When epilepsy and dementia overlap—as they often do in older adults—treatment becomes a delicate balancing act. Seizures must be managed carefully without worsening cognitive decline, and medications prescribed for dementia must avoid interfering with seizure control. In this post, we’ll explore the latest pharmacological and non-drug strategies for treating both conditions together, with special attention to tailoring care for older adults. 

Clarifying the Seizure Type: Why Terminology Matters 

Before diving into treatment, it’s critical to clarify the type of seizures we’re talking about. Many older adults with dementia experience focal-onset impaired awareness seizures. These seizures often involve confusion, word-finding pauses, or blank stares that last longer than typical “absence seizures” and are sometimes misinterpreted as cognitive decline. 

Importantly, these are not the same as generalized onset non motor seizures—commonly called “absence seizures”—which typically begin in childhood or adolescence. While patients sometimes describe both types as “spacing out,” the clinical classification is entirely different. Absence seizures are brief, usually benign, and not associated with progressive brain damage. Focal impaired awareness seizures, on the other hand, are strongly linked to dementia risk and often mimic its symptoms, making accurate diagnosis and targeted treatment all the more important. 

Pharmacological Approaches: Balancing Seizure Control and Cognition 

Treating epilepsy in dementia patients begins with choosing anti-seizure medications (ASMs) that manage seizures without compromising cognitive function. The wrong medication can worsen memory, cause sedation, or even accelerate decline. 

• Levetiracetam (LEV): 

One of the most commonly used ASMs in older adults, LEV is often favored for its relatively benign cognitive profile. It may improve aspects of attention and processing speed, but patients should be monitored for mood changes like irritability, anxiety, or depression—especially in dementia populations already vulnerable to these symptoms (Nadkarni & Devinsky, 2005). 

• Lamotrigine (LTG): Another well-tolerated option, LTG is associated with fewer cognitive side effects and may improve mood. It is often considered for patients with comorbid mood disorders and seizure activity, though dose titration is slow and requires close monitoring. It is often considered a favorable option in patients with epilepsy and comorbid mood disorders, particularly due to its relatively benign cognitive profile. (Mula & Trimble, 2009). 

• Avoiding Valproic Acid (VPA): 

Although VPA is effective for seizure control, it has been associated with worsening cognition and sedation in dementia patients. Most neurologists avoid it in this population (Zhang et al., 2022). 

In parallel, dementia-specific treatments may support cognition and daily functioning: 

• Cholinesterase Inhibitors (e.g., donepezil, rivastigmine): 

These drugs increase acetylcholine in the brain, supporting memory and attention in Alzheimer’s disease (Young & Jones, 2011). Though not directly affecting seizure activity, they can improve quality of life. 

• Memantine: 

Commonly prescribed in moderate to severe dementia, memantine helps regulate glutamate (an excitatory neurotransmitter in the brain) activity and may provide modest benefits in cognition and behaviour. It is often used in moderate to severe Alzheimer’s disease and may reduce agitation or improve communication (Overshott & Burns, 2005). 

Non-Pharmacological Strategies: Supporting the Brain Holistically 

Non-drug interventions are also important when managing two neurologically complex conditions. These approaches can complement medication by promoting brain health and emotional well-being: 

• Cognitive Behavioral Therapy (CBT): 

CBT can help reduce anxiety, improve sleep, and support emotional adjustment in dementia patients. Less anxiety and better sleep may also help stabilize seizure activity (Kraus et al., 2009). 

• Ketogenic Diet (under supervision): 

Originally developed for drug-resistant epilepsy, this high-fat, low-carbohydrate diet is being explored for its anti-inflammatory and neuroprotective effects. Early studies suggest that ketogenic interventions may benefit both epilepsy and dementia, but adherence can be challenging and should be supervised by a healthcare provider (Verrotti et al., 2020). 

