Epilepsy Medicines in Older Adults: Newer vs Older

This systematic review compared newer and older epilepsy medicines in older adults, looking at seizure control, staying on treatment, and side effects. Its findings were uncertain.

Source: Frontiers in neurology

Summary

What was studied

This systematic review and meta-analysis compared newer-generation with older-generation antiseizure medications in older adults with epilepsy. Researchers searched four major databases from inception through April 30, 2026.

Nine studies involving 2,507 participants were included. The evidence comprised randomized, open-label, post-hoc subgroup, and retrospective studies. Outcomes included seizure freedom, seizure-free retention, treatment retention, withdrawal for any reason, discontinuation due to adverse events, and adverse reactions.

What they found

Overall seizure freedom did not differ significantly between newer- and older-generation medications (RR 1.18, 95% CI 0.80–1.76), with substantial variation across studies (I² = 93%). A restricted sensitivity analysis also found no significant difference (RR 1.11, 95% CI 0.94–1.30). There was no significant difference in seizure-free retention.

Newer-generation medications were associated with higher treatment retention (RR 1.34, 95% CI 1.22–1.47). Withdrawal for any reason was lower (RR 0.71, 95% CI 0.64–0.80), as was discontinuation due to adverse events (RR 0.54, 95% CI 0.45–0.64).

An exploratory post-stroke analysis based on two randomized studies did not find a significant difference in seizure freedom (RR 1.30, 95% CI 0.81–2.08; I² = 77%).

Limits of the evidence

The certainty of the evidence was low or very low. Only nine studies were included, and the evidence differed in study design, definitions of older adults, and outcome windows. Seizure-freedom results showed substantial statistical heterogeneity. The exploratory post-stroke analysis was based on only two randomized studies and also showed heterogeneity.

The newer- and older-generation categories contained pharmacologically different medications, so these class-level findings may not apply equally to individual medications. The mixed study designs and clinical heterogeneity mean the results should be interpreted cautiously.

For families and caregivers

Seizure freedom did not clearly differ between newer- and older-generation medications. Newer-generation medications were more likely to be continued and less likely to be stopped because of adverse events. However, the evidence is uncertain, and these findings do not mean that every newer medication is preferable to every older medication.

What to watch next

Further head-to-head research using consistent age definitions and outcome windows, and comparing individual medications, would help clarify these findings.

Terms in this summary

Antiseizure medication (ASM): A medicine used to prevent or reduce epileptic seizures.
Seizure freedom: Having no seizures during the outcome window defined by a study.
Treatment retention: Continuing the assigned medication for the period assessed by a study.
Risk ratio (RR): A measure comparing how often an outcome occurred between groups.
95% confidence interval (CI): A range expressing uncertainty around an estimated result.
I²: A measure of statistical heterogeneity, or how much results vary across studies.
Sensitivity analysis: A repeat analysis using different inclusion criteria to assess whether the main finding remains consistent.
Post-stroke epilepsy: Epilepsy that develops after a stroke.