Epilepsy in the Elderly

Acute Abortive Therapies for Seizure Clusters in Long-Term Care

OBJECTIVES

To describe acute seizure treatment for the long-term care setting, emphasizing rescue (acute abortive) medications for on-site management of acute unexpected seizures and seizure clusters.

DESIGN

Narrative review.

SETTING AND PARTICIPANTS

People with seizures in long-term care, including group residences.

METHODS

PubMed was searched using keywords that pertained to rescue medications, seizure emergencies/epilepsy, seizure action plans, and long-term care.

RESULTS

Seizure disorder, including epilepsy, is prevalent in long-term care residences, and rescue medications can be used for on-site treatment. Diazepam rectal gel, intranasal midazolam, and diazepam nasal spray are US Food and Drug Administration (FDA)-approved seizure-cluster rescue medications, and intravenous diazepam and lorazepam are approved for status epilepticus. Benzodiazepines differ by formulation, route of administration, absorption, and metabolism. Intranasal formulations are easy and ideal for public use and when rectal treatment is challenging (eg, wheelchair). Intranasal, intrabuccal, and rectal formulations do not require specialized training to administer and are easier for staff at all levels of training compared with intravenous treatment. Off-label rescue medications may have anecdotal support; however, potential disadvantages include variable absorption and onset of action as well as potential risks to patients and caregivers/care partners. Delivery of intravenous-administered rescue medications is delayed by the time needed to set up and deliver the medication and is subject to dosing errors. Seizure action plans that include management of acute seizures can optimize the quality and timing of treatment, which may reduce emergency service needs and prevent progression to status epilepticus.

CONCLUSIONS AND IMPLICATIONS

Seizure disorder is prevalent across all ages but is increased in older adults and in those with intellectual and developmental disabilities. Prompt intervention may reduce negative outcomes associated with acute unexpected seizures and seizure clusters. Seizure action plans that include acute seizures can improve the treatment response by detailing the necessary information for staff to provide immediate treatment.

Medical and surgical treatment of epilepsy in older adults: A national survey

OBJECTIVE

There are no clinical guidelines dedicated to the treatment of epilepsy in older adults. We investigated physician opinion and practice regarding the treatment of people with epilepsy aged 65 years or older. We also sought to study how our opinion and practice varied between geriatricians, general neurologists, and epilepsy neurologists (i.e., epileptologists).

METHODS

We initially piloted our survey to measure test-retest reliability. Once finalized, we disseminated the survey via two rounds of facsimiles, and then conventional mail, to eligible individuals listed in a national directory of Canadian physicians. We used descriptive statistics such as stacked bar charts and tables to illustrate our findings.

RESULTS

One hundred forty-four physicians (104 general neurologists, 25 geriatricians, and 15 epileptologists) answered our survey in its entirety (overall response rate of 13.2%). Levetiracetam and lamotrigine were the preferred antiseizure medications (ASMs) to treat older adults with epilepsy. Two thirds of epileptologists and almost half of general neurologists would consider prescribing lacosamide in >50% of people aged >65 years; only one geriatrician was of the same opinion. More than 40% of general neurologists and geriatricians erroneously believed that none of the ASMs mentioned in our survey was previously studied in randomized controlled trials specific to the treatment of epilepsy in older adults. Epileptologists were more likely as compared to general neurologists and geriatricians to recommend epilepsy surgery (e.g., 66.6% vs. 22.9%-37.5% among older adults).

SIGNIFICANCE

Therapeutic decisions for older adults with epilepsy are heterogeneous between physician groups and sometimes misalign with available clinical evidence. Our surveyed physicians differed in their approach to ASM choice as well as perception of surgery in older adults with epilepsy. These findings likely reflect the lack of clinical guidelines dedicated to this population and the deficient implementation of best practices.

