Pharmacological and clinical aspects of antiepileptic drug use in the elderly

The implications of frailty in older adults with epilepsy

Older adults constitute a large proportion of people with epilepsy (PWE) due to the changing demographics worldwide and epilepsy's natural history. Aging-related pathophysiological changes lower the tolerance and increase our vulnerability to stressors, which manifests as frailty. Frailty is closely associated with adverse health outcomes. This narrative review examines the interplay between frailty and epilepsy, especially in older adults, emphasizing its clinical implications, including its role in managing PWE. Mechanistically, frailty develops through complex interactions among molecular and cellular damage, including genomic instability, mitochondrial dysfunction, and hormonal changes. These contribute to systemic muscle mass, bone density, and organ function decline. The concept of frailty has evolved from a primarily physical syndrome to include social, psychological, and cognitive dimensions. The "phenotypic frailty" model, which focuses on physical performance, and the "deficit accumulation" model, which quantifies health deficits, provide frameworks for understanding and assessing frailty. PWE are potentially more prone to developing frailty due to a higher prevalence of risk factors predisposing to frailty. These include, but are not limited to, polypharmacy, higher comorbidity, low exercise level, social isolation, low vitamin D, and osteoporosis. We lack commercial biomarkers to measure frailty but can diagnose it using self- or healthcare provider-administered frailty scales. Recent attempts to develop a PWE-specific frailty scale are promising. Unlike chronological age, frailty is reversible, so its management using multidisciplinary care teams should be strongly considered. Frailty can affect antiseizure medication (ASM) tolerance secondary to its impact on pharmacokinetics and pharmacodynamics. While frailty's effect on seizure control efficacy of ASM is poorly understood, its undoubted association with overall poor outcomes, including epilepsy surgery, behooves us to consider its presence and implication while treating older PWE. Incorporation of frailty measures in future research is essential to improve our understanding of frailty's role in PWE health. PLAIN LANGUAGE SUMMARY: Frailty is the declining state of the human body. People with epilepsy are more prone to it. It should be factored into their management.

Safety and Efficacy of Cenobamate for the Treatment of Focal Seizures in Older Patients: Post Hoc Analysis of a Phase III, Multicenter, Open-Label Study

BACKGROUND

Cenobamate is an antiseizure medication (ASM) approved in the US and Europe for the treatment of uncontrolled focal seizures.

OBJECTIVE

This post hoc analysis of a phase III, open-label safety study assessed the safety and efficacy of adjunctive cenobamate in older adults versus the overall study population.

METHODS

Adults aged 18-70 years with uncontrolled focal seizures taking stable doses of one to three ASMs were enrolled in the phase III, open-label safety study; adults aged 65-70 years from that study were included in our safety analysis. Discontinuations due to adverse events and treatment-emergent adverse events (TEAEs) were assessed throughout the study in all patients who received one or more doses of cenobamate (safety study population). Efficacy was assessed post hoc in patients who had adequate seizure data available (post hoc efficacy population); we assessed patients aged 65-70 years from that population. Overall, 100% responder rates were assessed in the post hoc efficacy maintenance-phase population in 3-month intervals. Concomitant ASM drug load changes were also measured. For each ASM, drug load was defined as the ratio of actual drug dose/day to the World Health Organization defined daily dose (DDD).

RESULTS

Of 1340 patients (mean age 39.7 years) in the safety study population, 42 were ≥ 65 years of age (mean age 67.0 years, 52.4% female). Median duration of exposure was 36.1 and 36.9 months for overall patients and older patients, respectively, and mean epilepsy duration was 22.9 and 38.5 years, respectively. At 1, 2, and 3 years, 80%, 72%, and 68% of patients overall, and 76%, 71%, and 69% of older patients, respectively, remained on cenobamate. Common TEAEs (≥ 20%) were somnolence and dizziness in overall patients, and somnolence, dizziness, fall, fatigue, balance disorder, and upper respiratory tract infection in older patients. Falls in older patients occurred after a mean 452.1 days of adjunctive cenobamate treatment (mean dose 262.5 mg/day; mean concomitant ASM drug load 2.46). Of 240 patients in the post hoc efficacy population, 18 were ≥ 65 years of age. Mean seizure frequency at baseline was 18.1 seizures/28 days for the efficacy population and 3.1 seizures/28 days for older patients. Rates of 100% seizure reduction within 3-month intervals during the maintenance phase increased over time for the overall population (n = 214) and older adults (n = 15), reaching 51.9% and 78.6%, respectively, by 24 months. Mean percentage change in concomitant ASM drug load, not including cenobamate, was reduced in the overall efficacy population (31.8%) and older patients (36.3%) after 24 months of treatment.

CONCLUSIONS

Results from this post hoc analysis showed notable rates of efficacy in older patients taking adjunctive cenobamate. Rates of several individual TEAEs occurred more frequently in older patients. Further reductions in concomitant ASMs may be needed in older patients when starting cenobamate to avoid adverse effects such as somnolence, dizziness, and falls.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov NCT02535091.

Reductions in concomitant antiseizure medication drug load during adjunctive cenobamate therapy: Post-hoc analysis of a subset of patients from a phase 3, multicenter, open-label study

OBJECTIVE

Many patients with epilepsy require polytherapy, which increases their antiseizure medication (ASM) drug load, a measure that considers the doses of all ASMs a patient is taking. Changes in concomitant ASM drug load after adding cenobamate were evaluated post-hoc in a subset of the open-label, phase 3 study.

METHODS

Patients 18-70 years old with uncontrolled focal seizures taking 1-3 ASMs were enrolled. Total concomitant ASM drug load (not including cenobamate) was calculated by dividing the patient's prescribed dose for each ASM by its defined daily dose, per the World Health Organization, then summing the ratios. Changes in concomitant ASM drug load were measured from baseline in 3-month intervals up to 24 months by both total and class-specific ASM drug load. Subgroups of interest included: older adults (65-70 years), prior epilepsy-related surgery vs none, and baseline seizure frequency < 3 vs ≥ 3 seizures/28 days.

RESULTS

Data from 240 patients were available (mean age 41.8 years, mean baseline drug load 3.57). Following cenobamate initiation, the mean concomitant ASM drug load was reduced by 29.4 % at Month 12 % and 31.8 % at Month 24. Reductions occurred in all assessed ASM drug classes, with the largest reduction in benzodiazepines (55.2 % at Month 24). Each assessed subgroup exceeded a 30 % reduction in concomitant ASM drug load at Month 24. Over 24 months, maintenance of ≥ 50 % response occurred in 89.3 %, 86.4 %, and 90.6 % of patients with low (-0.25 to <0), moderate (-0.59 to -0.25), or high (-3.3 to -0.59) numerical reductions in concomitant ASM drug load from baseline, respectively, compared with 86.0 % in patients with no change in drug load; maintenance of 100 % response occurred in 80.7 %, 84.3 %, and 70.0 % of patients with low, moderate, or high numerical reductions in concomitant ASM drug load, compared with 82.0 % in patients with no change.

CONCLUSIONS

Adding cenobamate led to reduced mean concomitant ASM drug loads during 1 and 2 years of treatment. Reductions occurred regardless of ASM drug class, patient age, or epilepsy disease characteristics and did not impact maintenance of response rates.

Neuropathic Pain in Aged People: An Unresolved Issue Open to Novel Drug Approaches, Focusing on Painful Diabetic Neuropathy

A majority of older patients suffer from neuropathic pain (NP) that significantly alters their daily activities and imposes a significant burden on health care. Multiple comorbidities and the risk of polypharmacy in the elderly make it challenging to determine the appropriate drug, dosage, and maintenance of therapy. Age-dependent processes play a contributing role in neuropathy given that diabetic neuropathy (DN) is the most common form of neuropathy. This narrative review is mainly focused on the drug treatment approach for neuropathy-associated pain in aged people including both drugs and dietary supplements, considering the latter as add-on mechanism-based treatments to increase the effectiveness of usual treatments by implementing their activity or activating other analgesic pathways. On one hand, the limited clinical studies assessing the effectiveness and the adverse effects of existing pain management options in this age segment of the population (> 65), on the other hand, the expanding global demographics of the elderly contribute to building up an unresolved pain management problem that needs the attention of healthcare providers, researchers, and health authorities as well as the expansion of the current therapeutic options.

