Antiepileptic drug use in nursing home admissions

Garrard, Judith; Harms, Susan; Hardie, Nancy A.; Eberly, Lynn E.; Nitz, Nicole M.; Bland, Patricia C.; Gross, Cynthia R.; Leppik, Ilo E.

doi:10.1002/ana.10593

Cited by 71 publications

(45 citation statements)

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“…6 Antiepileptic drugs (AEDs) are used by 2% of community-dwelling and by 4-11% of the institutionalized elderly. [7][8][9][10][11] Carbamazepine and gabapentin are the most commonly used AEDs in Europe, 10,12 and phenytoin and gabapentin are the most commonly used in the United States. 13 At the time the present study was designed, carbamazepine was a standard choice for elderly patients in the European Union; however, as cytochrome P450 inducers, carbamazepine and phenytoin interact with many drugs.…”

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confidence: 99%

A randomized, double‐blind comparison of antiepileptic drug treatment in the elderly with new‐onset focal epilepsy

et al. 2015

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SUMMARYObjective: To compare the effectiveness of controlled-released carbamazepine (CR-CBZ) to levetiracetam (LEV) and to lamotrigine (LTG) in elderly patients with newly diagnosed focal epilepsy. Methods: Randomized, double-blind, parallel-group trial conducted between January 2007 and August 2011, in 47 ambulatory or hospital sites in Germany, Austria, or Switzerland. Eligible participants were aged ≥60, had new-onset epilepsy, had no acute illness as the cause of their seizures, and had no contraindication to the drugs in the trial. Patients were randomized 1:1:1 to CR-CBZ, LTG, or LEV. Doses were up-titrated for 6 weeks and could be maintained or adjusted depending on seizure relapse or tolerability over an additional period of 52 weeks. Primary outcome was the retention to treatment at week 58; secondary measures related to seizure and adverse event frequency. Results: Of 361 randomized patients, 359 were included (CR-CBZ n = 121, LTG n = 117, LEV n = 122) in the modified intent-to-treat population (mean age [range] 71.4 [60-95] years). At week 58, the retention rate for LEV was significantly higher than for CR-CBZ (61.5% vs. 45.8%, p = 0.02), and similar to LTG (55.6%). Seizure freedom rates at weeks 30 and 58 were not different across the groups. Twice as many patients receiving CR-CBZ discontinued due to adverse events or death compared to those in the LEV group (32.2% vs. 17.2%; odds ratio 2.28, 95% confidence interval [CI] 1.25-4.19, p = 0.007), whereas discontinuation was intermediate for LTG (26.3%). Median daily doses of completers (n = 195) were CR-CBZ 380.0 mg/day (333.0-384.0), LTG 95 mg/day (94.0-97.0), and LEV 950 mg/day (940.0-985.0). Significance: In the initial monotherapy of focal epilepsy in the elderly, 1-year retention to LEV was higher compared to CR-CBZ due to better tolerability. Retention of LTG was intermediate and close to LEV, but did not differ significantly from either comparators. NCT00438451, www.clinicaltrials.gov.

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A randomized, double‐blind comparison of antiepileptic drug treatment in the elderly with new‐onset focal epilepsy

et al. 2015

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“…A closer examination of AED use in nursing homes revealed that approximately 7% of residents are receiving AEDs at the time of admission, but, surprisingly, approximately 3% have an AED newly prescribed after admission (9). Phenytoin is the most commonly used AED in nursing homes.…”

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Epilepsy in the Elderly

Leppik

2006

Epilepsia

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Summary: The elderly are the most rapidly growing segment of the population and the incidence of epilepsy is higher in the elderly than in any other age group. They have been subdivided into the “young old,” 65–74 years, “middle old” 75–84 years, and the “old old,” 85 years or older. But further subdivisions are needed: persons with only epilepsy, those with epilepsy and multiple medical problems, and the frail elderly. Thus, when considering therapy, one must tailor the interventions to nine categories: young old healthy, young old with medical problems, frail young old, old healthy, old with medical problems, frail old, old old healthy, old old with medical problems, and frail old old. The prevalence of antiepileptic drug (AED) use in community dwelling elderly is 1.5%; in the nursing home population it is 10%. Surprisingly, 3% have an AED newly prescribed after admission. Overall, 6.2% were using phenytoin, 1.8% carbamazepine, 0.9% valproic acid, 1.7% phenobarbital, and others combined, 1.2%. AEDs rank fifth among all drug categories as a cause of adverse reactions. There are very few data regarding the clinical use of AEDs in the elderly. The paucity of information makes it very difficult to recommend specific AEDs with any confidence that the outcomes will be optimal. An appropriate for elderly healthy may not be appropriate for elderly with multiple medical problems, and in frail elderly variable absorption may be a major problem. One of the major advantages of some newer AEDs is lack of drug interactions. Cost is an advantage of the older AEDs. Regardless of the AED chosen, one must use doses appropriate to the clearance of the drug, and AED levels, especially unbound (free) levels, must be monitored. The elderly nursing home resident may be more frail, be taking many medications, and have several concomitant illnesses, making them difficult to treat. The most commonly used AED, phenytoin, may not be the easiest or safest AED to prescribe in the elderly with multiple medical problems or the frail elderly.

