Variability of total phenytoin serum concentrations within elderly nursing home residents

Hardie, Nancy A.; Leppik, Ilo E.; Conway, Jeannine M.; Bowers, Sandra E.; Lackner, Thomas E.; Graves, Nina M.

doi:10.1212/01.wnl.0000052997.43492.e0

Cited by 74 publications

(45 citation statements)

References 17 publications

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“…A recently completed study of serial blood levels in elderly nursing home patients receiving stable doses of phenytoin, carbamazepine, and valproate revealed marked intrapatient variability. Blood levels in some patients varied by more than 100% (16). This will cause difficulties in interpreting blood level data and therapeutic decisions.…”

Section: Choosing Antiepileptic Drugs For the Elderlymentioning

confidence: 99%

Epilepsy in the Elderly

Leppik

2006

Epilepsia

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Summary: The elderly are the most rapidly growing segment of the population and the incidence of epilepsy is higher in the elderly than in any other age group. They have been subdivided into the “young old,” 65–74 years, “middle old” 75–84 years, and the “old old,” 85 years or older. But further subdivisions are needed: persons with only epilepsy, those with epilepsy and multiple medical problems, and the frail elderly. Thus, when considering therapy, one must tailor the interventions to nine categories: young old healthy, young old with medical problems, frail young old, old healthy, old with medical problems, frail old, old old healthy, old old with medical problems, and frail old old. The prevalence of antiepileptic drug (AED) use in community dwelling elderly is 1.5%; in the nursing home population it is 10%. Surprisingly, 3% have an AED newly prescribed after admission. Overall, 6.2% were using phenytoin, 1.8% carbamazepine, 0.9% valproic acid, 1.7% phenobarbital, and others combined, 1.2%. AEDs rank fifth among all drug categories as a cause of adverse reactions. There are very few data regarding the clinical use of AEDs in the elderly. The paucity of information makes it very difficult to recommend specific AEDs with any confidence that the outcomes will be optimal. An appropriate for elderly healthy may not be appropriate for elderly with multiple medical problems, and in frail elderly variable absorption may be a major problem. One of the major advantages of some newer AEDs is lack of drug interactions. Cost is an advantage of the older AEDs. Regardless of the AED chosen, one must use doses appropriate to the clearance of the drug, and AED levels, especially unbound (free) levels, must be monitored. The elderly nursing home resident may be more frail, be taking many medications, and have several concomitant illnesses, making them difficult to treat. The most commonly used AED, phenytoin, may not be the easiest or safest AED to prescribe in the elderly with multiple medical problems or the frail elderly.

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Section: Choosing Antiepileptic Drugs For the Elderlymentioning

confidence: 99%

Epilepsy in the Elderly

Leppik

2006

Epilepsia

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“…Fluctuations in ASD concentrations in elderly NH residents with phenytoin, carbamazepine, and valproic acid during constant dosing can be high in elderly persons in NHs. 35,36 This may lead to episodes of dizziness, loss of balance, and confusion, which may predispose to falls and fractures. A slightly lower rate of falls and fractures in the epi/sz cohort in this study was unexpected and may be a reflection of decreased mobility in those with stroke or more cautious nursing care for those with these diagnoses.…”

Section: Resultsmentioning

confidence: 99%

Prevalence of epilepsy/seizures as a comorbidity of neurologic disorders in nursing homes

