Treatment of epilepsy in the elderly

The elderly are the most rapidly growing segment of the population, and the incidence of epilepsy in persons over 65 is higher than in any other age group. In nursing homes, its incidence is even higher than in community-dwelling persons of similar ages. About 10% of nursing home residents are being treated with antiepileptic drugs (AEDs), with an "epilepsy/seizure" indication reported for about 7.7% of this use. Almost all elderly patients are being treated with AEDs introduced before 1978--phenytoin, carbamazepine, valproate, and barbiturates. However, age-related changes in protein binding, decreases in hepatic and renal clearance, alterations in gastrointestinal absorption, and interactions with drugs used for other conditions make the choice of the best AED difficult. AEDs that do not interact with other drugs, are not metabolized by the liver, and are readily absorbed may offer benefits for the elderly. To complicate matters, the elderly are not a homogeneous population. Today there are many AEDs to choose from, and some of the newer AEDs have more favorable characteristics than the older ones. Choice of an AED should be made on an individual basis, considering the cost of the drug, the cost of consequences of drug-drug interactions, and expenses associated with acute and chronic adverse effects. In other words, clinical skills rather than formulaic approaches are needed to match detailed knowledge of each patient's characteristics with the properties of the various AEDs.