Seizures and epilepsy in older adults: Treatment and prognosis

INTRODUCTION — 

This topic will cover aspects of the management of seizures and epilepsy that are specific to older adults. A more general discussion of the treatment of seizures and epilepsy is presented elsewhere. (See "Overview of the management of epilepsy in adults" and "Initial treatment of epilepsy in adults".)

The clinical presentation of seizures in older adults is frequently different from that of younger adults, and seizures are often difficult to recognize. The etiology, clinical presentation, and diagnosis of seizures and epilepsy in older adults is discussed separately. (See "Seizures and epilepsy in older adults: Etiology, clinical presentation, and diagnosis".)

TERMINOLOGY — 

Seizures are episodes of transient neurologic change due to overexcited, hypersynchronous neuronal activity. Seizures are divided into provoked and unprovoked:

●Provoked seizures, also known as acute symptomatic seizures, occur with an identifiable proximate cause and are not expected to recur in the absence of that particular cause or trigger (eg, hypoglycemia, alcohol withdrawal).

●Unprovoked seizures occur without an identifiable proximate cause, and epilepsy is defined as a condition of recurrent unprovoked seizures. In epilepsy, the seizures appear to occur spontaneously and are expected to recur in the absence of treatment.

APPROACH TO TREATMENT — 

The approach to treatment of seizures and epilepsy in older adults is similar to that of adults in general.

New-onset seizures — The decision to treat seizures in older adults should be made only after significant deliberation of the benefits and risks of treatment. Factors that should be considered include the degree of certainty about the seizure diagnosis, the individual risk of seizure recurrence, seizure severity, and risk of self-injury. However, starting an antiseizure medication (ASM) in older adults can lead to a variety of negative outcomes such as excessive somnolence, worsening cognition, worsening mood/behavior, and increased risk of falls.

Acute provoked seizures — In general, patients with acute provoked seizures due to a potentially reversible cause (eg, obvious metabolic derangements, drug intoxication, or medication or alcohol withdrawal) will not require long-term ASM treatment. However, patients with seizures occurring during a hospitalization due to a reversible cause should receive ASMs during the active phase of the illness. It is reasonable to withdraw ASMs at the post-discharge follow-up visit if seizures do not recur and if the underlying cause has resolved. Patients with seizures caused by an acute intracranial event (eg, stroke, head trauma, brain surgery, encephalitis or meningitis) may be at higher risk of recurrent seizures than those with a systemic cause; in such cases, ASM withdrawal should be individualized (algorithm 1). (See "Overview of the management of epilepsy in adults", section on 'Poststroke seizures'.)

After a first unprovoked seizure — The decision to start an ASM in an older patient with a first unprovoked seizure (ie, a seizure without an identifiable proximate cause) should be based on risk factors for seizure recurrence rather than age, similar to the decision in younger adults.

●When to start treatment – For older adults with a first unprovoked seizure, we suggest ASM treatment only in the setting of clearly documented potential symptomatic cause of epilepsy (eg, stroke, traumatic brain injury, brain tumor) based upon history, an abnormal neurologic examination, a relevant abnormality on brain imaging with computed tomography (CT) or magnetic resonance imaging (MRI), and/or epileptiform discharges on electroencephalography (EEG) (algorithm 2).

●When to defer treatment – In the absence of a symptomatic cause of epilepsy, it is appropriate to defer ASM treatment for patients with a single unprovoked seizure and an unremarkable brain MRI and EEG. A second unprovoked seizure, however, would be an indication for treatment. (See 'After two or more unprovoked seizures' below.)

●Risk factors for seizure recurrence – Limited data suggest that the risk of seizure recurrence after single unprovoked seizure in older adults is similar to that of younger adults and that the predictors of recurrence are similar. In a prospective observational study of over 1000 adults presenting with a first-ever unprovoked seizure, 139 of whom were ≥65 years of age (mean 74 years), the likelihood of a seizure recurrence at one year was similar in older compared with younger adults (53 versus 48 percent) [1]. Independent predictors of seizure recurrence included remote symptomatic etiology, first seizure arising from sleep (ie, a seizure that starts when the patient is asleep), epileptiform abnormality on EEG, and focal seizures, but not age. In another prospective observational report, in which 127 of the 568 adults with a single unprovoked seizure were >60 years of age, the cumulative risk of recurrence in this age group was 83 percent over three years; however, the overall recurrence rate was higher in this study (78 percent) across all age groups [2].

