Nonconvulsive status epilepticus in terminally ill patients-a diagnostic and therapeutic challenge

Practical Management of Epileptic Seizures and Status Epilepticus in Adult Palliative Care Patients

In terminally ill patients, paroxysmal or episodic changes of consciousness, movements and behavior are frequent. Due to ambiguous appearance, the correct diagnosis of epileptic seizures (ES) and non-epileptic events (NEE) is often difficult. Treatment is frequently complicated by the underlying condition, and an approach indicated in healthier patients may not always be appropriate in the palliative care setting. This article provides recommendations for diagnosis of ES and NEE and treatment options for ES in adult palliative care patients, including aspects of alternative administration routes for antiepileptic drugs such as intranasal, subcutaneous, or rectal application.

Nonconvulsive status epilepticus in palliative care patients

Altered mental status and reduced level of consciousness are common among patients admitted to palliative care units. However, nonconvulsive status epilepticus (NCSE) has rarely been considered as a possible cause, and electroencephalographic confirmation of the epileptic status is sparse. The clinical presentation of patients with NCSE varies from altered mental status to coma, with no or only minimal convulsions. We report a prospective evaluation of patients with altered mental status on admission to our palliative care unit in the year 2007. Of 290 patients admitted in 2007, 49 patients showed signs of confusion or delirium and/or a reduction in their level of consciousness. NCSE was suspected clinically in 22 of these patients, and epileptic activity could be confirmed in 15 (5.2%) of 290 patients. Nine of 15 patients could be effectively treated with anticonvulsants and regained communication ability before death. NCSE appears to be an important, often unrecognized, and potentially treatable cause of altered mental status in palliative care patients. Pharmacological treatment might restore communicative abilities even in severely ill patients.