Treatment of Seizures in Older Patients with Dementia

The numbers of patients with dementia and patients with epilepsy are increasing in the global population. In fact, these two conditions are related, and it is estimated that at least 5-10% of seizures or epilepsy in older individuals (aged > 60 years) are caused by a neurodegenerative dementia. In the vast majority, one of the four following diseases is involved: Alzheimer's disease, Lewy body dementia, frontotemporal dementia, or vascular dementia. These diseases cause, not only seizures or epilepsy in affected patients, but cognitive, behavioral, and motor disorders as well. As a result, the challenges of treating seizures in older patients with neurodegenerative disease go beyond the usual limitations associated with this age group (i.e., lower fluid compartment, lower protein binding, increased risk of drug-drug interactions) by imposing other issues and pitfalls. In this setting, the drug-related potential aggravation of neurodegenerative symptoms must be taken into account. As cognition is particularly vulnerable, the prescription of antiseizure medications in dementia must consider the potential neurocognitive impact and limit it as much as possible. Consequently, the choice of a treatment for seizures in this age group is even more demanding than in younger patients, and therefore more restricted. Based on current but limited evidence, it appears that second-generation antiseizure medications are more likely to be appropriate for the management of older patients with epilepsy with neurodegenerative disease given their more favorable pharmacokinetic profiles. Nevertheless, even newer antiseizure medications are not devoid of any risks, which can however be anticipated and corrected.