Effect of clinical features on antiseizure medication doses in patients with newly diagnosed epilepsy

Objective

We evaluate the effect of distinct clinical features on anti-seizure medication (ASM) doses in seizure-free and not seizure-free patients aged ≥16 years with new-onset epilepsy.

Materials and methods

This study included 459 patients with a validated diagnosis of epilepsy. The most prescribed ASMs were oxcarbazepine (OXC; n = 307), followed by valproic acid (VPA; n = 115), carbamazepine (CBZ; n = 81), and lamotrigine (LTG; n = 67). The seizure freedom rate with their first or subsequent ASM was 88.0%. A retrospective analysis of patient records was performed to determine any association between doses of ASMs and patient characteristics.

Results

The median OXC dose in seizure-free patients aged >60 years was 600 mg compared to 900 mg in younger patients. When controlling for age but not in an unadjusted model, the median dose of OXC was lower (300 mg, p = 0.018) for seizure-free patients compared to non-seizure-free patients, and the median dose of OXC was also 300 mg lower among older patients aged >60 years (p < 0.001). The median OXC doses for men aged ≤60 years were 300 mg higher than for women aged >60 years (900 mg vs. 600 mg, p = 0.021). The median dose of VPA was 400 mg higher in men than in women (p < 0.001) and 400 mg higher in not seizure-free patients compared to seizure-free patients only when adjusting for sex (p < 0.001). Higher median doses for CBZ were registered with FAS compared with FBTCS (difference in median doses of 200 mg; p = 0.017).

Conclusion

Significant OXC dose differences were detected between age groups, whereas VPA dosing was different in men and women. Moreover, CBZ doses were dependent on some seizure types. These data allow for the individualization of the initial target dosing based on key clinical characteristics.

Pharmacological treatment for older adults with epilepsy and comorbid neurodegenerative disorders

PURPOSE OF REVIEW

An increased interest in epilepsy in older adults has emerged as the global population ages. The purpose of this article is to review the literature regarding the pharmacological treatment of epilepsy in older adults, highlighting issues specifically pertinent to those living with comorbid neurodegenerative disorders.

RECENT FINDINGS

Although new original research remains sparse, in the last 5 years, there has been a growing number of studies addressing the relationship between epilepsy and neurodegenerative disorders. Accurate diagnosis is incredibly challenging with electroencephalogram findings often requiring circumspect interpretation. Older individuals are often excluded from or under-represented in clinical trials, and there are sparse guidelines offered on the management of these patients, with even less available in reference to those with neurodegenerative comorbidities.

SUMMARY

We propose that seizures occurring earlier in the neurodegenerative process should be treated aggressively, with the goal to inhibit neuro-excitotoxicity and the associated neuronal loss. By strategically choosing newer antiseizure medications with less adverse effects and a holistic approach to treatment, a patient's time living independently can be conserved. In addition, we advocate for original, multinational collaborative research efforts.

Management of epilepsy in older adults: A critical review by the ILAE Task Force on Epilepsy in the elderly

Older adults represent a highly heterogeneous population, with multiple diverse subgroups. Therefore, an individualized approach to treatment is essential to meet the needs of each unique subgroup. Most comparative studies focusing on treatment of epilepsy in older adults have found that levetiracetam has the best chance of long-term seizure freedom. However, there is a lack of studies investigating other newer generation antiseizure medications (ASMs). Although a number of randomized clinical trials have been performed on older adults with epilepsy, the number of participants studied was generally small, and they only investigated short-term efficacy and tolerability. Quality of life as an outcome is often missing but is necessary to understand the effectiveness and possible side effects of treatment. Prognosis needs to move beyond the focus on seizure control to long-term patient-centered outcomes. Dosing studies with newer generation ASMs are needed to understand which treatments are the best in the older adults with different comorbidities. In particular, more high-level evidence is required for older adults with Alzheimer's disease with epilepsy and status epilepticus. Future treatment studies should use greater homogeneity in the inclusion criteria to allow for clearer findings that can be comparable with other studies to build the existing treatment evidence base.

Comparative Effectiveness and Safety of Seizure Prophylaxis Among Adults After Acute Ischemic Stroke

BACKGROUND

Older adults occasionally receive seizure prophylaxis in an acute ischemic stroke (AIS) setting, despite safety concerns. There are no trial data available about the net impact of early seizure prophylaxis on post-AIS survival.

METHODS

Using a stroke registry (American Heart Association's Get With The Guidelines) individually linked to electronic health records, we examined the effect of initiating seizure prophylaxis (ie, epilepsy-specific antiseizure drugs) within 7 days of an AIS admission versus not initiating in patients ≥65 years admitted for a new, nonsevere AIS (National Institutes of Health Stroke Severity score ≤20) between 2014 and 2021 with no recorded use of epilepsy-specific antiseizure drugs in the previous 3 months. We addressed confounding by using inverse-probability weights. We performed standardization accounting for pertinent clinical and health care factors (eg, National Institutes of Health Stroke Severity scale, prescription counts, seizure-like events).

RESULTS

The study sample included 151 patients who received antiseizure drugs and 3020 who did not. The crude 30-day mortality risks were 219 deaths per 1000 patients among epilepsy-specific antiseizure drugs initiators and 120 deaths per 1000 among noninitiators. After standardization, the estimated mortality was 251 (95% CI, 190-307) deaths per 1000 among initiators and 120 (95% CI, 86-144) deaths per 1000 among noninitiators, corresponding to a risk difference of 131 (95% CI, 65-200) excess deaths per 1000 patients. In the prespecified subgroup analyses, the risk difference was 52 (95% CI, 11-72) among patients with minor AIS and 138 (95% CI, 52-222) among moderate-to-severe AIS patients. Similarly, the risk differences were 86 (95% CI, 18-118) and 157 (95% CI, 57-219) among patients aged 65 to 74 years and ≥75 years, respectively.

CONCLUSIONS

There was a higher risk of 30-day mortality associated with initiating versus not initiating seizure prophylaxis within 7 days post-AIS. This study does not support the role of seizure prophylaxis in reducing 30-day poststroke mortality.

Optimal Use of Perampanel in Elderly Asian Patients with Epilepsy: Expert Opinion

Managing epilepsy in the elderly remains complicated largely due to factors related to aging. In this population, management practices are increasingly shifting towards the use of newer-generation anti-seizure medications (ASMs) as they are generally associated with better tolerability and safety profiles than older ones. Perampanel is a new ASM with broad-spectrum efficacy and a favorable safety profile. However, because of the lack of information and experience in its use, the prescription of perampanel has not been optimized in the elderly in the real-world setting in Asia. A group of epilepsy experts across the region convened at a series of virtual meetings to share their experience and discuss recommendations on perampanel use in elderly patients, including dose optimization, considerations with treatment initiation, and strategies to manage adverse events and maximize tolerability. This article summarizes key clinical and real-world evidence for perampanel in the elderly and consolidates the experts’ opinions on optimizing perampanel use in elderly Asian patients with epilepsy, providing practical guidance for clinicians to address challenges related to treatment initiation and tolerance.