Comparative economic outcomes in patients with focal seizures initiating eslicarbazepine acetate versus brivaracetam in the long-term care setting in the USA

Aim: To compare all-cause and epilepsy-specific pharmacy and total costs associated with initiation of eslicarbazepine acetate (ESL) or brivaracetam (BRV) among patients with focal seizures in long-term care (LTC) in the US. Methods: This retrospective analysis used data from IQVIA's New Data Warehouse. Results: 298 patients initiated ESL and 282 patients initiated BRV. Initiation of ESL versus BRV was associated with 33.3% lower all-cause pharmacy costs, 34.4% lower epilepsy-specific pharmacy costs, 21.3% lower all-cause total costs and 30.9% lower epilepsy-specific total costs (all p < 0.0001). Conclusion: Among patients with focal seizures in LTC in the US, initiation of ESL versus BRV was associated with significant reductions in all-cause and epilepsy-specific pharmacy and total costs compared with initiation of BRV.

Incident epilepsy in the cognitively normal geriatric population, irrespective of seizure control, impairs quality of life

PURPOSE OF THE RESEARCH

The geriatric population is the fastest-growing population in the United States and the impact of incident epilepsy on the cognitively intact geriatric population is not well-studied. Understanding how epilepsy affects the elderly is important to improve the quality of treatment and care for our aging population. This study sought to address the impact of incident epilepsy on the perceived Quality of Life (QOL) in cognitively intact elderly using the SF-36 questionnaire.

METHODS

Nine hundred and twenty-seven participants were assessed from a community-based cohort. Based on a history of subsequent development of new-onset seizures, participants were divided into two groups, an incident seizure group that developed new-onset seizures after 65 years of age and the control group without incident seizures. Of this, six hundred eleven were analyzed with the SF-36 questionnaire after excluding for cognitive decline and inconsistent medical data.

PRINCIPAL RESULTS

Statistically significant differences were found in 9 items on SF-36, involving perception of increased physical disability (p < 0.01; t-test), frailty (p < 0.04; t-test), emotional health limitations (p < 0.03; t-test), anxiety and sadness (p < 0.04; t-test), problems interfering with social activities (p < 0.0001; t-test). No between-group differences were found for demographic variables including age, education, gender, or minority status. Among the 611 subjects who remained cognitively normal across all longitudinal visits, 12 reported a history of new-onset seizures. Ten of these 12 subjects were seizure free as a result of treatment, with only 2 experiencing recent seizures. The incidence of seizures in our population was 300 per 100,000 person years.

MAJOR CONCLUSIONS

This study identified the elderly population with incident epilepsy as a subgroup with an unmet health need, and healthcare professionals should address the potential impact of seizures with their geriatric patients to ensure comprehensive care.

Care Needs and Health Care Burden of Persons With Epilepsy Receiving Home Care Services

The purpose of this study was to describe the characteristics of persons with epilepsy (PWE) receiving home care services. A cross-sectional study was conducted comparing the characteristics of PWE with those without epilepsy (comparison group). PWE were more likely to have mental health issues and functional, mobility, and cognitive impairments; to receive a variety of psychotropic medications; to experience psychosocial issues such as isolation and conflicts in their relationships; to have caregivers experiencing psychological distress; and to be economically disadvantaged necessitating making economic trade-offs in their care. Epilepsy is associated with caregiver distress and has an impact on health resource utilization. Future studies are needed to identify strategies to improve the quality of care and life of PWE.

Risk factors for post-stroke seizure recurrence after the first episode

PURPOSE

Seizure is a common complication after stroke. However, the clinical characteristics, treatment, and recurrence rates in patients with the first episode of post-stroke seizure remain unclarified. The aim of this study was to identify the predictors of seizure recurrence in those patients.

METHOD

We retrospectively identified patients admitted to our hospital between July 2010 and June 2014 and followed-up until June 2015 because of the first episode of post-stroke seizure. We classified post-stroke seizure as early (within one week after stroke) or late (in the second week or later). We compared the baseline clinical characteristics and treatment between the groups and investigated the factors that determined seizure recurrence by Cox proportional hazards model.

