Epilepsy in Special Populations and Psychosocial Issues
Core concepts
Special populations require tailored approaches: children, older adults, women of childbearing age, and people with intellectual disability.
Women and pregnancy
- Preconception counseling is essential. Folic acid supplementation is recommended.
- Valproate carries the highest teratogenic risk (neural tube defects, neurodevelopmental impairment) - avoid when possible.
- Most ASMs require dose adjustment in pregnancy due to altered clearance (especially lamotrigine, levetiracetam).
- Breastfeeding is generally encouraged.
Older adults
New-onset seizures in older adults are often due to stroke, tumors, or neurodegenerative disease. Drug interactions and renal/hepatic clearance matter; choose ASMs with favorable interaction profiles (e.g., lamotrigine, levetiracetam).
Children
Recognize age-dependent syndromes (infantile spasms, Dravet, rolandic epilepsy, Lennox-Gastaut). Consider developmental and educational impact.
Psychosocial issues
Address driving restrictions, employment, stigma, depression/anxiety, and SUDEP counseling. Psychiatric comorbidity is common and bidirectional with epilepsy. Screen for depression.
Traps
- Assuming pregnancy contraindicates all ASMs - untreated seizures also harm mother and fetus.
- Forgetting dose changes in pregnancy.
- Overlooking SUDEP discussion and depression screening.
Rule of thumb
Preconception: folate, avoid valproate, plan dose monitoring. Older adults: think structural cause and drug interactions.