|Year : 2022 | Volume
| Issue : 2 | Page : 93-97
Clinical profile of new-onset seizures in the elderly
Mahadev Hanmantappa Malge1, BS Nagaraja2, Avinash Hanbe Rajanna3
1 Department of Medicine, Gulbarga Institute of Medical Sciences, Kalburgi, Karnataka, India
2 Department of Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
3 Department of Medicine, ESIC Medical College, PGIMSR and Model Hospital, Bengaluru, Karnataka, India
|Date of Submission||20-Mar-2021|
|Date of Decision||01-May-2021|
|Date of Acceptance||03-May-2021|
|Date of Web Publication||02-Mar-2022|
Dr. Avinash Hanbe Rajanna
Assistant Professor, Department of Medicine, Esic Medical College, PGIMSR and Model Hospital, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: The aim of the study is to determine the etiology of seizures in the elderly and types of seizure in elderly populations. Materials and Methods: This was a cross-sectional study carried out on patients of age more than 60 years with seizures and who satisfied inclusion and exclusion criteria, admitted in Bangalore Medical College and Research Institute (BMCRI) attached hospitals, Bengaluru, between November 2016 and October 2018. After obtaining ethical clearance and approval from the institutional ethics committee of BMCRI, written informed consent was taken from the patients. Detailed history was taken from all patients, and all patients underwent thorough clinical examination and investigations. The diagnostic probability was based on the clinical data obtained from the patient charts and the results of electroencephalography (EEG) and computed tomography (CT) scans. The etiology of seizures was determined on the basis of medical history, neurologic examination, EEG, and CT scans. Results: A total of 58 patients of new-onset seizure included in the study out of which 30 were male and 28 were female. Majority of the patients were aged between 60 and 70 years. Male-to-female ration was almost equal. GTCS was the major type of seizure. Cerebrovascular infarct was the most common etiology. Diabetes and hypertension (HTN) were the most common comorbid conditions. Conclusion: Seizure was the dominant manifestation of various underlying disorders in the elderly, of which cerebrovascular disease was the most common cause, followed by metabolic cause. Comorbidities such as diabetes and HTN also had an important role in seizure activity. GTCS was the most common type of seizure in the elderly.
Keywords: Cerebrovascular accidant, diabetes mellitus, electroencephalogram, generalised tonic clonic seizure, hypertension, seizure
|How to cite this article:|
Malge MH, Nagaraja B S, Rajanna AH. Clinical profile of new-onset seizures in the elderly. APIK J Int Med 2022;10:93-7
|How to cite this URL:|
Malge MH, Nagaraja B S, Rajanna AH. Clinical profile of new-onset seizures in the elderly. APIK J Int Med [serial online] 2022 [cited 2022 May 26];10:93-7. Available from: https://www.ajim.in/text.asp?2022/10/2/93/338899
| Introduction|| |
Seizures can arise at any part of the brain as a result of disruption in the normal alternating pattern of the brain impulses. Seizures are usually manifested as loss of muscle control and awareness, tremors, and emotional changes. The underlying causes of seizures usually include certain drugs, high fever, and diseases such as epilepsy and head injuries.
The common etiologies of acute symptomatic seizures include traumatic brain injury, drug withdrawal, infraction, metabolic insults, and cerebrovascular diseases.
The annual incidence of acute symptomatic seizure is estimated to be 29–39 cases per 100,000 people and that of single unprovoked seizure is 23–61 cases per 100,000 people. However, the incidence of epilepsy is estimated to be 1 in 26 people. Unprovoked seizures are common in the elderly and affect around 4% of the population aged over 80 years.,
The prevalence of epilepsy increases with age. According to Jacqueline, a French neurologist and a member of the American Academy of Neurology, the onset of epilepsy is likely to occur during two peak periods in a person's life: one during childhood and the other after 65 years of age.
Hauser and Beghi reported that people experiencing single unprovoked seizures have a standardized mortality rate of 2.3. However, patients with new-onset unprovoked seizures have been reported to have a standardized mortality rate ranging from 2.5 to 4.1. Single unprovoked seizures are more prevalent in men and elderly over 65 years of age. About 25% of the new cases of epilepsy are reported in the elderly.
The diagnosis of seizures in the elderly is often challenging due to the presence of atypical presentations, involving various set of etiologies, comorbidities, and cognitive decline. Literature evidence pertaining to new-onset epileptic seizures in the elderly is limited, and there is no clear consensus on the various presentations and etiologies of new-onset elderly seizures. In this regard, the present study was conducted to evaluate the pattern and the etiologies of new-onset seizures in the elderly.
Aims and objectives
- To study the pattern of new-onset seizures in the elderly
- To determine the various etiologies of seizures in the elderly.
| Materials and Methods|| |
The cross-sectional study was conducted on patients with seizure disorder aged over 60 years, who attended or admitted to Bangalore Medical College and Research Institute (BMCRI), Bangalore, Karnataka, India, between November 2016 and October 2018. The study was approved by the institutional ethics committee and informed consent was obtained from all the participants. Seizures were classified according to the revised International League Against Epilepsy Guidelines, 2016.
Based on previous study by Hussain et al., in Meghalaya, the generalized tonic–clonic seizure was 57.7%.
