This study used the national inpatient, outpatient, and pharmacy databases from the US Veterans Health Administration to examine prescribing patterns for older patients with epilepsy and to determine the factors associated with receiving recommended antiepileptic drugs (AEDs) such as lamotrigine, gabapentin, or carbamazepine. Among patients with epilepsy, the AED monotherapy most prescribed was phenytoin (70%), followed by phenobarbital (17%). While the rate of phenytoin use was similar for both previously and newly diagnosed patients with epilepsy, phenobarbital was less commonly used in newly diagnosed patients. Multivariable analyses suggested that receiving outpatient neurological care was the strongest predictor of receipt of recommended AED regimens in newly diagnosed elderly patients with epilepsy. These data suggest that the challenge remains to narrow the gap between expert recommendations and actual practice if patients with epilepsy are to fully benefit from the tremendous progress that has been made in the pharmacological management of this disease.