Valproic acid autoinduction: a case-based review

Although valproic acid (VPA) induces the metabolism of multiple other drugs, the clinical reports of VPA autoinduction are rare. A comprehensive literature search yielded only one published case series, which provided the rationale to conduct a review of the published cases along with a new case of VPA autoinduction. Although there may be myriad of reasons for lack of published cases of VPA autoinduction, potential underreporting may be one of the core reasons. Lack of understanding into the highly complex metabolism of VPA may also make it difficult to recognize and report VPA autoinduction. However, it is important to mention that in addition to autoinduction increased elimination of VPA may be mediated by several pharmacokinetic (PK) factors, such as drug interactions, genetic polymorphisms of metabolic enzymes, and protein displacement reactions. As VPA is metabolized by multiple metabolic pathways, the risk for drug interactions is relatively high. There is also a growing evidence for high genetic inducibility of some enzymes involved in VPA metabolism. Protein displacement reactions with VPA increase the biologically active and readily metabolizable free fraction and pose a diagnostic challenge as they are usually not requested by most clinicians. Thus, monitoring of free fraction with total VPA levels may prevent clinically serious outcomes and optimize VPA treatment in clinically challenging patients. This case-based review compares the clinical data from three published cases and a new case of VPA autoinduction to enhance clinicians' awareness of this relatively rare but clinically relevant phenomenon along with a discussion of potential underlying mechanisms.

Anticonvulsant Primary and Secondary Prophylaxis for Acute Ischemic Stroke Patients: A Decision Analysis

Background and Purpose

We examined the impact of 3 anticonvulsant prophylaxis strategies on quality-adjusted life-years (QALYs) among patients with an incident acute ischemic stroke.

Methods

We created a decision tree to evaluate 3 strategies: (1) long-term primary prophylaxis; (2) short-term secondary prophylaxis after an early seizure with lifetime prophylaxis if persistent or late seizures (LSs) developed; and (3) long-term secondary prophylaxis if either early, late, or persistent seizures developed. The outcome was quality-adjusted life expectancy (QALY). We created 4 base cases to simulate common clinical scenarios: (1) female patient aged 40 years with a 2% or 11% lifetime risk of an LS and a 33% lifetime risk of an adverse drug reaction (ADR); (2) male patient aged 65 years with a 6% or 29% LS risk and 60% ADR risk; (3) male patient aged 50 years with an 18% or 65% LS risk and 33% ADR risk; and (4) female patient aged 80 years with a 29% or 83% LS risk and 80% ADR risk. In sensitivity analyses, we altered the parameters and assumptions.

Results

Across all 4 base cases, primary prophylaxis yielded the fewest QALYs when compared with secondary prophylaxis. For example, under scenario 1, strategies 2 and 3 resulted in 7.17 QALYs each, but strategy 1 yielded only 6.91 QALYs. Under scenario 4, strategies 2 and 3 yielded 2.85 QALYs compared with 1.40 QALYs for strategy 1. Under scenarios in which patients had higher ADR risks, strategy 2 led to the most QALYs.

Conclusions

Short-term therapy with continued anticonvulsant prophylaxis only after postischemic stroke seizures arise dominates lifetime primary prophylaxis in all scenarios examined. Our findings reinforce the necessity of close follow-up and discontinuation of anticonvulsant seizure prophylaxis started during acute ischemic stroke hospitalization.

Post-stroke epilepsy and antiepileptic drug use in men and women

Evidence-based recommendations for choice of antiepileptic drug (AED) in post-stroke epilepsy (PSE) are lacking. The aim of this study was to describe the use and persistence of AEDs when initiating treatment in men and women with PSE. An observational study based on individual-level patient data from a regional healthcare register in Stockholm, Sweden, was conducted. Adults (≥18 years) with a stroke diagnosis 2012-2016, a dispensed prescription of any AED within two years after the stroke, and with an epilepsy-related diagnosis were identified. Multinomial logistic regression and logistic regression were used to identify factors associated with choice of AED and discontinuation within 90 days, respectively. Of 9652 men and 9844 women with a stroke diagnosis, 287 men and 273 women had PSE and were dispensed AED. More than 60% of both men and women with PSE were treated with levetiracetam. Carbamazepine was the second most common drug followed by lamotrigine and valproic acid. There were significant differences in AED choice depending on for instance sex, age and renal impairment. Levetiracetam had the highest persistence in both men and women. Choice of AED, oral anticoagulant use and percutaneous endoscopic gastrostomy (PEG) showed an association with the persistence to therapy. We conclude that in both men and women with PSE, levetiracetam was the most used AED for initiation of treatment and also had the highest persistence.

Seizures and Epilepsy After Stroke: Epidemiology, Biomarkers and Management

Stroke is the leading cause of seizures and epilepsy in older adults. Patients who have larger and more severe strokes involving the cortex, are younger, and have acute symptomatic seizures and intracerebral haemorrhage are at highest risk of developing post-stroke epilepsy. Prognostic models, including the SeLECT and CAVE scores, help gauge the risk of epileptogenesis. Early electroencephalogram and blood-based biomarkers can provide information additional to the clinical risk factors of post-stroke epilepsy. The management of acute versus remote symptomatic seizures after stroke is markedly different. The choice of an ideal antiseizure medication should not only rely on efficacy but also consider adverse effects, altered pharmacodynamics in older adults, and the influence on the underlying vascular co-morbidity. Drug-drug interactions, particularly those between antiseizure medications and anticoagulants or antiplatelets, also influence treatment decisions. In this review, we describe the epidemiology, risk factors, biomarkers, and management of seizures after an ischaemic or haemorrhagic stroke. We discuss the special considerations required for the treatment of post-stroke epilepsy due to the age, co-morbidities, co-medication, and vulnerability of stroke survivors.

Epilepsy: Workup and Management in Adults

When managing epilepsy, there is a temptation to focus care with respect to the last and the next seizure. However, epilepsy is a multifaceted chronic condition and should be treated as such. Epilepsy comes with many physical risks, psychological effects, and socioeconomic ramifications, demanding a long-term commitment from the treating physician. Patients with epilepsy, compared to other chronically ill patient populations, have a worse quality of life, family function, and less social support. The majority of patients are well controlled on antiseizure drugs. However, approximately one-third will continue to have seizures despite optimized medical management. The primary aim of this article is to explore the long-term management of chronic epilepsy, and to address some of the particular needs of patients with chronic epilepsy.

Patterns of anticonvulsant use and adverse drug events in older adults

PURPOSE

To examine indications for, duration of use, and rate of adverse drug events (ADE) attributable to anticonvulsant initiation, as adjudicated by expert review of electronic health records (EHR) of older adults.

METHODS

We identified a cohort of community dwelling Medicare beneficiaries with linked EHR (aged 65+, continuously enrolled with a large health system/until death between 2012 and 2014, n = 20 945) and drew a stratified EHR review sample (n = 1534). An expert reviewed all records to adjudicate anticonvulsant use, years of use, indication for use, and evidence of ADEs attributable to anticonvulsant initiation. After excluding patients with insufficient EHR data (n = 37; 2%), we reconstructed the cohort using inverse probability weights to resemble the original cohort of eligible beneficiaries (n = 20 380). Among incident users of a single anticonvulsant, we estimated the rate of ADEs and described the type and severity of ADEs.

RESULTS

Overall, 12% (n = 2469) of eligible beneficiaries used at least one anticonvulsant in the 2012 to 2014 period (4% [n = 757] incident users, 8% [n = 1712] prevalent users). Incident users were most frequently prescribed gabapentin (n = 461/757, 61%), benzodiazepines (n = 122/757, 16%), and levetiracetam (n = 74/757, 10%); the most common indication was pain relief (n = 214; 28%) followed by epilepsy (n = 53; 7%). Among incident users, the overall ADE rate was 10/100 person-years (95% CI 4-20/100 person-years), of which 29% (n = 28/97) were life threatening (eg, somnolence). Most ADEs among incident monotherapy users were nervous system related (68%, n = 66/97).

