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April2012 Vol.49 Issue:      2 Table of Contents
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Clinical Presentation and Aetiology of First-ever Seizures in Hospital-based Elderly Patients

Hala M. El-Khawas


Department of Neurology, Ain Shams University; Egypt

 



ABSTRACT

Background: There is increasing evidence that the prevalence of new-onset epilepsy is quite high among the elderly. Frequently, it is difficult to establish the diagnosis of epilepsy in the older individual, as most seizures in elderly patients are misdiagnosed as mental changes. Objective: Is to study the possible causes and clinical characteristics of seizures in elderly population. Methods: The study included 73 patients who developed epilepsy after the age of 60 years. All the patients were subjected to: Detailed history, full physical and neurological examination, laboratory investigations, routine EEG, and Brain MRI. Results: Seventy three patients were included in this study; their mean age was 70.77+_9.14 years (range 61-96 years). Nine patients (12.3%) presented with partial seizures, while 24 patients (32.8%) had partial seizures with secondary generalization. Generalized tonic-clonic seizures were found in 27 (37%) of the patients, while 13 (17.8%) presented with status epilepticus. Vascular cause was the aetiology of seizures in 37 (50.7%) of cases. Brain tumours were found in four cases (5.5%) and posttraumatic seizures were in 2 cases (2.7%), while CNS infection was present in one patient. No identifiable aetiology was found in 29 (39.7%) of our cases. EEG abnormalities were met in 57 patients (78.1%) while MRI was abnormal in 64 patients (87.7%). Normal MRI was found in 9 patients out of them, EEG was abnormal in only 6 patients. Conclusion: The most common aetiology for seizures in the elderly is cerebrovascular, primarily ischemic and the commonest clinical presentation is generalized tonic clonic. [Egypt J Neurol Psychiat Neurosurg.  2012; 49(2): 137-142]

Key words: Epilepsy, Elderly, First-ever, Clinical presentation.

Correspondence to Hala M. El-Khawas, Department of Neurology, Ain Shams University, Egypt. Tel.; +01005297952. Email: halaelkhawas@hotmail.com.





INTRODUCTION

 

Epilepsy is the most common serious chronic neurological disorder in the elderly after stroke and dementia. The overall age-specific incidence of epilepsy is bimodal, with a peak in the new-born and a more pronounced peak in those aged over 60 years1. The incidence of a first seizure in those aged 40-59 years is 50–60 per 100,000 people, rising in those aged over 65 years to 136 per 100,000.2

Epileptic seizures are often not recognized in elderly patients and are instead misdiagnosed as mental changes of uncertain origin, confusion, syncope, memory disorders, or vertigo.3 An episode of altered consciousness and fixed gaze followed by a few minutes of confusion may be the sole clinical manifestation of an epileptic seizure in an elderly patient. Premonitory sensations (aura) are present in about 50% of young adults with focal epilepsy4 but rare in older patients.5 The lack of an aura makes epileptic seizures more difficult to recognize and to classify. Generalized tonic-clonic seizures are recognized by most observers as epileptic and often lead to a diagnosis of epilepsy, yet they are rarer in elderly patients (26%) than  in  younger  ones  (65%).6

In addition, post ictal confusion in an elderly patient can last considerably longer than is usual in younger patients (for hours or days) leading to the erroneous diagnosis of dementia or stroke.7 Thus, whenever an elderly patient presents with acute confusion, computerized tomography reveals no structural change in the brain, and no other apparent explanation for a cognitive deficit is present (e.g., dehydration, infection, or hyperglycemia), an epileptic seizure or nonconvulsive status epilepticus should be considered and electroencephalography (EEG) should be performed.8 Epidemiological studies on patients over age 60 without any history of stroke, trauma, or dementia have shown that the risk of epilepsy in this group is 1.1%. This figure is still twice as high as the corresponding figure for young adults, yet much lower than the incidence of epilepsy when stroke, trauma, or dementia is present9.

