The Increase in life expectancy has led to a progressive growth in chronic degenerative diseases and neurological disorders such as epilepsy, defined the brain by Caused disorder Persistent predisposition of the brain to generate epileptic seizures, with neurobiological, cognitive and psycho-social policies, que Affects Approximately 1% of the world's population. It is of multifactorial origin, and has the cerebrovascular disease of the most common etiology in this specific cohort. Thus, it is Necessary to know the peculiarities of the aging process and to identify the particular presentations of early these seizures in the elderly, and qualified through the broad approach.

Diagnosis in this population can be hampered by atypical presentation and comorbidities. The focal crises are more frequent, with less prominent auras and automatisms and with longer duration of the post-ictal confusion. Status epilepticus is common, with high mortality rate.

Treatment at this age group is challenging because of drug pharmacokinetic and pharmacodynamic changes, polypharmacy, drug interactions, low compliance, and cognitive problems. It must be stipulated carefully considering the safety, tolerability and effectiveness of the medication, are que there are no Consequences que lead to deterioration of the quality of life, loss of functionality and autonomy.

Seizures can be commonly controlled with low doses of a single antiepileptic medication (AEM). Drug-resistant epilepsy is uncommon. The aim of this review was to understand the clinical manifestations, etiology and the best therapeutic options available for epilepsy in the elderly population.

It is concluded que, despite the existence of a collection of papers related to epilepsy, there is still little scientific data on this subject in this population, especially in extreme frail elderly. Therefore, there is a need for more studies in this area with the greater inclusion of the elderly in clinical trials, as well as the development of models for the comprehensive care of care these patients.

Keywords: signs and symptoms, diagnosis, epilepsy, therapeutic, anticonvulsivants, aged

Population aging is a global phenomenon and Brazil already accounts for 13% of the population, average life expectancy of 75.8 years. THEs projections indicate that by 2060 the population of people aged 65 or over will reach 26.7% of total population.¹

The elderly are affected more often by Geriatric syndromes and chronic degenerative diseases of great impact on quality of life.

Neurological disorders such as epilepsy, which will be addressed in this article, is a disorder with major repercussions on the overall health of the individual, whose definition extends beyond the occurrence of at least one spontaneous seizure with neurological manifestations, but also includes the behavioural, psychiatric and cognitivas^2-5 demonstrations.

Its incidence is higher in the elderly than in other age group, exceeding 100 cases per 100,000 inhabitants / year. Approximately 25% of new cases occur in individuals 65 years or older, due mainly to degenerative neurological diseases and injuries cerebrovasculares.^3,6-8

Clinical and epidemiological analysis of epilepsy in the elderly is hampered by several factors: lack of epidemiological studies in this age group, heterogeneous characteristics, complexity of distinction between senescence and senility, co morbidities and sub diagnostics.

Therefore, with the suspicion of a seizure in the elderly, a careful semiotic analysis is needed, with proper diagnosis and treatment, as the crises increase the risk of falls, injuries, functional impairment and rebound biopsicossocial.^7,9

Treatment directed to the elderly must respect the pharmacokinetics and pharmacodynamics of aging, seizure type, patient profile, adverse effects, interactions, comorbidities and polifarmácia.⁹

So perform the workup of this disorder in clinical practice is challenging, as few studies have emphasized the neurobiological and clinical aspects of epilepsy in this age group, making it difficult to definition, preventive and therapeutic strategies that could modify the prognosis clinico.¹⁰

The purpose of the article was to review the literature, the clinical features of epilepsy in the elderly; approach, identification and treatment that should be applied in this population. In addition to spark interest in better understanding the subject.

This is a review, the past two decades, with searches of journal articles available in the databases PubMed/ Medline, SciELO and LILACS, in English and Portuguese.

Also Ministry of Health data were analyzed (MS), Brazilian Institute of Geography and Statistics (IBGE) and other scientific sources (books, magazines, websites) that addressed the issue. Descriptors were used in the Health Sciences (MeSH): signs and symptoms (Signs and Symptoms), diagnosis (diagnosis), epilepsy (epilepsy), seizures (epilepsy), treatment (therapy); antiepileptic (anticonvulsants), old (aged).¹¹

As inclusion criteria, the selected articles addressed the epidemiology, demographics, workup, features, available and appropriate therapy for epilepsy in the elderly population. They were analyzed and summarized in a table in order to facilitate identification of the studies.

