Epilepsy doesn’t follow a single trajectory as you age. For some people, seizures become less frequent or stop entirely over time. For others, new health conditions like stroke or dementia can trigger seizures for the first time in later life, or make existing epilepsy harder to manage. Whether epilepsy “gets worse” depends heavily on the type of epilepsy you have, what’s causing it, and how your body handles medication as it ages.
New-Onset Epilepsy Is Most Common in Older Adults
One of the most surprising facts about epilepsy is that older adults develop it at higher rates than almost any other age group. A nationwide study of over 40 million Medicare beneficiaries found that epilepsy rates in people over 65 were higher than the general U.S. population average of 7.1 per 1,000. Among Medicare beneficiaries, prevalence reached 10.8 per 1,000, and incidence rates climbed steadily with age. In one community-based study from the Bronx, epilepsy incidence was 0.26 per 1,000 patient-years for ages 60 to 74, then nearly quadrupled to 1.01 per 1,000 for those aged 75 to 89.
The most common reason for this spike is cerebrovascular disease. Stroke is considered the single most frequent cause of epilepsy in older people. Neurodegenerative conditions like Alzheimer’s disease also play a role. In many cases, a first seizure after age 60 isn’t a sign that childhood epilepsy has “gotten worse.” It’s an entirely new condition triggered by age-related brain changes.
Long-Standing Epilepsy Often Improves
If you’ve had epilepsy since childhood or early adulthood, the odds are actually in your favor. Roughly two-thirds of people with epilepsy eventually enter a sustained period of seizure freedom. For childhood-onset epilepsy specifically, seizure frequency tends to be highest in early childhood, then decreases significantly through the teenage years before plateauing in adolescence.
Even people with drug-resistant epilepsy, the most difficult form to control, sometimes experience what researchers call “burned-out epilepsy.” A study that followed 226 people with drug-resistant epilepsy for a median of 52 years found that 17% achieved late-life seizure freedom lasting at least two years before death. This typically happened around age 68, with the seizure-free period lasting a median of seven years. That said, intermittent stretches of seizure freedom lasting a few years can happen at any point in adulthood, so a quiet period doesn’t always mean epilepsy is permanently gone.
Why Seizures Can Be Harder to Recognize in Seniors
When seizures do occur in older adults, they often look different than the dramatic convulsions people associate with epilepsy. Seizure presentations in the elderly frequently differ from those in younger adults, which means they can be missed entirely or mistaken for confusion, a ministroke, or early dementia. Prolonged confusion after a seizure (the postictal period) can last much longer in older adults, adding to the diagnostic challenge. If you or a family member experiences unexplained episodes of confusion, staring, or repetitive movements later in life, it’s worth considering seizures as a possible explanation.
Medication Gets Trickier with Age
Even when seizure frequency stays the same, managing epilepsy often becomes more complicated as you get older, largely because of how aging changes the way your body processes medication. Your kidneys gradually clear drugs more slowly, meaning the same dose you’ve taken for years can start building up to higher levels in your bloodstream. Your liver function also declines, which reduces a key blood protein that normally binds to medication and keeps it in check. When less of that protein is available, more of the active drug circulates freely, raising the risk of side effects like dizziness, drowsiness, or unsteadiness.
Polypharmacy is the other major issue. Older adults typically take medications for blood pressure, cholesterol, heart rhythm, or mood, and many of these interact with seizure drugs. One study of elderly patients with newly diagnosed epilepsy found that 27% were on an excessive number of medications. Among those taking carbamazepine, a common older seizure drug, 32% had at least one significant drug interaction, and 31% had two or more. Blood thinners, cholesterol-lowering statins, calcium channel blockers for blood pressure, and certain psychiatric medications were the most frequent sources of interaction. Newer seizure medications tend to have fewer of these conflicts, which is one reason doctors often prefer them for older patients.
Bone Health and Long-Term Medication Use
One underappreciated way epilepsy can “get worse” with age has nothing to do with seizures themselves. Long-term use of certain seizure medications accelerates bone loss, and this compounds the natural bone thinning that comes with aging. Older enzyme-inducing medications like phenytoin, carbamazepine, and phenobarbital are the main culprits. Phenytoin alone can decrease bone density by about 1.8% per year.
A longitudinal study of women with epilepsy aged 65 and older found that seizure medication use accelerated bone loss at the hip. Researchers estimated that if left unchecked, this rate of loss would increase hip fracture risk by 29% over five years. Fracture risk also rises with cumulative years of exposure, so someone who has been on these medications for decades faces a compounding problem. Vitamin D monitoring and supplementation (often 2,000 to 4,000 IU daily for those on the highest-risk drugs) can help counteract this effect, and periodic bone density screening is recommended for anyone on long-term seizure medication.
The Link Between Epilepsy and Dementia
Epilepsy and cognitive decline have a two-way relationship that becomes increasingly relevant with age. Having epilepsy raises your risk of developing dementia. A large European analysis found that people with epilepsy had a relative risk of 1.5 for being diagnosed with dementia over an eight-year period compared to the general population. The connection to Alzheimer’s disease specifically was even more striking: the greatest risk occurred in people who had epilepsy for fewer than 10 years (relative risk of 2.5), compared to those with epilepsy lasting more than 10 years (relative risk of 1.4). This pattern suggests that new-onset epilepsy in later life may sometimes be an early marker of a neurodegenerative process already underway.
The relationship also runs in the other direction. People with Alzheimer’s disease and other dementias develop seizures at significantly higher rates than the general population. As the brain undergoes progressive damage, it becomes more susceptible to abnormal electrical activity. For families watching a loved one with both conditions, it’s worth knowing that treating the seizures can sometimes improve alertness and day-to-day functioning, even if the underlying dementia continues to progress.
SUDEP Risk by Age
Sudden unexpected death in epilepsy (SUDEP) is the most serious risk associated with uncontrolled seizures. It peaks in young adults rather than seniors. In one large registry of 237 SUDEP cases, the median age was 26 years, with the highest concentration between ages 11 and 40. Most cases occurred during sleep (70%), in an unwitnessed setting (93%), and were associated with a preceding seizure (74%). While SUDEP can occur at any age, the data suggest that younger adults with frequent uncontrolled convulsive seizures face the greatest risk. Maintaining seizure control, sleeping with someone nearby when possible, and avoiding sleeping face-down are practical steps that reduce risk at any age.