In patients with a first unprovoked seizure who are found to have a relevant brain abnormality on neuroimaging (such as a tumor, remote stroke, or scar tissue from an old head injury or infection), the risk of seizure recurrence is increased. Such patients likely have a sufficiently high risk of seizure recurrence to meet criteria for epilepsy according to International League Against Epilepsy (ILAE) guidelines [3]. These criteria consider patients with a single unprovoked seizure and an estimated risk of recurrence ≥60 percent over 10 years to have epilepsy, similar to those with two unprovoked seizures occurring >24 hours apart.

After two or more unprovoked seizures — The general consensus is to begin treatment with ASM therapy if a patient has experienced two or more well-documented unprovoked seizures (algorithm 2), since seizure recurrence indicates that the patient has a substantially increased risk for additional seizures (ie, epilepsy). (See "Initial treatment of epilepsy in adults", section on 'Second unprovoked seizure'.)

However, in some circumstances (eg, if the diagnosis is uncertain because the events were not witnessed), withholding ASM treatment may be appropriate. (See "Initial treatment of epilepsy in adults", section on 'Choose immediate versus deferred treatment'.)

Status epilepticus — Generalized convulsive status epilepticus (GCSE) is a medical emergency that requires prompt evaluation and treatment. The approach to GCSE in older adults is similar to that of younger adults (algorithm 3) [4]. However, morbidity and mortality are higher in older adults (see 'Prognosis' below). The treatment of GCSE is discussed in detail separately. (See "Convulsive status epilepticus in adults: Management".)

Nonconvulsive status epilepticus (NCSE) is a condition of ongoing or intermittent seizure activity without convulsions, without recovery of consciousness between attacks, and lasting more than 10 minutes. NCSE is a challenging diagnosis, particularly in the older patient; a high index of suspicion in a comatose patient is often necessary to confirm NCSE, and the diagnosis is largely based on a confirmatory EEG and response to appropriate treatment. (See "Seizures and epilepsy in older adults: Etiology, clinical presentation, and diagnosis", section on 'Nonconvulsive status epilepticus'.)

In all patients with NCSE, a concerted effort should be made to diagnose and treat seizures as quickly as possible but with minimal sedation, to avoid inducing or prolonging coma and intubation, as reviewed separately. (See "Nonconvulsive status epilepticus: Treatment and prognosis".)

Patient education — An important aspect of caring for a patient with epilepsy includes counseling on safety issues and lifestyle modifications [5]. In the United States, a few states legally require health care providers to submit confidential reports to local health agencies and/or transportation departments after diagnosing a patient with seizure(s). Although mandatory reporting is limited to a handful of states, most require health care clinicians to counsel patients to stop driving until they are seizure-free for a certain period of time. (See "Overview of the management of epilepsy in adults", section on 'Driving and other activities'.)

Clinicians should also initiate a discussion about alcohol intake, informing patients that heavier consumption (three or more drinks in a 24-hour period) increases the risk of seizures [6]. (See "Alcohol use disorder: Treatment overview".)

ANTISEIZURE MEDICATION TREATMENT

Selection of antiseizure medication — Antiseizure medications (ASMs) are the mainstay of epilepsy treatment. However, their use in older patients is complicated by several factors, including altered pharmacokinetics and increased risk for both common and rare adverse effects (table 1 and table 2) and drug-drug interactions [7].

The choice of a specific ASM in an older patient should take into account the types of seizures the patient is experiencing (eg, focal seizure, myoclonic seizures, generalized tonic-clonic seizures), the potential for drug-drug interactions, comorbid medical conditions, and the mode of administration (swallowed completely versus crushed versus gastrostomy tube) [7].

A detailed review of ASMs is provided elsewhere. (See "Antiseizure medications: Mechanism of action, pharmacology, and adverse effects".)

