New-onset epilepsy in the elderly: Challenges for the internist

Abstract

New-onset epilepsy in the elderly is difficult to diagnose, owing to atypical presentation, concomitant cognitive impairment, similarities with other common disorders, and nonspecific changes on electroencephalography (EEG). Its management is also challenging because of its deranging physiology, comorbidities, and polypharmacy. Antiepileptic drugs must be carefully chosen and closely monitored. Support of the patient and caregiver is key.

Seizures in Setting of Dementia

“…The study by Bernardi et al also showed that CPS with secondary generalization was the most common seizure type [26]. CPS in these patients most commonly manifest as confusion spells (dyscognitive) with minimal motor manifestations and hence can be difficult to distinguish from behavioral changes and are highly likely to go unrecognized [8]. As a consequence to the above, the reported incidence of CPS in these patients is likely a gross underestimation accounting for the discrepancy in incidence between the studies.…”

“…The most important initial step in management is to rule out acute symptomatic seizures (seizures due to a recent acute cause) and other etiologies that tend to resemble seizures such as syncope, arrhythmias, metabolic disturbances, transient ischemic attack (TIA), transient global amnesia (TGA), and psychogenic disorders. This requires a careful history of the event, comorbidities, and medication use and could prove to be much more challenging in the elderly than in the young [8]. History taking in these patients could be rather demanding secondary to memory deficits of the patient.…”

“…Nearly 25 % of new onset seizures happen in patients over 65 years of age [8]. Neurodegenerative conditions are an important etiologic factor causing about 10 % of new onset seizures in the elderly [9••, 10].…”

“…Seizures in this setting can further worsen the quality of life and add to care giver burden [8,16]. In addition, the prolonged postictal period seen in these patients would further complicate care and increase risk for accidents and injuries [8,17]. In this review article, we will first discuss the incidence of seizures in patients with dementia and the proposed mechanisms behind this.…”

Aging and Neurological Diseases

“…There should be a high index of suspicion for electrolyte imbalance, especially hyponatremia and hypoglycemia, in this group of patients. Other metabolic disorders, such as hyperglycemia and uremic or hepatic encephalopathy, are less specific to this age group [77]. The role of alcohol appears to be less important in the elderly than in young adults, but should not be neglected [78], as it may intensify the number of calcium channels and promote seizure activity by increasing the concentration of neurotransmitters [79].…”