SAN JUAN, P.R. – Seizures in older adults have a different presentation than they do in younger patients, with these events resembling many other conditions and making diagnosis difficult, but there are a few keys that can help make the right diagnosis, said one expert speaking at the annual meeting of the American Association for Geriatric Psychiatry.
Seizures in older adults often are a byproduct of stroke and/or hemorrhage, said Dr. Joseph I. Sirven, of the department of neurology at the Mayo Clinic in Phoenix, who spoke from anecdotal experience. In addition, neurodegenerative conditions, such as dementia, also cause problems that lead to seizures.
In general, partial seizures are most commonly seen in older adults because there is a specific area of injury or damage involved, said Dr. Sirven. In older adults, the foci of seizures usually occur in the frontal or parietal lobes.
“We also know that simple partial seizures, in which there is not a loss of consciousness, tend to have more focal and/or sensory symptoms [such as] tremor or a sense of numbness,” said Dr. Sirven. Auras–primarily dizziness–may also be present. Complex partial seizures often present with altered mental activity, staring, blackouts, and confusion.
Diagnosing seizures in older adults is difficult because the presentation can resemble so many other conditions. “The differential mirrors almost everything else,” said Dr. Sirven, including syncope, transient ischemic attack, transient global amnesia, vertigo, and delirium.
The key to seizure recognition is episodic frequency of symptoms that are stereotypic. In particular, episodes may present with loss of consciousness, dizziness, confusion, or language change. “If you see transient episodes of certain behaviors that are stereotypic, the first test really is the EEG,” said Dr. Sirven. Other diagnostic tests to consider include MRI, laboratory tests, cardiovascular testing, ambulatory EKG, and tilt table testing.
Seizure medication should be considered only if the seizures are truly impacting the patient's quality of life. “Why I'm making a big deal about it is that the moment you start someone on seizure medication … you've branded that person and no one down the road is going to stop that medication,” said Dr. Sirven.
Dr. Sirven listed the following three main points to consider when deciding on a seizure medication for an elderly patient:
▸ Efficacy. Try to use monotherapy whenever possible. Choose a medication that is appropriate for the seizure type. If the seizure type is unspecified, choose a broad-spectrum agent.
▸ Safety and tolerability. First minimize drug interactions. In addition, choose a drug with a favorable safety profile that minimizes the inhibition of cognitive function and has a minimal effect on gait, balance, and orthostatic blood pressure.
▸ Simplification. Once-daily dosing helps with patient compliance. Choose a drug with a quick onset of action. Reduce interacting drugs, especially psychoactive ones.