Value of inpatient diagnostic CCTV-EEG monitoring in the elderly

Clinical and Instrumental Characterization of Patients With Late-Onset Epilepsy

Epilepsy is classically considered a childhood disease. However, it represents the third most frequent neurological condition in the elderly, following stroke, and dementia. With the progressive aging of the general population, the number of patients with Late-Onset Epilepsy (LOE) is constantly growing, with important economic and social consequences, in particular for the more developed countries where the percentage of elderly people is higher. The most common causes of LOE are structural, mainly secondary to cerebrovascular or infectious diseases, brain tumors, trauma, and metabolic or toxic conditions. Moreover, there is a growing body of evidence linking LOE with neurodegenerative diseases, particularly Alzheimer's disease (AD). However, despite a thorough characterization, the causes of LOE remain unknown in a considerable portion of patients, thus termed as Late-Onset Epilepsy of Unknown origin (LOEU). In order to identify the possible causes of the disease, with an important impact in terms of treatment and prognosis, LOE patients should always undergo an exhaustive phenotypic characterization. In this work, we provide a detailed review of the main clinical and instrumental techniques for the adequate characterization of LOE patients in the clinical practice. This work aims to provide an easy and effective tool that supports routine activity of the clinicians facing LOE.

New-Onset Geriatric Epilepsy in China: A Single-Center Study

Background

Few studies have been published on new-onset geriatric epilepsy especially in older Chinese people. This study was to have a comprehensive understanding of new-onset geriatric epilepsy and find a more reasonable diagnosis and management of epilepsy in older people.

Methods

One hundred and three patients with onset age 60 years and older were admitted between January 2008 and December 2016. Electronic medical records were reviewed to collect information.

Results

There were 103 older patients with new-onset epilepsy. The mean age of the patients was 68.5 ± 6.4 years (range: 60-89 years), and there were 67 (65%) men and 36 (35%) women. The mean onset age was 67.9 ± 6.2 years (range: 60-89 years). The most common identifiable etiology of symptomatic seizures was autoimmune epilepsy in 43 (41.7%) patients. The second most common etiology was stroke in 15 (14.6%) patients. Seven (6.8%) older patients with acute seizures present with status epilepticus and 26 (25.2%) patients experienced clustered seizures (more than three events in 24 h) at seizure onset. Focal seizures (96.1%) were more common than generalized seizures (3.9%). Fifty-three (51.5%) patients had an abnormal brain magnetic resonance imaging (MRI) scan. Among them, video-electroencephalogram findings in 31 (30.1%) patients correlated with MRI abnormalities. Levetiracetam was the most used drugs before admission, in hospital, and during follow-up.

Conclusions

Autoimmune encephalitis is becoming an increasing risk factor of subsequent epilepsy in older people. Older patients with new epilepsy are more likely to respond to antiepileptic drugs, and drug-resistant epilepsy is uncommon.

Usefulness of video-EEG in the paediatric emergency department

Over the past two decades the EEG has technically improved from the use of analog to digital machines and more recently to video-EEG systems. Despite these advances, recording a technically acceptable EEG in an electrically hostile environment such as the emergency department (ED) remains a challenge, particularly with infants or young children. In 1996, a meeting of French experts established a set of guidelines for performing an EEG in the ED based on a review of the available literature. The authors highlighted the most suitable indications for an emergency EEG including clinical suspicion of cerebral death, convulsive and myoclonic status epilepticus, focal or generalized relapsing convulsive seizures as well as follow-up of known convulsive patients. They further recommended emergency EEG in the presence of doubt regarding the epileptic nature of the presentation as well as during the initiation or modification of sedation following brain injury. Subsequently, proposals for expanding the use of EEG in emergency patients have been advocated including trauma, vascular and anoxic-ischemic injury due to cardiorespiratory arrest, postinfective encephalopathy and nonconvulsive status epilepticus. The aim of this review is to show the diagnostic importance of video-EEG, as well as highlighting the predictive prognostic factors for positive and negative outcomes, when utilized in the pediatric ED for seizures as well as other neurological presentations.