Epilepsy in the elderly is potentially life threatening. Elderly people with epilepsy have a two- to three-times greater mortality than the general population; status epilepticus in the elderly, in particular, may carry a probability of mortality of approximately 50%.10-11 Furthermore, seizures in older people more frequently result in physical injury. However, bony fractures in older people with epilepsy more often result from their increased propensity for mechanical falls, rather than from the seizures themselves.12

In many older patients, an underlying cause of seizure activity is clearly identifiable. Seizures can happen in the context of an acute insult to the central nervous system e.g. stroke and CNS infection, during an acute metabolic disturbance such as uremia, hyperglycemia, hypoglycaemia, and hyponatremia, or as a manifestation of brain tumours13. However, about 25% of elderly epileptic  patients had no identifiable cause14-16.

The aim of this work is to study the possible causes and clinical characteristics of epilepsy in a hospital-based elderly population who developed their first-ever seizures after the age of 60 years.

 

SUBJECTS AND METHODS

 

This hospital-based study was conducted during the period from October 2010 and November 2011. It included 73 patients attended the outpatient clinic or admitted to the inpatient Neurology department of Ain Shams university specialized hospital, who developed epilepsy after the age of 60 years. The diagnosis of epilepsy was established clinically from the history and seizures were classified according to ILAE (1989)17. Patients were excluded when they experienced their first seizure under age of 60 years, or if they have provoked seizures i.e. due to hypoglycaemia, uremia or electrolytes imbalance.

All the patients were subjected to: Detailed history including seizure semiology; full physical and neurological examination; laboratory investigations: CBC, renal and liver profiles, and electrolytes. Conventional EEG using 16 channels digital EEG machine (Nihon Khoden) was done to all patients and scalp electrodes were applied according to the 10-20 system. Brain MRI was done using 1.5 Tesla machine with a 30 mT/min gradient with head coil including (T1, T2, T2*, Flair, and diffusion weighted images) in 5 mm slice thickness sections.

The data were collected, coded and SPSS (statistical package for social science), windows version 11.5 was used for analysis. Data were expressed as number, percentage and mean ± standard deviation.

 

RESULTS

 

Seventy three patients aged more than 60 years were included in this study, their mean age was 70.77±9.14 years range (61-96 years). Forty- four (60-3%) were males and twenty nine (39.7%) were females. 

Regarding type of seizure on presentation, nine patients (12.3%) presented with partial seizures; 3/9 (4.1%) with simple partial seizures, and 6/9 (8.2%) with complex partial seizures, while 19 patients (26%) had simple partial seizures with secondary generalization and 5 (6.8%) had complex partial seizures with secondary generalization. Generalized tonic-clonic seizures were found in 27 (37%) of the patients, while 13 (17.8%) presented with status epilepticus (Table 1).

Considering the aetiology of seizures, vascular cause was found to be the aetiology of seizures in 37 (50.7%) of our cases, the majority of them were ischemic 34 (46.6%) while 3 (4.1%) were hemorrhagic. Brain tumours were found in four cases (5.5%) and posttraumatic seizures were in 2 cases (2.7%; five months and two years posttraumatic), while CNS infection was present in one patient. No identifiable aetiology was found in 29 (39.7%) of our cases (Table 2).

EEG findings: EEG was normal in 16 patients (21.9%). Epileptiform activity was found in 40 (54.8%) of our cases while EEG slowing was found in 17 patients (23.3%) (Table 3).

Brain MRI was normal in 9 patients (12.3%). Focal pathology was found in 33 (45.2%) while 12 (16.4%) showed multifocal pathology e.g. multiple infarctions and 19 cases (26.1%) showed diffuse pathology e.g. brain atrophic changes or periventricular leukoariosis (Table 4).

Regarding correlation between MRI and EEG findings, sixty four patients had MRI abnormalities, out of this group EEG was abnormal in 51 patients only. On the other hand, normal MRI was found in 9 patients, out of them EEG was abnormal in only 6 patients (Table 5).


Table 1. Types of seizures on presentation of the studied group.

 

Types of Seizures

Number

%

Partial seizures

     Simple partial seizures

     Complex partial seizures

Partial seizures with secondary generalization

       Simple partial

       Complex partial

Generalized Tonic-Clonic

Status Epilepticus

 

3

6

 

19

5

27

13

 

4.1%

8.2%

 

26%

6.8%

37%

17.8%

Total

73

100%

Table 2. Aetiology of seizures of the studied group.

