly [1,2]. The causes and clinical manifestations of seizures and epilepsy differ in this age group and affect the diagnostic approach. Treatment issues are complicated in elderly patients. Finally, there are significant implications of a seizure diagnosis in the older person already vulnerable to loss of independence, driving restrictions, impaired self-confidence, and risk of falls, which result in physical injury and other sequelae.
Acute symptomatic seizures are provoked events that are not expected to recur in the absence of a particular trigger (eg, hypoglycemia, alcohol withdrawal). Epilepsy is a condition in which recurrent unprovoked seizures are expected in the absence of treatment.
This topic will cover aspects of the management of seizures and epilepsy that are specific to elderly individuals. A more general discussion of the treatment of seizures and epilepsy is presented elsewhere. The etiology, clinical presentation and diagnosis of seizures and epilepsy in the elderly patient is also discussed separately. (See "Initial treatment of epilepsy in adults" and "Overview of the management of epilepsy in adults" and "Seizures and epilepsy in the elderly patient: Etiology, clinical presentation, and diagnosis".)
In general, patients with acute symptomatic seizures due to obvious metabolic derangements, medication, or medication withdrawal will not require seizure treatment. Patients with acute seizures caused by an acute intracranial event (stroke, head trauma) are often treated for a limited time (a few weeks to a few months). If seizures do not recur, withdrawal of antiepileptic drugs (AEDs) should be considered depending on the patient's other risk factors and comorbidity. (See "Overview of the management of epilepsy in adults", section on 'Post-stroke seizures'.)
There are few data regarding the risk of seizure recurrence in elderly patients with unprovoked seizures, but rates of 80 to 90 percent are often mentioned. In part, this has been inferred from a high rate of recurrence in patients with late-onset seizures following stroke and also from studies in the general adult epileptic population in which the seizure recurrence rate in the setting of a known underlying cause is as high as 80 percent. In a prospective observational study of over 1000 adults presenting with a first-ever unprovoked, 139 of whom were ≥65 years of age (mean, 74 years), the likelihood of a seizure recurrence at one year was similar in older compared with younger adults (53 versus 48 percent) . By five years, however, the cumulative risk of recurrent seizure was higher in older adults (75 versus 61 percent). Independent predictors of seizure recurrence included remote symptomatic etiology, first seizure arising from sleep, epileptiform abnormality on EEG, and focal seizures, but not age.
- Ramsay RE, Rowan AJ, Pryor FM. Special considerations in treating the elderly patient with epilepsy. Neurology 2004; 62:S24.
- Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet 1990; 336:1267.
- Lawn N, Kelly A, Dunne J, et al. First seizure in the older patient: clinical features and prognosis. Epilepsy Res 2013; 107:109.
- Ramsay RE, Pryor F. Epilepsy in the elderly. Neurology 2000; 55:S9.
- Pryor, FM, Ramsay, RE, Rowan, AJ, et al. Epilepsy in older adults: update from VA Cooperative Study #428. Epilepsia 2002; 43 Suppl 7:165 [abstract].
- Mehta, S, Pryor, FM, Kraut, L, et al. Efficacy and tolerability of Topiramate in the elderly population. Epilepsia; 43 Suppl 7:165 [abstract].
- Brodie MJ, Overstall PW, Giorgi L. Multicentre, double-blind, randomised comparison between lamotrigine and carbamazepine in elderly patients with newly diagnosed epilepsy. The UK Lamotrigine Elderly Study Group. Epilepsy Res 1999; 37:81.
- Ferrendelli JA, French J, Leppik I, et al. Use of levetiracetam in a population of patients aged 65 years and older: a subset analysis of the KEEPER trial. Epilepsy Behav 2003; 4:702.
- Kutlu G, Gomceli YB, Unal Y, Inan LE. Levetiracetam monotherapy for late poststroke seizures in the elderly. Epilepsy Behav 2008; 13:542.
- Saetre E, Perucca E, Isojärvi J, et al. An international multicenter randomized double-blind controlled trial of lamotrigine and sustained-release carbamazepine in the treatment of newly diagnosed epilepsy in the elderly. Epilepsia 2007; 48:1292.
- Brodie MJ, Perucca E, Ryvlin P, et al. Comparison of levetiracetam and controlled-release carbamazepine in newly diagnosed epilepsy. Neurology 2007; 68:402.
- Werhahn KJ, Trinka E, Dobesberger J, et al. A randomized, double-blind comparison of antiepileptic drug treatment in the elderly with new-onset focal epilepsy. Epilepsia 2015; 56:450.
- Saetre E, Abdelnoor M, Perucca E, et al. Antiepileptic drugs and quality of life in the elderly: results from a randomized double-blind trial of carbamazepine and lamotrigine in patients with onset of epilepsy in old age. Epilepsy Behav 2010; 17:395.
- Rowan AJ, Ramsay RE, Collins JF, et al. New onset geriatric epilepsy: a randomized study of gabapentin, lamotrigine, and carbamazepine. Neurology 2005; 64:1868.
- Cumbo E, Ligori LD. Levetiracetam, lamotrigine, and phenobarbital in patients with epileptic seizures and Alzheimer's disease. Epilepsy Behav 2010; 17:461.
- Arif H, Buchsbaum R, Pierro J, et al. Comparative effectiveness of 10 antiepileptic drugs in older adults with epilepsy. Arch Neurol 2010; 67:408.
- French JA, Chadwick DW. Antiepileptic drugs for the elderly: using the old to focus on the new. Neurology 2005; 64:1834.