Seizure type

●Focal seizures – Focal seizures with impairment of awareness are the most common types of new-onset seizures in older adults. Lamotrigine and levetiracetam are reasonable first-line medications for focal seizures because of the relative lack of sedation and absence of bidirectional drug interactions encountered with these two ASMs. Lamotrigine is appropriate if the clinical scenario does not require an immediate therapeutic level (eg, seizures are infrequent and/or mild). Levetiracetam is appropriate if there is a more urgent need to reach therapeutic dosing more quickly; it is available in both tablet and liquid formulations.

●Myoclonic seizures – Rarely, in patients with Alzheimer disease or other neurodegenerative conditions, the primary seizure subtype may be myoclonic seizures [8-11]. Levetiracetam and valproate are efficacious [12,13].

●Generalized seizures – New-onset generalized seizures are unlikely in older adults, such that observed generalized seizures are more likely to be focal seizures with secondary generalization. Therefore, the approach to therapy is the same as stated above for focal seizures.

Dosing strategies — In all cases, we recommend starting ASMs for older adult patients at low doses and increasing doses gradually. Older patients generally require doses far below standard therapeutic levels and experience toxicity with traditionally therapeutic doses typically used in younger patients. Potential nonurgent/outpatient dosing strategies for specific ASMs are as follows:

●Lamotrigine – In older patients >85 years of age, the starting dose of lamotrigine may be as low as 12.5 mg daily with an incremental increase of 12.5 mg per week to a goal dose of 25 mg twice a day. In younger, healthy older patients (65 to 75 years of age), individuals may tolerate a starting dose of 25 mg twice a day with an incremental increase of 25 mg per week, reaching a goal of 50 to 75 mg twice a day. It is reasonable to use the extended-release formulation of lamotrigine for more stable steady-state concentrations, which may improve tolerability [14].

●Levetiracetam – Levetiracetam can be started at a dose of 250 mg twice a day in healthy older patients (<85 years of age) and increased to 500 mg twice a day in three to seven days. In patients ≥85 years of age, levetiracetam should be started at a dose of 125 mg daily or twice daily and increased incrementally by 125 mg/week to a goal dose of 250 mg twice a day. Levetiracetam should be used with caution in individuals who have advanced dementia and behavioral issues (eg, patients with trisomy 21 [Down syndrome], patients with features of Alzheimer disease) because of the increased risk of aggressive behavior and irritability.

●Valproate – Available formulations of valproate (active moiety) include valproic acid, valproate sodium, and divalproex sodium. For patients who can swallow tablets whole, the extended-release formulation of divalproex sodium is better tolerated than other forms of valproate. Extended-release divalproex sodium can be started at 250 mg daily and increased by 250 mg/week to a goal dose of 250 to 500 mg twice a day. For patients with swallowing difficulties, divalproex sodium sprinkle capsules (125 mg) can be opened and the sprinkles placed in applesauce. This formulation should be dosed two or three times a day, with a typical starting dose of 125 mg two or three times a day.

●Gabapentin – Available formulations of gabapentin include capsules and tablets. The typical starting dose is 100 mg twice a day and is increased slowly (by 100 mg every week) to a target dose of 300 mg two or three times a day.

Efficacy and tolerability — The available evidence, although limited by a paucity of head-to-head comparisons, suggests that the more commonly used ASMs (ie, lamotrigine, levetiracetam, valproate, gabapentin) have similar efficacy and tolerability for older patients with epilepsy.

●Evidence from randomized trials – A 2019 network meta-analysis of five randomized controlled trials with 1425 patients evaluated ASM monotherapy (with carbamazepine, gabapentin, lacosamide, lamotrigine, levetiracetam, phenytoin, and valproic acid) for older adults with epilepsy [15]. In both the pairwise and network meta-analyses, there were no differences in any of the comparisons for seizure freedom at 6 and 12 months; carbamazepine had the highest probability of treatment discontinuation.

