Seizures in the elderly: Development and validation of a diagnostic algorithm

Seizures provoked by over-the-counter cough and cold medications in an elderly patient: a case report

BACKGROUND

Seizures are common neurological emergencies in the elderly that are frequently provoked. Geriatrics have higher rates of neurological disorders and other comorbidities that could affect seizure threshold.

CASE PRESENTATION

An 83-year-old male Arabic patient presented to the emergency department with an acute confusional state and urinary incontinence followed by a witnessed tonic-clonic seizure in the hospital. Thorough investigations and imaging were positive only for nonspecific magnetic resonant imaging findings with a negative electroencephalogram. The patient was diagnosed with provoked seizure due to over-the-counter cold medications that included pseudoephedrine and caffeine. He was not prescribed antiepileptic medications at discharge and did not develop subsequent seizures up to this date.

CONCLUSION

Over-the-counter cough and cold medications with sympathomimetic ingredients can be associated with provoked seizures in the elderly. Physicians should be aware of the potentially serious adverse events associated with commonly used nonprescription sympathomimetics such as pseudoephedrine and caffeine in elderly patients.

Diagnostic Performance of the Electroencephalogram in the Elderly Manifesting With Episodes of Unresponsiveness

This study aimed to determine diagnostic performance of the EEG in diagnosing seizures and to ascertain risk factors associated with seizures in the elderly presenting with episodes of unresponsiveness compared with younger patients. This is a cross-sectional study. Only EEGs requested with indication of transient unresponsiveness (TUR) were included. Patients were divided into 2 groups, younger (aged 18-49 years) and elderly (aged >60 years). The EEG was an index test. Reference standard, independently verified by 2 board-certified neurologists, was a clinical diagnosis of presence or absence of epilepsy/probable seizures. Univariate and multivariate analyses were performed to ascertain associated risk factors for epilepsy/probable seizures. Among 2187 total EEG recordings, 244 (11.16%) recordings were requested with indication of TUR. A total of 156 patients (50 younger and 106 elderly) were recruited for analysis. Prevalence of epilepsy/probable seizures in patients with TUR was 26.9%. Prevalence of interictal epileptiform discharges was 16% in the younger and 12.3% in the elderly. Overall diagnostic performance was poorer in the elderly. Associated risk factors for having seizures were presence of intermittent slow waves in the younger and presence of positive motor signs as well as presence of nonepileptiform abnormalities in the elderly. Prevalence of seizures and interictal epileptiform discharges was low in the elderly who manifests with TUR. Overall diagnostic performance of the EEG in diagnosing seizures was poorer in the elderly mainly due to low sensitivity. When we encounter patients with TUR, thorough and detailed history is still a mainstay of a diagnosis of seizures, not the EEG results.

The yield of routine EEG in geriatric patients: A prospective hospital-based study

STUDY AIM

To study the yield of routine EEG in geriatric patients.

PATIENTS AND METHODS

We examined standard EEG recordings of 701 patients aged 84.6±6.4 years. These were performed over a 15 month-period in a geriatric hospital. The majority of patients were hospitalized and 46.5% suffered from multiple medical problems.

RESULTS

We found EEG abnormalities in 392/701 (56%) patients. These consisted of permanent diffuse slowing, either isolated (17.1%) or with intermixed epileptiform abnormalities (2.4%), focal slowing (15.4%), intermittent diffuse slowing (8.9%), triphasic waves (1.14%), periodic epileptiform discharges (0.57%), flat and inactive tracing (0.14%), status epilepticus (0.99%), seizures (0.42%), interictal epileptiform abnormalities (8.7%). Epileptiform abnormalities (both ictal and interictal) were observed in 92/701 (13.1%) patients. These were focal in the majority of cases (85.9%), most frequent in temporal regions (42%), followed by centroparietal (20.2%) and temporo-parieto-occipital carrefour regions (17.2%), but less frequent in frontal (6.3%) and occipital regions (3.8%). We found sleep activity without other EEG abnormalities in 13.7% of patients and subclinical rhythmic electrographic discharge in adult (SREDA) in 1% of cases.

CONCLUSIONS

In this study, EEG abnormalities were very common, which reflects the high frequency of cerebral dysfunction in geriatric patients. These abnormalities are of various types, often suggestive of different aetiologies, and may be helpful in clinical management.