Epilepsy in the Elderly

Ann Johnston; Phil EM Smith

Disclosures

Expert Rev Neurother. 2010;10(12):1899-1910. 

In This Article

Epilepsy Mimics

The diagnosis of epilepsy in the elderly is difficult and too often it is incorrect. The differential diagnosis of an episode of altered consciousness in the elderly may be similar to that in a younger person, but clinicians must take additional account of the increased prevalence of comorbidities and the increased likelihood of polypharmacy.

Some common clinical scenarios encountered in the elderly may mask or mimic epilepsy. These include mechanical falls, syncope (especially orthostatic hypotension, but also cardiac arrhythmogenic syncope), confusional states, memory problems and sleep disorders (Box 1).

Cardiac Arrhythmias

Cardiac arrhythmias are a relatively common and a potentially life threatening cause of sudden loss of consciousness in the elderly. Characteristically, they occur without warning, and may be brief and not associated with post-event fatigue. Elderly people with ischemic heart disease are at an increased risk of cardiac arrhythmias, including ventricular tachycardia (from ventricular scar tissue) or diseased conduction systems.

An electrocardiogram (ECG) is, therefore, essential in all cases of undiagnosed transient loss of consciousness in the elderly, particularly looking to identify features of ischemic heart disease, such as pathological Q waves and abnormal T wave morphology.

People with previous cardiac disease presenting with blackouts should be assumed to be at a high risk of sudden death, and thus should be referred promptly to an arrhythmia service for investigation and management.

Transient Ischemic Attacks

Transient ischemic attacks (TIAs) are commonly (and usually incorrectly) diagnosed when patients present with transient loss of consciousness. TIAs rarely cause a true loss of consciousness unless there is focal involvement of the brainstem reticular activating system or medial thalamus. However, a 'limb-shaking TIA' caused by bilateral critical carotid stenosis is an important and potentially reversible cause of stereotyped events with focal features.

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