- Email: [email protected]
EEG monitoring analysis
Epilepsy & Behavior 7 (2005) 447–450 www.elsevier.com/locate/yebeh
Seizures in the elderly: Video/EEG monitoring analysis Abuhuziefa Abubakr *, Ilse Wambacq New Jersey Neuroscience Institute, Seton Hall University for Graduate Medical Education, 65 James Street, Edison, NJ 08818, USA Received 8 February 2005; revised 12 May 2005; accepted 10 June 2005 Available online 13 September 2005
Abstract 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. Fiftyeight 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. Ó 2005 Elsevier Inc. All rights reserved. Keywords: Elderly; Non-epileptic seizures; Complex partial seizures; Video-EEG; Diagnosis; Events
1. Introduction Classic epidemiological surveys held that the majority of epilepsies (75%) occurred in patients younger than 20 years of age. This figure was given by Gower [1] and subsequently confirmed by Lennox and Lennox [2]. Recent observations, however, indicate that unprovoked seizures occur more commonly in the older population, representing a second peak in the incidence of epilepsy in all age groups *
Corresponding author. Fax: +1 732 744 5821. E-mail address: [email protected] (A. Abubakr).
1525-5050/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2005.06.012
after an initial peak in the first years of life [3–7]. This remarkable increase in seizures in the elderly must be viewed in the context of the growing size of this segment of the population. The clinical presentations of seizures in the elderly differ from those in other age groups [8]. Nonetheless, there is little information on the characteristic presentations of epileptic and nonepileptic events in the elderly. Video/EEG monitoring is an ideal method for diagnosis of epileptic and nonepileptic episodes, but seems to be underused in the elderly population, partly because the elderly represent a small percentage of admissions to epi-
448
A. Abubakr, I. Wambacq / Epilepsy & Behavior 7 (2005) 447–450
lepsy monitoring units [9]. We report the results of video/ EEG recording in patients aged 60 or older admitted over a 2-year period to the comprehensive epilepsy unit of the New Jersey Neuroscience Institute at J.F.K. Medical Center. 2. Methods
Table 2 Reason for admission
Diagnosis of events Characterization/localization of events Treatment adjustment SEa (subclinical seizures) a
A retrospective analysis was performed on all patients admitted to the epilepsy monitoring unit (EMU) at the New Jersey Neuroscience Institute from December 1999 to December 2001. Video/EEG reports were analyzed, and reasons for admission were categorized into (1) diagnosis of events (patients with psychogenic nonepileptic seizures (PNES) were challenged with placebo, which produced symptoms associated with the patientÕs typical event); (2) characterization and localization of seizures; (3) adjustment of medication; (4) status epilepticus (nonconvulsive). All patients underwent continuous CCTV/ EEG monitoring with cable telemetry using the 64-channel Nicolet BMSI (Madison, WI, USA) system. Scalp electrodes were applied in accordance with the international 10–20 placement system. The Gotman spike and seizure detection computer program was used throughout the monitoring period to screen the EEG in real time and mark the data file with pointers to possible electrographic seizures and interictal discharges. The records were reviewed by a board-certified epileptologist and neurophysiologists. Clinical data, including age, sex, reason for admission, and final diagnosis, were obtained from the patientsÕ charts. 3. Results A total of 58 elderly patients were admitted to the EMU, 26 women in the age range 60–91 years and 33 men in the age range 60–84 years, constituting 17% of the total admissions to the EMU over a 2-year period (Table 1). The majority of men were in their sixties. However, most of the women were in their seventies or older. Mean length of stay in the EMU was 3.2 days (range, 2–9). The predominant reason for admission was diagnosis of an event (33 patients, 57%). The second most frequent reason for admission was seizure characterization and localization (21 patients, 36%) (Table 2). There were six patients with PNES; five were women and four of them were older than 70 (Table 3). Two of the six patients were suspected of having PNES before admission. All PNES patients presented with motor sympTable 1 Age and gender distribution
Male Female Total
60–69 years
70–79 years
>80 years
20 7 27
8 11 19
4 8 12
60–69 years
70–79 years
>80 years
11 13
13 5
9 3
1 2
1 —
— —
SE, status epilepticus.