Temporal lobe epilepsy in the elderly

The incidence of epilepsy has bimodal distribution peaking at the extremes of life. Incidence is greater in younger and older age groups (Hauser et al., 1993, Sidenvall et al., 1993, Forsgren et al., 1996, and Olafsson et al., 2005). As the world population ages more elders with epilepsy will be identified. In the high-income countries with longer life expectancy, the number of elders with epilepsy will be even higher. CPSs account for 40% of all seizure types in the elderly (Hauser et al., 1992); however, the proportion with temporal lobe epilepsy (TLE) is uncertain.

A critical appraisal on the utility of long-term video-EEG monitoring in older adults

BACKGROUND

World-over, the majority of patients undergoing video-EEG monitoring (VEM) are in their second or third decades. Although elderly represent the fastest growing segment of population with epilepsy, only few of them undergo VEM. We critically evaluated the utility of VEM in the diagnosis and long-term management of older adults with paroxysmal behavioral events.

METHODS

148 consecutive patients aged 45 and above, who underwent long-term (≥8 h) inpatient VEM from 1996 to 2009 formed the study cohort. Utilizing a structured proforma, we gathered their demographic, clinical, electrophysiological and long-term outcome data. VEM was considered as "useful" when it changed the diagnosis and/or management; it was "corroborative" when it helped the treating physician to confirm the diagnosis and "not useful" when it neither helped to improve the diagnosis nor the management.

RESULTS

The mean age was 51.3 (SD 6.4) years; mean duration of VEM was 69.3 h. Out of 117 patients with a diagnosis of epileptic seizures referred for presurgical evaluation or classification, VEM was "useful" or "corroborative" in 111 patients (94.8%; p=0.0001). It was also "useful" or "corroborative" in 29 out of 31 patients (93.5%) referred with a suspicion of associated or pure psychogenic non-epileptic seizures (p=0.0001). None developed any complications during monitoring. At a mean follow-up of 37.7 months there was significant reduction in AED usage in patients with epilepsy (p=0.0001) and epilepsy with associated PNES (p=0.001). At a mean follow-up of 34.2 months, all patients with pure PNES were event-free and medication-free at last follow-up (p=0.002). Twenty-three patients (19.6%) underwent surgery, all except one remaining seizure-free at a mean follow-up of 39.2 months.

CONCLUSIONS

VEM is a safe and cost-effective investigation strategy in older-adults. It aided in improving the diagnosis, offered better treatment including surgery and helped in excluding non-epileptic paroxysmal events in majority.

Treatment and management of epilepsy in the elderly demented patient

Epilepsy and seizures are more frequent in the elderly population than in any other age group. The number of individuals older than 65 is constantly increasing, and dementia is a process that predominantly affects this age group. Several studies have shown that dementia is an important risk factor for developing seizures and epilepsy. Seizure semiology in the elderly demented might differ from that of younger age groups and diagnosis can be complicated further by the variety of other causes of transient changes of alertness and behavior that affects these patients. The pharmacokinetic changes of antiepileptic drugs in the elderly make this group a major therapeutic challenge. Side effects and drug interactions play a major role in the choice of antiepileptic agents. This review intends to summarize the existing data to see whether this can help guide the clinician in the treatment and management of epilepsy in the elderly patient with dementia. Nonpharmacologic therapeutic options are also briefly considered.

