Anticonvulsant Therapy in the Elderly - a Need for Placebo Controlled Trials?

Cameron, Heather J.; Reid, Wayne G.J.; Macphee, G. J. A.

doi:10.1093/ageing/23.suppl_1.p17-b

Cited by 9 publications

(11 citation statements)

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“…In terms of potential clinical relevance of the present findings, much is known about the impact of aging on drug metabolism and increased risk of drug AEs (31,32). The increased susceptibility to mental impairments related to age-associated diseases (i.e., stroke and dementia) makes the potential for adverse events related to AEDs even more important (29).…”

Section: Discussionmentioning

confidence: 84%

Comparative Cognitive Effects of Carbamazepine and Gabapentin in Healthy Senior Adults

et al. 2001

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Summary:Purpose: This study compared the cognitive effects of carbamazepine (CBZ) and gabapentin (GBP) in healthy senior adults by using a randomized, double-blind crossover design.Methods: Thirty-four senior adults were randomized to receive one of the two drugs followed by a 5-week treatment period. A 4-week washout phase preceded initiation of the second drug. Antiepileptic drugs (AEDs) were titrated to target doses of either CBZ (800 mg/day) or GBP (2,400 mg/day). Primary outcome measures were standardized neuropsychological tests of attention/vigilance, psychomotor speed, motor speed, verbal and visual memory, and the Profile of Mood State (POMS), yielding a total of 17 variables. Each subject received cognitive testing at predrug baseline, end of first drug phase, end of second drug phase, and 4 weeks after completion of the second drug phase.Results: Fifteen senior adults (mean age, 66.5 years; range, 59-76 years) completed the study. Seniors completing the study did not differ significantly from noncompleting seniors in terms of demographic features or baseline cognitive performances. Fifteen of the 19 seniors not completing the study dropped out while receiving CBZ. Adverse events were frequently reported for both AEDs, although they were more common for CBZ. Mean serum levels for the completers were within midrange clinical doses (CBZ, 6.8 g/ml; GBP, 7.1 g/ml). Significant differences between CBZ and GBP were found for only one of 11 cognitive variables, with better attention/vigilance for GBP, although the effect was modest. Performances on the nondrug average were significantly better on 45% of cognitive variables compared with CBZ and 36% compared with GBP. The overall pattern of means favored GBP over CBZ on 15 of 17 (p < 0.001), nondrug over CBZ on 17 of 17 (p < 0.0000), and nondrug over GBP on eight of 17 (NS).Conclusions: Mild cognitive effects were found for both AEDs compared with the nondrug average condition. The magnitude of difference between the two AEDs across the cognitive variables was modest. Self-reported mood was not significantly affected by either AED. However, overall tolerability and sideeffect profile of CBZ were poorer than those of GBP in senior adults at doses and titration rates reported in this study. Key Words: Carbamazepine-Gabapentin-Cognition-MoodSenior adults.Epidemiologic estimates indicate that the incidence of epilepsy in senior adults has increased over the past several decades, with annual estimates of new epilepsy cases in those older than 60 years approaching 45-50,000 in the United States (1). The prevalence rate of active epilepsy in persons older than 60 years now approaches 1% (2). Treatment for senior adults with epilepsy has relied on the incorporation of studies on younger patients that do not fully account for the complex physiologic and pharmacokinetic changes that occur with aging (3). This complexity makes an already difficult treatment selection even more so, when considering the range of medication side effects and interactions that are more proble...

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Section: Discussionmentioning

confidence: 84%

Comparative Cognitive Effects of Carbamazepine and Gabapentin in Healthy Senior Adults

et al. 2001

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“…47 Similarly, there is only a limited number of low-quality studies examining the safety of VPA use in the elderly with epilepsy by direct comparison with other AEDs. 42,48 Tremor is a common side effect. In adult populations, a minority of individuals develop parkinsonism.…”