• Exercise and Lifestyle Changes: 

Physical activity promotes brain plasticity, enhances mood, and reduces both seizure frequency and cognitive decline. Consistent aerobic and strength-training exercises have been shown to improve executive function and reduce seizure frequency. Additionally, sticking to a structured daily routine supports circadian stability, which is important for both seizure regulation and sleep (George & Reddy, 2019). 

• Caregiver Education: 

Empowering caregivers to recognize subtle signs of seizure activity—such as unusual staring, repeated gestures, or brief confusion—is essential. Many seizures go undetected in dementia patients until a caregiver reports a pattern. Education around seizure first aid, medication adherence, and environmental safety (e.g., fall prevention) can greatly enhance care. 

Early Diagnosis = Better Outcomes 

One of the biggest barriers to treatment is misdiagnosis. Many focal seizures are dismissed as “just ageing” or assumed to be dementia-related behaviors. But with early and accurate diagnosis—including EEG testing—patients can receive treatments that stabilize or even improve cognition by addressing undetected seizures. 

Understanding the unique intersection of epilepsy and dementia allows physicians, patients, and caregivers to pursue the most effective path forward. With the right tools and awareness, we can move toward better outcomes and better lives. 

Wrapping Up the Series 

Throughout this four-part series, we’ve explored how epilepsy and dementia are deeply interconnected, both in how they affect the brain and in how they present in older adults. We began by uncovering the bidirectional relationship between the two, then explored how chronic seizures can accelerate cognitive decline and how dementia can increase seizure risk. Finally, we turned toward hope: recognizing that early diagnosis and tailored treatment strategies—both pharmacological and non-pharmacological—can meaningfully improve quality of life. 

While much remains to be learned, one thing is clear: epilepsy and dementia should not be treated in isolation. A deeper understanding of how these conditions interact will empower patients, families, and clinicians alike. By staying informed, advocating for comprehensive care, and embracing individualized treatment, we take one step closer to helping people not just live longer, but live better. 

For questions or support, contact the Epilepsy Foundation of Northeastern New York at (518) 456-7501 or visit our website. 

References 

Allendorfer, J. B., et al. (2019). The psychopharmacology of epilepsy. Handbook of Clinical Neurology. 

Caramelli, P., & Castro, L. H. M. (2005). Dementia associated with epilepsy. International Psychogeriatrics. 

Epilepsy Foundation. (n.d.). What is epilepsy? https://www.epilepsy.com/what-is-epilepsy 

George, A. A., & Reddy, D. S. (2019). Exercise and epilepsy: Experimental and clinical evidence. Epilepsy Research, 156, 107774. 

Ghosh, S., et al. (2021). Pharmacological and therapeutic approaches in the treatment of epilepsy. Biomedicines. 

Kraus, C., et al. (2009). Cognitive behavioral therapy in dementia. Neuropsychiatrie, 23(2), 108–114. 

Mula, M., & Trimble, M. R. (2009). Antiepileptic drug-induced cognitive adverse effects: Potential mechanisms and contributing factors. CNS Drugs, 23(2), 121–137. https://doi.org/10.2165/00023210-200923020-00003 

Nadkarni, S., & Devinsky, O. (2005). Psychotropic effects of antiepileptic drugs. Epilepsy Currents. 

Overshott, R., & Burns, A. (2005). Memantine in Alzheimer’s disease: A review. International Journal of Geriatric Psychiatry, 20(4), 378–384. 

Verrotti, A., et al. (2020). The ketogenic diet and epilepsy: Is it time to revisit therapeutic options? Nutrients, 12(3), 825. 

Young, J., & Jones, E. (2011). Drugs for Alzheimer’s disease. BMJ, 343, d5205. 

Zhang, D., et al. (2022). The clinical correlation between Alzheimer’s disease and epilepsy. 

Frontiers in Neurology. 

Zhang, Y., et al. (2024). Flavonoids as therapeutic agents for epilepsy. Frontiers in Pharmacology.