 

Variable

Number

%

Vascular

       Ischemic

       Hemorrhagic

Brain tumour

Trauma

CNS infection

Undetermined

37

34

3

4

2

1

29

50.7

46.6%

4.1%

5.5%

2.7%

1.4%

39.7%

Total

73

100%

 

Table 3. Correlation between EEG findings and types of seizures in the studied group.

 

Types of seizures

EEG findings

Normal

Slowing

Epileptiform activity

Focal

Generalized

Focal

Generalized

Focal with 2ry generalization

Rt

Lt

Rt

Lt

Partial seizures

     Simple partial                        

     Complex partial

Partial seizures with secondary generalization

    Simple partial

    Complex partial

Generalized Tonic-Clonic

Status Epilepticus

 

0

2

 

 

0

2

12

0

 

1

1

 

 

2

0

1

0

 

0

0

 

 

2

0

2

1

 

0

1

 

 

3

0

1

2

 

0

1

 

 

6

1

5

4

 

2

0

 

 

4

1

3

2

 

0

0

 

 

0

0

2

3

 

0

1

 

 

2

1

1

1

Total

16

5

5

7

17

12

5

6

 

Table 4. Correlation between MRI findings and types of seizures of the studied group.

 

Types of seizures

MRI findings

Total

Normal

Focal pathology

Multifocal pathology

Diffuse pathology

Right

Left

Partial seizures

        Simple

        Complex

Partial seizures with secondary generalization

        Simple

        Complex

Generalized Tonic-Clonic

Status Epilepticus

 

0

0

 

2

0

4

3

 

1

1

 

10

1

4

2

 

2

2

 

2

1

5

2

 

0

1

 

3

1

5

2

 

0

2

 

2

2

5

4

 

3

6

 

9

5

17

13

Total

9

19

14

12

19

73

 

Table 5. Correlation between EEG findings and MRI findings in the studied group.

 

EEG findings

MRI findings

Total

Normal

Focal pathology

Multifocal pathology

Diffuse pathology

Right

Left

Normal

3

0

3

3

7

16

Slowing

 

 

 

 

 

 

      Focal (RT)

0

4

0

0

1

5

      Focal (LT)

1

1

1

2

0

5

      Diffuse

1

2

0

2

2

7

Epileptiform activity

 

 

 

 

 

 

      Focal (RT)

0

9

2

3

3

17

      Focal (LT)

1

2

6

1

2

12

      Focal with 2y Gen.

1

1

2

1

1

6

      Generalized

2

0

0

0

3

5

Total

9

19

14

12

19

73


DISCUSSION

 

Seizures in the elderly can be more subtle than in younger people. Complex partial seizures are the most common presentation, although may initially evade diagnosis. Older patients are more likely to have an extra-temporal epileptic focus and so less commonly report the typical olfactory/déjà vu auras or automatisms typical of younger patients.15,16,18  Should an aura be reported, it may be described only as dizziness, altered mental status, periods of staring, unresponsiveness, brief  losses of consciousness, inattention, memory lapses or confusion.  Aetiologies of seizures vary among the different age groups. The most common aetiologies for seizures in the elderly tend to be in the category of cerebrovascular disease, predominantly infarctions, followed by cerebral haemorrhages, neurodegenerative disorders such as Alzheimer’s disease, metabolic defects, and other aetiologies including neoplasms.19

The objective of this work was to study the possible aetiological determinants and clinical presentations of seizures in a hospital-based elderly population who developed their first-ever seizures after the age of 60 years.

The study included 73 patients attended the outpatient clinic or admitted to the inpatient department of ASUSH, who developed epilepsy after the age of 60 years. The diagnosis of epilepsy was established clinically from the history and seizures were classified according to ILAE (1989).17 Their mean age was 70.77±9.14 years range (61-96 years); 44 males (60.3%) and 29 (39.7%) females; 60.2% of our patients had hypertension, 52% had diabetes mellitus,26.1% had cardiac disease, and 12.3% had renal impairment. The distribution of associated medical conditions was comparable to other studies. Rowan and co-workers (2005)19 reported 44.8% of their >60 years old patients had hypertension, 26.8% with heart diseases, but less for diabetes mellitus (13.3%). Also Timmons et al.20 in their study found that 41% of their  epileptic elderly patients had hypertension and 40% had ischemic heart diseases.

