Abstracts

Status epilepticus is associated with significant morbidity. In the elderly, non-convulsive status epilepticus (NCSE) poses a particular problem given the frequency of associated cognitive impairment and the failure to consider, identify and appropriately treat this disorder.
We undertook this study to better understand seizures that present as confusional spells in the elderly. A retrospective chart review of successive elderly pts presenting acutely to the ER or office with NCSE was undertaken at two institutions in order to better characteristize semiology, determine underlying EEG and imaging patterns and clinical outcomes. Time to diagnosis was delayed in all 22 patients. 14 women [amp] 8 men (70[plusmn]11 yrs) presenting with confusion for 1 -120 hours (mean 31[plusmn]30 hours) were found to have NCSE. 15 with prior NCSE had a average of 29 hours compared to 35 hours for 7 patients with the first episode of NCSE. For these 15 pts NCSE had occured between 1 and 10 times. Despite prior seizures or NCSE, family members did not seek evaluation for many hours. For 9 pts with prior seizures confusion was present for 22.3 h before a diagnosis of NCSE was made compared to 37 h for 13 pts without a prior seizures (p=0.13). For this later group the initial diagnosis included dementia, TIAs, metabolic disease, or a psychiatric illness before NCSE was recognized. NCSE was much more frequently focal (frontal or central in 10, temporal in 4 patients or 8 anteriorly dominant diffuse epileptiform activity) whereas only 2 had primary generalized NCSE. 9 patients had normal MRIs, 13 had lesions (in only 5 patients did the lesion correspond with EEG focality, in the remainder the MRI showed non-specific small vessel disease or atrophy). Time to diagnosis was considerably longer (34 hours) if MRI was normal versus 21 hours if MRI showed lesion. NCSE required multiple medications administered acutely and 2 patients required pentobarbital to control status. All 22 patients eventually recovered from NCSE and could be discharged home. Confusional NCSE lasted 1 to 140 hrs before epilepsy was considered. Surprisingly, this delay existed despite prior NCSE or seizrues. Furthermore, once brought to medical attention, the possibiltiy of NCSE was not considered early in the evaluation, with a wide variety of other diagnosis entertained before NCSE. Once established, NCSE was difficult to control and required multiple medications including theraputic coma. Unlike NCSE presenting with coma or NCSE in an ICU setting, all elderly patients presenting with confusional NCSE eventually recovered and were discharged home. Unlike NCSE in younger age groups, frontal or frontocentral epilepsy was the commonest type. Accordingly, caretakers and physicians need to be made aware that in the ambulatory elderly patient NCSE can present with confusion, this is particularly true of non-lesional NCSE.