RESULTS

A total of 153 patients (84 men; mean age, 73.7±12.3years; 73 hemorrhagic and 80 ischemic strokes; 63 early and 90 late seizure) were included. Compared with the late seizure group, the early seizure group more frequently manifested with status epilepticus; tended to less often undergo stereotactic aspiration of hematoma; and less frequently used anti-epileptic drugs. During the observation period (median 364days, IQR 124-680days), 40 patients were lost to follow-up; subsequently, 113 patients were included in the analysis. The early seizure group had lower survival and seizure recurrence rates than the late seizure group. The factors significantly associated with seizure recurrence were presence of status epilepticus in the early group (HR 4.75, 95% CI 1.28-17.62) and younger age in the late seizure group (HR 0.95, 95% CI 0.93-0.99).

CONCLUSIONS

In patients with post-stroke seizure, status epilepticus and younger age were the predictors of recurrence after early and late seizure, respectively.

Management of Adult Onset Seizures

Epilepsy is a common yet heterogeneous disease. As a result, management often requires complex decision making. The ultimate goal of seizure management is for the patient to have no seizures and no considerable adverse effects from the treatment. Antiepileptic drugs are the mainstay of therapy, with more than 20 medications currently approved in the United States. Antiepileptic drug selection requires an understanding of the patient's epilepsy, along with consideration of comorbidities and potential for adverse events. After a patient has failed at least 2 appropriate antiepileptic drugs, they are determined to be medically refractory. At this time, additional therapy, including dietary, device, or surgical treatments, need to be considered, typically at a certified epilepsy center. All these treatments require consideration of the potential for seizure freedom, balanced against potential adverse effects, and can have a positive effect on seizure control and quality of life. This review article discussed the treatment options available for adults with epilepsy, including medical, surgical, dietary, and device therapies.

Comparative effectiveness of levetiracetam, valproate and carbamazepine among elderly patients with newly diagnosed epilepsy: subgroup analysis of the randomized, unblinded KOMET study

Background

Few clinical trials have evaluated the efficacy and tolerability of antiepileptic drugs (AEDs) as initial monotherapy for elderly patients.

Methods

This post-hoc subgroup analysis of data from an unblinded, randomized, 52-week superiority study (KOMET) compared the effectiveness of levetiracetam (LEV) with extended-release sodium valproate (VPA-ER) and controlled-release carbamazepine (CBZ-CR) as monotherapy in patients aged ≥ 60 years with newly diagnosed epilepsy. The physician chose VPA or CBZ as preferred standard treatment; patients were randomized to standard AEDs or LEV. The primary endpoint was time to treatment withdrawal. Results are exploratory, since KOMET was not powered for a subgroup analysis by age.

Results

Patients (n = 308) were randomized to LEV (n = 48) or VPA-ER (n = 53) in the VPE-ER stratum or to LEV (n = 104) or CBZ-CR (n = 103) in the CBZ-CR stratum. Mean age was 69.6 years, range 60.2–89.9 years (intention-to-treat population n = 307). Time to treatment withdrawal hazard ratio [HR] (95 % confidence interval [CI]) for LEV vs. standard AEDs was 0.44 (0.28–0.67); LEV vs. VPA-ER: 0.46 (0.16–1.33); LEV vs. CBZ-CR: 0.45 (0.28–0.72). Twelve-month withdrawal rates were: LEV vs. standard AEDs, 20.4 vs. 38.7 %; LEV vs. VPA-ER, 10.4 vs. 23.1 %; LEV vs. CBZ-CR, 25.0 vs. 46.6 %. Time to first seizure was similar between LEV and standard AEDs (HR: 0.92, 95 % CI: 0.63–1.35), LEV and VPA-ER (0.77, 0.38–1.56), and LEV and CBZ-CR (1.02, 0.64–1.63). Adverse events were reported by 76.2, 67.3, and 82.5 % of patients for LEV, VPA-ER, and CBZ-CR, respectively. Discontinuation rates due to AEs were 11.3, 10.2, and 35.0 % for LEV, VPA-ER, and CBZ-CR, respectively.