CONCLUSION

Many older adult community dwelling traditional Medicare beneficiaries had clinically significant ADEs likely attributable to the initiation of anticonvulsant therapy, which was begun for a range of indications.

Surgery for temporal lobe epilepsy in the elderly: Improving quality of life despite cognitive impairment

INTRODUCTION

Temporal lobe epilepsy (TLE) surgery is still underutilized, especially in the elderly population because of concerns related to postoperative complication rate and cognitive deterioration. The aim of the study was to evaluate surgical data, quality of life and neuropsychological outcome in elderly patients, who underwent resective surgery for drug resistant TLE.

METHODS AND MATERIALS

All patients underwent standardized presurgical assessment including clinical, neuroradiological, neuropsychological, and EEG examination. Elderly were considered all patients being 50 years or above (mean 56 yr., range 50-71 yr.). Neuropsychology was assessed before and after surgery, health-related quality of life (HRQOL) only after surgery.

RESULTS

A total of 94 consecutive elderly patients were analyzed. Temporo-mesial resections were performed in 85 patients (90 %). Seizure outcome was available in all patients with a mean follow-up of 5.2 years (1.2-19 ± 3.75 years). 57 patients (60.6 %) were completely seizure free (ILAE 1). The overall morbidity was 10 % including 5 surgical complications and 5 permanent neurological deficits. Neuropsychological assessments in 60 patients showed considerable preoperative impairment, losses in different domains in 25-45 % and gains in about 25 % of the patients. Postoperative HRQOL data was available in 75 patients, revealing significant increase of HRQOL in all domains. Complete seizure freedom was the strongest predictor for postoperative HRQOL (p < 0.001).

CONCLUSION

Surgery for drug resistant temporal lobe epilepsy is a feasible option for elderly patients as seizure control rates are comparable to the younger population. The acceptable rate of permanent neurological deficits and relevant improvements in quality of life, despite considerable postoperative cognitive impairment, justify surgical resection in properly selected elderly patients.

The Prevalence and Factors Associated with Antiepileptic Drug Use in US Nursing Home Residents

BACKGROUND

Antiepileptic drugs (AEDs) are commonly used by nursing home residents, both on- and off-label. The landscape of AED use has changed over the past two decades; however, despite this, contemporaneous research on AED use in US nursing home residents is scant.

OBJECTIVE

The aim of this study was to estimate the prevalence of AED use, describe prescribing patterns, identify factors associated with AED use, and assess whether these factors differ among AEDs with expanded indications in older adults (i.e. gabapentin, pregabalin, topiramate, and lamotrigine).

METHODS

We conducted a cross-sectional study among 549,240 long-stay older residents who enrolled in fee-for-service Medicare and lived in 15,111 US nursing homes on 1 September 2016. Demographics and conditions associated with AED indications, epilepsy comorbidities, and safety data came from the Minimum Data Set Version 3.0 (MDS 3.0). Medicare Part D claims were used to identify AED use. Robust Poisson models and multinomial logistic models for clustered data estimated adjusted prevalence ratios (aPR), adjusted odds ratios (aOR), and 95% confidence intervals (CIs).

RESULTS

Overall, 24.0% used AEDs (gabapentin [13.3%], levetiracetam [4.7%], phenytoin [1.9%], pregabalin [1.8%], and lamotrigine [1.2%]). AED use was associated with epilepsy (aPR 3.73, 95% CI 3.69-3.77), bipolar disorder (aPR 1.20, 95% CI 1.18-1.22), pain (aPR_{moderate/severe vs. no pain} 1.42, 95% CI 1.40-1.44), diabetes (aPR 1.27, 95% CI 1.26-1.28), anxiety (aPR 1.12, 95% CI 1.11-1.13), depression (aPR 1.17, 95% CI 1.15-1.18), or stroke (aPR 1.08, 95% CI 1.06-1.09). Residents with advancing age (aPR_{85+ vs. 65-74 years} 0.73, 95% CI 0.73-0.74), Alzheimer's disease/dementia (aPR 0.87, 95% CI 0.86-0.88), or cognitive impairment (aPR_{severe vs. no impairment} 0.62, 95% CI 0.61-0.63) had decreased AED use. Gabapentinoid use was highly associated with pain (aOR_{moderate/severe vs. no pain} 2.07, 95% CI 2.01-2.12) and diabetes (aOR 1.79, 95% CI 1.76-1.82), but not with an epilepsy indication.

CONCLUSIONS

AED use was common in nursing homes, with gabapentin most commonly used (presumably for pain). That multiple comorbidities were associated with AED use underscores the need for future studies to investigate the safety and effectiveness of AED use in nursing home residents.

Antiepileptic drug use and mortality among community-dwelling persons with Alzheimer disease

Objective

To evaluate the risk of death in relation to incident antiepileptic drug (AED) use compared with nonuse in people with Alzheimer disease (AD) through the assessment in terms of duration of use, specific drugs, and main causes of death.

Methods

The MEDALZ (Medication Use and Alzheimer Disease) cohort study includes all Finnish persons who received a clinically verified AD diagnosis (n = 70,718) in 2005–2011. Incident AED users were identified with 1-year washout period. For each incident AED user (n = 5,638), 1 nonuser was matched according to sex, age, and time since AD diagnosis. Analyses were conducted with Cox proportional regression models and inverse probability of treatment weighting (IPTW).

Results

Nearly 50% discontinued AEDs within 6 months. Compared with nonusers, AED users had an increased relative risk of death (IPTW hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.12–1.36). This was mainly due to deaths from dementia (IPTW HR, 1.62; 95% CI, 1.42–1.86). There was no difference in cardiovascular and cerebrovascular deaths (IPTW HR, 0.98; 95% CI, 0.67–1.44). The overall mortality was highest during the first 90 days of AED use (IPTW HR, 2.40; 95% CI, 1.91–3.03). Among users of older AEDs, relative risk of death was greater compared to users of newer AEDs (IPTW HR, 1.79; 95% CI, 1.52–2.16).

Conclusion

In older vulnerable patients with a cognitive disorder, careful consideration of AED initiation and close adverse events monitoring are needed.

Gabapentinoids: pharmacokinetics, pharmacodynamics and considerations for clinical practice

The gabapentinoids are often recommended as first-line treatments for the management of neuropathic pain. The differing pharmacodynamic and pharmacokinetic profiles can have implications for clinical practice. This article has summarised these key differences. In addition to their use in managing neuropathic pain, gabapentinoids are increasingly being used for off-label conditions despite the lack of evidence. Prescription rates for off-label conditions have overtaken that for on-label use. Similarly, the use of gabapentinoids in the perioperative period is now embedded in clinical practice despite conflicting evidence. This article summarises the risks associated with this increasing use. There is increasing evidence of the potential to cause harm in vulnerable populations such as the elderly and increasing prevalence of abuse. The risk of respiratory depression in combination with opioids is of particular concern in the context of the current opioid crisis. This article describes the practical considerations involved that might help guide appropriate prescribing practices.

Polyneuropathie im Alter

Das periphere Nervensystem ist im Laufe des Alternsprozesses Veränderungen unterworfen. So kommt es unter anderem zu einer Abschwächung von Muskeleigenreflexen und Propriozeption. Davon abzugrenzen sind Polyneuropathien als krankhafte Veränderungen des peripheren Nervensystems. Die jährliche Inzidenz von Polyneuropathien wird auf 118/100.000 geschätzt, die Prävalenz liegt bei etwa 1 %, für ältere Populationen werden 7 % angegeben. Die Ursachen sind vielfältig und ähnlich den Ursachen von Neuropathien des jüngeren Alters: Neben metabolischen, immunvermittelten, hereditären, toxischen und infektiösen Ätiologien können Polyneuropathien Ausdruck von Systemerkrankungen sein. Entsprechend der Altersverteilung der verschiedenen Ursachen sind Neuropathien im Zusammenhang mit Diabetes, monoklonalen Gammopathien und Malignomen im Alter häufiger. Allerdings nimmt der Anteil der kryptogenen Neuropathien, also ohne eindeutige Ursache, mit dem Alter zu. Bei alten Menschen führen Polyneuropathien zu einer zusätzlichen Beeinträchtigung der Mobilität und einem erhöhten Sturzrisiko, was auch die Abklärung funktioneller Fähigkeiten erforderlich macht.

