Monotherapy is desirable in this population, as polypharmacy tends to increase the incidence of doserelated side effects. However, until fairly recently, none of the second-generation AEDs had FDA approval for initial monotherapy. To address this, in 2004 the American Academy of Neurology and the American Epilepsy Society published guidelines for using second-generation AEDs in treating new onset epilepsy.
34 They recommended that gabapentin, lamotrigine, topiramate, and oxcarbazepine could be used for initial monotherapy in patients with newly diagnosed epilepsy. Another AED that is commonly used as initial monotherapy in elderly patients with new-onset epilepsy is levetiracetam.
29
All patients who still have uncontrolled seizures after 3 months of treatment should be referred to a specialist.
10 Also, patients should be counseled about possible seizure triggers, including sleep deprivation, use of alcohol or stimulants, and any known triggers for that person.
Patient education
Providing patients and their families with information about epilepsy can help to minimize the negative psychological impact of the diagnosis. Misconceptions about the disease and its treatment are common and can frighten or confuse patients, especially regarding their ability to live and care for themselves independently.19
Driving One area of concern is whether patients with seizures can drive safely.35 All 50 states require people to refrain from driving after a seizure for a period of time, usually 6 to 12 months.7 California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania require clinicians to report patients who are having seizures to the Department of Motor Vehicles, and if a patient with epilepsy is involved in an accident, the clinician could be found negligent for a failure to report. The Epilepsy Foundation provides a helpful, concise listing of each state's driving laws.
Adherence to treatment Seizures will be controlled only if the patient takes the AED regularly, as prescribed.
Compliance can be a challenge for those who may already be taking a number of drugs for other conditions. 15 Pills may look similar, dosing schedules may differ, and arthritic hands may have difficulty opening bottles and handling tiny pills. Clinicians must do their part to help patients adhere to treatment; diligent patient education and prescribing medications that require fewer daily doses help to increase compliance and the opportunity for the patient to remain seizure-free.17
Conclusion
New-onset seizures are relatively common in the elderly and often go unrecognized. Seizure characteristics in the older adult are different from those in younger people, and a high index of suspicion is necessary for proper evaluation and diagnosis. All elderly patients with new-onset seizures should have at least one EEG, an MRI of the brain, and an appropriate laboratory workup.7,20 AED therapy should be chosen to maximize tolerability; in most cases, this means prescribing one of the second-generation AEDs.
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