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Learning Objectives

  • Understand the epidemiology, classification, and common clinical presentations of epilepsy in older adults.

  • Learn the principles that guide treatment of epilepsy and how age-associated changes in body composition and drug metabolism affect therapy with antiepileptic drugs in older adults.

  • Acquire knowledge about the mechanism of action, indications, efficacy, and adverse effects of commonly used medications to treat epilepsy in older adults.

  • Learn about nonpharmacologic management of refractory epilepsy in older adults, including the role of resective surgery and neurostimulation.

  • Understand how common comorbidities can confound the clinical presentation and treatment of epilepsy in older adults.

Key Clinical Points

  1. The incidence of epilepsy increases significantly with aging and is more likely to be associated with secondary causes, such as stroke, Alzheimer disease, trauma, and tumor. However, it is not uncommon to fail to identify a discernible cause for epilepsy in older adults.

  2. Diagnosis of epilepsy in older adults requires a careful history. Brain imaging and electroencephalogram (EEG) are useful tools to make the diagnosis. A magnetic resonance imaging (MRI) brain scan can evaluate for culprits like infarction, tumor, or hemorrhage, while an EEG can be abnormal in about 50% of older patients.

  3. Choice of drug therapy is driven by the overall efficacy, adverse effect profile, and age-associated changes in the body composition and organ function that can alter drug absorption, plasma levels, and excretion.

  4. Treatment of a seizure in an acute medical setting generally requires short-term therapy or watchful waiting, while that related to conditions, such as stroke, brain tumor, trauma, or Alzheimer disease may need long-term drug therapy.

  5. Management of refractory epilepsy may need additional nonpharmacologic therapies, such as resective surgery and neurostimulation.


Older adults, often defined as those 65 years and older, currently number 40 million in the United States alone. Demographic trends predict that this number is expected to double by 2030, and will at that point comprise nearly one in five Americans. Coupled with the fact that the incidence of epilepsy is highest in this cohort, this lays the foundation for a rapidly growing patient population in need of treatment for this complex disorder. Epilepsy, especially in older adults, tends to become a chronic condition. It is therefore imperative for a geriatrician to develop a working knowledge and level of familiarity with its evaluation and management.


A poorly defined medical condition may lead to confusion about when and how to definitely diagnose and treat it. To that end, the International League Against Epilepsy (ILEA) revised its definition of epilepsy to be “a disease of the brain defined by any of the following conditions: (1) at least two unprovoked (or reflex) seizures occurring greater than 24 hours apart; (2) one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next ...

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