Epilepsy in later life

Epilepsy is most likely to develop in later life. The burden of this disorder on health-care resources will rise further as the world's population continues to age. Making a secure diagnosis can be challenging because the clinical manifestations of seizures and the differential diagnoses and causes of epilepsy can be different in older individuals compared with younger individuals. Obtaining a reliable account of the events for accurate assessment is particularly important in guiding the appropriate choice and interpretation of investigations to arrive at the correct diagnosis. In older age, unique pharmacokinetic and pharmacodynamic changes occur. The use and selection of antiepileptic drugs is often further complicated by the presence of comorbidities, polypharmacy, and concomitant functional impairment, but there is a paucity of high-level clinical evidence on the effects of these factors as well as on the choice of treatment in the elderly. A comprehensive model of care should combine expertise in the diagnosis and treatment of epilepsy with effective assessment and management of the psychosocial effects to improve the prognosis in this vulnerable and poorly studied group of patients.

Video-EEG monitoring of paroxysmal events in the elderly

OBJECTIVES

To determine the importance of video-EEG monitoring (VEM) in elderly patients with various paroxysmal events.

MATERIAL AND METHODS

We retrospectively identified 16 subjects > or = 60 years old out of 834 (1.9%; 7 females, mean age 67.8 +/- 7.7 years), who were admitted to the Video-EEG Unit between 1997 and 2005 and compared data between those with and without epileptic events.

RESULTS

Epilepsy was confirmed in six patients, psychogenic non-epileptic seizures (NES) were diagnosed in seven, one patient had NES and epilepsy whereas the recorded events were non-conclusive in two. NES patients had a higher predisposition to psychiatric disturbances (P<0.02). Following VEM and management alteration, the frequency of monthly events decreased significantly for the cohort as a whole (P<0.001). VEM directly influenced the diagnosis, treatment and outcome of 14 of 16 (88%) patients.

CONCLUSION

Video-EEM plays a vital role in the evaluation of paroxysmal events in the elderly, but is vastly underutilized in this population group.

Diagnosing Epilepsy in the Elderly

Elderly individuals represent the fastest-growing segment of the US population. Seizures are common among elderly persons, and the etiology, clinical presentation, and prognosis of seizure disorders can often differ between elderly patients and younger individuals. However, published information regarding the diagnosis and management of epilepsy in elderly patients is scarce. Because a number of conditions that are common in elderly patients may resemble epilepsy, diagnosis can be challenging. Cardiovascular conditions, migraines, drug effects, infections, metabolic disturbances, sleep disorders, and psychiatric disorders are all associated with signs and symptoms that may often mimic epilepsy. New paradigms must be put into practice to establish an accurate diagnosis in the elderly patient; besides an initial evaluation, the patient history and an electroencephalogram should be obtained. Proper diagnosis is essential for proper treatment in the elderly patient.

Elders with epilepsy

Why is it important to learn about epilepsy in the elderly? The answers are many. As this article has highlighted, compared with younger individuals epilepsy is more common and the causes are more structural and symptomatic than in younger patients (particularly stroke). The clinical presentation is different in the elderly. The diagnosis is more difficult and often delayed. The most common seizures are simple partial and complex partial seizures, which are more often extratemporal in location. Confusion and memory problems are common presenting symptoms and postictal deficits often are prolonged. The prognosis for epilepsy in the elderly generally is favorable for seizure control, but if untreated, depression and quality of life suffer and seizures frequently recur. Seizures respond well at lower serum concentrations of antiepileptic drugs but these patients are also more sensitive (less tolerant) to side effects at lower doses than younger adults.

Seizure versus syncope

One of the most common but difficult management problems in medicine is that of patients who present with a paroxysmal loss of consciousness. All too often the underlying diagnosis remains elusive. This has a cost both in terms of mortality and ongoing morbidity and in terms of the financial burden associated with hospitalisation and repeated investigations. We describe a practical approach to this clinical dilemma, which is rooted in adherence to basic principles of history taking and examination, formulation of a reasonable differential diagnosis, followed by an intelligent use of specific investigations and selection of an appropriate treatment. We also discuss the effect of sudden unexpected death in epilepsy and sudden cardiac death. Despite a careful and thorough approach to the patient with a "seizure versus syncope" problem, many will require repeated assessment before a diagnosis is made.

