Diagnosis and treatment selection in elderly patients with epilepsy

Demographic data indicate that new-onset epilepsy is more prevalent in the elderly than in any other age group. Because unprovoked seizures in this age group are frequently due to symptomatic causes (most commonly cerebrovascular), treatment is typically lifelong; therefore, the selection of an appropriate antiepileptic drug (AED) is of critical importance for this patient cohort. First- and second-generation AEDs are available as potential therapy and offer physicians several options. Nonetheless, there is a paucity of rigorous data comparing the efficacy of these agents, and few well-controlled trials examine their use in the elderly population. One recently published landmark study that was begun in the 1990s, the Veterans Affairs Cooperative Study 428, objectively examined treatment issues in an elderly cohort with new-onset epilepsy. Results from this study indicate that successful treatment must take into account tolerability and efficacy. Evidence suggests that select second-generation agents may offer distinct advantages over first-generation agents in elderly patients with epilepsy. In light of these clinical trial results and the specific needs of this patient group, there is a need to revisit treatment practices in the elderly cohort. The treatment parameters of first- and second-generation AEDs in the elderly are evaluated for pharmacokinetics, drug interactions, cognitive profiles, and safety profiles. Selection of certain new AEDs as early therapy in elderly patients with epilepsy can now be strongly advocated, but implementation of these practices requires further educational initiatives targeted to physicians who initially treat these patients.