Pharmacologic Management of Epilepsy in the Elderly
Pharmacologic Management of Epilepsy in the Elderly
Objective: To review the epidemiology and pharmacologic management of epilepsy in elderly patients.
Data Sources: Controlled trials, case studies, and review articles identified via MEDLINE using the search terms epilepsy, seizures, elderly, phenobarbital, primidone, phenytoin, carbamazepine, valproic acid, felbamate, gabapentin, lamotrigine, topiramate, tiagabine, levetiracetam, oxcarbazepine, and zonisamide. Recently published standard textbooks on epilepsy were also consulted.
Data Synthesis: Epilepsy is a common neurologic disorder in the elderly. Cerebrovascular and neurodegenerative diseases are the most common causes of new-onset seizures in these patients. Alterations in protein binding, distribution, elimination, and increased sensitivity to the pharmacodynamic effects of antiepileptic drugs (AEDs) are relatively frequent, and these factors should be assessed at the initiation, and during adjustment, of treatment. Drug-drug interactions are also an important issue in elderly patients, because multiple drug use is common and AEDs are susceptible to many interactions. In addition to understanding age-related changes in the pharmacokinetics and pharmacodynamics of AEDs, clinicians should know the common seizure types in the elderly and the spectrum of AED activity for these seizure types. AEDs with activity against both partial-onset and generalized seizures include felbamate, lamotrigine, levetiracetam, topiramate, valproic acid, and zonisamide. Other AEDs discussed in this review (carbamazepine, gabapentin, phenobarbital, phenytoin, primidone, and tiagabine) are most useful for partial-onset seizures.
Conclusion: The provision of safe and effective drug therapy to elderly patients requires an understanding of the unique age-related changes in the pharmacokinetics and pharmacodynamics of AEDs as well as an appreciation of common seizure types and the drugs that are effective for the specific types seen in the elderly.
The proportion of the world's population over 60 years old is expected to increase dramatically in future decades. In 1998 an estimated 580 million people worldwide were over the age of 60 years. By 2050 this segment of the population is expected to reach 82 million in the United States and to approach 2 billion worldwide. As the elderly population increases, the management of epilepsy in these patients will become a common pharmacotherapeutic challenge.
Managing drug therapy in elderly individuals with epilepsy requires paying special attention to age-related alterations in both the pharmacokinetic disposition and pharmacodynamic effects of antiepileptic drug (AED) therapy. Pharmacokinetic parameters such as protein binding, distribution, and elimination change with age,andthese changes may complicate dosing and monitoring of AEDs in elderly patients. Generally, the elderly are more sensitive to the pharmacodynamic effects of many medications, especially those affecting the central nervous system (CNS).
As a class, AEDs are frequently involved in drug interactions. In elderly epileptic patients, the presence of concomitant illnesses requiring multiple medications increases the potential for drug interactions. A study of elderly nursing home residents showed that individuals taking an AED were receiving an average of 5.6 additional medications. Drug accumulation due to reduced clearance and increased sensitivity to drug effects also place the elderly at risk for adverse drug effects.
In addition to having an understanding of age-related alterations in AED response and drug interactions, clinicians caring for elderly patients with epilepsy need to know the common causes of seizures and seizure types in this population, as well as the spectrum of AED activity in these seizure types. The purpose of this article is to provide a review of the epidemiology of epilepsy in the elderly and an overview of drug therapy for epilepsy in this population, with emphasis on pharmacokinetics, adverse effects, and drug interactions.
Objective: To review the epidemiology and pharmacologic management of epilepsy in elderly patients.
Data Sources: Controlled trials, case studies, and review articles identified via MEDLINE using the search terms epilepsy, seizures, elderly, phenobarbital, primidone, phenytoin, carbamazepine, valproic acid, felbamate, gabapentin, lamotrigine, topiramate, tiagabine, levetiracetam, oxcarbazepine, and zonisamide. Recently published standard textbooks on epilepsy were also consulted.
Data Synthesis: Epilepsy is a common neurologic disorder in the elderly. Cerebrovascular and neurodegenerative diseases are the most common causes of new-onset seizures in these patients. Alterations in protein binding, distribution, elimination, and increased sensitivity to the pharmacodynamic effects of antiepileptic drugs (AEDs) are relatively frequent, and these factors should be assessed at the initiation, and during adjustment, of treatment. Drug-drug interactions are also an important issue in elderly patients, because multiple drug use is common and AEDs are susceptible to many interactions. In addition to understanding age-related changes in the pharmacokinetics and pharmacodynamics of AEDs, clinicians should know the common seizure types in the elderly and the spectrum of AED activity for these seizure types. AEDs with activity against both partial-onset and generalized seizures include felbamate, lamotrigine, levetiracetam, topiramate, valproic acid, and zonisamide. Other AEDs discussed in this review (carbamazepine, gabapentin, phenobarbital, phenytoin, primidone, and tiagabine) are most useful for partial-onset seizures.
Conclusion: The provision of safe and effective drug therapy to elderly patients requires an understanding of the unique age-related changes in the pharmacokinetics and pharmacodynamics of AEDs as well as an appreciation of common seizure types and the drugs that are effective for the specific types seen in the elderly.
The proportion of the world's population over 60 years old is expected to increase dramatically in future decades. In 1998 an estimated 580 million people worldwide were over the age of 60 years. By 2050 this segment of the population is expected to reach 82 million in the United States and to approach 2 billion worldwide. As the elderly population increases, the management of epilepsy in these patients will become a common pharmacotherapeutic challenge.
Managing drug therapy in elderly individuals with epilepsy requires paying special attention to age-related alterations in both the pharmacokinetic disposition and pharmacodynamic effects of antiepileptic drug (AED) therapy. Pharmacokinetic parameters such as protein binding, distribution, and elimination change with age,andthese changes may complicate dosing and monitoring of AEDs in elderly patients. Generally, the elderly are more sensitive to the pharmacodynamic effects of many medications, especially those affecting the central nervous system (CNS).
As a class, AEDs are frequently involved in drug interactions. In elderly epileptic patients, the presence of concomitant illnesses requiring multiple medications increases the potential for drug interactions. A study of elderly nursing home residents showed that individuals taking an AED were receiving an average of 5.6 additional medications. Drug accumulation due to reduced clearance and increased sensitivity to drug effects also place the elderly at risk for adverse drug effects.
In addition to having an understanding of age-related alterations in AED response and drug interactions, clinicians caring for elderly patients with epilepsy need to know the common causes of seizures and seizure types in this population, as well as the spectrum of AED activity in these seizure types. The purpose of this article is to provide a review of the epidemiology of epilepsy in the elderly and an overview of drug therapy for epilepsy in this population, with emphasis on pharmacokinetics, adverse effects, and drug interactions.
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