The lack of studies on the features and epilepsy therapy in the elderly may be related to lack of screening, identifying difficulties and cases studied age group that most often does not include the large elderly or is not principal^5,12 sample.

However, some studies of epilepsy in the elderly population were found, analyzed and the content of that review will be addressed and discussed below.

The elderly may be affected by neurological disorders such as epilepsy and seizures related to anatomical changes and brain biochemistry altering neuronal response to insults with increasing epileptogenic seizures, especially in older patients with multiple comorbidades.^6,9

Epilepsy was already a known disease in ancient Egypt, and only Hippocrates (460-377 BC), in his work "On the Sacred Disease", referred to the seizure of more rational and established scientific principles to his fisiopatologia.⁹

The term epilepsy, according to Avicenna (980 AD) meant "being seized or possessed". In 1980, with the ratings of the International League of Epilepsy (ILAE), the term, epileptic syndrome was introduced. The Brazilian Association of Epilepsy, based on terminology revised in 2010, defines epilepsy as a brain disorder caused by persistent predisposition of the brain to generate seizures, with neurobiological consequences, cognitive and psicossociais.^2,4,9,13

The seizure stems from excessive and synchronous neuronal electrical activity with different manifestations (sensory, autonomic, motor, cognitive or behavioural), as the area affected. And seizure, is motor manifestation resulting from this crise.^3,13

Symptomatic acute crisis (or caused) is derived from an identified immediate cause (metabolic disorder, exogenous intoxication, withdrawal from sedatives, acute neuronal injury, trauma, infection and neoplasia) 3.6.

Since the only crisis (isolated) is defined as emergency or crisis using the 24-hour period corresponding to the symptomatic acute attack or the first manifestation of epilepsy, if recorrente.^3,14

The epileptics status is determined by crisis lasting more than 30 minutes or the presence of two or more seizures without return of consciousness between elas.^3,9

According to the World Health Organization (WHO), epilepsy is the most common brain disease, affecting 1% of the world population, with incidence and prevalence increasing with age. The estimated incidence in the western population is 1 case per 2,000 people / year. The overall probability of being affected by epilepsy throughout life is 3%.^7,15

The incidence of epilepsy is higher in the first year of life and increases again after age 60, and It relates to the comorbidities and twice in the presence of one and seven times higher in those with three or more comorbidades.^16,17

The prevalence rates of active epilepsy in the elderly in Brazil is 11.9/1,000 in São Paulo, 16.5/1000 in Porto Alegre and 8.5/1000 the study covering Campinas and São José do Rio Preto.^7,18 The prevalence in the US was 10.8 per 1,000 individuals. It is estimated that between 60-69 years there are 76-100 cases per 100,000 inhabitants and more than 70 years ago the dobro.⁶ In long-term care facilities is a prevalence of seizures five times higher than in Community.⁹

Epilepsy the age of 65 may be idiopathic (49.7%), Cerebrovascular disease (30-49%), neurodegenerative disorders (9-17%), tumors (4.5 to 11%), trauma (3%) infection (0.6%), Toxic-metabolic disorders, neuropsychiatric disorders (depression, anxiety).^6,9,17,19,20

Since the causes of acute symptomatic seizures in elderly are metabolic encephalopathy (10-30%), trauma (4-17%), intoxication or withdrawal from alcohol or drugs (10%) cancers (8.8%) and infections (2 %). ^9,20,21

The classification of epileptic seizures, are based on the clinical description, in EEG findings and topography. They are divided into: partial seizures (CP) at first located (focused) or generalized seizures (CG), involving both hemispheres simultaneously. CP are subdivided into simple partial seizures (CPS), with no change of consciousness, and complex partial seizures (CPS), with alteration of consciousness.^5,7,9,10

Among the crises in the elderly, there are the CPS, CPC and status epileptics. The CG are less frequentes.^9,22

THE study VACS (Veterans Administration Cooperative Study # 428) of epilepsy in elderly showed that only 27% of patients had GC (50% immediately identified) and more than 60%were CPS and CPC, whose clinical manifestations are more difficult to be determined (only 21% of cases detected early) with generalization in 26% of the evaluated elderly patients; 13% of secondary generalized seizures and partial seizures mistas.²³ Given these, corroborated by other estudos.^9,21

The PSC, in general, originate in the temporal lobe, but in the elderly are generally in the frontal region, which occur most cerebrovascular accidents (stroke), the major causes of epilepsy in geriatric^6,24 population.