Table 3 Diagnosis a
NES PNES CPS ± GTCS SPS SE (subclinical) GTCS
60–69 years
70–79 years
>80 years
Total
10 1 15 1 1 1
11 3 4 — — 1
5 2 4 1 — —
26 6 23 2 1 2
a NES, physiologic nonepileptic seizures; PNES, psychogenic nonepileptic seizures; CPS, complex partial seizures; SPS, simple partial seizures; SE, status epilepticus; GTCS, generalized tonic–clonic seizures.
toms, except for an 87-year-old man who presented with abdominal spasm. Two patients were admitted with suspicion of status epilepticus (SE), but neither was proved to have SE. However, one patient admitted with confusion and fluctuating level of consciousness was found to have nonconvulsive complex partial SE. The most frequent diagnosis was physiologic nonepileptic seizures (NES), which occurred in 26 patients (45%) (Table 3). Seven of these patients (27%) were on antiepileptic drugs (AEDs), which were discontinued after the diagnosis of NES. There were various etiologies of NES including confusion in eight patients, agitation in two, slurred speech and falling (transient ischemic attacks) in two, drop attacks in two, altered mental status in six, syncope in three, and tremors and falls in three patients. Two patients with a history of epilepsy also had NES (dual presentation): a 66-year-old man with panic attacks and 74year-old woman with arm shaking. Seizures were characterized and localized (CPS ± GTCS) in 21 patients (36%) (Table 2). The most frequent seizure type was CPS in 23 patients, and 6 of them (27%) had CPS with secondary generalization (GTCS). All 6 patients with secondary generalized seizures were between the ages of 60 and 69, except for one who was 70 years old. Only two patients had GTCS from the outset; one presented with history of confusion and the other with myoclonic jerks of the axial parts of his body. In both patients, seizures were not suspected prior to video/EEG monitoring. Two patients had simple partial seizures (SPS), one with lethargy and the other with right arm numbness and slurred speech. Similarly, the diagnosis of seizures was not suspected in these two patients, and the patient with slurred speech and arm numbness had been investigated repeatedly for ischemic cerebrovascular disease.
A. Abubakr, I. Wambacq / Epilepsy & Behavior 7 (2005) 447–450
4. Discussion In this study, 17% of all admissions to the EMU were elderly patients, with an average age of 70. The percentage of elderly patients in our series is relatively high compared with that in a recent series by McBride et al. [9] on older patients admitted to the EMU, which had similar demographics of patients. In their series, which spanned over 8 years, 94 patients with an average age of 70 were admitted to the EMU. This represented 8% of the total admissions in their study. More than half of them (56%) were admitted for diagnosis of paroxysmal events, which is similar to our finding of 57%. Similarly, Drury et al. [10] reviewed 18 patients with a mean age of 69 years, representing 4.5% of all admissions. In their series all patients were admitted for differential diagnosis of clinical episodes. Also Lancman et al. [11] reviewed 20 elderly patients (>60 years) admitted to the EMU. They recorded a similar mean age of 67 years, but the elderly patients represented only 1.5% of total admissions. Compared with prior studies, our series has the highest percentage (17%) of elderly patients admitted to the EMU, and this may be due to the referral pattern and location of the institute within a large community hospital. In our study, physiologic NES were frequent, occurring in 45% of the patients. This was similar to the findings of Drury et al. [10] and McBride et al. [9]. Of the physiologic NES seen in our study, various etiologies were determined, and there were no typical categories. Lancman et al. [11] and McBride et al. [9] reported a similar diversity of etiologies in their population with physiologic NES. In our study only 27% of the patients with NES were taking AEDs, compared with 12 of 14 patients in the McBride et al. series. Similarly, Drury et al. determined that most of their patients with NES were treated with AEDs (8/10) [10]. The small number of patients on AEDs in our series may be due to the pattern of early referral for evaluation of this population. This further demonstrates the importance of diagnosing NES in the elderly to obviate unnecessary use of AEDs and their potentially deleterious adverse effects. Partial seizures were the most frequent seizure type, occurring in 26 of 28 patients with seizures, and CPS constituted 82%. This was similar to the findings of Drury et al. [10] and McBride et al. [9]. Partial seizures have consistently been found to be the most common seizure type in the elderly [9]. In the Rotterdam study [12] of epilepsy in the elderly, in half of the patients with localization-related epilepsy, the etiology was cryptogenic, suggesting that, in the majority of the elderly patients with partial seizures, etiology could not be determined. In our study only two patients presented with GTCS from the outset. This was in accord with McBride et al. [9] and Ramsay and Pryor [14], who found that GTCS are infrequent in the elderly. Kellinghaus et al. studied seizure semiology in the elderly in comparison to younger patients, and found that simple motor seizures were less
