Epilepsy in Older Adults – Epilepsy: The Untold Side

Living with epilepsy

Epilepsy is not only a condition of childhood or younger adulthood. New-onset epilepsy becomes more common again in later life, and diagnosis can be harder because seizures may overlap with stroke, syncope, dementia, falls, medication effects and other health problems.

Key point: epilepsy in later life needs an individualised approach that takes account of comorbidities, other medicines, cognition, frailty, falls, bone health and independence — not simply the seizure type.

Why epilepsy in later life is different

Older adults are more likely to have multiple long-term health conditions and to take several medicines. The causes of epilepsy also shift with age, with stroke and other structural brain disorders becoming particularly important.

ILAE reviews highlight that older adults can have atypical or subtle seizure presentations, neurodegenerative conditions, cardiovascular disease and complex drug regimens that complicate both diagnosis and treatment.

Late-onset seizures should be investigated properly

A first suspected seizure in an older adult should not be dismissed as simply “old age”, confusion or a fall. NICE recommends urgent specialist assessment after a first suspected seizure, with the same need to consider ECG, metabolic causes, EEG and appropriate brain imaging as in younger people.

New-onset epilepsy in later life may be the first clue to an underlying structural or neurological condition.

Read more: Diagnosis and Tests →

Stroke is one of the most important causes

Cerebrovascular disease is a major cause of new-onset epilepsy in older adults. Seizures can occur during the acute phase of a stroke or can begin later because a permanent brain lesion creates an enduring predisposition to seizures.

An acute symptomatic seizure during a stroke is not automatically the same as post-stroke epilepsy. The timing, recurrence risk and clinical context matter.

Other causes in older adults

Other recognised causes include previous traumatic brain injury, brain tumours, neurodegenerative disease, infection, autoimmune disease and other structural brain changes. In some people, no single cause is identified even after appropriate investigation.

The fact that epilepsy begins later in life does not mean it is automatically “secondary” to dementia or stroke; the cause still needs to be established rather than assumed.

Focal seizures can look like confusion rather than convulsions

Older adults often have focal seizures. These may cause a brief period of impaired consciousness, staring, speech arrest, automatisms, an unusual sensation, sudden fear, memory disturbance or a short episode of confusion.

Because the person may not fall or shake, such events can be mislabelled as “senior moments”, dementia, delirium or transient ischaemic attacks.

A repeated, stereotyped pattern — especially with altered responsiveness and a recognisable recovery phase — is one clue that an event may be epileptic.

Syncope and cardiac causes are major mimics

Loss of consciousness in an older person is not automatically a seizure. Cardiac rhythm disorders, orthostatic hypotension and vasovagal syncope can all cause collapse and may sometimes include brief jerking movements.

This is why NICE recommends a 12-lead ECG after a first suspected seizure: cardiac conditions can mimic epilepsy and may require completely different treatment.

Falls can be both a clue and a consequence

An unexplained fall may occasionally be caused by a seizure, but falls are also common in older adults for many non-epileptic reasons. Medication, poor balance, neuropathy, visual impairment, low blood pressure and environmental hazards all need consideration.

Once epilepsy is present, seizure-related falls can increase the risk of fractures and head injury, especially where osteoporosis or frailty already exists.

Dementia and epilepsy can overlap

Epilepsy is more common in some neurodegenerative disorders, including Alzheimer’s disease and other dementias. At the same time, focal impaired-consciousness seizures can resemble episodes of confusion, staring or memory loss.

Not every fluctuation in a person with dementia is a seizure, and not every seizure in an older adult means dementia is present. Diagnosis requires attention to timing, stereotypy, witness accounts, EEG findings and the wider neurological picture.

Memory problems need careful interpretation

Memory difficulty in an older person with epilepsy can arise from several sources at once: the underlying brain disorder, seizures, postictal effects, antiseizure medication, depression, poor sleep or neurodegenerative disease.

A new cognitive decline should not automatically be blamed on epilepsy or ageing. NICE recognises the importance of coordinated care when epilepsy coexists with cognitive impairment or dementia.

Read more: Memory & Cognition →

Medication in older adults needs a different strategy

NICE specifically recommends taking particular care when starting antiseizure medication in older adults, especially when there are comorbidities or several other medicines.

Important principles include:

checking for drug interactions
taking kidney and liver function into account
usually starting at a lower dose
increasing the dose more slowly
using monotherapy where possible
reviewing the effect on balance, alertness, cognition and mood

The principle is often summarised clinically as start low and go slow, but treatment still has to reach an effective dose if seizures continue.

Polypharmacy matters

Older adults may already be taking medicines for blood pressure, anticoagulation, heart disease, diabetes, pain, mood, sleep or dementia. Adding an antiseizure medicine can create interactions or amplify dizziness, sedation and falls.

Enzyme-inducing antiseizure medicines can alter the metabolism of other medicines, while other drugs may raise or lower antiseizure medication levels. This is one reason medication review should consider the whole prescription list rather than the epilepsy medicine in isolation.

Kidney and liver function can change dosing

Renal clearance often declines with age, and liver disease or reduced hepatic reserve can also affect drug handling. Some antiseizure medicines therefore require dose adjustment or slower titration.

