What is the best seizure medication for the elderly? A comparative guide

Oct 17, 2025 5 min read •

Geriatrics neurology Epilepsy

Epilepsy is surprisingly common in older adults, with population studies showing that the incidence and prevalence of seizure disorders increase significantly after the age of 60. When considering what is the best seizure medication for the elderly, physicians must navigate a complex landscape of safety, efficacy, and potential drug interactions with other medications this population often takes.

Quick Summary

Selecting the optimal antiepileptic drug for seniors is crucial due to age-related changes affecting metabolism and increased sensitivity to side effects. Newer-generation medications like levetiracetam and lamotrigine are often preferred over older agents because of their favorable side-effect profiles and reduced interactions with other drugs.

Key Points

Levetiracetam (Keppra) is often a first-choice medication: It has minimal drug interactions and is generally well-tolerated, making it suitable for older adults on multiple medications.
Lamotrigine (Lamictal) is another preferred option: It has positive or neutral effects on mood and cognition but requires slow dosage titration to minimize rash risk.
Older AEDs carry greater risks: Medications like carbamazepine and phenytoin have higher risks of adverse effects and serious drug interactions, so they are generally avoided for new treatment plans in the elderly.
Start low and go slow: Older adults are more sensitive to side effects, so dosages should be initiated at lower levels and increased gradually to minimize adverse events.
Consider comorbidities and polypharmacy: An individual's overall health, including kidney or liver function, cardiac status, and other medications, is critical in determining the most appropriate and safest seizure medication.
Monitoring is essential for safety: Regular clinical monitoring for side effects, tolerability, and signs of drug toxicity is key to effective and safe management in the elderly.

Navigating Seizure Medications for the Elderly

Treating epilepsy in older adults presents a unique set of challenges compared to treating younger patients. As the body ages, changes in metabolism, liver and kidney function, and the prevalence of co-existing medical conditions—such as heart disease or dementia—all influence how a medication is processed and tolerated. Moreover, many older adults are on multiple medications (polypharmacy), making the risk of significant drug-drug interactions a primary concern.

For these reasons, newer antiepileptic drugs (AEDs) are often preferred over older agents, which are more likely to cause adverse effects and interfere with other medications. While there is no single "best" medication for all elderly patients, clinical evidence points to several modern AEDs as more favorable options based on their safety profile, fewer drug interactions, and better tolerability.

Preferred Newer Seizure Medications

Levetiracetam (Keppra)

Levetiracetam is a frequently recommended first-line agent for older adults due to its excellent tolerability and favorable pharmacological properties. It is primarily cleared by the kidneys and does not significantly interact with other medications metabolized by the liver's cytochrome P450 enzyme system. This makes it a particularly attractive choice for patients on multiple other drugs. While side effects can include fatigue, dizziness, and mood changes (like irritability), these are generally less severe than with older AEDs. Dosing typically starts low and is adjusted based on kidney function. Studies have also shown a better cognitive outcome with levetiracetam compared to other AEDs in patients with concurrent dementia.

Lamotrigine (Lamictal)

Lamotrigine is another effective and well-tolerated option for the elderly, especially for focal-onset seizures. It has a neutral or even positive effect on cognitive function and can improve mood, making it a good choice for patients with co-occurring depression or bipolar disorder. The main drawback is the need for very slow dose titration to minimize the risk of a severe rash, including Stevens-Johnson syndrome, though the risk is not significantly higher in older adults. Compared to older AEDs like carbamazepine, it has a lower incidence of tolerability issues and fewer drug interactions.

Lacosamide (Vimpat)

Lacosamide is a newer agent used for focal-onset epilepsy that is well-tolerated and has a low risk of drug-drug interactions, making it suitable for older patients. However, it can cause dose-dependent side effects like dizziness, fatigue, and ataxia, which are particularly concerning in the elderly due to the increased risk of falls. It should be used with caution in patients with pre-existing cardiac conduction issues.

Brivaracetam (Briviact)

Similar to levetiracetam, brivaracetam is a newer-generation AED with an overall good tolerability profile and low potential for drug interactions. It is effective as an adjunctive treatment for focal seizures in older adults and can be initiated at a target dose without slow titration. Common side effects include somnolence and dizziness, but fewer patients discontinue it due to side effects compared to older medications.

Gabapentin (Neurontin)

Gabapentin is another well-tolerated medication with minimal drug-drug interactions, primarily cleared by the kidneys. It can be a good choice for elderly patients, particularly those who also have neuropathic pain. Older adults may experience side effects like fatigue, dizziness, and unsteadiness, which can increase the risk of falls. Dosing requires adjustment based on renal function.

Older Seizure Medications: A Cautious Approach

Older AEDs such as carbamazepine, phenytoin, and valproic acid are generally avoided as first-line treatments for older adults due to their more challenging side effect profiles and significant potential for drug-drug interactions.