449
frequent in the elderly patients [15]. A possible reason for the difference is cerebral atrophy and white matter lesions in the elderly. In our series we did not evaluate the patients for cerebral atrophy or white matter lesions, but we can expect similar findings in our aging population. This may help to contradict the speculation that the aging brain is less able to prevent the spread of focal seizure activity. Finally, Tuniper et al. studied seizure patterns in the elderly population and found that, in less than half of the patients, seizures became progressively less elaborate and briefer with time [16]. This further supports the notion that epilepsy in the elderly is predominantly focal. Psychogenic nonepileptic seizures occurred in six patients, similar to the Lancman et al. study [11], in which only two patients had PNES. In the McBride et al. series [9], 13 patients had PNES, a relatively large number compared with our series. This may be due to the duration of their study, which spanned 8 years. Similarly, in the series of Drury et al. [10] four of five patients with CPS had a change in seizure semiology. These new events were suspected to be psychogenic; however, the diagnosis of PNES was not substantiated in those patients whose pattern of clinical events changed. PNES typically occurs in young females and is considered to be rare in the elderly apart from a few case reports [13]. In our series, however, all but one patient with PNES were above 70 years, and among these patients was an 89-year-old woman and an 87-year-old man. The actual prevalence of PNES in the elderly is not known, however, the number of patients in our series may reflect a relative estimate of PNES in the elderly. Studies of other comorbidities are needed to better treat elderly patients with PNES. Status epilepticus was suspected in two patients, but neither of them proved to have SE. However, in our study one patient presented with confusion. Although the diagnosis of NES was suspected initially, this patient was finally diagnosed with nonconvulsive complex partial SE. Litt et al. reported on 24 critically ill elderly admitted to the ICU with the diagnosis of nonconvulsive SE [17]; however, only two patients had a known history of seizure. In our series neither of the two patients had a history of epilepsy, which is in accordance with the McBride et al. [9]. series, in which the typical patient admitted to the EMU is not critically ill, representing a different set of the patient population. The high index of suspicion and low yield of SE reflect the atypical presentation of seizures in the elderly. Most of the patients admitted to the EMU were on AEDs. In our series, 37.5% of the patients were on medication. McBride et al. also reported that most patients with NES were taking AEDs, and 5 of 11 patients with PNES were treated with AEDs [9]. Drury et al. also determined that most patients with NES were treated with AEDs, finding 8 of 10 patients in this category [10]. This further demonstrates the importance of diagnosing NES in the elderly to avoid unnecessary AEDs and their potentially harmful side effects.
450
A. Abubakr, I. Wambacq / Epilepsy & Behavior 7 (2005) 447–450
References [1] Gowers WR. Epilepsy and other chronic convulsive diseases. New York: William Wood; 1985. [2] Lennox WG, Lennox MA. Epilepsy and related disorders, vol. 1. Boston: Little, Brown; 1960.. [3] Hauser WA, Annenger JF, Kurland LT. The incidence of epilepsy in Rochester, Minnesota, 1935–1984. Epilepsia 1993;34:453–68. [4] Hauser WA. Epidemiology of seizures in the elderly. In: Rowan AJ, Ramsay RE, editors. Seizures and epilepsy in the elderly. New York: Butterworth–Heinemann; 1997. p. 7–8. [5] Loiseau J, Loiseau P, Duche B, Guyont M, Dartigues J, Aublet B. A survey of epileptic disorders in southwest France: Seizures in elderly patients. Ann Neurol 1990;27:232–7. [6] Thomas RJ. Seizures and epilepsy in the elderly. Arch Intern Med 1997;157:605–17. [7] Scheuer ML, Cohen JC. Seizures and epilepsy in the elderly: Epilepsy 1: Diagnosis and treatment. Neurol Clin 1993;11:787–804. [8] Rowan AJ. Reflections on the treatment of seizures in the elderly population. Neurology 1998;51(Suppl. 4):28–33.