A 2019 systematic review and meta-analysis identified 18 studies evaluating 12 different ASMs in people at least 60 years of age with epilepsy; 10 studies with 1999 patients were suitable for meta-analysis [16]. The probability of seizure freedom was more likely with levetiracetam compared with lamotrigine (risk ratio [RR] 0.83, 95% CI 0.68-0.97), although the statistical significance was marginal. Discontinuation due to adverse events was more likely with carbamazepine compared with lamotrigine (pooled weighted RR 1.83, 95% CI 1.23-2.43). There was also evidence from individual studies supporting the efficacy and/or tolerability of brivaracetam, gabapentin, lacosamide, perampanel, and topiramate. However, there were too few trials to carry out a meta-analysis of additional head-to-head ASM comparisons or to evaluate the impact of epilepsy type and other patient characteristics on the efficacy and tolerability of ASMs, and the quality of the evidence was generally low or unknown.

●Age-related concerns – Compared with younger adults, older adults appear to be more sensitive to side effects of ASMs, experiencing them more frequently and with lower doses. General dose-dependent side effects of ASMs that can be particularly problematic in older patients include falls, confusion, impaired gait, sedation, tremor, dizziness, and visual disturbance.

●Drug-related concerns – Other considerations when selecting an ASM include the following (see "Drug prescribing for older adults"):

•Polypharmacy – Carbamazepine and phenytoin have multiple drug-drug interactions (table 3 and table 4) and should probably be avoided in older patients with polypharmacy.

•Patients at risk for hyponatremia – Carbamazepine, oxcarbazepine, and eslicarbazepine increase the risk of symptomatic hyponatremia, especially in patients receiving selective serotonin reuptake inhibitors (SSRIs) and/or diuretics.

•Patients taking metformin – Topiramate and zonisamide are associated with increased rates of metabolic acidosis, especially if administered in conjunction with metformin.

•Patients with renal insufficiency – Levetiracetam is mainly renally cleared and the dose must be adjusted in individuals with chronic kidney disease.

•Patients with advanced dementia – Gabapentin and oxcarbazepine can rarely precipitate or induce myoclonic seizures in older patients with advanced dementia.

•Patients at risk for bone disease and falls – Some ASMs (eg, phenytoin, carbamazepine, phenobarbital) increase the rate of bone loss and may increase the risk of bone injury and fracture. It is somewhat reassuring that a case-control study involving 124,655 fracture cases found only a limited increased fracture risk among users of ASMs [17]. Another study found that most of the increased risk of fractures in persons with epilepsy was related to seizures and not to bone biomechanic competence [18]. Gait impairment from ASM use is another potential contributor to falls and fractures in older patients with epilepsy [19]. These issues are reviewed in detail elsewhere. (See "Antiseizure medications and bone disease".)

Therapeutic monitoring — Older patients are less likely to take their ASMs as directed compared with younger counterparts, with some studies demonstrating nonadherence in one-third to one-half of older adults [20-22]. Nonadherence is associated with increased seizures and injury, higher risk of mortality, and greater health care utilization [23]. Attention to medication costs, more frequent clinic visits, and simpler regimens appear to mitigate these problems [22].

When evaluating older patients for "breakthrough seizures," it is important to investigate whether nonadherence is a factor before adjusting ASM doses. A review of pharmacy refill dispense dates, frank conversations about prescription affordability, and patient willingness to use pill organizers (eg, weekly pill box or blister packaging) should be undertaken. (See "Antiseizure medication maintenance therapy and drug monitoring", section on 'Nonadherence with ASM therapy'.)

Dose adjustments with aging — Patients with epilepsy onset in earlier years of life will often remain on chronic ASM therapy. Later in life, these patients may require dosing adjustments because of the changing physiology associated with aging and changes in drug absorption, metabolism, distribution, and excretion, as well as potential pharmacokinetic or pharmacodynamic interactions with other drugs that may be started in aging patients. Much of the age-related pharmacokinetic changes that require dose adjustment are due to decline in renal function and reduced metabolism of cytochrome P450 (CYP) enzymes in the liver.

The clinician needs to think about dose adjustments in the older patient with renal impairment and/or hepatic impairment, particularly if severe. Patients should be monitored for subtle signs of ASM toxicity including blurry vision, dizziness, gait imbalance, and nausea. It is advisable to obtain serum trough levels and compare them with historical values to guide the amount of dose reduction [24]. (See "Antiseizure medications: Mechanism of action, pharmacology, and adverse effects" and "Antiseizure medication maintenance therapy and drug monitoring".)

