What is the best approach to manage seizures and cognitive deficit in an older adult with a history of seizures and cognitive impairment living in a skilled nursing home?

Managing Seizures and Cognitive Deficit in Skilled Nursing Home Residents

For older adults with seizures and cognitive impairment in skilled nursing facilities, levetiracetam should be the first-line antiepileptic drug, started at 500 mg twice daily and titrated to 1000-1500 mg twice daily, while simultaneously implementing non-pharmacological interventions for behavioral symptoms and avoiding antipsychotics unless absolutely necessary due to increased mortality risk. 1, 2

Antiepileptic Drug Selection and Dosing

First-Line Agent: Levetiracetam

• Levetiracetam is the optimal choice for elderly cognitively impaired patients because it has favorable pharmacokinetics, lacks major drug interactions, causes minimal cognitive slowing, and has demonstrated both efficacy and cognitive tolerability in this specific population 2
• Start with 500 mg twice daily (1000 mg/day total), then increase by 1000 mg/day every 2 weeks to a maximum of 3000 mg/day (1500 mg twice daily) 1
• In a prospective study of 24 cognitively impaired elderly patients, 69% achieved complete seizure freedom on levetiracetam, with the remainder having satisfactory control 2
• Cognitive function actually improved in patients remaining on levetiracetam at 3 months, with significant improvements on Mini-Mental State Examination and Alzheimer's Disease Assessment Scale-Cognitive scores 2
• Fatigue is the most common side effect but occurred in only 5 of 24 patients in the elderly cognitive impairment study 2

Renal Dosing Adjustments (Critical in Elderly)

• Always calculate creatinine clearance before dosing, as elderly patients frequently have renal impairment 1
• For CrCl 50-80 mL/min: 500-1000 mg every 12 hours 1
• For CrCl 30-50 mL/min: 250-750 mg every 12 hours 1
• For CrCl <30 mL/min: 250-500 mg every 12 hours 1

Alternative Agents (If Levetiracetam Fails or Is Not Tolerated)

• Carbamazepine, valproic acid, gabapentin, or lamotrigine are acceptable alternatives with minimal cognitive adverse effects 3
• Avoid phenytoin and phenobarbital despite their historical use in nursing facilities (56.8% and 15.6% of residents respectively), as they cause significant cognitive impairment and have problematic drug interactions 4, 3

Seizure Diagnosis and Monitoring Challenges

Diagnostic Pitfalls in This Population

• Cognitive impairment impedes accurate seizure diagnosis—manifestations may be mistaken for symptoms of underlying dementia 3
• Episodes of loss of consciousness, falls, or amnestic events require detailed description and urgent assessment to rule out epileptic seizures 5
• In one nursing facility study, 86% of seizure types were unspecified, representing a critical gap that affects treatment selection 4

Essential Monitoring

• Document seizure frequency over 3-month periods—approximately 9% of nursing facility residents with seizure diagnoses have documented seizures during routine monitoring 4
• Monitor for accumulating cognitive and behavioral impairments from recurrent seizures, as these may be reversible if seizures are controlled early but can become irreversible if a "time window" is exceeded 6

Managing Cognitive Impairment

Medication Review and Deprescribing

• Conduct comprehensive polypharmacy assessment, as 13-74% of skilled nursing facility patients take 9 or more medications, and 59% take potentially inappropriate medications 7
• Deprescribing in long-term care may reduce mortality and falls by approximately 25% 7
• Assess total anticholinergic burden using tools like the Drug Burden Index, as anticholinergics worsen cognitive impairment 8

Cholinesterase Inhibitors

• Consider discontinuation if no perceived benefit (stabilizing cognition/function) is achieved in the first 3 months, or when dementia has progressed to severe stages 7
• Taper over 2-4 weeks after obtaining family agreement, with monitoring for worsening behaviors 7

Cognitive Assessment Tools

• Use Brief Interview for Mental Status (MDS 3.0 standard): scores ≤12 indicate cognitive impairment 7
• Montreal Cognitive Assessment is more sensitive for detecting mild impairment missed by standard screening 7

Managing Behavioral and Psychiatric Symptoms

Non-Pharmacological Interventions (First-Line)

• Implement before considering antipsychotics: caregiver redirection/reorientation techniques, environmental modifications, simplifying tasks, activity participation, optimizing sensory input, ensuring social engagement, and maintaining sleep-wake cycles 7, 8
• Simulated presence therapy using audio/video recordings of positive past experiences reduces agitation in severe dementia 7
• Massage therapy, animal-assisted interventions, and personally tailored interventions help manage agitation 7

Pharmacological Management of Behavioral Symptoms

• SSRIs are first-line for agitation and depression in vascular cognitive impairment, significantly improving overall neuropsychiatric symptoms 7
• Serotonergic antidepressants improve agitation and increase odds of depression remission in patients with vascular cognitive impairment 7

Antipsychotic Use (Last Resort Only)

• Aripiprazole and other antipsychotics carry a black box warning for increased mortality in elderly patients with dementia-related psychosis, primarily from cardiovascular or infectious causes 8
• If deemed absolutely necessary for severe behavioral and psychological symptoms of dementia, use the lowest effective dose with close cognitive monitoring and regular reassessment 8
• Gradual withdrawal over >1 month is recommended if discontinuing, as abrupt cessation causes dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome 7

Interdisciplinary Care Coordination

Nursing Home Care Team Approach

• The care team must include nursing staff, attending physician, consultant pharmacist, patient, and family 7
• Implement treatment protocols to prevent unnecessary emergency visits for recurrent seizures 5
• Provide electronic resources and improve awareness of antiepileptic drug efficacy, drug-drug interactions, and monitoring requirements 5

Goals of Care Alignment

• Advanced care planning should address individual healthcare objectives, as goals obligate changes with declining functionality in long-term care residents 7
• Person-centered care that is individualized and adapted to changing preferences, abilities, and needs maximizes quality of life 7

Common Pitfalls to Avoid

• Do not use enzyme-inducing antiepileptic drugs (phenytoin, phenobarbital, carbamazepine) as first-line agents due to cognitive effects and drug interactions, despite their historical overuse in nursing facilities 5, 4
• Do not treat after a single seizure unless there is focal neurological involvement or high risk of recurrence 3
• Do not combine multiple antiepileptic drugs without clear indication—25% of nursing facility residents with seizures receive combination therapy, often unnecessarily including phenobarbital 4
• Do not assume behavioral changes are solely due to dementia—always consider seizures as a potential cause, especially in Alzheimer's disease where 10-22% develop seizures, typically >6 years into disease course 3