Epilepsy in older people

Globally, as populations age there will be challenges and opportunities to deliver optimal health care to senior citizens. Epilepsy, a condition characterised by spontaneous recurrent seizures, is common in older adults (aged >65 years) and yet has received comparatively little attention in this age group. In this Review, we evaluate the underlying causes of epilepsy in older people, explore difficulties in establishing a diagnosis of epilepsy in this population, discuss appropriate antiseizure medications, and evaluate potential surgical treatment options. We consider cognitive, psychological, and psychosocial comorbidities and the effect that epilepsy might have on an older person's broader social or care network in high-income versus middle-income and low-income countries. We emphasise the need for clinical trials to be more inclusive of older people with epilepsy to help inform therapeutic decision making and discuss whether measures to improve vascular risk factors might be an important strategy to reduce the probability of developing epilepsy.

Epilepsy in the Elderly: Treatment and Consideration of Comorbid Diseases

Epilepsy is the third most common neurological disorder affecting older adults after stroke and dementia, and the incidence of epilepsy is increasing rapidly in this population. A further increase in the incidence and prevalence of epilepsy is expected in aging societies. The establishment of a correct differential diagnosis between epilepsy and other seizure disorders that are common in the elderly is crucial. The symptoms of seizures in the elderly may be different from those in younger populations. The diagnosis is difficult, probably because of nonspecific characteristics, short-term symptoms, and absence of witnesses. There are three important issues in the treatment of epilepsy in the elderly: changes in pharmacokinetic parameters, polytherapy (including non-antiepileptic and antiepileptic drugs), and susceptibility to adverse drug effects. Antiepileptic drugs (AEDs) with fewer adverse effects, including cognitive effects, and AEDs without significant pharmacokinetic drug interactions are needed. Several studies found that stroke was strongly associated with a high incidence of early seizures and epilepsy. Stroke is also one of the major causes of status epilepticus. Cortical involvement and large lesions are strongly associated with the development of seizures and epilepsy. The severity of the initial neurological deficit is a strong clinical predictor of seizures after ischemic stroke. The optimal quality of life of dementia patients cannot be achieved without a proper diagnosis of coexisting epilepsy.

New anti-seizure medication for elderly epileptic patients

Introduction: Epilepsy treatment in older people requires specific consideration owing to more physical co-morbidities, the risk of drug-to-drug interactions through polypharmacy, and differences in pharmacodynamics and pharmacokinetics. There are many 'newer' antiepileptic drugs (AEDs) widely used for various seizure types and seizure disorders. However, there is limited specific evidence for the efficacy, safety, and tolerability of these treatments in the elderly population. Areas covered: This review summarises the current most robust evidence available for the use of the newer AEDs belonging to generation two and three in elderly people with epilepsy. The article provides practical evidenced based clinical information to help prescribers choose the most appropriate AED from the drugs discussed. Expert opinion: Diagnosing new onset epilepsy in the elderly population requires specialist assessment. Treatment plans need to be tailored to accommodate an individual's co-morbidities, concurrent medications, and general health status. To date, few clinical investigations consider the elderly population specifically despite the increased risk factors. There is a need for large quality trial data to assess the impact of the newest AEDs on seizure control and quality of life in this population with complex needs.

Antiepileptic Drugs and Accumulation of Hospital Days Among Persons With Alzheimer's Disease

OBJECTIVES

To compare the accumulation of hospital days between initiators and noninitiators of antiepileptic drugs (AEDs) among persons with Alzheimer's disease (AD).

DESIGN

Exposure-matched cohort study.

SETTING AND PARTICIPANTS

Persons newly diagnosed with AD in 2005-2011 (n = 70,718) and initiating AED use identified from Finnish health care registers. For each AED initiator, 1 noninitiator matched on age, sex, and time since AD diagnosis was selected. Persons with epilepsy were excluded from the study.

METHODS

Association between AED initiation or use of individual AEDs and accumulation of hospital days during a 2-year follow-up was assessed using negative binomial model.

RESULTS

AED initiators (n = 4432) were hospitalized on average for 43.7 (SD: 88.3) days and matched noninitiators for 32.2 (SD: 71.3) days during the 2-year follow-up. Altogether, 27.3% of the AED initiators and 35.6% of the noninitiators had no hospital days during the study period. Number of accumulated hospital days during the follow-up was 31% higher [adjusted incidence rate ratio (aIRR): 1.31, 95% confidence interval (CI): 1.19-1.43] among AED initiators than the noninitiators. Hospital days due to diseases of the nervous system excluding dementia (aIRR: 2.72, 95% CI: 1.72-4.31), musculoskeletal system (aIRR: 2.49, 95% CI: 1.73-3.58), respiratory system (aIRR: 1.89, 95% CI: 1.47-2.43), and mental and behavioral disorders excluding dementia (aIRR: 1.96, 95% CI: 1.02-3.79) were more common among the AED initiators than noninitiators. Among pregabalin (aIRR: 0.65, 95% CI: 0.56-0.77), gabapentin (aIRR: 0.66, 95% CI: 0.49-0.88), and clonazepam (aIRR: 0.73, 95% CI: 0.55-0.96) initiators, the number of accumulated hospital days was 27% to 35% lower than the days accumulated among the initiators of valproic acid.

CONCLUSIONS AND IMPLICATIONS

AED initiators had more hospital days than noninitiators. Pregabalin and gabapentin were associated with a lower number of hospital days than valproic acid. Further research is needed on the reasons for these findings.

Psychopharmacology and pharmacokinetics

The overall physiologic changes associated with aging lead to changes in both pharmacokinetic and pharmacodynamic actions of many medications. This, in turn, leads to changes in the impact that a wide variety of medications have on older adults when compared to younger, healthy individuals. These pharmacokinetic and pharmacodynamic variations can cause either lesser or greater than expected responses to medication. Knowledge of the physiologic changes that are expected to occur in the elderly can help to identify medications that may require dose adjustments or that should be avoided, due to increased risk in this population. As a general principle, medications should be started at lower doses in the elderly with slow titration schedules to reduce the risk of adverse effects.

New-onset epilepsy in the elderly

People who are 60 years old and older have the highest incidence of developing new-onset epilepsy. The increase of the ageing population has resulted in a greater number of patients with new-onset epilepsy or at risk of developing the condition. Previously published review articles regarding epilepsy in older patients have had a broad focus, including people who were diagnosed with epilepsy in their childhood or middle age. The present review focuses on the causes, treatment, prognosis and psychosocial impact of new-onset epilepsy in people aged ≥60 years. Following a search of the medical electronic databases and relevant references, we identified 22 studies overall that met the inclusion criteria. Only four randomized clinical trials (RCTs) were identified that compared different antiepileptic drug treatments in this population, demonstrating that newer-generation antiepileptic drugs (e.g. lamotrigine and levetiracetam) were generally better tolerated. One uncontrolled study provided promising evidence of good outcomes and safety for surgical resection as a treatment for people with uncontrolled seizures. Five studies reported that people ≥60 years with new-onset epilepsy have significant cognitive impairments (e.g. memory loss) and psychological issues including depression, anxiety and fatigue. We found that there is limited evidence to guide treatment in people with Alzheimer's disease and epilepsy. The specific features of new-onset epilepsy in this target population significantly influences the choice of treatment. Cognitive and psychiatric screening before treatment may be useful for management. Two studies with proposed guidelines were identified but no formal clinical practice guidelines exist for this special population to assist with appropriate management. There is a need for more RCTs that investigate effective treatments with limited side effects. More research studies on the psychosocial effects of new-onset epilepsy, and long-term outcomes, for people aged ≥60 years are also required.