Antiseizure medication discontinuation — Because of the high rates of adverse effects associated with ASMs, it is reasonable to consider drug discontinuation in patients with a reliable history who have been seizure-free for two to three years and who lack a clear remote symptomatic cause for their epilepsy diagnosis. The risk of seizure recurrence, the severity of seizures, whether the patient lives alone, and the risk for self-injury are the key factors in this decision. Patients should be counseled to stop driving, swimming alone, climbing ladders, or operating heavy machinery during the tapering period and for three months after drug discontinuation. (See "Approach to the discontinuation of antiseizure medications".)

DRUG-RESISTANT EPILEPSY

Definition — Patients with epilepsy whose seizures do not successfully respond to antiseizure medication (ASM) therapy are considered to have drug-resistant epilepsy (DRE). This condition is also referred to as intractable, medically refractory, or pharmacoresistant epilepsy. "Drug-resistant" is defined as the failure of adequate trials of two tolerated, appropriately chosen and administered ASMs (whether as monotherapy or in combination) to achieve seizure freedom. (See "Evaluation and management of drug-resistant epilepsy", section on 'Definition'.)

Resective epilepsy surgery is the treatment of choice for DRE with localization-related or partial epilepsy, as this has the most likely chance of producing remission. Further ASM trials, neurostimulation techniques, and the ketogenic diet can reduce seizure frequency and improve quality of life but are more likely to be palliative, rather than curative, treatment options. (See "Evaluation and management of drug-resistant epilepsy", section on 'Treatment options'.)

Patients with poorly controlled seizures should be instructed to avoid driving, swimming alone, climbing ladders, or operating heavy machinery.

Epilepsy surgery — Surgical therapy can be an effective treatment for patients with drug-resistant focal epilepsy. Although age is not a contraindication for epilepsy surgery, experience is limited in the population of older adults. Surgery should only be considered in individuals with DRE without signs/symptoms of a progressive neurodegenerative condition. (See "Resective and ablative surgical treatment of epilepsy in adults".)

While randomized trial data regarding the efficacy of epilepsy surgery in older adult patients are lacking, the available literature suggests that surgery is similarly effective in older and younger adults, while complication rates are higher in older adults. A 2024 systematic review and meta-analysis evaluated studies of epilepsy surgery performed after 1990 and included 11 case series and 14 cohort studies with 1111 older adults (age ≥50 years) and 4111 younger adults (age <50 years) as controls [25]. The pooled incidence of seizure freedom after epilepsy surgery for older adults was 70.1 percent; the incidence of seizure freedom in cohort studies was similar for older and younger adults (RR 1.05; 95% CI 0.97-1.14). The pooled incidence of perioperative complications in older adults (reported in 22 studies) was 26.2 percent and in younger adults (reported in 11 studies) was 9.1 percent, with major complications experienced by 7.5 percent of older adults and 2.6 percent of younger adults. In studies with data for both age groups, the risk of any complication was higher for older compared with younger adults (RR 2.8; 95% CI 1.5-5.4); the risk of serious complications trended higher for older adults, although the difference was not statistically significant (RR 1.3, 95% CI 0.6-2.6). The most frequent complications were language disturbance, cerebral infarctions, subdural hemorrhage, and intracerebral hemorrhage.

Further antiseizure medication trials — Further trials of ASMs in mono- or polytherapy can sometimes be of benefit in individuals with DRE. This is discussed separately. (See "Evaluation and management of drug-resistant epilepsy".)

Neurostimulation — A variety of neurostimulation techniques are options for patients with DRE who are not candidates for focal resective epilepsy surgery. Methods include vagus nerve stimulation, responsive cortical stimulation, deep brain stimulation, transcranial magnetic stimulation, and trigeminal nerve stimulation. However, there is little published literature about the use of neurostimulation for DRE in older adults. (See "Evaluation and management of drug-resistant epilepsy", section on 'Neurostimulation'.)

