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Misleading Presentation of Seizures in the Elderly

Misleading Presentation of Seizures in the Elderly Patients with seizures can have various unusual and unexpected symptoms. In a review of the literature on presentation of epilepsy in middle-aged and elderly people, Godfrey’ described some of the presentations that have appeared in the medical literature. For example, a variant of Todd‘s palsy with a transient increase in hemiparesis can occur in an elderly patient with a previous cerebral infarct. In an earlier study, Godfrey et a12 found that the phenomenon of postictal weakness occurred in 16% of 81 elderly epileptic patients, and a number of these were incorrectly diagnosed as having recurrent cerebrovascular .accidents or transient ischemic attacks. Similarly, Norris and Hachinski? who examined 821 patients with acute stroke, found that the diagnosis was incorrect in 13%, with unrecognized seizures that caused transient postictal hemiparesis being the most common mistake. Seizure presenting as a confusional state, even lasting for days in the elderly, is also reported. In most of the above cases the diagnostic problem arose because the postictal events, such as hemiplegia or confusion, were so striking that they obscured the fact that the preceding event was an epileptic seizure. However, Godfrey recently presented a few cases that demonstrate that the event itself, even when witnessed, may not immediately be recognized as being epileptic and only careful examination of corroborative history will allow one to make the correct diagnosis.’ A few details of these cases will be reviewed. The first case was an 85-year-old woman who lived alone but was dependent on a home care agency. She apparently had well-preserved intellectual function, with only mild memory impairment. One morning, she was found by her home health aide sitting slumped in a chair in front of the television set and was drowsy, with indistinct speech, and had been incontinent, Over the previous 5 years, several admissions to the hospital occurred with episodes of confusion and mild left-sided weakness, Once again this left-sided weakness was found. Within a few hours, she recoyred completely. EEG done on admission was only mildly abnormal, but an EEG done 3 years previously showed bilateral spike waves. Treatment was commenced with phenytoin (250 mg daily), and 6 weeks later no seizures recurred. She died shortly afterward at home. Cause of death was not established. The second case involved an 80-year-old woman who also lived alone. One day while attempting to sit down to a meal, she said that she felt unwell and collapsed and became still. She remained unarousable for 24 hours, with extreme sleepiness for a few days. A neighbor who was interviewed described having seen several episodes of drowsiness lasting for several days, with complete recovery in between. EEG showed sharp wave discharges from the left frontotemporal area. Phenytoin (250 mg daily) was started, and 7 weeks later, the symptoms had not recurred. The third patient was an 83-year-old woman with moderate-to-severe impairment of intellectual function caused by dementia, but with reasonably preserved abilities. She was able to walk unaided and was continent. She was living with her daughter, who described several trancelike episodes associated with grayish pallor, during which time the patient would stare fmedly ahead and not respond to questioning. During a symptomless period, she had an EEG that showed frequency bursts of high-voltage delta activity with sharp components. Again, phenytoin was begun and the symptoms did not recur. The final case was an exceptionally fit 77-year-old woman who was highly socially engaged and interested in outdoor pursuits. She gave a @-year history of blackouts, which had been increasing in frequency. They were preceded by an aura described as ”a swishing in my ears“ and what appeared to be a reduction of the temporal visual fields, followed by loss of consciousness. She would remain unarousable for several hours. The patient’s daughter had witnessed dozens of these episodes. Again, EEG showed sharp waves, especially over the left temporal area. After phenytoin was begun, she had been free of these symptoms for over a year. The diagnosis of epilepsy in these four patients was based on the eyewitness reports of similar repetitive events associated with abnormal interictal EEGs. The events seem to have been generalized seizures with tonid clonic components that were not recognized as being epileptic either by the patients themselves or by the patients’ relatives, aides, or physicians, In fact, Godfrey noted that there “seemed often to be a degree of helpless acceptance on the part of the patients and their caregivers for these ‘funny turns’.” These examples highlight the particular difficulty in diagnosing seizures in the elderly. The incidence of seizures increases after the age of 60 years,4 but the incidence of other $vents that may be mistaken for epilepsy, such as cardiac dysrhythmias, cerebrovascular incidents, and other events, also increases with age. Godfrey suspects that atypical presentation of seizures in the elderly is common. He notes that these four cases are merely the best documented examples of a much larger group that he has seen over a number of years.