[9] McBride AE, Shih TT, Hirsch JH. Video-EEG monitoring in the elderly: A review of 94 patients. Epilepsia 2002;43:165–9. [10] Drury I, Selwa LM, Schuh LA, et al. Value of inpatient diagnostic CCTV-EEG monitoring in the elderly. Epilepsia 1999;40:1100–2. [11] Lancman ME, OÕDonovan CO, Dinner DS. Usefulness of prolonged video-EEG in the elderly. J Neurol Sci 1996;142:54–8. [12] De La Court A, Breteler MB, Meindari H, Hauser A, Hofman A. Prevalence of epilepsy in the elderly: The Rotterdam study. Epilepsia 1996;37:141–7. [13] Fakhoury T, Abou-Khalil B, Newman K. Psychogenic seizures in old age: a case report. Epilepsia 1993;34:1049–51. [14] Ramsay RE, Pryor F. Epilepsy in the elderly. Neurology 2000;55(Suppl. 1):458–63. [15] Kellinghaus C, Loddenkemper T, Dinner DS, Lachhwani D, Luder HO. Seizure semiology in the elderly: A video analysis. Epilepsia 2004;45:263–7. [16] Tinuper P, Provini F, Marini C, et al. Partial epilepsy of longer duration: Changing semiology with age. Epilepsia 1996;37:162–4. [17] Litt B, Wityk RJ, Hertz SH, et al. Nonconvulsive status epilepticus in the critically ill elderly. Epilepsia 1998;39:1194–202.
Seizures in the elderly: Video/EEG monitoring analysis Abuhuziefa Abubakr *, Ilse Wambacq New Jersey Neuroscience Institute, Seton Hall University for Graduate Medical Education, 65 James Street, Edison, NJ 08818, USA Received 8 February 2005; revised 12 May 2005; accepted 10 June 2005 Available online 13 September 2005
Abstract 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. Fiftyeight 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. Ó 2005 Elsevier Inc. All rights reserved. Keywords: Elderly; Non-epileptic seizures; Complex partial seizures; Video-EEG; Diagnosis; Events
1. Introduction Classic epidemiological surveys held that the majority of epilepsies (75%) occurred in patients younger than 20 years of age. This figure was given by Gower [1] and subsequently confirmed by Lennox and Lennox [2]. Recent observations, however, indicate that unprovoked seizures occur more commonly in the older population, representing a second peak in the incidence of epilepsy in all age groups *
Corresponding author. Fax: +1 732 744 5821. E-mail address: [email protected] (A. Abubakr).
1525-5050/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2005.06.012
after an initial peak in the first years of life [3–7]. This remarkable increase in seizures in the elderly must be viewed in the context of the growing size of this segment of the population. The clinical presentations of seizures in the elderly differ from those in other age groups [8]. Nonetheless, there is little information on the characteristic presentations of epileptic and nonepileptic events in the elderly. Video/EEG monitoring is an ideal method for diagnosis of epileptic and nonepileptic episodes, but seems to be underused in the elderly population, partly because the elderly represent a small percentage of admissions to epi-
448
A. Abubakr, I. Wambacq / Epilepsy & Behavior 7 (2005) 447–450
lepsy monitoring units [9]. We report the results of video/ EEG recording in patients aged 60 or older admitted over a 2-year period to the comprehensive epilepsy unit of the New Jersey Neuroscience Institute at J.F.K. Medical Center. 2. Methods
Table 2 Reason for admission
Diagnosis of events Characterization/localization of events Treatment adjustment SEa (subclinical seizures) a
A retrospective analysis was performed on all patients admitted to the epilepsy monitoring unit (EMU) at the New Jersey Neuroscience Institute from December 1999 to December 2001. Video/EEG reports were analyzed, and reasons for admission were categorized into (1) diagnosis of events (patients with psychogenic nonepileptic seizures (PNES) were challenged with placebo, which produced symptoms associated with the patientÕs typical event); (2) characterization and localization of seizures; (3) adjustment of medication; (4) status epilepticus (nonconvulsive). All patients underwent continuous CCTV/ EEG monitoring with cable telemetry using the 64-channel Nicolet BMSI (Madison, WI, USA) system. Scalp electrodes were applied in accordance with the international 10–20 placement system. The Gotman spike and seizure detection computer program was used throughout the monitoring period to screen the EEG in real time and mark the data file with pointers to possible electrographic seizures and interictal discharges. The records were reviewed by a board-certified epileptologist and neurophysiologists. Clinical data, including age, sex, reason for admission, and final diagnosis, were obtained from the patientsÕ charts. 3. Results A total of 58 elderly patients were admitted to the EMU, 26 women in the age range 60–91 years and 33 men in the age range 60–84 years, constituting 17% of the total admissions to the EMU over a 2-year period (Table 1). The majority of men were in their sixties. However, most of the women were in their seventies or older. Mean length of stay in the EMU was 3.2 days (range, 2–9). The predominant reason for admission was diagnosis of an event (33 patients, 57%). The second most frequent reason for admission was seizure characterization and localization (21 patients, 36%) (Table 2). There were six patients with PNES; five were women and four of them were older than 70 (Table 3). Two of the six patients were suspected of having PNES before admission. All PNES patients presented with motor sympTable 1 Age and gender distribution
Male Female Total
60–69 years
70–79 years
>80 years
20 7 27
8 11 19
4 8 12
60–69 years
70–79 years
>80 years
11 13
13 5
9 3
1 2
1 —
— —
SE, status epilepticus.
