Epilepsy in the elderly is defined as first onset of epileptic seizures in patients from the age of 601,2 or, according to other authors, from the age of 65,3,4 respectively. It has been established that approximately one-third of patients with newly diagnosed epilepsy are older than 60 years and also half of all adult patients with known epilepsy are beyond an age of 60.5 The symptomatic focal epilepsy is the most frequently diagnosed type. Main causes are strokes6,7 followed by brain tumours4 and degenerative diseases of the brain.2 Regarding anticonvulsant therapy, physicians have to be aware of differences in the therapy of older patients. The brain of the elderly patient has a high sensitivity to centrally acting medication which may lead to fatigue and somnolence as well as cognitive side effects even at a low dose. Furthermore, physicians should be aware of a reduction in renal clearance and impaired hepatic metabolism of anti-epileptic drugs in the elderly. In addition, many patients of advanced age are suffering from chronic diseases requiring extensive non-anticonvulsant co-medication that can cause significant drug interactions. Therefore, an anti-epileptic drug used in the elderly patient ideally should have a low potential for cognitive impairment, an adequate clearance despite reduced metabolism and a low possibility for drug–drug interaction. Furthermore, the anticonvulsant used should be effective as monotherapy.
Taking these considerations into account, it is surprising that carbamazepine is still the most widely prescribed anti-epileptic drug in the German-speaking area, despite the advantages of recently approved anticonvulsant drugs. There are several studies investigating the efficacy or efficacy respectively of new anticonvulsants such as gabapentin, lamotrigine, levetiracetam, oxcarbazepine, tiagabine, topiramate and zonisamide in the epilepsy of the elderly.8–18 Unfortunately only two of these are randomized, controlled, double-blind studies.8,9 The aim of this report is to discuss the significance of topiramate in the therapy of epilepsy in the elderly.
In general, topiramate has advantages over previously established anticonvulsant drugs. A prospective, randomised double-blind study conducted by Privitera et al. 19 investigated the efficacy of topiramate 100mg or 200mg/per day compared with carbamazepine 600mg/day and valproic acid 1250mg/day in patients aged six and above.