Euro-Esli: a European audit of real-world use of eslicarbazepine acetate as a treatment for partial-onset seizures

The Euro-Esli study was an exploratory pooled analysis of data from 14 European clinical practice studies, which was conducted to audit the real-world effectiveness, safety, and tolerability of eslicarbazepine acetate (ESL) as an adjunctive treatment for partial-onset seizures. Retention and effectiveness were assessed after 3, 6, and 12 months of ESL treatment, and at the final visit. Safety and tolerability were assessed throughout ESL treatment by evaluating adverse events (AEs) and ESL discontinuation due to AEs. Data from 2058 patients (52.1% male; mean age 44.0 years) were included. All 2058 patients were assessed for safety and 1975 (96.0%) patients were assessed for effectiveness. After 12 months, retention, responder (≥50% seizure frequency reduction), and seizure freedom rates were 73.4, 75.6, and 41.3%, respectively. AEs were reported for 34.0% of patients and led to discontinuation in 13.6% of patients. The most frequently reported AEs were dizziness (6.7% of patients), fatigue (5.4%), and somnolence (5.1%). No unexpected safety signals emerged over a median duration of follow-up of >5 years. Subgroup analyses revealed that ESL was significantly more effective in patients aged ≥65 versus <65 years, in patients who were not receiving treatment with other sodium channel blockers versus those who were receiving treatment with other sodium channel blockers, and in patients who were receiving <2 versus ≥2 concomitant antiepileptic drugs at baseline. Euro-Esli is the largest ESL clinical practice study conducted to date. This study provides strong and reassuring evidence of ESL’s safety profile, and complements the data from clinical trials.

Lacosamide and concomitant use of antiepileptic and other medications in a US population - A retrospective cohort study

Information on the use of lacosamide and concomitant antiepileptic and non-antiepileptic drugs (non-AEDs) is available from clinical trials and observational studies with small sample sizes. This retrospective cohort study was conducted to gain insight into the use of lacosamide in a large number of patients with epilepsy in real-life clinical practice with less restrictive selection criteria compared with clinical trial participants. The Truven Health MarketScan (Commercial Claims and Medicare Supplemental) database was used to identify patients with a prior diagnosis of epilepsy with at least one prescription claim for lacosamide between June 2009 and September 2013 and continuous health insurance enrolment with medical and pharmacy coverage during the 1-year pre-index baseline period. A total of 8859 eligible patients were identified, of whom, at index (lacosamide initiation), 16.8% received lacosamide as monotherapy and 54.0% as polytherapy. The median prescription duration was 196days (Interquartile range 69-476days). Levetiracetam was the most frequently prescribed concomitant AED across all age groups, followed by phenytoin among older (>65years) and lamotrigine among younger patients. Older patients who had LCM monotherapy at initiation, were prescribed fewer concomitant AEDs, but more non-AEDs. The most common non-AED medications were prescribed for pain, psychiatric conditions, hyperlipidemia and gastrointestinal diseases across all age groups. Overall, results suggest that the lacosamide use is driven predominantly by age and that there is substantial use of lacosamide monotherapy (16.8%), despite lack of indication at the time of the study. Results also reveal substantial use of concomitant non-AEDs; 90.4% among patients >65years of age and 54.3% among those ≤17years, confirming the high prevalence of comorbidities among patients with epilepsy across all ages. Despite the availability of numerous newer AEDs, older AEDs are still being frequently prescribed, especially for elderly patients, notably phenytoin. This warrants careful consideration, given the strong propensity of enzyme-inducing AEDs to interact with other drugs, producing unwanted side effects. These results highlight the value of real-life prescription patterns and the potential in informing treatment decisions to ensure patients receive appropriate treatment.

Treatment issues for children with epilepsy transitioning to adult care

This is the third of three papers that summarize the second symposium on Transition in Epilepsies held in Paris in June 2016. This paper focuses on treatment issues that arise during the course of childhood epilepsy and make the process of transition to adult care more complicated. Some AEDs used during childhood, such as stiripentol, vigabatrin, and cannabidiol, are unfamiliar to adult epilepsy specialists. In addition, new drugs are being developed for treatment of specific childhood onset epilepsy syndromes and have no indication yet for adults. The ketogenic diet may be effective during childhood but is difficult to continue in adult care. Regional adult epilepsy diet clinics could be helpful. Polytherapy is common for patients transitioning to adult care. Although these complex AED regimes are difficult, they are often possible to simplify. AEDs used in childhood may need to be reconsidered in adulthood. Rescue medications to stop prolonged seizures and clusters of seizures are in wide home use in children and can be continued in adulthood. Adherence/compliance is notoriously difficult for adolescents, but there are simple clinical approaches that should be helpful. Mental health issues including depression and anxiety are not always diagnosed and treated in children and young adults even though effective treatments are available. Attention deficit hyperactivity disorder and aggressive behavior disorders may interfere with transition and successful adulthood but these can be treated. For the majority, the adult social outcome of children with epilepsy is unsatisfactory with few proven interventions. The interface between pediatric and adult care for children with epilepsy is becoming increasingly complicated with a need for more comprehensive transition programs and adult epileptologists who are knowledgeable about special treatments that benefit this group of patients.

Patient-reported financial barriers to adherence to treatment in neurology

Objective

Many effective medical therapies are available for treating neurological diseases, but these therapies tend to be expensive and adherence is critical to their effectiveness. We used patient-reported data to examine the frequency and determinants of financial barriers to medication adherence among individuals treated for neurological disorders.

Patients and methods

Patients completed cross-sectional surveys on iPads as part of routine outpatient care in a neurology clinic. Survey responses from a 3-month period were collected and merged with administrative sources of demographic and clinical information (eg, insurance type). We explored the association between patient characteristics and patient-reported failure to refill prescription medication due to cost in the previous 12 months, termed here as “nonadherence”.

Results

The population studied comprised 6075 adults who were presented between July and September 2015 for outpatient neurology appointments. The mean age of participants was 56 (standard deviation: 18) years, and 1613 (54%) were females. The patients who participated in the surveys (2992, 49%) were comparable to nonparticipants with respect to gender and ethnicity but more often identified English as their preferred language (94% vs 6%, p<0.01). Among respondents, 9.8% (n=265) reported nonadherence that varied by condition. These patients were more frequently Hispanic (16.7% vs 9.8% white, p=0.01), living alone (13.9% vs 8.9% cohabitating, p<0.01), and preferred a language other than English (15.3% vs 9.4%, p=0.02).

Conclusion

Overall, the magnitude of financial barriers to medication adherence appears to vary across neurological conditions and demographic characteristics.

Anterior temporal lobectomy for older adults with mesial temporal sclerosis

OBJECTIVE

To compare postoperative seizure-free survival between older and younger adults.

METHODS

A retrospective cohort of 107 temporal lobe epilepsy patients with a diagnosis of mesial temporal sclerosis (MTS) received anterior temporal lobectomy (ATL) between 1993 and 2014. We divided the lower three quartiles (younger) and top quartile (older, all 47+ years) of patients, then reviewed patient registry and electronic medical records to determine time to first self-reported seizure after ATL, the primary outcome (mean=3.5years of follow-up, SD=3.6). We also assessed Engel classifications, intraoperative and postoperative treatment complications, and social disability. We used Cox proportional hazard models to assess the association between individual traits and time of seizure recurrence.

