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<p>Older adults represent one of the fastest-growing populations living with epilepsy, yet they remain underrepresented in clinical trials. In this age group, antiseizure medication selection is frequently complicated by multimorbidity, polypharmacy, age-related changes in renal and hepatic function, and vulnerability to adverse effects such as falls and cognitive impairment. Because many antiseizure medications demonstrate comparable efficacy for seizure control, medication tolerability and quality-of-life considerations often play a decisive role in treatment selection for older adults. This narrative review synthesizes available evidence on the tolerability of commonly used antiseizure medications in adults aged 65 years and older, with a focus on adverse-effect profiles, treatment retention, and clinical considerations unique to aging populations. Data from previous trials are reviewed for established agents (including levetiracetam, lamotrigine, carbamazepine, gabapentin, and pregabalin) as well as newer antiseizure medications such as lacosamide, brivaracetam, cenobamate, eslicarbazepine acetate, and perampanel. Emerging evidence suggests that newer agents demonstrate favorable efficacy and tolerability at lower doses in older adults, though falls, dizziness, and neuropsychiatric effects can be dose limiting. Newer intranasal benzodiazepine rescue therapies offer practical advantages for seizure clusters, but data specific to older adults remain limited. The review also addresses tolerability considerations related to renal and hepatic impairment, osteoporosis, anticoagulation, chemotherapy, and special populations including individuals with dementia, post-stroke epilepsy, tumor-related epilepsy, and depression. Overall, existing evidence supports the use of lower starting doses, slower titration schedules, and avoidance of enzyme-inducing antiseizure medications when possible in older adults. The heterogeneity of this population highlights the need for future studies stratified by frailty, cognitive status, and the living environment to better inform individualized tolerability-focused epilepsy care in later life.</p>

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Antiseizure Medications in Older Adults with Epilepsy: Considerations in Pharmacology, Safety, Tolerability, and Effectiveness of Newer Agents

  • 期刊论文

  • 发表日期：

    2026年2月18日

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  • Louise M. McCarthy,
  • Kelly A. Boylan,
  • Rani A. Sarkis

摘要

Older adults represent one of the fastest-growing populations living with epilepsy, yet they remain underrepresented in clinical trials. In this age group, antiseizure medication selection is frequently complicated by multimorbidity, polypharmacy, age-related changes in renal and hepatic function, and vulnerability to adverse effects such as falls and cognitive impairment. Because many antiseizure medications demonstrate comparable efficacy for seizure control, medication tolerability and quality-of-life considerations often play a decisive role in treatment selection for older adults. This narrative review synthesizes available evidence on the tolerability of commonly used antiseizure medications in adults aged 65 years and older, with a focus on adverse-effect profiles, treatment retention, and clinical considerations unique to aging populations. Data from previous trials are reviewed for established agents (including levetiracetam, lamotrigine, carbamazepine, gabapentin, and pregabalin) as well as newer antiseizure medications such as lacosamide, brivaracetam, cenobamate, eslicarbazepine acetate, and perampanel. Emerging evidence suggests that newer agents demonstrate favorable efficacy and tolerability at lower doses in older adults, though falls, dizziness, and neuropsychiatric effects can be dose limiting. Newer intranasal benzodiazepine rescue therapies offer practical advantages for seizure clusters, but data specific to older adults remain limited. The review also addresses tolerability considerations related to renal and hepatic impairment, osteoporosis, anticoagulation, chemotherapy, and special populations including individuals with dementia, post-stroke epilepsy, tumor-related epilepsy, and depression. Overall, existing evidence supports the use of lower starting doses, slower titration schedules, and avoidance of enzyme-inducing antiseizure medications when possible in older adults. The heterogeneity of this population highlights the need for future studies stratified by frailty, cognitive status, and the living environment to better inform individualized tolerability-focused epilepsy care in later life.