Table 3 Diagnosis a
NES PNES CPS ± GTCS SPS SE (subclinical) GTCS
60–69 years
70–79 years
>80 years
Total
10 1 15 1 1 1
11 3 4 — — 1
5 2 4 1 — —
26 6 23 2 1 2
a NES, physiologic nonepileptic seizures; PNES, psychogenic nonepileptic seizures; CPS, complex partial seizures; SPS, simple partial seizures; SE, status epilepticus; GTCS, generalized tonic–clonic seizures.
toms, except for an 87-year-old man who presented with abdominal spasm. Two patients were admitted with suspicion of status epilepticus (SE), but neither was proved to have SE. However, one patient admitted with confusion and fluctuating level of consciousness was found to have nonconvulsive complex partial SE. The most frequent diagnosis was physiologic nonepileptic seizures (NES), which occurred in 26 patients (45%) (Table 3). Seven of these patients (27%) were on antiepileptic drugs (AEDs), which were discontinued after the diagnosis of NES. There were various etiologies of NES including confusion in eight patients, agitation in two, slurred speech and falling (transient ischemic attacks) in two, drop attacks in two, altered mental status in six, syncope in three, and tremors and falls in three patients. Two patients with a history of epilepsy also had NES (dual presentation): a 66-year-old man with panic attacks and 74year-old woman with arm shaking. Seizures were characterized and localized (CPS ± GTCS) in 21 patients (36%) (Table 2). The most frequent seizure type was CPS in 23 patients, and 6 of them (27%) had CPS with secondary generalization (GTCS). All 6 patients with secondary generalized seizures were between the ages of 60 and 69, except for one who was 70 years old. Only two patients had GTCS from the outset; one presented with history of confusion and the other with myoclonic jerks of the axial parts of his body. In both patients, seizures were not suspected prior to video/EEG monitoring. Two patients had simple partial seizures (SPS), one with lethargy and the other with right arm numbness and slurred speech. Similarly, the diagnosis of seizures was not suspected in these two patients, and the patient with slurred speech and arm numbness had been investigated repeatedly for ischemic cerebrovascular disease.
A. Abubakr, I. Wambacq / Epilepsy & Behavior 7 (2005) 447–450
4. Discussion In this study, 17% of all admissions to the EMU were elderly patients, with an average age of 70. The percentage of elderly patients in our series is relatively high compared with that in a recent series by McBride et al. [9] on older patients admitted to the EMU, which had similar demographics of patients. In their series, which spanned over 8 years, 94 patients with an average age of 70 were admitted to the EMU. This represented 8% of the total admissions in their study. More than half of them (56%) were admitted for diagnosis of paroxysmal events, which is similar to our finding of 57%. Similarly, Drury et al. [10] reviewed 18 patients with a mean age of 69 years, representing 4.5% of all admissions. In their series all patients were admitted for differential diagnosis of clinical episodes. Also Lancman et al. [11] reviewed 20 elderly patients (>60 years) admitted to the EMU. They recorded a similar mean age of 67 years, but the elderly patients represented only 1.5% of total admissions. Compared with prior studies, our series has the highest percentage (17%) of elderly patients admitted to the EMU, and this may be due to the referral pattern and location of the institute within a large community hospital. In our study, physiologic NES were frequent, occurring in 45% of the patients. This was similar to the findings of Drury et al. [10] and McBride et al. [9]. Of the physiologic NES seen in our study, various etiologies were determined, and there were no typical categories. Lancman et al. [11] and McBride et al. [9] reported a similar diversity of etiologies in their population with physiologic NES. In our study only 27% of the patients with NES were taking AEDs, compared with 12 of 14 patients in the McBride et al. series. Similarly, Drury et al. determined that most of their patients with NES were treated with AEDs (8/10) [10]. The small number of patients on AEDs in our series may be due to the pattern of early referral for evaluation of this population. This further demonstrates the importance of diagnosing NES in the elderly to obviate unnecessary use of AEDs and their potentially deleterious adverse effects. Partial seizures were the most frequent seizure type, occurring in 26 of 28 patients with seizures, and CPS constituted 82%. This was similar to the findings of Drury et al. [10] and McBride et al. [9]. Partial seizures have consistently been found to be the most common seizure type in the elderly [9]. In the Rotterdam study [12] of epilepsy in the elderly, in half of the patients with localization-related epilepsy, the etiology was cryptogenic, suggesting that, in the majority of the elderly patients with partial seizures, etiology could not be determined. In our study only two patients presented with GTCS from the outset. This was in accord with McBride et al. [9] and Ramsay and Pryor [14], who found that GTCS are infrequent in the elderly. Kellinghaus et al. studied seizure semiology in the elderly in comparison to younger patients, and found that simple motor seizures were less
