TY - JOUR
T1 - Prescribing antiepileptics for the elderly
T2 - Differences between guideline recommendations and clinical practice
AU - Pugh, Mary Jo V.
AU - Foreman, Perry J.
AU - Berlowitz, Dan R.
N1 - Funding Information:
We acknowledge support from the South Texas Veterans Healthcare System, Audie L. Murphy Division (ALMD) and the Edith Nourse Rogers Memorial Veterans Affairs (ENRM VA) Medical Center. We also acknowledge the assistance of Jeffrey Tabares in the preparation of this manuscript.
Funding Information:
This study was funded by the Department of Veterans Affairs, Health Services Research and Development Service, IIR 02-274 to Dr Pugh. The Department of Veterans Affairs, Health Services Research and Development Service did not contribute to any aspect of the design, conduct, or preparation of this review. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.
PY - 2006
Y1 - 2006
N2 - The incidence of epilepsy in patients aged >60 years is higher than in any other period of life. Yet, until recently, what was known about the treatment of older patients with epilepsy has been inferred from studies in younger patients. A growing body of clinical evidence focused exclusively on the elderly suggests that, while some issues are similar for older and younger adults, older patients with epilepsy may require even more attention regarding antiepileptic drug (AED) selection than younger patients. This article reviews published guidelines and recommendations to identify explicit recommendations for use of specific AEDs in the elderly, and assesses the extent to which those recommendations have been adopted in clinical practice. We found that while one systematically derived guideline stated that lamotrigine may be a good choice for older patients because of its favourable adverse effect profile, only clinical recommendations based on expert opinion explicitly identified AEDs that are more and less appropriate for use in the elderly. Examination of published studies describing recent AED-prescribing patterns suggests that clinical recommendations have been, at best, slowly adopted. This observation is exemplified by the fact that older patients newly diagnosed with epilepsy are still prescribed phenobarbital - a drug identified as suboptimal in 1985. In order to better understand the delay in adopting clinical recommendations, we examine these findings in light of diffusion of innovations theory, a theory that has been used to understand dissemination of other new medical technologies. According to this theory, while it is too early to suggest that use of second-generation AEDs in the elderly has been delayed, the continued use of phenobarbital in older patients newly diagnosed with epilepsy represents a serious delay in adoption of recent guidelines. Delays may be related to lack of knowledge by primary care clinicians and emergency room physicians (who frequently treat older patients with epilepsy), lack of 'opinion leaders' in primary care and perhaps general neurology, clinicians' focus on seizure control as the primary endpoint in treating patients with epilepsy, and difficulties in changing long-standing prescribing patterns. Research targeting barriers to more appropriate prescribing is needed to determine appropriate strategies for changing AED prescribing practices in the elderly.
AB - The incidence of epilepsy in patients aged >60 years is higher than in any other period of life. Yet, until recently, what was known about the treatment of older patients with epilepsy has been inferred from studies in younger patients. A growing body of clinical evidence focused exclusively on the elderly suggests that, while some issues are similar for older and younger adults, older patients with epilepsy may require even more attention regarding antiepileptic drug (AED) selection than younger patients. This article reviews published guidelines and recommendations to identify explicit recommendations for use of specific AEDs in the elderly, and assesses the extent to which those recommendations have been adopted in clinical practice. We found that while one systematically derived guideline stated that lamotrigine may be a good choice for older patients because of its favourable adverse effect profile, only clinical recommendations based on expert opinion explicitly identified AEDs that are more and less appropriate for use in the elderly. Examination of published studies describing recent AED-prescribing patterns suggests that clinical recommendations have been, at best, slowly adopted. This observation is exemplified by the fact that older patients newly diagnosed with epilepsy are still prescribed phenobarbital - a drug identified as suboptimal in 1985. In order to better understand the delay in adopting clinical recommendations, we examine these findings in light of diffusion of innovations theory, a theory that has been used to understand dissemination of other new medical technologies. According to this theory, while it is too early to suggest that use of second-generation AEDs in the elderly has been delayed, the continued use of phenobarbital in older patients newly diagnosed with epilepsy represents a serious delay in adoption of recent guidelines. Delays may be related to lack of knowledge by primary care clinicians and emergency room physicians (who frequently treat older patients with epilepsy), lack of 'opinion leaders' in primary care and perhaps general neurology, clinicians' focus on seizure control as the primary endpoint in treating patients with epilepsy, and difficulties in changing long-standing prescribing patterns. Research targeting barriers to more appropriate prescribing is needed to determine appropriate strategies for changing AED prescribing practices in the elderly.
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U2 - 10.2165/00002512-200623110-00002
DO - 10.2165/00002512-200623110-00002
M3 - Review article
C2 - 17109565
AN - SCOPUS:33751243594
SN - 1170-229X
VL - 23
SP - 861
EP - 875
JO - Drugs and Aging
JF - Drugs and Aging
IS - 11
ER -