RESULTS

During follow-up, 35/107 (32.7%) patients had post-operative seizure(s). After adjustment for potential confounders there were no significant differences in the probability of post-operative seizures between the older and younger groups, though we had limited precision (hazard ratio of 0.67 [0.28-1.59]), (p=0.36). There were more treatment complications and disability in older patients (18% vs. 1.3% for any complications, 84.62% vs. 58.23% for driving disability, and 84.6% vs. 60.7% for work disability, p<0.05).

CONCLUSION

Older patients appear to have more complications after ATL, compared with younger patients. Age, however, does not appear to have a large independent association with seizure recurrence.

Fried frailty phenotype assessment components as applied to geriatric inpatients

BACKGROUND

Management of geriatric patients would be simplified if a universally accepted definition of frailty for clinical use was defined. Among definitions of frailty, Fried frailty phenotype criteria constitute a common reference frame for many geriatric studies. However, this reference frame has been tested primarily in elderly patients presenting with relatively good health status.

OBJECTIVE

The aim of this article was to assess the usefulness and limitations of Fried frailty phenotype criteria in geriatric inpatients, characterized by comorbidity and functional impairments, and to estimate the frailty phenotype prevalence in this group.

PATIENTS AND METHODS

Five hundred consecutive patients of the university hospital subacute geriatric ward, aged 79.0±8.4 years (67% women and 33% men), participated in this cross-sectional study. Comprehensive geriatric assessment and Fried frailty phenotype component evaluation were performed in all patients.

RESULTS

Multimorbidity (6.0±2.8 diseases) characterized our study group, with a wide range of clinical conditions and functional states (Barthel Index of Activities of Daily Living 72.2±28.2 and Mini-Mental State Examination 23.6±7.1 scores). All five Fried frailty components were assessed in 65% of patients (95% confidence interval [CI] =60.8-69.2) (diagnostic group). One or more components were not feasible to be assessed in 35% of the remaining patients (nondiagnostic group) because of lack of past patient's body mass control and/or cognitive or physical impairment. Patients from the nondiagnostic group, as compared to patients from the diagnostic group, presented with more advanced age, higher prevalence of dementia, lower prevalence of hypertension, lower systolic and diastolic blood pressure, body mass index, Mini-Mental State Examination and Barthel Index of Activities of Daily Living. Despite diagnostic limitations, we found ≥3 positive criteria (thus, frailty diagnosis) in 54.2% of the study group (95% CI =49.8-58.6), with prevalence from 31.7% in sexagenarians to 67.6% in nonagenarians.

CONCLUSION

Fried frailty phenotype criteria seem useful for geriatric inpatient assessment, despite diagnostic limitations. High prevalence of frailty among geriatric inpatients suggests that evaluation for frailty should be considered a part of the comprehensive geriatric assessment.

Association between addressing antiseizure drug side effects and patient-reported medication adherence in epilepsy

BACKGROUND AND AIM

Adherence to treatment is a critical component of epilepsy management. This study examines whether addressing antiepileptic drug (AED) side effects at every visit is associated with increased patient-reported medication adherence.

PATIENTS AND METHODS

This study identified 243 adults with epilepsy who were seen at two academic outpatient neurology settings and had at least two visits over a 3-year period. Demographic and clinical characteristics were abstracted. Evidence that AED side effects were addressed was measured through 1) phone interview (patient-reported) and 2) medical records abstraction (physician-documented). Medication adherence was assessed using the validated Morisky Medication Adherence Scale-4. Complete adherence was determined as answering "no" to all questions.

RESULTS

Sixty-two (25%) patients completed the interviews. Participants and nonparticipants were comparable with respect to demographic and clinical characteristics; however, a smaller proportion of participants had a history of drug-resistant epilepsy than nonparticipants (17.7% vs 30.9%, P=0.04). Among the participants, evidence that AED side effects were addressed was present in 48 (77%) medical records and reported by 51 (82%) patients. Twenty-eight (45%) patients reported complete medication adherence. The most common reason for incomplete adherence was missed medication due to forgetfulness (n=31, 91%). There was no association between addressing AED side effects (neither physician-documented nor patient-reported) and complete medication adherence (P=0.22 and 0.20).

DISCUSSION AND CONCLUSION

Among patients with epilepsy, addressing medication side effects at every visit does not appear to increase patient-reported medication adherence.

Aetiology and outcome of generalized convulsive status epilepticus in elderly

PURPOSE

Convulsive status epilepticus (CSE) is a common neurologic emergency in elderly people. The current study elaborates the clinical characteristics and outcome of CSE in elderly patients.

METHODS

Analysis of data of generalized CSE patients, aged 60 years and above admitted at the neurointensive care unit (NICU) was performed. The primary outcome for analysis was in-hospital mortality. The study population was divided into groups based on progression of CSE and mortality to analyze difference in study variables. Mortality of the group was analyzed using life tables.

RESULTS

A total of 33 patients satisfied the inclusion criteria from medical records of 212 patients with CSE. Mean age of the study population was 67.0 ± 6.8 years; 69.7% were men. Acute symptomatic aetiology was the commonest cause of CSE (60.6%); nine (27.3%) patients progressed to refractory status epilepticus (RSE) of which five patients had prolonged RSE. The overall mortality was 18.2%. Complications of mechanical ventilation and mean age were higher in patients who died. Though vascular aetiology was the leading cause of CSE (39.3%), it was not associated with progression to RSE or mortality. Acute symptomatic aetiology accounted for five out of the six deaths in the entire cohort.

CONCLUSION

Less than one-third of elderly patients with CSE progressed to RSE. Vascular aetiology, the leading cause of generalized CSE in elderly, was not associated with progression to RSE and mortality. Acute symptomatic aetiology was associated with high mortality.

Epilepsy in the elderly: restrictions, fears, and quality of life

OBJECTIVES

Due to demographic change and high incidence of epilepsy in elderly, the number of elderly with epilepsies is increasing. However, only few studies investigated the impact of epilepsy on quality of life (QoL). We investigated how epilepsy affects different aspects of QoL dependent on the age of the patients and the age of onset of epilepsy.

MATERIALS AND METHODS

In a multicenter, cross-sectional study, three patient groups were recruited from five centers: Group A1: 45 elderly (≥65 years.) with late onset of epilepsy (≥65 years), group A2: 51 elderly (≥65 years.) with early-onset, long-lasting epilepsy (≤50 years), group B: 41 young adults (≤50 years) with epilepsy. Statistical analysis of differences between groups was performed using generalized linear models.

RESULTS

Elderly with late-onset epilepsy (group A1) had a significantly lower seizure frequency, were treated with less anti-epileptic drugs (AEDs), and reported a better tolerability of AED treatment, but had more comorbidities compared with groups A2 and B. After adjusting for seizure frequency, tolerability of AEDs and comorbidity, young adults (group B) reported the highest overall QoL, whereas patients of group A1 and A2 did not differ significantly. Epilepsy-related fears, especially fears of stigmatization, were significantly higher in elderly with long-lasting epilepsy compared with groups A1 and B.

CONCLUSION

Seizure-related variables, tolerability of AEDs and comorbidity have a stronger impact on QoL and on restrictions due to epilepsy than age, age at onset of epilepsy or duration of epilepsy. However, some results indicate group-specific patterns of impairment and epilepsy-related fears.

Efficacy and safety of perampanel in the subgroup of elderly patients included in the phase III epilepsy clinical trials

Clinical data regarding use of antiepileptic drugs in the elderly are generally scarce. Therefore, a subanalysis of subjects aged ≥ 65 years who participated in the 3 phase III perampanel studies was undertaken to determine efficacy and safety in these patients. Efficacy (change in seizure frequency/28 days and 50% responder rate) in the elderly subgroup was found to be consistent with the adult population. Adverse event rates were also largely similar, with some exceptions. Because risks of falls, dizziness, and fatigue were greater in the elderly, careful titration of perampanel in patients aged ≥ 65 years is suggested, especially at higher doses, where balancing tolerability and clinical response is necessary.

