Epilepsy in the Elderly

Ann Johnston; Phil EM Smith

Disclosures

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

In This Article

Diagnosis

Diagnosing epilepsy in elderly patients can be more difficult and more time consuming than in younger patients, not only through its atypical presentation, but also because of the greater number of potential differential diagnoses and the higher prevalence of comorbidities. It takes a mean of 18 months from symptom onset to reach an epilepsy diagnosis in elderly patients.[33] There are several further reasons for this. It is often more difficult to obtain an eye-witnessed account, as elderly people are less frequently employed, less socially active and more likely to live alone.[13] Accurate self-reporting by older people may also be complicated by comorbid illness. Furthermore, elderly people may not recognize their symptoms or may not consider them serious enough to seek medical help and so may not report them to relatives or carers. A further wider problem is the lack of a research basis for decision making, since most clinical epilepsy research excludes the elderly.

The main differential diagnoses of an epileptic seizure at any age are syncope (reflex, cardiogenic or orthostatic) and psychogenic attacks. The clinical history, and if possible an eye-witnessed account of the event, is the cornerstone of diagnosis in episodes of altered consciousness, in this, as at any age.

The important items in the history are the circumstances and description of warning features of the event (including aura), of the event itself (including impaired consciousness, the presence or absence of pallor, cyanosis, abnormal movements, tongue biting, urinary incontinence) and of the post-event features (e.g., confusion, headache, drowsiness and Todd's paresis). A history of trauma, including physical abrasions, such as cuts, bruises and burns, may also be of help.[34] The history should also include a full list of medications (both prescribed and 'over the counter') and a detailed medical history, including cardiovascular risk factors (diabetes mellitus, hypertension and smoking) and any other potential epilepsy causes, such as a previous significant head injury, meningitis, encephalitis and, even in the elderly, a history of an abnormal birth or of febrile convulsions. A detailed family history may also be relevant.

The physical examination is important, but rarely adds to an epilepsy diagnosis; in elderly patients, clinicians should focus their examination on the cardiovascular and neurological systems.

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