Challenges in the pharmacological management of epilepsy and its causes in the elderly.

Epilepsy represents the third most common neurological disorders in the elderly after cerebrovascular disorders and dementias. The incidence of new-onsetepilepsy peaks in this age group. The most peculiar aetiologies of late-onsetepilepsy are stroke, dementia, and brain tumours. However, aetiology remainsunknown in about half of the patients. Diagnosis of epilepsy may be challengingdue to the frequent absence of ocular witnesses and the high prevalence ofseizure-mimics (i.e. transient ischemic attacks, syncope, transient globalamnesia or vertigo) in the elderly. The diagnostic difficulties are even greater when patients have cognitive impairment or cardiac diseases. The management oflate-onset epilepsy deserves special considerations. The elderly can reachseizure control with low antiepileptic drugs (AEDs) doses, and seizure-freedom ispossible in the vast majority of patients. Pharmacological management should takeinto account pharmacokinetics and pharmacodynamics of AEDs and the frequent occurrence of comorbidities and polytherapy in this age group. Evidences from double-blind and open-label studies indicate lamotrigine, levetiracetam andcontrolled-release carbamazepine as first line treatment in late-onset epilepsy.