Carbamazepine (Tegretol): Can cause hyponatremia (low sodium), cardiac conduction abnormalities, and multiple drug interactions due to liver enzyme induction. It is listed in the Beers Criteria as a drug to be used with caution in older adults.
Phenytoin (Dilantin): Associated with many side effects, including neurotoxicity, cognitive impairment, and osteoporosis, with a narrow therapeutic window in older patients. Extensive drug interactions are a major concern.
Valproic Acid (Depakote): Can cause significant side effects like sedation, tremors, weight gain, thrombocytopenia (low platelets), and liver toxicity in older adults. It also has numerous drug interactions.

Comparison of Key Seizure Medications for the Elderly


Feature	Levetiracetam (Keppra)	Lamotrigine (Lamictal)	Lacosamide (Vimpat)	Carbamazepine (Tegretol)	Phenytoin (Dilantin)
Drug-Drug Interactions	Minimal	Fewer than older AEDs	Minimal	Significant enzyme inducer	Significant enzyme inducer
Starting Dose	Lower than standard for younger adults, based on renal function	Lower than standard, slow titration	Standard dose, cautious titration	Cautious titration due to side effects	Cautious titration due to narrow therapeutic window
Common Side Effects	Fatigue, dizziness, mood changes	Rash (slow titration helps), dizziness, headache	Dizziness, drowsiness, ataxia	Drowsiness, dizziness, hyponatremia	Drowsiness, confusion, unsteadiness
Key Elderly Risks	Behavioral changes	Cardiac arrhythmia risk (caution with pre-existing conditions)	Dizziness (fall risk), cardiac effects	Hyponatremia, cardiac issues, osteoporosis	Neurotoxicity, osteoporosis, cognitive issues
Cognitive Effects	Often neutral or positive	Often neutral or positive	Can cause cognitive issues	Can impair cognition	Significant cognitive impairment

Dosage and Monitoring Considerations

Regardless of the medication chosen, the treatment approach for elderly patients typically follows a "start low, go slow" philosophy. Age-related physiological changes mean older adults can be more sensitive to medication side effects, often requiring lower dosages and longer intervals between doses. Close monitoring is essential to balance seizure control with a minimal side-effect burden.

For most newer AEDs, therapeutic drug monitoring is less critical than with older agents, but clinical response and tolerability should always guide dosage adjustments. The decision to switch from an older medication to a newer one should be made in careful consultation with a physician, especially for patients who have been seizure-free for many years, as a switch carries a risk of seizure recurrence.

Conclusion

While there is no single answer to what is the best seizure medication for the elderly, newer-generation antiepileptic drugs like levetiracetam (Keppra) and lamotrigine (Lamictal) are often the preferred choices for initial monotherapy. Their more favorable side-effect profiles, particularly regarding cognitive function, and lower potential for drug-drug interactions make them safer and better-tolerated options for this vulnerable population. Other newer medications, such as lacosamide, brivaracetam, and gabapentin, also represent valuable therapeutic options, depending on the patient's specific comorbidities and seizure type. Older AEDs are generally reserved for cases where newer agents have failed or if a patient has been successfully maintained on one for many years without significant side effects. The ultimate treatment plan must be highly individualized, carefully balancing efficacy with tolerability and considering the patient's overall health and medication regimen.

For more in-depth clinical guidelines and patient resources, consult authoritative sources such as the Epilepsy Foundation.

Frequently Asked Questions

For elderly patients with kidney problems, Levetiracetam (Keppra) is often a preferred option. It is primarily eliminated by the kidneys, but dosage can be easily adjusted based on creatinine clearance to avoid toxicity.

Yes, some seizure medications, including Levetiracetam, can cause mood and behavioral changes such as irritability or agitation. Other drugs, like Lamotrigine, may have more neutral or positive effects on mood.

Switching seizure medications can be safe, but it must be done carefully under a doctor's supervision. There is always a risk of seizure recurrence, especially for patients who have been seizure-free for a long time.

Older seizure medications often have a higher risk of side effects, more significant drug-drug interactions, and a greater potential for toxicity in older adults. For example, carbamazepine can cause low sodium levels, and phenytoin can cause cognitive and coordination problems.

Doctors typically follow a "start low, go slow" approach, beginning with a lower than standard dose and titrating it upwards gradually. The dosage is guided by the patient's clinical response and tolerability, considering factors like kidney function.

Yes, gabapentin can be a suitable option for seizures in older adults, particularly those who also experience neuropathic pain. It has few drug interactions but can cause dizziness, fatigue, and unsteadiness.

Some seizure medications can increase the risk of falls in the elderly by causing side effects like dizziness, drowsiness, and unsteadiness. This is especially a concern with medications like lacosamide. Close monitoring is essential.

References

Medical Disclaimer

This content is for informational purposes only and should not replace professional medical advice. Always consult a qualified healthcare provider regarding personal health decisions.