Elderly patients with epileptic seizures: In-patient observational study of two French community hospitals

Abstract

Epileptic seizures (ESs) in the elderly are recognized as frequent, and potentially difficult to diagnose. Their clinical features and relevant diagnostic problems still remain poorly investigated in hospital populations outside the setting of tertiary referral centres. In this study we attempted to improve the understanding of these aspects in community institutions. We conducted a four-year retrospective observational study of 104 consecutive elderly patients with the diagnosis of ES, in 2 French community hospitals. Most ESs were partial (n=50; 48.07%) but generalized ESs were also clinically frequent (n=41; 39.42%). Brain imaging was highly contributive for the diagnosis of partial ESs by demonstrating causative focal structural lesions. ESs were often unprovoked (n=82; 78.84%). Fifty six of these (68.29%) were symptomatic. Stroke lesions were the most identified cause (n=17; 20.73%). In 26 patients (31.70%) aetiology was unknown. Various diagnostic problems were identified. Inter-observer agreement between neurologists and non-neurologists based on clinical judgement was only "fair" (kappa coefficient: 0.28; 95% CI; p=0.002). ESs were initially misdiagnosed in 28 patients (26.92%). The misdiagnosis rate was higher among non-neurologists (n=25; 89.28%) as compared to neurologists (n=8; 28.57%) (p<0.0001). The presence of focal neurological abnormalities was an important diagnostic indicator of a positive diagnosis of ES. In conclusion, ESs in the elderly are generally partial, unprovoked and symptomatic, and caused by stroke-related lesions. Many are still overlooked, highlighting the important role of specialist input and rigorous clinical evaluation for diagnostic confirmation.

Caracterização da epilepsia com início após os 60 anos de idade

“…Epileptic seizures in patients above 60 years of age had a positive response to the monotherapy 13 . The infrequent use of lamotrigine is related to the fact that the sample of the study was taken from a public health service with limited financial resources.…”

Epilepsy with onset at over 50 years of age: clinical and electroencephalographic characteristics

“…To characterize the presentation of the ES, the following definitions proposed by Massengo et al 6 were used in this study: status epilepticus (SE) -a more prolonged ES or a sequence of ES without complete recovery of consciousness between them -and ES in series -various ES in one day.…”

“…Such episodes can be difficult to characterize, leading to confusion with dementias, memory lapses and even with episodes of mental confusion 9 . Thus, the diagnosis of ES may be retarded or may even not be made, as occurs in about 30% of the cases 3,6,[9][10][11] . Some authors have suggested that complex ES in the elderly present a ictalsemiology distinct from that found in the young adult, since in the elderly the localization most frequently found involves the frontal and parietal lobes and not the temporal lobe 4,12 .…”

“…Alterations in thebackground activity or non-specific symptoms can appear on the EEG of elderly individuals with advancing age, and EA can become less frequently associated with ES 4 . Some studies report the presence of epileptiform activity in 20 to 37% of epileptic patients over 60 years of age 2,6,20,22 . In the present research, the finding of EA in about 70% of the cases may have been due to recording the EEG soon after the ES.…”

“…These cases of epilepsy can occur due to an acute cerebral seizure or have no apparent precipitator 2,3 . On the other hand, there is consensus in the literature that epileptic seizures (ES) are more difficult to diagnose in the elderly for various reasons such as the difficulty in obtaining an accurate clinical history, a frequently atypical ictal presentation, difficulty in making a differential diagnosis between an epileptic and non-epileptic event [3][4][5][6] and due the occurrence of comorbidities 5,6 . Although epilepsy is considered to be one of the commonest neurological affections in the elderly, and despite the need to take public health measures due to the progressive increase in the elderly population, particularly in developing countries, no national (Brazilian) publications and only a few international ones on epilepsy in this age range were found.…”