Epilepsy is a neurological disorder defined by the enduring predisposition to generate recurrent, unprovoked seizures. Whether this condition worsens with age does not have a simple yes or no answer, as the long-term course is highly individualized. Epilepsy is a spectrum of syndromes, and its progression depends significantly on the specific type, its underlying cause, and changes in the patient’s body over time. The lifespan trajectory is a complex interplay between the intrinsic nature of the disorder and the physiological changes associated with aging.
Variability in Epilepsy Progression Across the Lifespan
The long-term progression of epilepsy can be categorized into three general trajectories. The most favorable outcome is remission, where seizures cease, often allowing for the eventual withdrawal of anti-seizure medication (ASM) without recurrence. Remission is common in many childhood-onset epilepsies and is an achievable goal for a significant portion of patients. Many enter a terminal remission, defined as being seizure-free for many years, on or off medication.
A second common trajectory is stability or control, where seizures are successfully managed by medication throughout a person’s life. In these cases, individuals remain seizure-free or experience only rare, provoked seizures. This outcome represents a good prognosis, where the epilepsy does not intrinsically progress or worsen over time, but requires ongoing pharmacological management to maintain control.
The third trajectory is progression toward intractability, or drug-resistant epilepsy (DRE). This occurs when seizures become more frequent, severe, or fail to be controlled by two appropriately chosen and tolerated ASMs. Approximately one-third of people with epilepsy develop this drug-resistant form, which is associated with structural and neurochemical changes in the brain that may worsen with time.
Specific Factors That Determine Long-Term Outcomes
The specific characteristics of the epilepsy are the strongest predictors of the long-term trajectory an individual will follow. The etiology, or underlying cause, is a major prognostic indicator. Epilepsy that is symptomatic or structural—caused by an identifiable brain lesion such as a stroke scar, tumor, or traumatic brain injury—generally carries a less favorable prognosis for seizure control. Conversely, idiopathic or genetic epilepsies, where no structural cause is found, are often associated with better long-term outcomes and higher rates of remission.
The epilepsy syndrome type also dictates the likelihood of achieving long-term seizure freedom. Certain syndromes, especially those beginning in childhood, are known for a high probability of spontaneous remission. Other syndromes, such as Lennox-Gastaut syndrome or Dravet syndrome, are inherently more severe and associated with intractability that persists into adulthood. This intrinsic severity means the prognosis is poor from the outset.
The initial response to treatment with ASMs is another powerful factor. Failure to achieve seizure control with the first or second medication trial significantly increases the probability of developing drug-resistant epilepsy. A high initial seizure frequency and poor short-term response to initial ASM therapy are strongly associated with long-term intractability.
How Physiological Changes in Older Age Impact Seizure Control
While the intrinsic disease type determines the overall prognosis, physiological changes that occur in older age can complicate seizure control, often leading to a perceived worsening of the condition. Comorbidity is a primary factor, as older adults frequently develop other health issues that can act as new triggers for seizures or worsen existing epilepsy. Cerebrovascular disease, particularly stroke, is the leading identified cause of new-onset epilepsy in individuals over age 60, accounting for up to half of new cases.
Brain tumors and neurodegenerative disorders like Alzheimer’s disease are other common acquired etiologies that increase seizure risk in the elderly. These age-related brain injuries can create new areas of abnormal electrical activity, leading to a recurrence of seizures in a previously stable patient or the development of late-onset epilepsy. This late-onset epilepsy is distinct from the progression of a long-standing childhood epilepsy, but it contributes significantly to the overall incidence of seizures in the older population.
Changes in pharmacokinetics with age also present substantial challenges to maintaining seizure control. Aging affects how the body handles medications, primarily through decreased renal and hepatic clearance. This means the kidneys and liver are less efficient at removing drugs from the body, which can result in higher-than-intended concentrations of ASMs in the bloodstream. This increases the risk of adverse effects like dizziness, confusion, or toxicity.
Furthermore, polypharmacy, or the use of multiple medications to manage age-related comorbidities, increases the potential for harmful drug-drug interactions. Many older ASMs can induce or inhibit liver enzymes, altering the metabolism of other drugs taken for conditions like heart disease or high blood pressure, and vice versa. These interactions can inadvertently lower the seizure threshold or lead to dangerous medication side effects, which complicates treatment and can be mistaken for a worsening of the underlying epilepsy.