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“…12 However, in our study, the vast majority of persons with an epi/sz diagnosis had one of the specified neurologic conditions (table 2). Only 4.8% of patients with epi/sz (data not shown) had none of the evaluated neurologic conditions.…”

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confidence: 49%

“…A previous nationwide study found that the prevalence of epilepsy on admission to NHs was 5.83%. 12 The total number of residents with epi/sz was .90,000 in our data for each year and represents a large proportion of all persons with epilepsy in the United States.…”

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confidence: 78%

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Prevalence of epilepsy/seizures as a comorbidity of neurologic disorders in nursing homes

et al. 2017

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Objective: To determine the prevalence of epilepsy/seizure (epi/sz) comorbid with other neurologic disorders in elderly nursing home residents and to examine demographic and regional variability and associations with clinical characteristics.Methods: We studied 5 cross-sectional cohorts of all residents in any Medicare/Medicaid-certified nursing home in the United States on July 15 of each year from 2003 to 2007. Epi/sz was identified by ICD-9 codes (345.xx or 780.39) or check box (Minimum Data Set). Epi/sz prevalence was stable across all years, so only 2007 data were examined further. Logistic regression with generalized estimating equations was used to model cross-sectional prevalence of epi/sz as a function of demographics and neurologic comorbidities of interest, with adjustment for clinical characteristics, including cognitive status, comorbidity burden, medication burden, and activities of daily living.Results: Point prevalence of epi/sz in 2007 was 7.7% (n 5 91,372 of N 5 1,186,579) differing by geographical region, race/ethnicity, age group, and sex. Neurologic conditions having the highest association with epi/sz were brain tumor (epi/sz prevalence 23.4%-35.2%), head injury (17.9%), hemiplegia (17.7%), and stroke (13.7%). Epi/sz comorbid with stroke or dementia had a strong decreasing association with age (65-74 years had z3.8-times higher odds of epi/sz than 851 years). Activities of daily living, comorbidity burden, and cognition scores were worse in persons with than without epi/sz. Conclusions:The prevalence of epi/sz in the elderly nursing home population is .7-fold higher compared to community-dwelling elderly and is 7 to 30 times higher among those with certain comorbid neurologic conditions. Demographics and clinical characteristics had weaker associations with epi/sz prevalence. Neurology ® 2017;88:750-757 GLOSSARY ASD 5 antiseizure drug; epi/sz 5 epilepsy/seizure; ICD-9 5 International Classification of Diseases, ninth revision; MDS 5 Minimum Data Set; MS 5 multiple sclerosis; NH 5 nursing home; OR 5 odds ratio.Because of their general health, elderly individuals are much more likely to have severe consequences from a seizure than younger persons.1 With increasing concern regarding the ability to provide adequate and appropriate care to the nursing home (NH) population, it is important to define the epidemiology of epilepsy in this cohort. In community-dwelling elderly, the prevalence of epilepsy is z1.1%.2,3 A majority of these cases are located in the geographic Stroke Belt. [4][5][6] Neurologic conditions comorbid with epilepsy are also common in NH elderly. Although the number of elderly will more than double in the United States, approaching 71.5 million by 2030, 7 and the lifetime probability of a person entering an NH before death is 43% to 46%, 8 there has not been a systematic evaluation of the prevalence of epilepsy with other neurologic disorders or the activity or cognitive status of these individuals.We obtained the Minimum Data Set (MDS) assessments completed on all resi...

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Antiepileptic drug use in nursing home admissions

Cited by 71 publications

References 44 publications

A randomized, double‐blind comparison of antiepileptic drug treatment in the elderly with new‐onset focal epilepsy

A randomized, double‐blind comparison of antiepileptic drug treatment in the elderly with new‐onset focal epilepsy

Epilepsy in the Elderly

Prevalence of epilepsy/seizures as a comorbidity of neurologic disorders in nursing homes

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