- Glauser T, Ben-Menachem E, Bourgeois B, et al. ILAE treatment guidelines: evidence-based analysis of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia 2006; 47:1094.
- Glauser T, Ben-Menachem E, Bourgeois B, et al. Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia 2013; 54:551.
- Fleisher AS, Truran D, Mai JT, et al. Chronic divalproex sodium use and brain atrophy in Alzheimer disease. Neurology 2011; 77:1263.
- Ramsay RE, Uthman B, Pryor FM, et al. Topiramate in older patients with partial-onset seizures: a pilot double-blind, dose-comparison study. Epilepsia 2008; 49:1180.
- Birnbaum A, Hardie NA, Leppik IE, et al. Variability of total phenytoin serum concentrations within elderly nursing home residents. Neurology 2003; 60:555.
- Cloyd JC, Lackner TE, Leppik IE. Antiepileptics in the elderly. Pharmacoepidemiology and pharmacokinetics. Arch Fam Med 1994; 3:589.
- Birnbaum AK. Pharmacokinetics of antiepileptic drugs in elderly nursing home residents. Int Rev Neurobiol 2007; 81:211.
- Ahn JE, Cloyd JC, Brundage RC, et al. Phenytoin half-life and clearance during maintenance therapy in adults and elderly patients with epilepsy. Neurology 2008; 71:38.
- Arif H, Svoronos A, Resor SR Jr, et al. The effect of age and comedication on lamotrigine clearance, tolerability, and efficacy. Epilepsia 2011; 52:1905.
- Ramsay, RE. Challenges in the diagnosis and treatment of the elderly patient with epilepsy. Paper presented at the Annual Meeting of the Southern Clinical Neurological Society, 2003.
- Shorvon SD, Tallis RC, Wallace HK. Antiepileptic drugs: coprescription of proconvulsant drugs and oral contraceptives: a national study of antiepileptic drug prescribing practice. J Neurol Neurosurg Psychiatry 2002; 72:114.
- Rao SC, Dove G, Cascino GD, Petersen RC. Recurrent seizures in patients with dementia: frequency, seizure types, and treatment outcome. Epilepsy Behav 2009; 14:118.
- Mattson RH, Cramer JA, Collins JF. A comparison of valproate with carbamazepine for the treatment of complex partial seizures and secondarily generalized tonic-clonic seizures in adults. The Department of Veterans Affairs Epilepsy Cooperative Study No. 264 Group. N Engl J Med 1992; 327:765.
- Cameron H, Macphee GJ. Anticonvulsant therapy in the elderly--a need for placebo controlled trials. Epilepsy Res 1995; 21:149.
- Griffith HR, Martin RC, Bambara JK, et al. Older adults with epilepsy demonstrate cognitive impairments compared with patients with amnestic mild cognitive impairment. Epilepsy Behav 2006; 8:161.
- Stephen LJ, McLellan AR, Harrison JH, et al. Bone density and antiepileptic drugs: a case-controlled study. Seizure 1999; 8:339.
- Vestergaard P, Rejnmark L, Mosekilde L. Fracture risk associated with use of antiepileptic drugs. Epilepsia 2004; 45:1330.
- Vestergaard P, Tigaran S, Rejnmark L, et al. Fracture risk is increased in epilepsy. Acta Neurol Scand 1999; 99:269.
- Koppel BS, Harden CL, Nikolov BG, Labar DR. An analysis of lifetime fractures in women with epilepsy. Acta Neurol Scand 2005; 111:225.
- Sirven JI, Sperling M, Naritoku D, et al. Vagus nerve stimulation therapy for epilepsy in older adults. Neurology 2000; 54:1179.
- Boling W, Andermann F, Reutens D, et al. Surgery for temporal lobe epilepsy in older patients. J Neurosurg 2001; 95:242.
- Sirven JI, Malamut BL, O'Connor MJ, Sperling MR. Temporal lobectomy outcome in older versus younger adults. Neurology 2000; 54:2166.
- Murphy M, Smith PD, Wood M, et al. Surgery for temporal lobe epilepsy associated with mesial temporal sclerosis in the older patient: a long-term follow-up. Epilepsia 2010; 51:1024.
- Grivas A, Schramm J, Kral T, et al. Surgical treatment for refractory temporal lobe epilepsy in the elderly: seizure outcome and neuropsychological sequels compared with a younger cohort. Epilepsia 2006; 47:1364.
- Acosta I, Vale F, Tatum WO 4th, Benbadis SR. Epilepsy surgery after age 60. Epilepsy Behav 2008; 12:324.
- Holt-Seitz A, Wirrell EC, Sundaram MB. Seizures in the elderly: etiology and prognosis. Can J Neurol Sci 1999; 26:110.
- Gupta SR, Naheedy MH, Elias D, Rubino FA. Postinfarction seizures. A clinical study. Stroke 1988; 19:1477.
- Stephen LJ, Kelly K, Mohanraj R, Brodie MJ. Pharmacological outcomes in older people with newly diagnosed epilepsy. Epilepsy Behav 2006; 8:434.
- Pugh MJ, Copeland LA, Zeber JE, et al. The impact of epilepsy on health status among younger and older adults. Epilepsia 2005; 46:1820.
- Mohanraj R, Norrie J, Stephen LJ, et al. Mortality in adults with newly diagnosed and chronic epilepsy: a retrospective comparative study. Lancet Neurol 2006; 5:481.