Conclusions

Time to treatment withdrawal was longer with LEV compared with standard AEDs. This finding was driven primarly by the result in the CBZ-CR stratum, which in turn was likely due to the more favorable tolerability profile of LEV. Results of this post-hoc analysis suggest that LEV may be a suitable option for initial monotherapy for patients aged ≥ 60 years with newly diagnosed epilepsy.

Trial registration

ClinicalTrials.gov: NCT00175903; September 9, 2005.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0663-7) contains supplementary material, which is available to authorized users.

Caracterização da epilepsia com início após os 60 anos de idade

Resumo Introdução: Apesar da elevada incidência, a epilepsia no idoso ainda exibe peculiaridades pouco estudadas. A apresentação clínica na maioria das vezes é atípica e os achados nos exames complementares pouco ajudam no diagnóstico. Existem poucas publicações caracterizando esse grupo de indivíduos. Objetivo: Descrever as características de pacientes com epilepsia iniciada após os 60 anos de idade. Método: Foi desenvolvido estudo descritivo de série de casos, onde foram avaliados, consecutivamente, 50 pacientes com diagnóstico de epilepsia iniciada após os 60 anos de idade, atendidos no ambulatório de epilepsia do Hospital da Restauração (Recife-PE). Resultados: Dos 50 pacientes incluídos no estudo, a idade média foi de 75,3 (±13) anos, sendo que 30 (60,0%) eram do sexo feminino e 20 (40,0%) do sexo masculino. A idade média da primeira crise foi de 72,5 (±11,5) anos. Predominaram as crises epilépticas focais (83,8%). A ocorrência de estado de mal epiléptico foi baixa nesse grupo (4,0%). A epilepsia sintomática foi a mais frequente, tendo como etiologia vascular a causa mais encontrada (43,0%). A medicação mais utilizada foi a carbamazepina, e as crises apresentaram uma boa resposta terapêutica com monoterapia em dose baixa. O eletroencefalograma apresentou resultado normal em número elevado de casos (50,0%) e a neuroimagem na maioria das vezes (83,0%) apresentou achados inespecíficos. Conclusão: A epilepsia no idoso é predominantemente focal e sintomática, apresenta baixa ocorrência de estado de mal epiléptico e boa resposta terapêutica. O eletroencefalograma e a neuroimagem, na maioria das vezes, são inespecíficos.

The Spanish Society of Neurology's official clinical practice guidelines for epilepsy. Special considerations in epilepsy: comorbidities, women of childbearing age, and elderly patients

INTRODUCTION

The characteristics of some population groups (patients with comorbidities, women of childbearing age, the elderly) may limit epilepsy management. Antiepileptic treatment in these patients may require adjustments.

DEVELOPMENT

We searched articles in Pubmed, clinical practice guidelines for epilepsy, and recommendations by the most relevant medical societies regarding epilepsy in special situations (patients with comorbidities, women of childbearing age, the elderly). Evidence and recommendations are classified according to the prognostic criteria of Oxford Centre of Evidence-Based Medicine (2001) and the European Federation of Neurological Societies (2004) for therapeutic interventions.

CONCLUSIONS

Epilepsy treatment in special cases of comorbidities must be selected properly to improve efficacy with the fewest side effects. Adjusting antiepileptic medication and/or hormone therapy is necessary for proper seizure management in catamenial epilepsy. Exposure to antiepileptic drugs (AED) during pregnancy increases the risk of birth defects and may affect fetal growth and/or cognitive development. Postpartum breastfeeding is recommended, with monitoring for adverse effects if sedative AEDs are used. Finally, the elderly are prone to epilepsy, and diagnostic and treatment characteristics in this group differ from those of other age groups. Although therapeutic limitations may be more frequent in older patients due to comorbidities, they usually respond better to lower doses of AEDs than do other age groups.

