Management of new-onset epilepsy in the elderly

The incidence of new-onset epilepsy is high among elderly patients. Seizures can present differently to and with more subtle semiology than those in younger adults. This difference in presentation frequently poses a diagnostic challenge. Elderly patients also often have comorbidities, are usually on multiple medications that can interact, have altered medication pharmacokinetics, and tend to be particularly sensitive to adverse effects of medication. Seizures in the elderly tend, however, to respond better to antiepileptic drugs than those in younger individuals, and can often be appropriately controlled with monotherapy. After the diagnosis of epilepsy is confirmed, treatment should be started with a single medication at a low dose, with subsequent gradual upward titration until seizures are controlled. First-generation antiepileptic drugs should be avoided in the elderly in view of poor tolerability. A large trial has shown that lamotrigine and gabapentin are better tolerated than carbamazepine. In elderly patients whose seizures remain uncontrolled on antiepileptic medications, surgery can be considered if excellent results are predicted and the risks are low.