Clinical manifestations in the elderly are often atypical and vague complaints, resulting in under diagnosis or misdiagnosis, especially in women, older people living alone, people with cognitive impairment, long-term care facility residents, fragile, with comorbidities and poly medicated. In addition, there are great semiotic difficulties in obtaining information from patients and witnesses as the episódio^10,24,25 characteristics.

It is reported that the manifestation of classical a urea’s is less common in the elderly, and the preceded crises, most commonly by paresthesias poorly located, muscle cramps, dizziness and stare. Crises can manifest as syncope, falls and confusional states. Drowsiness is more common that the motor manifestations (automatic), repetitive motor acts; and post-ictal state and cognitive deficits are more prolongados.^{6,9, 23-26}

The status epilepticus, which often occurs in the elderly, is presented as acute confusional frame, able to come to eat. It can occur in 70% of elderly people with no previous history of seizure and be confused with Delirium. The etiologic agents are: Stroke, hypoxia, metabolic disorders, exogenous intoxication (alcohol), anoxia, trauma, bleeding and withdrawal of sedative drugs, tumors or infection of the central nervous system (CNS), exacerbation of crises by irregular use of anti-epileptic drugs (MAE). It is a neurological emergency, whose mortality reaches 30%.^3,9

Early detection, as well as the differential diagnosis of epilepsy in the elderly is a challenge. When you have preserved awareness, differentiate movement disorders, Benign paroxysmal vertigo, transient ischemic episodes; if it occurs impaired consciousness: not psychogenic seizures, syncope, acute confusional state; and events during sleep, differentiate: physiological myoclonus, behavioural disorders of REM sleep, restless legs syndrome, apnea sono.^9,27

In the VACS study, 72% of patients had an initial diagnosis of epilepsy, only 26% were confirmed, and the rest were: altered mental status (40%), confusion (39%) and syncope/blackout (27%).²³ In Long Term Institution elderly analyzed in one study, it was found that 7.7% of the admitted elderly MAE using only 60% had indicated by epilépticas9 seizures.

Therefore, seniors who have a first episode of seizure must have a thorough clinical evaluation in an attempt to confirm the diagnosis before instituting treatment. Risk of recurrence in two years, if changes in the electroencephalogram and neuro imaging, early brain insult and noturnas^9,14 crises.

In essentially the clinical diagnosis of epilepsy, additional tests are advisable: electroencephalogram (EEG), which assists in identifying the epileptogenic region, etiology, prognosis and therapy in decision; electrocardiogram (ECG), laboratory tests and imaging studies (computed tomography -TC- skull or MRI brain -RNM-) are useful to rule out heart conditions, metabolic and structural respectivamente.^7,9,17,26

One study showed that 31% of patients who had normal EEG, when monitored by video-EEG examination revealed paroxysmal events, 50% of seizures and 45% of non-epileptic seizures, mainly psychogenic events, syncope, transient ischemia and tremors, noting that the normal EEG does not rule out the diagnosis of epilepsy in the elderly.^3,6

The brain CT scan and MRI were normal in only 18% of patients. The changes were detected: stroke (43%), small vessel disorders (41%), diffuse atrophy (35%), encefalomalácea (9%) and benign tumors (1.5%). Neuro imaging tests are important in the first crisis in the elderly to remove structural brain lesions, which may be present in 66% of casos.^3,23

In the course of the disease, the elderly person is subject to complications: related to epilepsy itself, the trauma (TBI vertebral fractures), risk of aspiration pneumonia, psychiatric co morbidity (depression and anxiety) and unexplained sudden death. In addition to acute and chronic adverse effects of MAE, bio psychosocial complications and increased risk of mortality in recurrent crises and evil state epiléptico.^26,28

The seizure does not always mean epilepsy and needs medical treatment. However, one should consider the presence of a risk factor (focal neurological deficit, brain injury, mental retardation and epileptiform EEG), whose presence increases by 80% the chances of a new episódio.^9,29

In epilepsy newly diagnosed with risk of recurrence (especially if partial seizure), it is argued early treatment at the first crisis. In elderly patients with single episode without pathology or structural CNS change, no family history, no post-ictal paralysis and normal EEG, it should be further research to non-epileptic paroxysmal events and delaying initiation of therapy, since a large percentage will not present a second convulsão.^{9,14,20,26,30}

The acute symptomatic seizures (or secondary), in turn, should be promptly treated with MSA for a given time, and should not be maintained after acute treatment (maximum 30 days) and the correction priority base^9,29 disease.

