Epilepsy in older adults: a comparison of early-onset persistent and late-onset epilepsy

BACKGROUND: In a globally ageing population, epilepsy in older adults has gained increased clinical relevance. This includes both individuals who have grown old with epilepsy and those who develop epilepsy later in life. Whether seizure outcomes and treatment patterns differ between these groups remains insufficiently characterised. METHODS: In this retrospective study, we included patients aged ≥ 65 years treated at three outpatient epilepsy clinics in Berlin between 2010 and 2025. Patients were categorised according to age at epilepsy onset. Early-onset persistent epilepsy (EOPE) was defined as onset < 40 years, and late-onset epilepsy (LOE) as onset ≥ 65 years. The primary endpoint was seizure freedom during the last 12 months. Secondary endpoints included markers of antiseizure medication burden, adverse effects and quality of life. RESULTS: A total of 243 patients were included (114 EOPE, 129 LOE). Seizure freedom was less frequent in EOPE compared to LOE (50.0% vs. 69.0%, p = 0.003). Patients with EOPE had a significantly higher drug load (median defined daily dose 1.00 vs. 0.67; p < 0.001). EOPE was independently associated with, among other variables, lower odds of seizure freedom (adjusted odds ratio (adjOR) 0.34, 95%CI 0.16-0.71) and more frequent use of first- or second-generation ASM (adjOR 5.99, 95%CI 2.47-14.54). The latter finding remained robust in a sensitivity analysis restricted to seizure-free patients. CONCLUSIONS: In older adults, EOPE and LOE are associated with differing clinical characteristics. Patients with EOPE show lower seizure freedom and higher treatment burden as compared to LOE. In seizure-free patients with long-standing epilepsy, ASM simplification may be considered.