Annals of Long-Term Care: Clinical Care and Aging. 2015;23(4)
Epilepsy is a neurological condition that increases the brain’s susceptibility to seizures, which can affect mental and physical function. As the fourth most common neurological disorder in the United States, the prevalence of epilepsy increases with age.1,2 Among nursing home residents, epilepsy most frequently occurs secondary to thrombotic or hemorrhagic stroke, which accounts for one-third of all cases of epilepsy, followed by central nervous system infections, and trauma, such as a fall.3 Diagnosis of epileptic seizures can be difficult in long-term care residents because they often present with nonspecific and/or atypical symptoms that are mistaken as sequelae of other physical or neurological comorbidities. As many long-term care facilities do not have neurologists or epileptologists on staff, it is important that clinicians and other direct care staff are cognizant of the various presentations of epileptic seizures in elderly residents so that they can respond with the appropriate treatment or provide a referral.
Partial-Onset Seizure Presentation
Patients with epilepsy may experience one or more types of seizure, which are classified according to the size and region of the brain that is affected. The majority of older adults with epilepsy experience partial-onset seizures,4,5 which can either be simple (consciousness and awareness is retained, lasting 30-60 seconds) or complex (consciousness is impaired or lost, lasting 1-2 minutes).
The symptoms of a partial-onset seizure tend to be nonspecific and vary drastically from patient to patient, with atypical presentations being significantly more common in geriatric patients than younger patients.3 For example, elderly patients with epilepsy are more likely to present with motionless staring, with only one-third of elderly patients with epilepsy presenting with convulsions, compared with two-thirds of all adults with epilepsy.3 Additionally, elderly patients with epilepsy are less likely to present with classic aura, a “warning sign” of seizure often described as local numbness or the feeling of déjà vu; instead, elderly patients may present with dizziness or tonic-motor activity.
Another complication of diagnosing complex partial-onset epileptic seizures is that the primary presenting characteristic—sudden change in mental status, or delirium—is often mistaken for a symptom of a variety of other geriatric syndromes. Symptoms such as confusion, hallucinations, memory impairment, or loss of consciousness may be attributed to other conditions, such as infection, anticholinergic medication, dementia, or falls.6-9 On the reverse side of this handout, the signs and symptoms of simple and complex partial-onset seizures in older adults are illustrated.
However, recognition of the symptoms of epileptic seizures is only part of the diagnostic process. Medical history, imaging studies, and laboratory tests are also important in ruling out other causes of seizures so that patients are appropriately treated. Annals of Long-Term Care: Clinical Care and Aging® (ALTC) asked Upinder Singh, MD, CMD, FACP, AGSF, Kindred Healthcare, Las Vegas, NV, to discuss the key components of a diagnostic work-up in patients with seizures.
ALTC: As many as 25% to 40% of seizures in elderly patients have no obvious etiology.2 Do you feel that it is important to identify and diagnose the etiology of the patient’s seizure before it can be treated?
Singh: It is true that in the vast majority of seizures cases, we can’t pinpoint the exact diagnosis, but there is still a big percentage of cases where, if we can find the exact etiology, we can target treatments to the root cause and thereby have a more effective response with fewer side effects. It becomes especially important because the treatment in many cases is life-long.
When patients present with seizures, how important is medical history in the differential diagnosis?
Medical history is very important in making the correct diagnosis. It has been my experience that when we don’t invest enough time in taking proper history from the patient as well as family members and caregivers, we make wrong diagnoses. Seizures can mimic other medical problems, and other medical problems may present as seizures. This is especially common in older adults because they tend to have multiple comorbidities. For example, seizures may be misdiagnosed as essential tremors, Parkinson’s, or syncopal attacks in older adults, or vice versa. The postictal phase of seizures in older adults may get misdiagnosed as a cerebrovascular accident, transient ischemic attack, or worsening of dementia, so taking proper history and having background knowledge is very important.
Are any imaging studies helpful in diagnosing seizures in the elderly?
My personal opinion is that we should definitely do a CT scan of the brain to rule out a space occupying lesion, bleeding, or stroke, which may be incidental findings in older adults. Also, dementia patients are at higher risk for seizures. Radiology will point in the right direction or just confirm our diagnosis.
Are any laboratory tests helpful in diagnosing seizures in the elderly?
There are a myriad of reasons for seizures in older adults. Something as simple as low blood sugar, low sodium, or calcium-level abnormalities can cause seizures, so routinely we should check for complete blood count and comprehensive metabolic panel. Other laboratory tests depend on the scenario and different settings, like assessing for drug overdose and medication side effects.
Recognizing the Signs and Symptoms of Partial-Onset Epileptic Seizures
Below is a figure illustrating the many different types of physical and cognitive symptoms that can present with a partial-onset epileptic seizure, which occur when abnormal electrical disturbances are contained within a limited area of the brain. A simple
partial-onset seizure typically does not affect awareness or memory, whereas a complex partial-onset seizure affects awareness or memory of events before, during, and immediately after the seizure; changes in behavior may present after a complex partial-onset
seizure. Both types of partial-onset seizures may progress into generalized seizures, which affect the whole brain.
This figure is based on information in references 1, 3, 4, 6, 8, and 9 in the citation list.
1. Epilepsy and the senior community. Epilepsy Foundation website. www.epilepsy.com/learn/age-groups/epilepsy-and-senior-community.
Accessed March 18, 2015.
2. Cloyd J, Hauser W, Towne A. Epidemiological and medical aspects of epilepsy in the elderly. Epilepsy Res. 2006;68(suppl 1):39-48.
3. Marasco RA, Ramsay RE. Defining and diagnosing epilepsy in the elderly. Consult Pharm. 2009;24(suppl A):5-9.
4. Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia. 1993;34(3):453-468
5. Stephen LJ, Brodie MJ. Epilepsy in elderly people. Lancet. 2000;355
6. Seizures. Mayfield Clinic website. www.mayfieldclinic.com/PE-Seizure.htm. Updated February 2013. Accessed March 18, 2015.
7. Han JH, Wilber ST. Altered mental status in older emergency department patients. Clin Geriatr Med. 2013;29(1):101-136.
8. Simple partial seizures. Epilepsy Foundation website. www.epilepsy.com/learn/types-seizures/simple-partial-seizures. Accessed March 18, 2015.
9. Partial (focal) seizure. Medline. www.nlm.nih.gov/medlineplus/ency/article/000697.htm. Updated February 2014. Accessed March 18, 2015.