Effect of the combination of uridine nucleotides, folic acid and vitamin B12 on the clinical expression of peripheral neuropathies

AIMS

Peripheral neuropathy (PN) is a common condition whose incidence is approximately 8% in elderly persons. Neuropathic pain (NeP) has a significant incidence in the general population and affects more than half of all patients with PN. The pathophysiology of PN is characterized by lesions of myelin-producing Schwann cells in peripheral nerves. Regeneration/protection of the myelin sheath after a nerve lesion is a fundamental element of repair in PN. Nucleotides such as uridine monophosphate (UMP) have proven to be efficacious in treating the cause of the myelin sheath lesion in several experimental and clinical models. Our objective was to evaluate clinical improvement in patients with PN and NeP treated with a combination of UMP+folic acid+vitamin B12 (Keltican).

PATIENTS AND METHODS

We performed an exploratory, open-label, multicenter, study of 212 patients followed for 2 months. Pain was assessed using the painDETECT questionnaire (PDQ).

RESULTS

The intensity of the NeP assessed at the time of the consultation progressed favorably and decreased significantly (p<0.001) in all the types of PN included. The global score for pain assessed using PDQ decreased from 17.5 points to 8.8 points at the final evaluation (p<0.001). Nonsteroidal anti-inflammatory drugs were decreased/withdrawn in 77.4% of patients.

CONCLUSIONS

The combination of UMP+folic acid+vitamin B12 is effective against NeP associated with PN. It leads to statistically significant reductions not only in the total PDQ score but also in the intensity of pain, number of areas affected, and pain radiation. Furthermore, it makes it possible to reduce the dosage of concomitant medication.

Patterns of chronic co-morbid medical conditions in older residents of U.S. nursing homes: differences between the sexes and across the agespan

OBJECTIVE

There are limited data on combinations of co-morbid conditions to guide efforts to improve therapeutic strategies in patients with multiple co-morbid conditions. To some extent, this may be due to limited data on combinations of co-morbid conditions in patient groups. Our goal was to determine the most common co-morbid medical conditions in older residents of U.S. nursing homes and identify sex differences in prevalences and changes across the agespan of nursing residents.

DESIGN

Cross sectional analysis of National Nursing Home Survey (NNHS)--a nationally representative sample with comprehensive medical data on nursing home residents.

SETTING

1174 Nursing homes.

PARTICIPANTS

Long term stay residents of U.S. Nursing Homes aged 65 years and older (11,734 :8745 women, 2989 men).

MEASUREMENTS

Determination of the prevalences of the most frequent two and three disease combinations identified using Clinical Classifications Software (CCS) for ICD-9-CM and a composite vascular disease diagnosis (atherosclerosis and/or coronary artery disease, and/or peripheral arterial disease, and/or cerebrovascular disease or stroke) from the most recent and only NNHS survey with comprehensive medical diagnosis information.

RESULTS

Frequent 2-disease combinations were: hypertension (HTN) + dementia (DEM) in 27%, HTN + any Vascular (Vasc) disease (26%), HTN + depression(DEP) 21%, HTN + arthritis(ARTH) 20%, DEM + Vasc (21%), DEM+Depression 19%, Arthritis + DEM 17%, DEP + Vasc (16%), ARTH + Vasc (15%), followed by HTN + GERD (14%) and ARTH + DEP (14%). Frequent 3-disease combinations: HTN +VASC+ DEP in 13%, HTN +DEM +DEP (11%), and HTN+Arthritis+DEM (10%). HTN was in 80% of the top 3-disease combinations, Vasc in 50%, HTN+VASC in 35%, DEM or DEP in 40%, ARTH in 25% and GERD in 20%. Combinations with anemia, arthritis, dementia, heart failure, osteroporosis, thyroid disease were higher in women, COPD combinations higher in men. As age increased, dementia, depression, arthritis, and anemia with hypertension were common co-morbid combinations, diabetes and heart failure were not.

CONCLUSIONS

Hypertension, vascular disease, dementia, arthritis, depression, and gastro-esophageal reflux disease were part of the most prevalent co-morbid conditions. Multimorbidity patterns can be identified in nursing home residents and vary with age and by sex.

Problems, needs, and useful strategies in older adults self-managing epilepsy: implications for patient education and future intervention programs

OBJECTIVE

The purpose of this study was to determine, in a sample of older adults diagnosed with epilepsy, perceived self-management problems and needs encountered since diagnosis, as well as strategies used to address problems and needs.

METHODS

Qualitative description was used. Twenty older adults engaged in face-to-face interviews. Interviews were analyzed via content analysis.

RESULTS

Participants reported problems, needs, and strategies in six categories: Information, Physical and Emotional Symptoms, Memory and Concentration, Medications, Commitments, and Relationships.

CONCLUSION

Participants noted some problems and needs previously documented in the literature, though current results have built upon extant literature to reveal etiologies of and contexts surrounding problems and needs; new findings were also revealed. This knowledge can be used by health-care providers in counseling and educating older adults with epilepsy and can inform formal self-management interventions.

PRACTICE IMPLICATIONS

Determining needs from the patient's perspective is consistent with today's focus on patient-centered care. Current findings have led to an organizing framework for problems and needs of older adults with epilepsy. More research is needed to develop the framework so that it can serve as a template for an intervention. In the interim, findings can inform educational practices of those caring for this population.

Assessment and management of pain, with particular emphasis on central neuropathic pain, in moderate to severe dementia

In patients with dementia, undertreatment of pain, irrespective of its aetiology, is widely recognized; the risk for undertreatment increases with the severity of dementia. We argue, however, that central neuropathic pain is by far the most undertreated type of pain in patients with dementia. Central pain is a type of neuropathic pain that is known to occur in stroke patients and is caused by white matter lesions. Although white matter lesions are also a neuropathological hallmark of dementia, central neuropathic pain has hardly been described in dementia. Therefore, the goal of this review was to address assessment and management of pain, with particular emphasis on central neuropathic pain, in moderate to severe dementia. Concerning pain assessment, the findings of this review suggest that self-report pain rating scales, in particular the Verbal Rating Scale, the Horizontal Visual Analogue Scale and the Faces Pain Scale can be administered to patients in a more advanced stage of dementia. For those who are no longer able to communicate pain, pain observation scales are most appropriate. Self-report and pain observation should be combined, if possible. For an overview of assessment tools to measure pain with older people unable to verbally communicate, we refer readers to the City of Hope Pain and Palliative Care Resource Center ( http://prc.coh.org/PAIN-NOA.htm ). The review further highlights that behavioural disturbances, e.g. agitation and physical inactivity, as well as autonomic responses, e.g. an increase in blood pressure and heart rate, may contribute to a more reliable assessment of pain. With respect to central neuropathic pain in particular, assessment of sensory abilities (touch, pinprick, temperature and vibration), mood (e.g. anxiety) and determination of the presence of a Babinsky reflex, accelerated tendon reflexes, and spasticity may contribute to reliable assessment. Management of pain, not of a central origin, starts with paracetamol (acetaminophen), which, together with opioids, is the most frequently prescribed analgesic drug in dementia. Non-steroidal anti-inflammatory drugs are hardly prescribed in a residential setting. Some authors advise starting treatment with a low dose of opioids. Antidepressants and antiepileptic drugs appear to have a positive effect on central neuropathic pain. In the review, advantages and disadvantages of amitriptyline, carbamazepine, lamotrigine, gabapentin and pregabalin are discussed; a negative effect of these drugs on liver and kidney functions, as well as on cognitive functions in patients who already suffer from cognitive impairment is highlighted. Next to pharmacotherapy, non-pharmacological treatment strategies such as transcutaneous electrical nerve stimulation may be effective as long as afferent pathways transmitting the electrical stimulus are still intact.