Section: Discussionmentioning

confidence: 99%

The medical treatment of epilepsy in the elderly: A systematic review and meta‐analysis

et al. 2019

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Objective To evaluate the efficacy and tolerability of antiepileptic drugs (AEDs) in elderly individuals with epilepsy. Methods We searched four electronic databases as well as bibliographies and conference abstracts. Published and unpublished, randomized, or quasirandomized trials reporting the use of AEDs in people aged at least 60 years with epilepsy were eligible for inclusion. Two authors independently carried out each stage of the review. Meta‐analyses were performed using random‐effects models. Results Three thousand four hundred seventeen titles and abstracts were reviewed. Eighteen studies evaluating 12 AEDs met all eligibility criteria. Ten studies, comprising 1999 subjects, were suitable for meta‐analysis. Among the elderly with epilepsy, lamotrigine (LTG) is better tolerated relative to carbamazepine (pooled weighted risk ratio [RR] of experiencing withdrawal due to adverse events = 1.83, 95% confidence interval [CI] = 1.23‐2.43). There is a higher probability, although with a 95% CI of borderline importance, of seizure freedom when comparing levetiracetam to LTG (RR = 0.83, 95% CI = 0.68‐0.97). Single studies provide evidence for the efficacy and/or tolerability of other AEDs in the elderly, including brivaracetam, gabapentin, lacosamide, perampanel, and topiramate. The risk of bias of the included studies was frequently low or unclear, although there was on occasion a high risk of bias (especially with regard to selective reporting). Significance There is some evidence for AED use in the elderly with epilepsy. More evidence is required, comparing newer AEDs to prior generations as well as examining the effects of determinants such as frailty, to guide clinicians when treating this rapidly growing patient population.

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“…The management of elderly people with intractable epilepsy is thought to be more complicated because of alterations in physiology, drug absorption and elimination, the presence of concomitant diseases, and drug interactions with other medication (1,24). Temporal lobectomy in TLE has been suggested to be effective and reasonably safe in this age group, but experience is limited.…”

Section: Discussionmentioning

confidence: 99%

Surgical Treatment for Refractory Temporal Lobe Epilepsy in the Elderly: Seizure Outcome and Neuropsychological Sequels Compared with a Younger Cohort

Grivas¹,

Schramm²,

Kral³

et al. 2006

Epilepsia

128

111

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Summary:Purpose: Surgical treatment of refractory temporal lobe epilepsy (TLE) is promising for selected patients, but only little experience has been acquired in operating on older patients, especially with limited resections. We intend to delineate clinical and surgical factors influencing outcome in patients older than 50 years at operation and to compare the results with those of a younger patient cohort.Methods: Fifty-two patients older than 50 years were operated on for intractable mesial or combined mesiolateral TLE between 1991 and 2002. The mean age at operation was 55 years, and the mean duration of epilepsy was 33 years. Forty selective amygdalohippocampectomies (33 for hippocampal sclerosis, seven for removal of a mesiotemporal lesion), five lateral temporal lesionectomies plus amygdalohippocampectomy, and seven anterior temporal lobectomies were performed. Eleven (21%) patients had undergone invasive presurgical video-EEG monitoring. The mean follow-up period was 33 months. We compared the results with those of a younger cohort operated on in the same time period.Results: Thirty-seven older patients attained complete seizure control (71% class I), and 10 patients had only rare postoperative seizures (19% class II). Four patients improved >75% (8% class III), and one patient did not improve (2% class IV). The same rate of seizure control was attained by 11 patients older than 60 years at surgery. These results were not significantly different from those in a younger patient group. A trend toward better seizure control was noted in 16 patients with an epilepsy duration of <30 years (all class I or II), and in 20 patients with a seizure frequency of fewer than five seizures per month (all class I or II). No mortality resulted from a total of 65 diagnostic and therapeutic procedures. A 3.8% permanent neurologic morbidity (dysphasia and hemiparesis) was noted. Hemianopia occurred in three (5.9%) patients. Neuropsychological testing revealed low preoperative performances and some gradual further deterioration after surgery.Conclusions: Results of surgery for TLE with mainly limited resections are promising in patients older than 50 years and older 60 years, despite the long seizure history. As expected, the risk of complications is somewhat higher compared with that in a younger control group. The impact of low neuropsychological performance is a concern.

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Anticonvulsant Therapy in the Elderly - a Need for Placebo Controlled Trials?

Cited by 9 publications

References 0 publications

Comparative Cognitive Effects of Carbamazepine and Gabapentin in Healthy Senior Adults

Comparative Cognitive Effects of Carbamazepine and Gabapentin in Healthy Senior Adults

The medical treatment of epilepsy in the elderly: A systematic review and meta‐analysis

Surgical Treatment for Refractory Temporal Lobe Epilepsy in the Elderly: Seizure Outcome and Neuropsychological Sequels Compared with a Younger Cohort

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