et al. 2017

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Objective: To determine the prevalence of epilepsy/seizure (epi/sz) comorbid with other neurologic disorders in elderly nursing home residents and to examine demographic and regional variability and associations with clinical characteristics.Methods: We studied 5 cross-sectional cohorts of all residents in any Medicare/Medicaid-certified nursing home in the United States on July 15 of each year from 2003 to 2007. Epi/sz was identified by ICD-9 codes (345.xx or 780.39) or check box (Minimum Data Set). Epi/sz prevalence was stable across all years, so only 2007 data were examined further. Logistic regression with generalized estimating equations was used to model cross-sectional prevalence of epi/sz as a function of demographics and neurologic comorbidities of interest, with adjustment for clinical characteristics, including cognitive status, comorbidity burden, medication burden, and activities of daily living.Results: Point prevalence of epi/sz in 2007 was 7.7% (n 5 91,372 of N 5 1,186,579) differing by geographical region, race/ethnicity, age group, and sex. Neurologic conditions having the highest association with epi/sz were brain tumor (epi/sz prevalence 23.4%-35.2%), head injury (17.9%), hemiplegia (17.7%), and stroke (13.7%). Epi/sz comorbid with stroke or dementia had a strong decreasing association with age (65-74 years had z3.8-times higher odds of epi/sz than 851 years). Activities of daily living, comorbidity burden, and cognition scores were worse in persons with than without epi/sz. Conclusions:The prevalence of epi/sz in the elderly nursing home population is .7-fold higher compared to community-dwelling elderly and is 7 to 30 times higher among those with certain comorbid neurologic conditions. Demographics and clinical characteristics had weaker associations with epi/sz prevalence. Neurology ® 2017;88:750-757 GLOSSARY ASD 5 antiseizure drug; epi/sz 5 epilepsy/seizure; ICD-9 5 International Classification of Diseases, ninth revision; MDS 5 Minimum Data Set; MS 5 multiple sclerosis; NH 5 nursing home; OR 5 odds ratio.Because of their general health, elderly individuals are much more likely to have severe consequences from a seizure than younger persons.1 With increasing concern regarding the ability to provide adequate and appropriate care to the nursing home (NH) population, it is important to define the epidemiology of epilepsy in this cohort. In community-dwelling elderly, the prevalence of epilepsy is z1.1%.2,3 A majority of these cases are located in the geographic Stroke Belt. [4][5][6] Neurologic conditions comorbid with epilepsy are also common in NH elderly. Although the number of elderly will more than double in the United States, approaching 71.5 million by 2030, 7 and the lifetime probability of a person entering an NH before death is 43% to 46%, 8 there has not been a systematic evaluation of the prevalence of epilepsy with other neurologic disorders or the activity or cognitive status of these individuals.We obtained the Minimum Data Set (MDS) assessments completed on all resi...

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“…Almost every aspect of drug physiology, namely absorption, distribution, metabolism, and excretion changes with age. Some AEDs like phenytoin are highly susceptible to these effects, and its levels in the elderly can fluctuate as much as tenfold [39,40]. Reduced gastric motility and blood flow coupled with low gastric acid production can vary the absorption of acidic and alkaline drugs [34].…”

Section: Pharmacokinetic Changes With Agingmentioning

confidence: 99%

Seizures in Setting of Dementia

Sivaraaman

Vajjala

2015

Curr Treat Options Neurol

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Dementia, especially Alzheimer's disease, is an important cause of seizures and epilepsy midst the elderly. With the increasing life span, the incidence of dementia and epilepsy is expected to increase exponentially. Care of patients with advanced dementia can be demanding and seizures add to this burden. Though recognition of seizures in these patients can be difficult, seizures in these patients tend to be highly responsive to pharmacological therapy. However, choosing the right antiepileptic drug can be a challenge and complicated by altered kinetics and polypharmacy. While ongoing seizures can worsen the cognitive status in these patients, antiepileptic drugs could also add to the cognitive burden. The newer generation drugs show promise in terms of their side effect profile without compromising on the efficacy.

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Variability of total phenytoin serum concentrations within elderly nursing home residents

Abstract: There is considerable variability in the total phenytoin concentrations in the elderly nursing home resident and measurement of a single total phenytoin concentration should not be used to guide treatment.

Cited by 74 publications

References 17 publications

Epilepsy in the Elderly

Epilepsy in the Elderly

Prevalence of epilepsy/seizures as a comorbidity of neurologic disorders in nursing homes

Seizures in Setting of Dementia

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