A dose that is routine in a younger adult may produce excessive adverse effects in an older person with reduced renal function.

Falls, dizziness and sedation are not minor side effects

In later life, dizziness, gait instability or drowsiness can lead directly to falls, fractures, loss of confidence and reduced independence. A medication can reduce seizures yet still create unacceptable functional harm if adverse effects are not recognised.

Treatment reviews should therefore ask whether the person is falling more, walking differently, sleeping excessively or becoming more confused after a medication change.

Bone health deserves attention

Older adults may already be at increased risk of osteoporosis and fracture. Some antiseizure medicines — particularly long-term enzyme-inducing drugs and valproate — have been associated with poorer bone health and vitamin D deficiency.

There is no single international bone-monitoring schedule for every person with epilepsy, but higher-risk individuals may benefit from review of vitamin D status, osteoporosis risk and bone-density assessment according to clinical circumstances.

This is especially relevant when epilepsy itself also increases fall risk.

Frailty changes the risk-benefit balance

Frailty can make a relatively brief seizure more dangerous because the consequences of a fall, aspiration, prolonged hospital admission or medication adverse effect may be greater.

At the same time, over-treating with sedating medication can worsen mobility and independence. Treatment therefore needs to balance seizure control with function, quality of life and the person’s own priorities.

Driving and independence

A new seizure can have an immediate effect on driving eligibility. In the UK, DVLA or DVA rules apply according to the person’s seizure history and licence category.

For an older adult, loss of driving can have a disproportionate effect on independence, access to healthcare and social contact, particularly in areas with limited public transport. Driving discussions therefore need to include practical support, not just the legal restriction.

Living alone may need a fresh risk assessment

A person who has lived independently for decades may suddenly be faced with questions about bathing, cooking, stairs, night-time seizures or emergency access after a new epilepsy diagnosis.

Safety planning should remain proportionate. The diagnosis alone does not mean someone can no longer live independently. The relevant issues are seizure type, frequency, warning, recovery, mobility, cognition and whether help can be summoned if needed.

Postictal confusion can be mistaken for delirium

Confusion after a seizure may last longer in some older adults, especially where there is underlying brain disease or cognitive impairment. A person may appear awake while still being disorientated or unable to form new memories normally.

Prolonged or unusual confusion still needs assessment because delirium, stroke, infection, medication toxicity and ongoing non-convulsive seizure activity may produce a similar picture.

Read more: Postictal Recovery →

Status epilepticus may be less obvious

Not all status epilepticus involves continuous convulsions. Older adults can develop non-convulsive status epilepticus presenting as prolonged confusion, reduced responsiveness or altered behaviour.

A marked or unexplained change from baseline, especially after a known seizure, may require urgent medical assessment and EEG.

Depression, anxiety and isolation can be overlooked

Later-life epilepsy can arrive alongside bereavement, retirement, chronic illness, reduced mobility or social isolation. Fear of another seizure may further limit activity.

Mental-health symptoms should not be dismissed as an inevitable reaction to ageing or illness. They deserve assessment and treatment in their own right.

Older people may need information in a different format

NICE specifically says information and support needs should be adapted for older people and those with complex needs. This can include longer appointments, large-print or audio information, clearer medication instructions and involvement of family members, carers or advocates when the person wishes.

Hearing impairment, visual impairment, cognitive difficulty and digital exclusion can all make standard information harder to use.

Carers often need support too

A spouse, adult child or other carer may suddenly take on medication supervision, seizure observation, driving, appointments or night-time monitoring. This can be a major change in the relationship and can create significant emotional and practical strain.

Good epilepsy care should recognise the information and support needs of carers as well as the person with epilepsy.

Drug-resistant epilepsy still needs specialist review

Age alone should not be used as a reason to continue ineffective medication indefinitely. If two appropriate antiseizure medication schedules have failed, drug-resistant epilepsy should be considered and tertiary specialist assessment may be appropriate.

Suitability for surgery or neurostimulation depends on the cause, seizure focus, comorbidities, frailty and individual goals — not age alone.

Mortality risk is shaped by more than SUDEP

Older adults with epilepsy may face risks from stroke, dementia, cardiovascular disease, falls, fractures, medication interactions and frailty in addition to seizure-related mortality and SUDEP.

A 2024 review in Epilepsia Open highlighted that mortality in older people with epilepsy is understudied and may be influenced by these combined comorbidities and external injury risks.

Risk discussions should therefore consider the whole health picture rather than focusing on one outcome in isolation.

The central point

Epilepsy in older adults is not simply the same condition occurring at an older age. The causes, mimics, comorbidities, medication issues and consequences of seizures can be different.

Good care combines accurate seizure diagnosis with stroke and dementia awareness, medication review, fall and bone-health assessment, support for independence and treatment that reflects the person’s priorities and overall health.

Where next?

Diagnosis and Tests →
Treatment Options →
Memory & Cognition →
Safety & Everyday Risks →
Postictal Recovery →
Back to Understanding Epilepsy →

Sources

Medical note: This page is for education and awareness. Older adults may have multiple conditions and medicines that change seizure risk and treatment choice, so individual assessment is essential.

Related researched deep dives

Later-life and complex-care deep dives

Evidence checked: September 2026.