Comprehensive educational plan for patients with epilepsy and comorbidity (EDU-COM): a pragmatic randomised trial

BACKGROUND

The impact of educational strategies in the management of adverse treatment effects and drug interactions in adult patients with epilepsy with comorbidities remains undetermined.

OBJECTIVE

The EDU-COM study is a randomised, pragmatic trial investigating the effect of a patient-tailored educational plan in patients with epilepsy with comorbidity.

METHODS

174 adult patients with epilepsy with chronic comorbidities, multiple-drug therapy and reporting at least one adverse treatment effect and/or drug interaction at study entry were randomly assigned to the educational plan or usual care. The primary endpoint was the number of patients becoming free from adverse treatment events and/or drug interactions after a 6-month follow-up. The number of adverse treatment events and drug interactions, health-related quality of life (HRQOL) summary score changes and the monetary costs of medical contacts and drugs were assessed as secondary outcomes.

RESULTS

The primary endpoint was met by 44.0% of patients receiving the educational plan versus 28.9% of those on usual care (p=0.0399). The control group reported a significantly higher risk not to meet successfully the primary endpoint at the end of the study: OR (95% CI) of 2.29 (1.03 to 5.09). A separate analysis on drug adverse effects and drug interactions showed that the latter were more sensitive to the effect of educational treatment. Quality of life and costs were not significantly different in the two groups.

CONCLUSIONS

A patient-tailored educational strategy is effective in reducing drug-related problems (particularly drug interactions) in epilepsy patients with chronic comorbidities, without adding significant monetary costs. Registered at ClinicalTrials.gov, identifier NCT01804322, (http://www.clinicaltrials.gov).

Antiepileptic drug treatment: new drugs and new strategies

PURPOSE OF REVIEW

Selection of the ideal antiepileptic drug (AED) for an individual patient can be a daunting process. Choice of treatment should be based on several factors, including but not limited to epilepsy classification, AED mechanism of action, AED side-effect profile, and drug interactions. Special consideration must be given to populations such as women, older adults, patients with other medical comorbidities, and patients who are newly diagnosed.

RECENT FINDINGS

Head-to-head trials between AEDs in newly diagnosed patients rarely demonstrate that one AED is more or less effective. The second-generation drugs, lamotrigine, topiramate, oxcarbazepine, zonisamide, and levetiracetam, have undergone head-to-head trials confirming similar efficacy and equal or better tolerability than standard drugs in focal epilepsy.

SUMMARY

A thoughtful approach to the AED selection process must factor in data from clinical AED trials as well as a variety of patient characteristics and confounding factors. When neurologists apply an individualized approach to AED drug selection for their patients, they can find an effective and well-tolerated drug for most patients.

Antiepileptic drug use in Austrian nursing home residents

PURPOSE

Currently around 30% of all newly developed seizures are diagnosed in persons older than 65 years. Five to 17% of nursing home-residents take antiepileptic drugs. The aim of our study was to analyze the type and frequency of prescribed antiepileptic drugs, as well as their indication, co-morbidities and co-medications in institutionalized elderly in Austria.

METHODS

This was a retrospective, cross-sectional study, which included all residents of the seven public nursing homes in Innsbruck, Austria. The data of 828 probands were extracted from the charts at site and maintained anonymously. The data collection was followed by descriptive statistics.

KEY FINDINGS

70 (8.5%; 26 M/44 F) of the 828 (192 M/636 F) residents took at least one antiepileptic medication. In 51.5% the reason for the prescription were epileptic seizures - yielding a minimum prevalence of 4.5%. The most often used antiepileptic drugs were gabapentin (37%), levetiracetam (24%) and valproate (18.5%). The three most common co-morbidities were arterial hypertension (49%), ischemic stroke (36%) and other cerebrovascular diseases (29%). Six to nine co-medications were prescribed in 41%, 26% had more than 10 additional drugs and 91% were treated with proconvulsive co-medications (64/70, median 2, range 0-6).