Seizures in the elderly: Video/EEG monitoring analysis

OBJECTIVE

Recently there has been a remarkable increase in the number of elderly people with epilepsy due to the growing size of this segment of the population. The literature provides little information on the characteristics of epileptic and nonepileptic events in the elderly. Therefore we report the results of video/EEG recordings in patients aged 60 or older admitted over 2 consecutive years to an epilepsy monitoring unit (EMU).

METHODS

We examined the records of all elderly patients admitted to our EMU between December 1999 and December 2001. Fifty-eight patients were older than 60, constituting 17% of the total admissions to the EMU. All patients underwent continuous video/EEG monitoring. On the basis of reasons for admission, video/EEG reports were categorized into (1) diagnosis of events, (2) characterization and localization of seizures, (3) adjustment of medication, and (4) status epilepticus (nonconvulsive).

RESULTS

There were 26 women between the ages of 60 and 91 and 32 men between the ages of 60 and 84. The main reasons for admission were diagnosis of events (57% of patients), followed by characterization and localization of events (36% of patients). There were 6 patients with psychogenic nonepileptic seizures (PNES); 5 were women and 4 of them were >70 years of age. All PNES patients presented with motor symptoms, except for an 87-year-old man who presented with abdominal spasm. Two of these six patients were suspected of having PNES before admission. Two patients were admitted with suspicion of status epilepticus, but neither proved to have status epilepticus. The most frequent diagnosis was physiologic nonepileptic seizures (26 patients; 45%), and 27% of these patients were on antiepileptic drugs, which were discontinued after the diagnosis of nonepileptic seizures. Complex partial seizure was the most frequent seizure type, occurring in 23 patients, 6 of whom (27%) had both complex partial seizures and secondarily generalized seizures.

CONCLUSION

In the elderly, video/EEG results in a definitive diagnosis in the majority of cases and can assist in the decision whether antiepileptic drugs are necessary. PNES can occur in the elderly, and video/EEG monitoring can facilitate their recognition and management.

Characteristics of male veterans with psychogenic nonepileptic seizures

PURPOSE

To describe male patients (pts) with psychogenic nonepileptic seizures (PNESs) followed up in a Veteran's Administration (VA) seizure clinic and to compare them with those with epileptic seizures (ESs) by using clinical, and psychosocial variables.

METHODS

Adult male veterans seen between 1997 and 2000 with ESs were compared with those with PNESs with respect to clinical history (head trauma, antiepileptic drug exposure, depression, anxiety, substance abuse, seizure description), documented chronic pain, posttraumatic stress disorder (PTSD), compensation for diagnosis, neurologic examination, and test results including imaging and EEG data.

RESULTS

Men with PNESs were younger and reported more frequent events, and diagnoses of chronic pain, anxiety, and PTSD were significantly greater. Neuroimaging [computed tomography (CT) or magnetic resonance imaging (MRI) of the brain] and neurologic examination were significantly more likely to be normal or nonspecific in pts with PNESs, although history of ictal urinary incontinence or service-connected compensation for diagnosis did not distinguish the groups.

CONCLUSIONS

Male veterans with PNESs have characteristics similar to those reported in the literature, even though younger women have dominated previously studied populations. Compared with men with ESs, those with PNESs are more likely to have chronic pain, anxiety, and PTSD, as well as normal examinations and brain imaging.

Evaluating the Utility of Inpatient Video‐EEG Monitoring

PURPOSE

Inpatient video-EEG monitoring (VEM) is widely used for the diagnosis, seizure classification, and presurgical evaluation of patients with seizure disorders. It is resource intensive and relatively expensive, so its utility continues to be debated. Few studies have specifically evaluated the utility of inpatient VEM in altering diagnosis or management of patients with seizure disorders. We sought to assess the proportion of patients for whom the preadmission diagnosis and management were altered after inpatient VEM of patients admitted for diagnostic and presurgical evaluation of seizure disorders.

