Archives of Neurology
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Protracted Ictal Confusion in Elderly Patients
Sheth RJ, Drazkowski JF, Sirven JL, et al.
Archives of Neurology. 2006:63;529-532
Overview
Status epilepticus (SE) is a neurologic emergency associated with significant morbidity and mortality. Up to150,000 cases have been estimated to occur annually in the United States, leading to approximately 55,000 deaths per year. Although SE traditionally has been defined as continuous seizure activity lasting at least 30 minutes or as 2 or more discrete seizures between which consciousness is not fully regained, Lowenstein and colleagues have proposed a change in the length of time of the seizure to be more than 5 minutes. The reasoning behind the revised definition relies on the fact that generalized tonic-clonic seizures rarely last more than 5 minutes and that the chances of spontaneous termination after that time are low. Prompt recognition and treatment of SE is pivotal to reducing the associated morbidity and mortality since the longer the seizure continues, the more difficult it will be to control and the greater the risk of neuronal injury. Nonconvulsive status epilepticus (NCSE) differs from convulsive SE in that it lacks a predominant motor component and should be considered in any patient presenting with an alteration in mental status of indeterminate cause. The incidence of SE in the elderly population is at least twice that of the general population and is of great concern because of the existence of concurrent medical conditions that are more likely to complicate treatment and worsen the prognosis. Often, elderly patients present with SE with minimal or no motor movements or with protracted ictal confusion, thus creating a diagnostic challenge. Sheth and colleagues created a case series of 22 consecutive ambulatory patients with acute ictal confusion to help define protracted ictal confusion in the elderly and to characterize its features and outcome.
Results
Ictal confusion was defined as episodes during which the patient was unable to function and think with customary speed, clarity, and coherence. In addition, the events were associated with electroencephalographic (EEG) features consistent with SE. The main outcome measure included imaging results where the duration of ictal confusion was correlated with age and lesions noted on the imaging and video-EEG studies. The results of the study revealed that 20 patients had partial complex SE and 2 were diagnosed with primary generalized SE. The ictal confusion was not diagnosed for up to 5 days in 22 patients (mean ± SD age, 70 ± 8.5 years), and motor movements were not appreciated in either group. Notably, although treatment was able to reverse the confusion, a few patients sustained a persistent reduction in their baseline cognitive status.
Conclusion
The findings of the case series highlight the need to consider NCSE in any patient, particularly in the elderly who present with an alteration in mental status. The use of EEG studies allows for the confirmation of the diagnosis and hopefully prompts treatment of the problem.
http://www.medscape.com/medline/abstract/16606764