Pharmacotherapy for epilepsy in the elderly

Abstract

Epilepsy is the most common chronic neurological disorder worldwide and its incidence increases with age. A thorough clinical assessment, neuroimaging (ideally magnetic resonance imaging) and electroencephalography must be performed in all patients with epilepsy to determine the seizure type and the underlying aetiology. Epilepsy may be classified as either focal or generalised. In the elderly, focal epilepsy secondary to structural pathology (particularly stroke) is the most common cause. Careful cardiovascular risk assessment is therefore recommended in elderly patients with new seizures. In younger patients, genetic generalised epilepsies predominate. When a decision is made to initiate anti-epileptic pharmacotherapy, the classification of epilepsy, its underlying cause and patient characteristics (particularly comorbidities and polypharmacy) determine the most suitable agent. In elderly patients, a single drug is often effective in controlling seizures. Although data in this population are limited, there is emerging evidence that newer anti-epileptics such as levetiracetam and gabapentin are better tolerated. Some older agents such as phenytoin should be avoided due to the risks of toxicity and drug interactions. In this article, we outline the classification and causes of epilepsy and review the treatment options with an emphasis on the evidence base in the elderly. For the majority of elderly patients, anti-epileptic pharmacotherapy will be required lifelong.