Annals of Long Term Care

**sub**Overview of Anticonvulsants **endsub**
“The U.S. population over the age of 65 is growing at a rapid pace, and faster than the population in general,” began Lon S. Schneider, MD, Professor of Psychiatry, Neurology, and Gerontology, University of Southern California School of Medicine, Los Angeles, and Symposium Chairman. The speaker pointed out that epilepsy—often overlooked in the elderly because of the focus on dementia—has its highest incidence in the first year of life and after age 75. “The causes of seizures in the elderly include brain injury due to stroke and aneurysm, tumors, alcohol and substance abuse, infection, hyperlipidemia, and hypoglycemia,” he continued.

Dr. Schneider discussed clinical considerations with anticonvulsants in the elderly. “Although thought of as a class of drugs, they differ in many ways among themselves and have different structures.” He noted that drug–drug interactions, pharmacokinetics, and effects on cognitive function are also issues of concern with regard to anticonvulsants. Common psychiatric disorders in the elderly are dementia (most common), depression, substance abuse, psychosis, schizophrenia, and developmental disabilities. “There is at least a 20% incidence of significant psychosis in the two-thirds of patients with dementia who do not have evidence of a behavioral disorder when first seen by a physician,” explained the speaker, noting that aggression is common across the psychiatric disorders, but does not meet the usual syndromal criteria.

Dr. Schneider mentioned the anticonvulsants divalproex/valproic acid, carbamazepine, gabapentin, lamotrigine, and topiramate, and possible indications for use: seizures, migraine headaches, cocaine and alcohol withdrawal, cerebral malaria, preeclampsia, mania, fibromyalgia, posttraumatic stress disorder, and Huntington’s disease.

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**sub**Managing Seizure Disorders: Anticonvulsant Therapy **endsub**
“The incidence of seizures in the elderly is six to eight times higher than in any other age group,” stated R. Eugene Ramsay, MD, Professor of Neurology and Psychiatry, University of Miami School of Medicine, Miami, FL, and Director, International Center for Epilepsy, Miami. This statement was based on data from a Veterans Affairs (VA) cooperative study that Dr. Ramsay and two colleagues conducted. He also stated that 50% of new-onset seizures will occur in those 60 years of age and older, within 20-30 years. “Seizures have a recurrent rate of 90% if untreated, and there is a tremendous amount of concurrent neurological and medical disorders in the elderly that must be taken into account,” he continued.

“Three-quarters of the elderly with psychiatric disorders have dyslipidemias,” noted Dr. Ramsay. “If vascular disease could be controlled or reduced, the incidence of epilepsy would be substantially reduced.” Most of the patients in the VA cooperative study had abnormal imaging studies, many with evidence of only small-vessel disease.

Dr. Ramsay noted that one reason epilepsy is underappreciated and underdiagnosed is that two-thirds of those with the condition do not have convulsions. Many patients who do have convulsions have them when they are alone, and they are diagnosed based on inference. “The older patient is less likely to have motor phenomena because the epilepsy results mostly from vascular disease, occurring in the middle or the anterior cerebral artery,” said Dr. Ramsay. “It does not occur in the posterior cerebral artery, which supplies most of the temporal lobe. It affects the motor-sensory strip or may present only as a lapse of consciousness.” He also explained that during a seizure the elderly usually sit and stare off into the distance, as opposed to smacking their lips and rubbing their clothes, as younger patients do.