449
frequent in the elderly patients [15]. A possible reason for the difference is cerebral atrophy and white matter lesions in the elderly. In our series we did not evaluate the patients for cerebral atrophy or white matter lesions, but we can expect similar findings in our aging population. This may help to contradict the speculation that the aging brain is less able to prevent the spread of focal seizure activity. Finally, Tuniper et al. studied seizure patterns in the elderly population and found that, in less than half of the patients, seizures became progressively less elaborate and briefer with time [16]. This further supports the notion that epilepsy in the elderly is predominantly focal. Psychogenic nonepileptic seizures occurred in six patients, similar to the Lancman et al. study [11], in which only two patients had PNES. In the McBride et al. series [9], 13 patients had PNES, a relatively large number compared with our series. This may be due to the duration of their study, which spanned 8 years. Similarly, in the series of Drury et al. [10] four of five patients with CPS had a change in seizure semiology. These new events were suspected to be psychogenic; however, the diagnosis of PNES was not substantiated in those patients whose pattern of clinical events changed. PNES typically occurs in young females and is considered to be rare in the elderly apart from a few case reports [13]. In our series, however, all but one patient with PNES were above 70 years, and among these patients was an 89-year-old woman and an 87-year-old man. The actual prevalence of PNES in the elderly is not known, however, the number of patients in our series may reflect a relative estimate of PNES in the elderly. Studies of other comorbidities are needed to better treat elderly patients with PNES. Status epilepticus was suspected in two patients, but neither of them proved to have SE. However, in our study one patient presented with confusion. Although the diagnosis of NES was suspected initially, this patient was finally diagnosed with nonconvulsive complex partial SE. Litt et al. reported on 24 critically ill elderly admitted to the ICU with the diagnosis of nonconvulsive SE [17]; however, only two patients had a known history of seizure. In our series neither of the two patients had a history of epilepsy, which is in accordance with the McBride et al. [9]. series, in which the typical patient admitted to the EMU is not critically ill, representing a different set of the patient population. The high index of suspicion and low yield of SE reflect the atypical presentation of seizures in the elderly. Most of the patients admitted to the EMU were on AEDs. In our series, 37.5% of the patients were on medication. McBride et al. also reported that most patients with NES were taking AEDs, and 5 of 11 patients with PNES were treated with AEDs [9]. Drury et al. also determined that most patients with NES were treated with AEDs, finding 8 of 10 patients in this category [10]. This further demonstrates the importance of diagnosing NES in the elderly to avoid unnecessary AEDs and their potentially harmful side effects.
450
A. Abubakr, I. Wambacq / Epilepsy & Behavior 7 (2005) 447–450
References [1] Gowers WR. Epilepsy and other chronic convulsive diseases. New York: William Wood; 1985. [2] Lennox WG, Lennox MA. Epilepsy and related disorders, vol. 1. Boston: Little, Brown; 1960.. [3] Hauser WA, Annenger JF, Kurland LT. The incidence of epilepsy in Rochester, Minnesota, 1935–1984. Epilepsia 1993;34:453–68. [4] Hauser WA. Epidemiology of seizures in the elderly. In: Rowan AJ, Ramsay RE, editors. Seizures and epilepsy in the elderly. New York: Butterworth–Heinemann; 1997. p. 7–8. [5] Loiseau J, Loiseau P, Duche B, Guyont M, Dartigues J, Aublet B. A survey of epileptic disorders in southwest France: Seizures in elderly patients. Ann Neurol 1990;27:232–7. [6] Thomas RJ. Seizures and epilepsy in the elderly. Arch Intern Med 1997;157:605–17. [7] Scheuer ML, Cohen JC. Seizures and epilepsy in the elderly: Epilepsy 1: Diagnosis and treatment. Neurol Clin 1993;11:787–804. [8] Rowan AJ. Reflections on the treatment of seizures in the elderly population. Neurology 1998;51(Suppl. 4):28–33.
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