The vagus nerve stimulator (VNS), a surgically implanted device, is the best-studied of these techniques and is a valid palliative treatment option for patients with DRE, used in conjunction with ASM therapy. However, there is little experience with VNS in older adult patients compared with younger adults. A retrospective review using data from the device manufacturer identified 45 patients over the age of 50 (seven were over 60 years old and only one was over 70 years of age) who received VNS for intractable epilepsy [26]. At three months, 27 percent achieved a 50 percent reduction in seizures; at one year, 67 percent had achieved a 50 percent reduction in seizures. No serious surgical complications occurred. These data compare well with the efficacy of VNS in other populations with epilepsy. However, VNS has also been associated with higher rates of obstructive sleep apnea and respiratory complications, an important consideration in the older population [27]. (See "Vagus nerve stimulation therapy for the treatment of epilepsy" and "Evaluation and management of drug-resistant epilepsy".)

Laser interstitial thermal therapy — Laser interstitial thermal therapy (LITT), also known as stereotactic thermocoagulation or stereotactic laser ablation, is a minimally invasive surgical method that is under investigation as an alternative form of treatment for patients with DRE. LITT may become an attractive option for older patients, but more data are needed [28]. Stereotactic laser ablation in mesial temporal lobe epilepsy (SLATE) is a multicenter prospective single-arm clinical trial enrolling patients ages 18 to 70 with seizure freedom as a primary outcome measure [29]. Secondary endpoints include cognitive and quality-of-life outcomes.

Ketogenic dietary therapies — Ketogenic dietary therapy (KDT) is an effective treatment for children and adults with epilepsy, but there are few data pertaining to its use for DRE in older adults. (See "Ketogenic dietary therapies for the treatment of epilepsy".)

PROGNOSIS

Long-term seizure control — There are limited long-term prospective data describing the prognosis of older patients with epilepsy. Overall, the data suggest that most older patients respond to antiseizure medications (ASMs) and are able to achieve seizure control on ASM monotherapy [30-34]. As examples, a single-center study of 201 patients age 65 years or older with newly diagnosed epilepsy and long-term follow-up reported that seizure freedom (no seizures for at least one year with no change in ASM) at last follow-up was found in 78.6 percent; among these, the proportion on ASM monotherapy was 95 percent [34]. Similarly, a population-based study of epilepsy in Italy identified 124 older adults newly diagnosed with epilepsy; approximately two-thirds of these adults achieved a two-year remission with or without medications [33].

Cognitive outcomes — Older patients with epilepsy rank cognitive problems as their greatest concern [35], and increasing evidence suggests that older patients with epilepsy experience faster cognitive decline, especially in processing speed [36]. The underlying pathophysiologic mechanisms for this observation remain unclear but may result from complex interactions among various factors including seizures, medications, and neurodegenerative and cerebrovascular disease burden [37].

Prognosis with status epilepticus — Older adults (age ≥60 years) who develop status epilepticus have a worse prognosis than younger adults with status epilepticus, including a higher mortality rate during the acute illness [4,38]. As an example, a retrospective report of 120 patients with status epilepticus found that mortality was higher in patients 60 years of age and older compared with younger patients (31 versus 7 percent) [39]. In various studies, in-hospital mortality has been associated with increasing age, anoxia as the etiology of status epilepticus, the duration of the seizure activity, refractory status epilepticus, a longer duration of mechanical ventilation, complications (eg, sepsis, renal failure, metabolic derangements), and the number of medical comorbidities [4,38,40-43].

Mortality is also high (18 to 52 percent) among older adults hospitalized with nonconvulsive status epilepticus [44-47]. Aggressive treatment of nonconvulsive status epilepticus may actually play a role in morbidity and mortality through induced hypotension, cardiac arrhythmias, and prolonged sedation [44,45,48].

Long-term mortality — Limited data suggest that new-onset epilepsy in older patients is associated with a high five-year mortality rate. A 2017 systematic review found that older adults with epilepsy had mortality rates that were approximately two times higher compared with older adults without epilepsy [49]. In a retrospective report that analyzed data for 33.6 million Medicare beneficiaries age 65 and older, the five-year mortality rate among the subgroup of 99,990 incident epilepsy cases was 63 percent, whereas the five-year mortality rate for the entire cohort was 29 percent [50].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Seizures and epilepsy in adults".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Seizures (The Basics)")

●Beyond the Basics topic (see "Patient education: Seizures in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Approach to treatment of new-onset seizures