Regarding the clinical presentation of seizures in our patients, complex partial seizures were found in only 8.2%; 4.1% had simple focal seizure; 32.8% had focal seizures with secondary generalization, and generalized tonic clonic in 37%. Status epilepticus was present in 17.8% of our patients. A higher percentage of  generalized tonic clonic seizures was met by Nikanfar et al.21, who reported that 61.9% of their patients had generalized tonic clonic seizures; while only 2.1% had complex partial seizures.

In this study, the aetiology of seizures was identified in 60.3% of our patients. Cerebrovascular stroke was found in 50.7% of our patients; ischemic infarction in 46.6%, and haemorrhagic stroke was found in 4.1%. Ruggles and co-workers22 in their study in the Marshfield area, found that stroke was the aetiology in 44% whereas 31% were of unknown origin. Also in agreement with other  literatures who found that ischemic stroke was the aetiology of the epilepsy in their patients followed by haemorrhagic stroke.21,23 Post-stroke epilepsy usually develops within 3–12 months; the seizure risk increases 20-fold in the first year after a stroke, but may still occur many years later.24-26 Epilepsy and seizures are more likely after hemorrhagic than ischemic strokes: 80% compared with 5% developing seizures within 2 weeks, respectively20. A pragmatic approach for elderly patients developing new-onset seizures should include a thorough assessment for cerebrovascular risk factors.

The contribution of other aetiologies as a cause of seizures in the elderly varied in the different studies. Previous studies demonstrated that brain tumours could be responsible for 4.5-10% of cases, head trauma in 3%, and CNS infections in 2%.23-27,28  These results were in accordance to our results where we found causes of epilepsy other than stroke: previous head trauma (2.7% with a post stroke duration 5months and two years), brain tumours (5.5%), and CNS infection (1.4%). Age over 65 years is an important risk factor for post-traumatic epilepsy. Head injury, mostly from falls, causes up to 20% of epilepsy in the elderly. Post-traumatic epilepsy is higher if trauma was associated with loss of consciousness, post-traumatic amnesia beyond 24 hours, skull fracture, brain contusion and subdural hematoma.22,23 Seizures may be the presenting feature of tumours at any age. In later life, the most common tumours causing seizures are gliomas, meningioma and metastases.24,25 In the current study, meningioma was found in two patients (2.7%), glioma in one (1.4%) and metastasis in one patient (1.4%). survivors of CNS infections have a threefold increased risk for epilepsy. This risk was higher in the first 5 years after infection but remained elevated for the next 15 years. Early or acute symptomatic seizures were a risk factor for the development of late seizures.21,22

There is lower incidence of interictal epileptiform activity in EEG of the elderly patients. Thus, elderly patients have a greater likelihood of non-diagnostic findings on routine examination.28 In current study, interictal epileptiform activity was found in 54.8% of cases, EEG slowing was found in 23.3% and was normal in 21.9%. In agreement to our results. Sinha et al.29, studied 201 elderly individuals, who manifested with new onset seizures. They found EEG abnormalities in 124 patients (61.7%) and the abnormalities included diffuse slowing in (32.8%) and focal slowing in (7%). Epileptiform activities were evident in one third of patients. Also, Stephen and co-workers30 found that 28% of their epileptic patients have epileptic activity in their EEG, and Khan et al.23 found normal EEG in 25% of his patients. However, McBride and colleagues31 in their study using EEG –video monitoring of elderly epileptic patients reported interictal epileptiform activity in 76% of their patients.

