As with younger patients, the most useful history is that provided by the patient, supplemented by a reliable observer for any period during which the patient was unconscious or confused.
To evaluate a possible first seizure in seniors, it is critical to inquire about:
Other elements of the patient's history that should be elicited include:
Physical and neurologic examinations should address mainly the issues of cardiovascular function, metabolic-endocrine status, and prior neurologic insults.
In emergencies, metabolic studies (electrolytes, calcium, magnesium, glucose, renal and liver function tests), a toxicology screen, and a complete blood count should generally be performed. If symptoms or signs of infection are present, a lumbar puncture should be done, generally after a neuroimaging procedure. Noncontrast computed tomography (CT) is adequate to rule out hemorrhage or a large mass lesion.
In non-emergencies, MRI is indicated because of its high sensitivity to potentially treatable structural lesions, particularly small neoplasms.
Electroencephalography is a noninvasive, relatively inexpensive test that can:
In the acute setting, if full recovery does not follow promptly after the seizure apparently terminates, EEG is necessary to rule out ongoing nonconvulsive status epilepticus.53
The EEG usually need not be obtained immediately, but the yield of interictal epileptiform discharges and diagnostic postictal slowing is maximal if the test is done soon after the event. In some situations, such as if encephalitis is suspected, the EEG can be crucial to early diagnosis.54
Epileptiform findings on EEG—particularly periodic lateralized epileptiform discharges—are also highly predictive of the development of seizures after stroke even if no seizures have been observed.55
If diagnosis remains uncertain or frequent events are occurring despite treatment, long-term video-EEG monitoring, perhaps with additional ECG and polysomnography, is indicated.
The electroencephalographer must be familiar with the effects of normal aging on the EEG, particularly temporal slowing, which is often asymmetric (L>R), and with normal variants that could be mistaken for epileptiform abnormalities.54-56
Reviewed and revised June 2004 by Steven C. Schachter, MD, epilepsy.com Editorial Board.
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