A discussion of seizures and epilepsy specific to the elderly patient is important for many reasons. A high proportion (25 percent) of new seizures occur in individuals over the age of 65 years, and nearly 25 percent of all persons with epilepsy are elderly [1,2]. The causes and clinical manifestations of seizures and epilepsy differ in this age group and affect the diagnostic approach. Treatment issues are complicated in elderly patients. Finally, there are significant implications of a seizure diagnosis in the older person already vulnerable to loss of independence, driving restrictions, impaired self confidence, and risk of falls, which result in physical injury and other sequelae.
Acute symptomatic seizures are provoked events that are not expected to recur in the absence of a particular trigger (eg, hypoglycemia, alcohol withdrawal). Epilepsy is a condition in which recurrent unprovoked seizures are expected in the absence of treatment.
This topic will cover aspects of the management of seizures and epilepsy that are specific to elderly individuals. A more general discussion of the treatment of seizures and epilepsy is presented elsewhere. The etiology, clinical presentation and diagnosis of seizures and epilepsy in the elderly patient is also discussed separately. (See "Initial treatment of epilepsy in adults" and "Overview of the management of epilepsy in adults" and "Seizures and epilepsy in the elderly patient: Etiology, clinical presentation, and diagnosis".)
In general, patients with acute symptomatic seizures due to obvious metabolic derangements, medication, or medication withdrawal will not require seizure treatment. Patients with acute seizures caused by an acute intracranial event (stroke, head trauma) are often treated for a limited time (a few weeks to a few months). If seizures do not recur, withdrawal of antiepileptic drugs (AEDs) should be considered depending on the patient's other risk factors and comorbidity. (See "Overview of the management of epilepsy in adults", section on 'Post-stroke seizures'.)
There are few data regarding the risk of seizure recurrence in elderly patients with unprovoked seizures, but high rates (80 to 90 percent) are often mentioned. In part, this has been inferred from a high rate of recurrence in patients with late-onset seizures after stroke and from studies in the general adult epileptic population in which the seizure recurrence rate in the setting of a known underlying cause is as high as 80 percent. In a prospective observational study of adults presenting with a first-ever unprovoked seizure that included over 1000 patients, 139 of whom were ≥65 years of age (mean, 74 years), the likelihood of a recurrent seizure at one year was similar in older compared with younger adults (53 versus 48 percent) . By five years, however, the cumulative risk of recurrent seizure was higher in older adults (75 versus 61 percent). Independent predictors of seizure recurrence included remote symptomatic etiology, first seizure arising from sleep, epileptiform abnormality on EEG, and focal seizures, but not age.