However, the brain imaging modality of choice for the evaluation of elderly patients with seizures is MRI because of its sensitivity for detecting subtle lesions.28,32 Brain MRI of our patients revealed focal pathology in 45%, 16.4% showed multifocal pathology while 26.1% of our cases showed diffuse pathology. Brain MRI was normal in 12.3% of cases. These figures are nearly similar to Stephen et al.30, who found normal brain MRI in 19.3%, multifocal pathology in 19.3%, diffuse pathology in 45.1%, and focal pathology in 16.1%. However, Khan and colleagues23 found that 25% of their cases had normal brain imaging. In our results, 64 patients had MRI brain abnormality; out of this group EEG was abnormal in 51 patients. On the other hand, normal brain MRI was found in 9 patients out of them 6 patients had abnormal EEG. It is clear that the two tests complement each other for the final diagnosis. Prolonged EEG, preferably with video monitoring, could certainly illustrate much more abnormalities than could conventional EEG does.

In conclusion, there is increasing evidence that the prevalence of new-onset epilepsy is quite high among the elderly, the most rapidly growing segment of the population. Because seizures in the elderly may mimic other conditions, such as transient ischemic attacks or confusion in demented patients, syncope, cardiac disease, metabolic disorders and drugs, epilepsy often goes undiagnosed in elderly patients. In this study the most common aetiologies for seizures in the elderly tended to be in the category of cerebrovascular disease, predominantly infarction, followed by cerebral haemorrhages, brain tumours and posttraumatic seizures. Elderly people, who are suspected for epilepsy, are recommended to have thorough investigations including MRI brain and long term video EEG.

 

[Disclosure: Authors report no conflict of interest]

 

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الملخص العربي

 

الخصائص الإكلينيكية وأسباب الصرع  عند كبار السن حديثي العهد بمرض الصرع

 

مشكلة مرض الصرع عند كبار السن في تزايد مستمر بسبب زيادة معدل الأعمار مما يجعلها من اهم الامراض المزمنة التي تصيب هذه الشريحة من المرضى. وقد استهدف هذا البحث دراسة الاسباب الممكنة والخصائص الاكلينيكية  لحدوث مرض الصرع عند كبار السن.

وقد أجريت هذه الدراسة على ثلاثة وسبعون مريضا تزيد اعمارهم عن ستين عاما بدوا يعانون من مرض الصرع بعد سن الستين حيث تم اخذ التاريخ المرضى ويشمل وصف النوبة الصرعية كما تم عمل الفحص السريري للجهاز العصبي وتم عمل الفحوصات المخبرية اللازمة  شاملة صورة الدم، وظائف الكلى والكبد، املاح الدم، وغيرها كما تم عمل تخطيط المخ الرقمي واشعة الرنين المغناطيسي على المخ.

وقد أظهرت الدراسة ان 12.3% من المرضى يعانون من نوبات جزئية منهم 4.1% نوبات جزئية حركية و8.2% نوبات جزئية مركبة و 32.8% نوبات جزئية يتبعها نوبات عامة ثانوية، بينما كان 37% من المرضى يعانون من نوبات عامة وقد حدثت نوبات ممتدة لحوالي 17.8% من المرضى.

وقد وجد ان السكتة الدماغية هي السبب الرئيسي لحدوث الصرع عند كبار السن ممثلة  50.7% من أسباب الصرع في المرضى تحت الدراسة وكانت نسبتهم كما يلى: 46.6% منهم نتيجة جلطات بالمخ و 4.1% نتيجة نزيف بالمخ. بينما كانت الأسباب الأخرى تتمثل في صورة أورام بالمخ عند 5.5%  وما بعد إصابات الدماغ عند 2.7% من الحالات، وكان التهاب المخ في حالة واحدة ولم يتم التوصل الى سبب محدد للصرع في 39.7% من الحالات.

وقد كان تخطيط المخ الرقمي طبيعيا في 21.9% من الحالات, بينما ظهر اضطراب بنشاط المخ في حوالى 54.8% و بطء بالموجات في 23.3% من الحالات.

وكانت أشعة الرنين المغناطيسي على الدماغ طبيعية في 12.3% من الحالات، بينما أظهرت تغير باثولوجي جزئي في 45.2% وتغيرات باثولوجية متعددة في 16.4%، بينما أظهرت تغيرات عامة في 26.1% من الحالات.



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