METHODS

Data from a consecutive cohort of patients admitted over a 3-year period to an inpatient VEM unit in a tertiary referral hospital were retrospectively analyzed. The preadmission diagnosis and management by the referring neurologist was compared with the diagnosis and management after the VEM.

RESULTS

Of 131 patients, 91 (70%) were admitted for diagnostic evaluation and 39 (30%) for a presurgical workup. Mean evaluative period was 5.6 days. Mean number of seizures recorded was 2.9. No seizures were recorded in 31% of patients. Interictal EEG showed epileptiform changes in 56 (43%). In 76 (58%), the diagnosis was altered as a result of the VEM, with the greatest change being an increase in the nonepileptic diagnosis group (7% to 31%) and the generalized diagnosis group (5% to 11%). Management was changed after the VEM in 95 (73%).

CONCLUSIONS

The results of this study demonstrate that inpatient VEM has a high yield in changing diagnosis and management. Future long-term cost-benefit studies of the management changes resulting from VEM evaluation will aid in further reinforcing its role.

Seizure Semiology in the Elderly: A Video Analysis

PURPOSE

To describe the seizure semiology of patients older than 60 years and to compare it with that of a control group of younger adults matched according to the epilepsy diagnosis.

METHODS

Available videotapes of all patients aged 60 years and older who underwent long-term video-EEG evaluation at the Cleveland Clinic Foundation (CCF) between January 1994 and March 2002 were analyzed by two observers blinded to the clinical data. A younger adult control group was matched according to the epilepsy diagnosis, and their seizures also were analyzed.

RESULTS

Fifty-four (3.3%) of the 1,633 patients were 60 years or older at the time of admission. For 21 of them, at least one epileptic seizure was recorded. Nineteen patients had focal epilepsy (nine temporal lobe, two frontal lobe, two parietal lobe, eight nonlocalized), and two patients had generalized epilepsy. Seventy-three seizures of the elderly patients and 85 seizures of the 21 control patients were analyzed. In nine elderly patients and 14 control patients, at least one of their seizures started with an aura. Eleven elderly patients and 19 control patients lost responsiveness during their seizures. Approximately two thirds of the patients in both groups had automatisms during the seizures. Both focal and generalized motor seizures (e.g., clonic or tonic seizures) were seen less frequently in the elderly.

CONCLUSIONS

Only a small percentage of the patients admitted to a tertiary epilepsy referral center for long-term video-EEG monitoring are older than 60 years. All seizure types observed in the elderly also were seen in the younger control group, and vice versa. Simple motor seizures were seen less frequently in the elderly.

Epilepsy in the elderly

BACKGROUND

Epilepsy is one of the most common neurologic diseases that affect the elderly population. Underlying etiologies as well as diagnostic and treatment issues vary from that of younger adults and deserve special consideration.

REVIEW SUMMARY

The substantially increased risk of seizures and epilepsy in the elderly is associated with medical conditions that affect this group such as stroke, dementia, and metabolic disturbances. In addition, there is an increased incidence and associated mortality of status epilepticus among seniors. Distinguishing epilepsy from paroxysmal nonepileptic events can be a particular challenge. As in the general adult population, EEG and MRI are the cornerstones of diagnostic assessment; however, the clinician must be aware of nonspecific changes associated with aging that do not necessarily indicate an underlying predisposition for epilepsy. Finally, there are unique challenges to the treatment of epilepsy in this population, but fortunately there are multiple treatment options available, including nonpharmacological therapies.

CONCLUSIONS

Knowledge of the unique challenges in identifying and treating the elderly patient with epilepsy is important for effective management as well as maximizing quality of life. However, further studies in this area are still needed to establish optimal treatment strategies.