The basic goal to start treatment is to avoid new crises. The control is achieved in 70% of cases, while 20-30% of patients develop symptomatic chronic epilepsy and of these, 5% present intractable epilepsy with impairment and dependência.⁹

For therapeutic decision are considered some criteria: etiology of crises, risks and consequences of recurrent crises, peculiarities of pharmacokinetics and pharmacodynamics in the elderly, properties, efficacy and adverse effects of MAE.^9,19,22,30

Historically, antiepileptic drugs can be classified into three generations. The first includes potassium bromide, phenobarbital, phenytoin (PTH), primidone, ethosuximide, and trimethadione. The second includes carbamazepine (CBZ), sodium valproate (VPA) and benzodiazepines (BZD). After 1980 appeared the third generation, progabide, gabapentin (GBP), vigabatrin, tiagabine, lamotrigine (LTG) and topiramate (TPM) later, developed molecules with more suitable properties: fosphenytoin, oxcarbazepine (OXC), levetiracetam ( LEV) and pregabalin (PGB).³⁰

The principles for prescribing MAE follow the same pharmacology in this age group: start with monotherapy, low dose use of short half-life MAE, slow titration, not abruptly discontinue use (unless present allergic reaction).^9,30

Despite the therapeutic options, there is no established consensus on the clinical use of MAE in the elderly, but the experience of experts, studies and guidelines make recommendations that assist in therapeutic decision. (Annex 1) ^31-45 Also, knowing the adverse reactions and the occurrence of potential elderly, also assists in that decision (Annex 2).⁴⁶

Before the survey data, it is recommended for the elderly, MAE not induce hepatic metabolism, with better tolerability profile, less drug interactions, dosing convenience, less ataxia and cognitive impairment, as the most modern agents that may have advantages with respect to these effects, however does not have intravenous formulations and the cost is high. And despite the drawbacks, traditional drugs are still widely used, and have efficacy in partial crisis, typical in idoso.^9,26

In specific cases, such as dementia with epilepsy, using MAE with safer profile (LTG, GBP and OXC). In advanced stages, however, where the myoclonic seizures are more common, it is chosen to VPA or Divalproex of sódio.^10,23

consider the recommendations of the American Geriatrics Society should be (AGS) about some inappropriate medications for the elderly: as phenol barbital should be avoided by the high rate of dependency and intoxication; benzodiazepines (inappropriate for insomnia, agitation and delirium) may be used for controlling some seizures; CBZ avoid association with antidepressants and OXC (fencing inhibitors of serotonin, norepinephrine, tricyclic) and diuretics, the risk of  hyponatremia and syndrome of inappropriate secretion of anti diuretic hormone; using LEV, PGB and GBP at reduced doses in patients with glomerular filtration less than 60 ml/min.⁹

It is important to mention that the state epilepticus affects 10 times more in elderly and 0.5% admitted to the Intensive Care Unit (ICU) suffer this crisis, whose mortality rate is 18-52%, depending on the cause, with cognitive sequelae. Therapy should be early, but cautious, as aggressive therapy MAE is controversial and without satisfactory results. Start with intravenous BZD (Diazepam and Lorazepam), if the situation persists, ndovenoso MAE (phenytoin), treat the cause and monitor in UTI.^3,6,9

is not recommended polytherapy with MAE, the drug interactions, adverse effects and idiosyncratic reactions; but in 10-15% of patients refractory after 3 months of monotherapy, it is necessary to conduct associations for seizure control.^2,7,9,47

In epilepsy therapy, 50% of patients will not relapse after cessation of drug treatment. On the other hand, Suitable drugs using the same type of seizure, 20-30% are refractory and 15% is unsatisfactory control in focal epilepsy (partial) being candidates for treatment cirúrgico.⁷