•With acute provoked seizures – Patients with acute provoked seizures due to an identifiable proximate cause should receive antiseizure medications (ASMs) during the active phase of the illness. In general, those with a potentially reversible cause (eg, obvious metabolic derangements, drug intoxication, or medication or alcohol withdrawal) will not require long-term ASM treatment, and ASMs can be withdrawn once seizures and the underlying cause have resolved. However, patients with acute seizures caused by an acute intracranial event (eg, stroke, head trauma, encephalitis, or meningitis) may be at higher risk of recurrent seizures; in such cases, ASM withdrawal should be individualized (algorithm 1). (See 'Acute provoked seizures' above.)

•First unprovoked seizure – For older adult patients with a first unprovoked seizure (ie, a seizure without an identifiable proximate cause), we suggest ASM treatment only in the setting of clearly documented potential symptomatic cause of epilepsy (eg, stroke, traumatic brain injury, brain tumor) based upon history, an abnormal neurologic examination, a relevant abnormality on brain imaging with CT or MRI, and/or epileptiform discharges on EEG. In the absence of a symptomatic cause of epilepsy, it is reasonable to defer ASM treatment for patients with a single unprovoked seizure and an unremarkable brain MRI and EEG (algorithm 2). (See 'After a first unprovoked seizure' above.)

•Two or more unprovoked seizures – For a patient who has two or more well-documented unprovoked seizures, ASM therapy should be started (algorithm 2). (See 'After two or more unprovoked seizures' above and "Initial treatment of epilepsy in adults", section on 'Second unprovoked seizure'.)

●Antiseizure medication treatment

•Selection of an antiseizure medication – As with adults in general, ASM selection for older adults should be individualized according to seizure or epilepsy type, comorbidities, adverse effect profile (table 1 and table 2), and drug-drug interactions.

Lamotrigine and levetiracetam are reasonable first-line medications for focal seizures, which are the most common types of new-onset seizures in older adults. Observed generalized seizures in older adults are more likely to be focal seizures with secondary generalization and can also be treated with lamotrigine or levetiracetam.

Valproate or levetiracetam are efficacious for myoclonic seizures, which may develop in patients with neurodegenerative conditions such as Alzheimer disease. (See 'Selection of antiseizure medication' above and 'Seizure type' above.)

•Dose – For older patients, ASMs should be started at very low doses and titrated gradually. Target doses are generally much lower in older adults compared with younger patients. Suggested dosing strategies for several commonly used ASMs (lamotrigine, levetiracetam, valproate, and gabapentin) are discussed above. (See 'Dosing strategies' above.)

●Drug-resistant epilepsy

•Epilepsy surgery – Surgical therapy can be an effective treatment for patients with drug-resistant focal epilepsy. Although age is not a contraindication for epilepsy surgery, experience is limited in the population of older adults. Surgery should only be considered in individuals with drug-resistant epilepsy without signs/symptoms of a progressive neurodegenerative condition. (See 'Epilepsy surgery' above.)

•Other options – For patients who are not candidates for epilepsy surgery, treatment options for drug-resistant epilepsy include further ASM trials, neurostimulation, and the ketogenic diet. (See 'Further antiseizure medication trials' above and 'Neurostimulation' above and 'Laser interstitial thermal therapy' above and 'Ketogenic dietary therapies' above.)

●Prognosis

•Long-term seizure control – Available data suggest that most older patients respond to ASMs and can achieve seizure control on ASM monotherapy. (See 'Long-term seizure control' above.)

•Cognitive outcomes – Increasing evidence suggests that older patients with epilepsy experience faster cognitive decline, especially in processing speed. (See 'Cognitive outcomes' above.)

•Status epilepticus – With status epilepticus, older adults have a worse prognosis than younger adults, including a higher mortality rate during the acute illness. (See 'Prognosis with status epilepticus' above.)

•Long-term mortality – New-onset epilepsy in older patients is associated with a high five-year mortality rate. (See 'Long-term mortality' above.)

ACKNOWLEDGMENTS — 

The UpToDate editorial staff acknowledges Anil Mendiratta, MD, and Hyunmi Choi, MD, MS, who contributed to an earlier version of this topic review.