Epilepsy and EEG in the elderly

Seizures are now the third most frequently encountered neurologic problem in the elderly population. The incidence of recurrent unprovoked seizures peaks in older patients. Because of this age-related increase and the growing elderly population, evaluation and treatment of the elderly patient has received increasing attention. This article focuses on epilepsy, not acute seizures in the elderly. The causes and types of epilepsy older individuals experience are reviewed, along with the diagnostic role of EEG. Treatment options are briefly addressed.

Video-EEG monitoring in the elderly: a review of 94 patients

PURPOSE

We sought to determine the utility and results of video-EEG monitoring in elderly patients. There is an increased incidence of epilepsy in the elderly population. Few studies have assessed the characteristics of epileptic and nonepileptic seizures in this age group. Diagnostic evaluation with video-EEG monitoring is a means to distinguish these different types of events.

METHODS

The authors reviewed all patients aged 60 years and older who were admitted to the epilepsy monitoring unit at Columbia-Presbyterian Medical Center from January 21, 1991, to April 12, 1999.

RESULTS

A total of 94 patients and 99 patient admissions were identified, accounting for 8% of all admissions. The average age was 70 years, and the mean length of stay was 3.8 days. Typical events were recorded in 75 of the 99 patient admissions. A total of 118 seizures was recorded in 46 patients, and 98 nonepileptic events were seen in 27 patients. Of the patients with nonepileptic events, 13 had psychogenic seizures. The majority of patients with nonepileptic events were taking antiepileptic medication. Whereas 76% of the patients with epileptic events had interictal epileptiform discharges, 26% of the patients with nonepileptic events had epileptiform discharges as well.

CONCLUSIONS

Video-EEG monitoring in the elderly leads to a definitive diagnosis in the majority of patients in a relatively short time. Interictal recordings are inadequate in determining the nature of paroxysmal events. Nonepileptic events are common in the elderly, including psychogenic seizures, and these are often misdiagnosed and mistreated as epileptic seizures.

Treating epilepsy in the elderly: safety considerations

The incidence of epilepsy increases with advancing age. Epilepsy in the elderly has different aetiologies from that in younger populations, cerebrovascular disease being the most common condition associated with seizures. Partial seizures are the predominant seizure type in older patients. A diagnosis of epilepsy in the elderly is based mainly on the history and is frequently delayed. In addition, seizure imitators are especially frequent. In many cases ancillary tests for diagnosis may show normal age-related variants, sometimes making results difficult to interpret. Treating epilepsy in the elderly is problematic due to a number of issues that relate to age and comorbidity. The physical changes associated with increasing age frequently lead to changes in the pharmacokinetics of many anticonvulsants. The treatment of epilepsy in the elderly is also complicated by the existence of other diseases that might affect the metabolism or excretion of anticonvulsants and the presence of concomitant medications that might interact with them. Moreover, specific trials of anticonvulsants in the aged population are scarce. General guidelines for treatment include starting at lower doses, slowing the titration schedule, individualising the choice of anticonvulsant to the characteristics of the patient, avoiding anticonvulsants with important cognitive or sedative adverse effects, and where possible, treating with monotherapy.

Long-term EEG monitoring: a clinical approach to electrophysiology

Long-term electroencephalographic monitoring (LTM) is the capability of recording the EEG over long periods of time and not a specific duration. Prolonged EEG recording is used primarily for epilepsy monitoring, but LTM is also used in the intensive care unit, the operating room, and in the emergency department. The purpose of LTM is to expand the limited time sampling associated with shorter "routine" EEG recording. Audiovisual monitoring may also be used in conjunction with LTM to evaluate simultaneously a specific clinical behavior that may or may not be associated with EEG alteration. This is typically performed in a hospital setting for safety and ancillary testing purposes. LTM is used most frequently in the diagnosis and management of seizures and "spells," but has also gained wider application in the evaluation of sleep disorders, cerebrovascular disease, psychiatric conditions, and movement disorders. Computer-assisted LTM systems that process, analyze, compress, and store data digitally have become widely available in clinical practice both in the hospital as well as outside the hospital when the patient is ambulatory.