Epilepsy in Elderly People and its Management

Definition and burden. The elderly have the highest incidence of new-onset epilepsy of any age group — over 100 per 1,00,000 per year after 65. ILAE definition: two unprovoked seizures more than 24 hours apart, or one unprovoked seizure with a recurrence risk above 60%, or an epilepsy syndrome. Because recurrence after a first unprovoked seizure with a structural lesion is 60–90% in old age, treatment is usually started after the first seizure.

Causes. Cerebrovascular disease is the commonest cause (30–50%) — both acute stroke and chronic small-vessel disease. Others: neurodegenerative dementia (Alzheimer’s carries up to a 10-fold risk), brain tumour (primary and metastatic), head trauma and chronic subdural haematoma, CNS infection (in India, neurocysticercosis and tuberculoma), metabolic derangement, and alcohol or drug withdrawal. Around 25–50% remain unexplained (late-onset unexplained epilepsy).

Seizure types. Focal (partial) seizures predominate, most often focal seizures with impaired awareness of temporal or frontal origin, with or without secondary generalisation. Primary generalised epilepsy beginning in old age is rare, so a generalised seizure in an older person should prompt a search for a focal structural or metabolic cause.

Atypical presentation — the core geriatric point. The aura is often absent or not reported. Seizures present as brief staring and behavioural arrest, unexplained confusion, memory lapses, wandering, falls or syncope-like collapse. Automatisms may be subtle. Post-ictal confusion is prolonged — often hours to days, occasionally weeks — and Todd’s paresis lasts longer, so epilepsy is frequently misdiagnosed as TIA, syncope, delirium or dementia.

Acute symptomatic (provoked) seizures must be separated from epilepsy. Seizures occurring within 7 days of a stroke, head injury or CNS infection, or from hypoglycaemia, hyponatraemia, uraemia, hepatic failure, hypoxia, sepsis, drugs or alcohol withdrawal, are provoked — they do not by themselves define epilepsy and often do not require long-term antiseizure medication once the cause is corrected.

Differential diagnosis. Syncope (cardiac arrhythmia, orthostatic hypotension, carotid sinus hypersensitivity — the commonest misdiagnosis), TIA (negative rather than positive phenomena, no post-ictal confusion), transient global amnesia, hypoglycaemia, delirium, sleep disorders including REM sleep behaviour disorder, drop attacks, and psychogenic non-epileptic attacks.

History is the single most valuable investigation. Obtain a detailed eyewitness account — posture and circumstances at onset, warning, colour, duration, movements, tongue biting, incontinence, and the nature and duration of recovery. Review the drug chart for pro-convulsant drugs: tramadol, quinolones, bupropion, theophylline, antipsychotics, high-dose beta-lactams, and abrupt benzodiazepine withdrawal.

Investigations. ECG with 24-hour Holter or tilt testing to exclude cardiac syncope. Blood tests: sodium, calcium, magnesium, glucose, urea, creatinine, LFT, and drug levels. EEG has low sensitivity in the elderly (about 26–38%) and interictal abnormalities are less common, so a normal EEG never excludes epilepsy; use sleep-deprived, prolonged or video-EEG where doubt persists. MRI brain is the imaging investigation of choice — superior to CT for hippocampal sclerosis, small infarcts and tumour.

Non-convulsive status epilepticus (NCSE). An under-recognised and treatable cause of unexplained prolonged confusion, stupor or coma in the elderly, often after a generalised seizure or in a septic/metabolically deranged patient. EEG is mandatory in any older patient whose consciousness does not recover within 30–60 minutes of a seizure.

Principles of drug therapy. Use monotherapy; start low, go slow, and aim for a lower maintenance dose than in younger adults. Age alters pharmacokinetics: reduced serum albumin raises the free (active) fraction of phenytoin and valproate, reduced hepatic and renal clearance prolongs half-lives, and reduced lean body mass lowers the volume of distribution. Measure free rather than total phenytoin where available.

Drug of choice. Levetiracetam and lamotrigine are first line for focal epilepsy in older adults, with lacosamide as an alternative; levetiracetam has the highest chance of long-term seizure freedom and lamotrigine the best tolerability. Avoid enzyme-inducing drugs — carbamazepine, phenytoin and phenobarbitone — because they interact with warfarin, DOACs, statins, antihypertensives, antiarrhythmics and chemotherapy, and accelerate vitamin D metabolism and bone loss. Gabapentin is a last resort.

Adverse effects that matter in old age. Hyponatraemia (carbamazepine, oxcarbazepine, eslicarbazepine); ataxia, dizziness and falls with almost all agents; sedation and cognitive slowing (topiramate, phenobarbitone, benzodiazepines); osteoporosis and fracture with enzyme inducers; behavioural change, irritability and depression with levetiracetam; rash and Stevens–Johnson syndrome with lamotrigine if titrated fast; oedema and cognitive change with gabapentin and pregabalin; and phenytoin’s zero-order kinetics, gum hypertrophy and cerebellar atrophy.

Status epilepticus. ABC, oxygen, IV access, capillary glucose, and IV thiamine before glucose. First line: IV lorazepam 0.1 mg/kg (or IM midazolam 10 mg if no access). Second line: IV levetiracetam 60 mg/kg, fosphenytoin 20 PE/kg, or valproate 40 mg/kg — all equally effective. Third line: anaesthesia with midazolam or propofol infusion and continuous EEG. In the elderly, reduce doses, infuse slowly and monitor blood pressure and respiration closely.

Holistic and non-drug management, and prognosis. Injury and falls prevention, bathing and cooking safety, driving restriction, treatment of vascular risk factors, deprescribing pro-convulsant and anticholinergic drugs, bone health (calcium, vitamin D, DEXA), screening for depression and cognitive impairment, carer education in first aid, and counselling about SUDEP. Prognosis is good — about 80% become seizure-free on low-dose monotherapy — but mortality, fracture and dementia risk remain elevated.

ILAE Task Force on Epilepsy in the Elderly — critical review (Epilepsia, 2023). An individualised approach is essential because older adults are a highly heterogeneous group. Across comparative studies, levetiracetam has the highest probability of long-term seizure freedom, while carbamazepine users are almost twice as likely to discontinue treatment for adverse effects as lamotrigine users. Current practice therefore places lamotrigine, levetiracetam and lacosamide first line, with gabapentin as a last resort. The Task Force also highlighted that quality of life is a missing outcome in most trials, and that prognosis must move beyond seizure control to patient-centred outcomes.

Late-onset unexplained epilepsy (LOUE) is a marker of vascular brain disease and future dementia. Recent cohort work and the prospective multicentre ELUCID study (2025) show that in LOUE the excess morbidity and mortality relate more to incident dementia and stroke than to the seizures themselves, and that seizures are usually easily controlled. Practical implication: a first seizure after the age of 55 should trigger aggressive vascular risk-factor management and structured cognitive follow-up, not merely a prescription for an antiseizure drug.

Antiseizure medication–anticoagulant interactions (2024–2025). Emerging evidence, including a systematic review of levetiracetam and DOACs (2024) and outcome data in older Asian patients with atrial fibrillation (2025), suggests that even “non-interacting” agents such as levetiracetam may lower DOAC levels through P-glycoprotein induction. About one in six older patients with epilepsy is at risk of a clinically significant drug interaction. Non-enzyme-inducing agents remain preferred, but a formal interaction check — not an assumption of safety — is now the standard.