SIGNIFICANCE

Austrian nursing home residents receive more frequently newer antiepileptic drugs compared to other countries, but co-prescription of proconvulsive drugs is common.

Prevalence and socioeconomic aspects of epilepsy in the Croatian county of Sibenik-Knin: community-based survey

The aim of the survey was to estimate the prevalence rate of epilepsy, as well as seizure types, frequency, etiology, and comorbidity, by gender, age, and socioeconomic status among people with epilepsy in the Croatian county of Sibenik-Knin. The survey revealed that of 112,871 inhabitants, 1228 were identified as having active epilepsy. The crude prevalence rate for Sibenik-Knin County was 10.9 per 1000 inhabitants. Prevalence rates (per 1000) by age and gender were: 6.9 (ages 0-19); 10.6 (ages 20-59); 15.1 (ages 60+), 10.1 (females), and 11.7 (males). A significant number of subjects had different comorbid disorders. Although the literature suggests that Dalmatia is a region with a low prevalence of epilepsy, our results showed that Sibenik-Knin County has a higher prevalence of epilepsy than expected for European populations. The most common comorbid disorders, such as mental retardation, psychotic episodes, and substance addiction, highly influence socioeconomic status and quality of life.

Levetiracetam in brain ischemia: clinical implications in neuroprotection and prevention of post-stroke epilepsy

Several new antiepileptic drugs (AEDs) have been introduced for clinical use recently. These new AEDs, like the classic AEDs, target multiple cellular sites both pre- and postsynaptically. The use of AEDs as a possible neuroprotective strategy in brain ischemia is receiving increasing attention and the antiepileptic drug levetiracetam, a 2S-(2-oxo-1-pyrrolidiny1) butanamide, belonging to the pyrrolidone family, could have a crucial role in regulation of epileptogenesis and neuroprotection. Recent observations suggest that levetiracetam is both safe and effective against post-stroke seizures. In this review, the potential neuroprotective role in brain ischemia and the therapeutic implications of levetiracetam in post-stroke epilepsy are discussed.

Exercise as an intervention for the age-related decline in neural metabolic support

To identify interventions for brain aging, we must first identify the processes in which we hope to intervene. Brain aging is a period of decreasing functional capacity and increasing vulnerability, which reflect a reduction in morphological organization and perhaps degeneration. Since life is ultimately dependent upon the ability to maintain cellular organization through metabolism, this review explores evidence for a decline in neural metabolic support during aging, which includes a reduction in whole brain cerebral blood flow, and cellular metabolic capacity. Capillary density may also decrease with age, although the results are less clear. Exercise may be a highly effective intervention for brain aging, because it improves the cardiovascular system as a whole, and increases regional capillary density and neuronal metabolic capacity. Although the evidence is strongest for motor regions, more work may yield additional evidence for exercise-related improvement in metabolic support in non-motor regions. The protective effects of exercise may be specific to brain region and the type of insult. For example, exercise protects striatal cells from ischemia, but it produces mixed results after hippocampal seizures. Exercise can improve metabolic support and bioenergetic capacity in adult animals, but it remains to be determined whether it has similar effects in aging animals. What is clear is that exercise can influence the multiple levels of support necessary for maintaining optimal neuronal function, which is unique among proposed interventions for aging.

Disparate inclusion of older adults in clinical trials: priorities and opportunities for policy and practice change

Older adults are vastly underrepresented in clinical trials in spite of shouldering a disproportionate burden of disease and consumption of prescription drugs and therapies, restricting treatments' generalizability, efficacy, and safety. Eliminating Disparities in Clinical Trials, a national initiative comprising a stakeholder network of researchers, community advocates, policymakers, and federal representatives, undertook a critical analysis of older adults' structural barriers to clinical trial participation. We present practice and policy change recommendations emerging from this process and their rationale, which spanned multiple themes: (1) decision making with cognitively impaired patients; (2) pharmacokinetic differences and physiological age; (3) health literacy, communication, and aging; (4) geriatric training; (5) federal monitoring and accountability; (6) clinical trial costs; and (7) cumulative effects of aging and ethnicity.

