What is the first-line treatment for patients with dementia and epilepsy?

From the Guidelines

The first-line treatment for patients with dementia and epilepsy is levetiracetam (Keppra), due to its minimal drug interactions and less impact on cognition compared to older antiepileptic drugs. When considering treatment options, it's essential to prioritize the patient's quality of life, morbidity, and mortality. According to the most recent evidence, levetiracetam is a preferred choice, starting at 250-500mg twice daily and titrating up as needed to control seizures, with a usual maintenance dose of 1000-3000mg daily divided into two doses 1.

Key Considerations

• Levetiracetam has minimal drug interactions, which is crucial for patients with dementia who may be taking multiple medications.
• It does not require extensive monitoring, making it a more practical option for elderly patients with dementia.
• Levetiracetam has less impact on cognition compared to older antiepileptic drugs, which is essential for maintaining the patient's quality of life.
• Alternative first-line options include lamotrigine and lacosamide if levetiracetam is not tolerated.
• Enzyme-inducing antiepileptic drugs like phenytoin, carbamazepine, and phenobarbital should be avoided in these patients as they can worsen cognitive function and interact with dementia medications.

Treatment Approach

• Treatment should be individualized based on seizure type, comorbidities, concurrent medications, and the patient's ability to adhere to the regimen.
• Regular follow-up is essential to monitor for seizure control, medication side effects, and any changes in cognitive function.
• The patient's living environment and care should be taken into consideration to minimize stress and maximize support.
• High-quality, person-centered care, including psychosocial interventions, is now recognized as the first line of prevention and treatment for behavioral and psychological symptoms of dementia (BPSD) and for supporting quality of life generally in patients with dementia 1.

Medication Management

• Medication should be started at lower doses and increased more gradually to minimize side effects in elderly patients with dementia.
• The patient's medication regimen should be regularly reviewed to ensure that it is optimized and that any potential interactions are minimized.
• Valproate, although effective in treating epilepsy, may not be the first-line choice for patients with dementia due to its potential side effects and interactions with other medications 1.

From the Research

First-Line Treatment for Patients with Dementia and Epilepsy

• The first-line treatment for patients with dementia and epilepsy is not clearly established, but some studies suggest that levetiracetam and lamotrigine may be suitable options due to their low interaction profile and good tolerability 2.
• A systematic review of pharmacological medical treatment of epilepsy in patients with dementia found that levetiracetam may improve cognition and have fewer adverse events compared to other anti-epileptic drugs 3.
• Another study found that levetiracetam, lamotrigine, and phenobarbital had similar efficacy in treating epilepsy in patients with Alzheimer's disease, but levetiracetam may have a more favorable cognitive profile 4.
• A network meta-analysis of antiepileptic drug monotherapy for epilepsy found that lamotrigine and levetiracetam had a favorable profile in terms of treatment failure and seizure control 5.
• In general, the choice of anti-epileptic drug for patients with dementia and epilepsy should take into account the patient's comorbidities, type of epilepsy, and potential interactions with other medications.

Considerations for Treatment

• Patients with dementia and epilepsy often have comorbidities and polypharmacy, which can complicate treatment 2.
• Anti-epileptic drugs with a low interaction profile and high tolerability, such as levetiracetam and lamotrigine, may be preferred 2.
• The efficacy and tolerability of anti-epileptic drugs in patients with dementia and epilepsy require further study, particularly in the form of large, double-blind, parallel-group randomized controlled trials 4.