The study by Dr. Werhahn et al provides well needed information in a special subgroup of epilepsy patients: the elderly. The elderly are the fastest growing segment of our population. However, despite this fact, the elderly also are the group of epilepsy patients for whom we have the least amount of data with regard to choice of antiepileptic drug (AED).
Managing elderly patients with epilepsy is challenging because of this group’s chronic conditions and comorbidities. Consideration also has to be given to the other medications they are on and to their decreased metabolism. As mentioned in this study, the target dose for an AED in the elderly is lower than in other subgroups, which is a point often forgotten by clinicians.
The study showed that levetiracetam was as efficacious as, but better tolerated than, controlled-release carbamazepine. Differences in the tolerability, in turn, influenced retention rate, suggesting that tolerability in this special subgroup could be a major factor in the choice of AED for new-onset focal epilepsy. Common adverse effects such as fatigue, dizziness, and confusion can be problematic for anyone, but more so for the elderly because they can indirectly contribute to falls, injury, and hospitalization. Tolerability also affects compliance, which, as has been shown in many prior studies, affects seizure recurrence rate.
This study was unique because it included patients with one prior seizure, but that practice is in keeping with the new International League Against Epilepsy definition of epilepsy. The three treatment groups in the intent-to-treat population had similar baseline characteristics. This study will likely lead to further research on comparing additional AEDs in the elderly with regard to side effects or efficacy. These future studies will assist clinicians with regard to the choice of AEDs.
—Nikesh Ardeshna, MD
Medical Director, Epilepsy Services
Erlanger Health System
Chattanooga, Tennessee