Seizures in the elderly: impact on mental status, mood, and sleep

Comorbidities of epilepsy have not been well explored in the elderly. Herein, we examined mental status, mood, and sleep in elderly patients with epilepsy, compared with age- and gender-matched community controls without epilepsy from the Einstein Aging Study. Testing included a mental status test, the Blessed Information Memory and Concentration (BIMC) test; Prime-MD Patient Health Questionnaire (PHQ) Depression and Anxiety Modules; and Medical Outcomes Study Sleep Scale. Persons with epilepsy (n=31) had higher mean BIMC scores than controls (n=31, BIMC 6.3 vs.1.2, P<0.0001). Mean PHQ Depression scores were higher for cases than controls, indicating more depressive symptoms (4.2 vs 0.8, P=0.006); six cases (18%) and no controls met screening criteria for depression. Mean PHQ Anxiety scores were also higher for cases than controls (3.7 vs 0.0, P=0.001). Cases had poorer sleep scores in the categories of somnolence (P=0.009) and shortness of breath/headache (P=0.021). Thus, comorbidities of epilepsy in this elderly population included decreased mental status, a higher prevalence of depression and anxiety, and poorer sleep health when compared with agemates without epilepsy. Mental status impairment was not related to antiepileptic medication or mood disturbance. Further investigation will explore these associations prospectively.

Levetiracetam in newly diagnosed late-onset post-stroke seizures: a prospective observational study

Levetiracetam (LEV) monotherapy was investigated in 35 patients (pts) (16M/19F, 71.9+/-7.3 years of age) with late-onset post-stroke seizures (i.e. seizures occurring at least 2 weeks after an ischemic stroke) in a prospective open-label study. Overall, 27 pts (77.1%) achieved a condition of seizure freedom (defined as 1 year without seizures): 19 (54.3%) at a daily LEV dose of 1000mg, 7 (20.0%) at 1500mg, 1 (2.8%) at 2000mg. Four pts (11.4%) discontinued the drug because of intolerable side effects (drowsiness associated to gait disturbance in 1 pt, and aggressive behaviour in the remaining 3 pts); 3 pts were unresponsive at a dose of 3000mg, and 1 pt was lost at follow-up. These observations suggest that LEV exhibits safety and efficacy profiles which make it an optimal candidate as a first-choice drug against post-stroke seizures.

Generic antiepileptic drugs: current controversies and future directions

The Food and Drug Administration requires rigorous testing of generic formulations of antiepileptic drugs to assure bioequivalence to the brand product and asserts that all approved formulations are interchangeable. Physician surveys, case reports, and "switchback" rates from large-scale generic conversions imply that all generic formulations may not be equal to the brand drug for all patient groups. This review presents the current state of the data on bioequivalence and therapeutic equivalence and proposes a series of studies to better clarify the risks of generic formulation substitution in susceptible populations. Until such studies are completed, when switching to generic formulations, health-care providers and people with epilepsy would do well to proceed cautiously and understand the potential risks and benefits of substitution. Extra caution may be needed for patients at highest risk of seizure complications, such as the pregnant patient, patients with recurrent status epilepticus, or patients who have been seizure-free for long periods of time and are driving.

Levetiracetam monotherapy in Alzheimer patients with late-onset seizures: a prospective observational study

Levetiracetam (LEV) monotherapy was investigated in 25 patients with advanced Alzheimer's disease (AD) and new-onset epileptic seizures in a prospective open-label study. At a daily dose of 1000-1500 mg, 72% were seizure-free for at least one year; 16% discontinued for untolerability; 8% were unresponsive; 4% were lost to follow-up. These results suggest the need for controlled studies to confirm if LEV can be a first-choice drug in AD.