Page 424 - ILAE_Lectures_2015

most studies report that the vast majority of older people with seizures are readily controlled
with a low dose of a single antiepileptic drug (AED). A Veterans Administration trial of
AEDs in adults showed that a higher proportion of older adults achieved control than did
younger adults13.

Management

As with younger people, accurate diagnosis is crucial. A trial of an AED is rarely appropriate
and a brief period of hospital admission for observation may be useful if the history is unclear.

Identification of the underlying aetiology of seizures is necessary for counselling and may be
relevant in deciding future management plans. General management, including reassurance
and education for both the person and carer, is crucial. A multidisciplinary approach is
helpful: nursing staff are vital in counselling and monitoring the person and an occupational
therapist can advise on safety aspects, which may include a home visit and provision of a
personal alarm where appropriate.

There is a lack of relevant data allowing rational therapeutic policies to be made for the
treatment of seizures in old age. Information regarding seizure recurrence after an incident
seizure and response to AEDs is scant. Such data are necessary to weigh the risks of treatment
against the risks of epilepsy and its complications.

Acute symptomatic seizures are most appropriately managed by treating the underlying
precipitant (e.g. treatment of infection, correction of metabolic upset, or withdrawal of drug
precipitant). AED therapy may be necessary in some circumstances on a temporary basis to
suppress seizures while control of the underlying illness is achieved. Advanced age appears
to be an independent risk factor for increased mortality in status epilepticus, and this should
therefore be treated vigorously.

The approach to treatment of a first unprovoked seizure in an older person is more
contentious. Such people are often classifiable as having remote symptomatic seizures
secondary to a cerebral infarct. Treatment to prevent serious injury and the dangers of
prolonged post-ictal states may well be justified after a first generalised seizure on the basis
of a persisting, epileptogenic focus. However, some such seizures may be erroneously
classified as remote symptomatic if a concurrent acute vascular event is clinically silent. For
people with simple partial seizures and in whom investigation is unremarkable, a ‘wait and
see’ policy may be more appropriate.

Recurrent unprovoked seizures clearly require treatment. Potential first-line broad-spectrum
AEDs that may be used in the elderly include lamotrigine, levetiracetam and sodium
valproate; comparative trials in older persons are, however, few. A multicentre trial
comparing sodium valproate and phenytoin suggested both agents were useful first-line
drugs14. More failure occurred for people receiving phenytoin (poor control 6%, adverse
events 14%) than sodium valproate (poor control 1%, adverse events 9%) although the
differences were not significant. A study assessing the impact of sodium valproate and
phenytoin on cognitive function found no difference between the drugs in a group of
elders15,16. Frequent non-cognitive side effects were, however, reported. Trials have also
shown no difference of efficacy between lamotrigine, carbamazepine and gabapentin1618.

AED pharmacokinetics may be altered by age. It should be emphasised that inter-individual
variability may be much more important than changes associated with age alone19,20.
Tailoring of the dose with regard to concurrent illness and drug treatment is paramount to
avoid toxicity.