The neurosurgery for epilepsy correction is made less frequently in elderly, because: seizures are easily controlled with MAE, there is a higher prevalence of cardiovascular diseases and comorbidities that increase surgical risks, some patients do not meet clinical criteria for surgery or when operated not completely remit of crises. Patients aged 50 years or more with intractable seizures of hippocampal sclerosis showed positive results after temporal lobectomy that are comparable to young patients long prazo. Older Patients should not be denied treatment on the basis of age. However, lobectomy or hemispherectomy has been successfully performed in this population, and this type of treatment should not be denied based on age. Hitherto, it has been reported that the older patient undergoing the surgery was 76 anos.^19,48-50

And for starting to discontinuation of treatment, it is necessary to consider risk/benefit It should happen by: lack of response after 3 months with treatment at maximum doses; seizure remission (after 2 years of treatment); acute neurological injury (suspended for 12 weeks).^7,30

Nevertheless, slow reductions were suggested, according to previously established criteria for each MAE. And an intermediate position defined "conservative", suggesting reductions of 25% of the dosage of the drug every three meses.^26,30

The latest definitions, it is considered more epilepsy when, in the period of 10 years or more, there is the presence of seizures and no use of MAE. However there are no guarantees about futures 4 crises.

The drugs can prevent seizures without altering the natural history of epilepsy, as 50% -70% of patients come into lasting remission and 40% go into remission even without the use of MSA. Delay or stop treatment for any reason, does not imply change of course prognosis once considered certain kindness that surrounds the global prognosis of most epilepsias30apud.^51,52

To encourage the initiation and maintenance of long-term treatment, it is necessary to expose the treatment performed in an individualized manner, respecting the specificities, has great chances of complete control of seizures. And consequently, there will be a satisfactory outcome, while maintaining the functionality and independencepatient.^2,6,9,10,19

Epilepsy is a common neurological condition in the geriatric population, and like all chronic diseases in this age group, requires professional skills with thorough and timely diagnostic workup, given the atypical presentations and aging characteristics.

It is important to follow the International League of Epilepsy, which periodically makes updates. The classification of epilepsies of the International League against Epilepsy (ILAE) is to aid in the diagnosis of patients in research, development and antiepileptic therapies for communication around the world. It was updated in 2017 according to the new knowledge of epilepsy and scientific development, and incorporates the etiology and comorbidities such as steps required for diagnosis, for promoting therapeutic implications significantes.⁵³  Within this new perspective, the elderly population, which significantly, has pluripatologias and comorbidities may have a more precise classification of epilepsy before the epileptic seizures.

The treatment applied must be careful not to compromise the adhesion, present minor adverse reactions, considering comorbidities, degree of dependence and need for third party monitoring.

The choice of MAE depends on the type of crisis, tolerability, cost/benefit, possible effects associated with altered pharmacokinetics and pharmacodynamics. Therefore, appropriate adjustments to MAE for the elderly include prescription with lower starting dose, slower titration and a lower target dose than for younger adults.

In this article, we describe the particular characteristics and peculiarities for the treatment of epilepsy in the elderly. The recommendations were based on the studies analyzed, cautiously drew a parallel between the characteristics of the elderly and pharmacological profiles. Thus, a careful and individualized approach will always be useful in clinical practice in order to make a good therapeutic decision.

Despite the new generation of medications, there is need to develop new treatments for epilepsy, with effective drugs for resistant cases, with fewer side effects and to modify the natural history of the disease, protecting the brain damage. In addition to more studies related to therapeutic behaviour and response of epilepsy in the elderly.

It is known that elderly patients with newly diagnosed epilepsy have a good prognosis and a good chance of successfully MAE alone.

It is essential to clarify that uncontrolled epilepsy has important implications for the independence, security and quality of life of the elderly. And the goal of treatment is to achieve seizure control with minimal side effects and preservation of functional status.

Finally, it is expected that, given the new classification of the ILAE, there is an improvement in research and care in epilepsy, considering the age of the elderly, especially the large elderly over 80 years, so that we have emplacements for a treatment more safety.

None.

None.

The authors of this manuscript have no competing interests.

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