The sample size calculation is:
n = 4pq/d2
where p (proportion) =57.7, q (100 − p) =42.3
d (precision) =13
n = 4 × 57.7 × 42.3/(13) 2
The inclusion and exclusion criteria employed for selection of subjects were as follows:
- Patients above 60 years of age presenting with new onset seizures (seizures were classified using the revised International League Against Epilepsy, 1981)
- Patients willing for study
- Patients willing to give written informed consent.
- Patients with onset of seizures before age of 60 years and continuing into later life
- Patients with nonepileptic events such as syncope, psychogenic seizures, and transient ischemic attacks
- Head injury presenting with seizures.
Demographic characteristics and detailed history were collected from all the participants. The routine clinical, laboratory, and radiological investigations performed on the subjects were complete blood count, erythrocyte sedimentation rate, random blood sugar (RBS), blood urea, serum creatinine, liver function tests, serum electrolytes test, lipid profile, complete urine examination, electrocardiography (ECG), and electroencephalography (EEG). Specific investigations such as computed tomography (CT)/magnetic resonance imaging (MRI) scan, chest X-ray, cerebrospinal fluid (CSF) analysis, serum anticysticercal antibodies test, Mantoux test, and serum antitubercular antibodies test were conducted when indicated. The diagnosis of seizure was based on the clinical data obtained from the patient charts and the results of ECG and/or CT scan. The etiology of seizures was determined based on the medical history, neurologic examination, EEG recording, and/or CT.
Method of statistical analysis
The data were entered in Microsoft Excel Sheet and were analyzed using IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. IBM Corp. Released 2015.20-Oct-2020. The categorical data were represented in the form of frequency and percentage. Chi-square test/Fisher's exact test was used to test the significance for qualitative data. Continuous data were represented as mean and standard deviation. P < 0.05 was considered statistically significant.
| Results|| |
Age and sex distribution of patients
In the present study, majority of the patients, i.e. 37 (63.8%), were in the age group of 60–70 years followed by 16 (27.6%) in 71–80 years, 4 in 81–90 years, and only 1 case in > 90 years of age group. Mean age in the present study was 70.07 years with standard deviation of 8.01 years. In that, 28 (48.3%) were male and 30 (51.7%) were female, with male-to-female ratio being almost equal to 1.07:1.
Among the study subjects, GTCS was the most common type of seizure in both the genders, comprising 22 (78.6%) out of 28 females and 27 (90%) out of 30 males. Next to that was Focal seizure with secondary generalization (FSSG) type comprising 3 (10.7%) out of 28 females and 3 (10%) out of 30 males and focal seizure type comprising 3 (10.7%) out of 28 females and no male cases.
In our study, 27 (46.65%) subjects had hyponatremia, i.e., serum sodium levels <135 mEq/L, out of which 12 (42.9%) were female patients and 15 (50%) were male patients. This was not statistically significant. 12 patients had hypoglycemia, i.e., <70 mg/dl, out of which 7 had <40 mg/dl and 5 had 40–70 mg/dl. 3 (10.7%) females and 4 (13.3%) males had RBS values <40 mg/dl. 4 (14.3%) females and 1 (3.3%) males had RBS values between 40 and 70 mg/dl.
In our study, 45 (77.6%) subjects had blood urea <70 mg/dl, 9 (15.5%) subjects had blood urea 70–120 mg/dl, and 4 (6.9%) subjects had blood urea >120 mg/dl. CSF analysis was done only in 4 (3.8%) patients out of them 1 (3.6%) female and 1 (3.3%) male had abnormal reports.
In our study, out of 58 subjects studied, the most common cause was found to be cerebrovascular accident (CVA)-infarct comprising 20 (34.5%) subjects, hypoglycemia in 6 (10.3%) subjects, hyponatremia in 6 (10.3%) subjects, cryptogenic in 5 (8.6%) subjects, gliosis in 4 (6.9%) subjects, uremic encephalopathy in 4 (6.9%) subjects, neuroinfection in 4 (6.9%) subjects, CVA-hemorrhage in 3 (5.2%) subjects, sepsis in 2 (3.4%) subjects, cerebral venous thrombosis in 1 (1.7%) subject, hypocalcemia in 1 (1.7%) subject, neurocysticercosis in 1 (1.7%) subject, and subdural hygroma in 1 (1.7%) subject [Table 1].
In our study, the most common cause for seizures in the elderly was CVA-infarct comprising 20 (40%) out of which 11 (29.7%) were in the age group of 60–70 years, 7 (43.8%) were in the age group of 71–80 years, and 2 (40%) were in the age group of >80 years. Second-most common cause of seizure was hypoglycemia and hyponatremia comprising 6 (10.3%) patients each [Table 2]. Among 6 (10.3%) patients with hypoglycemia, 3 (8.1%) were in the age group of 60–70 years and 3 (18.8%) were in the age group of 71–80 years.
|Table 2: Cause of seizure distribution in relation to age in years of patients studied|
Click here to view
Among 6 (10.3%) patients with hyponatremia, 5 (13.5%) were in the age group of 60–70 years and 1 (6.3%) were in the age group of 71–80 years. Cryptogenic was the third-most common cause of seizure in our study comprising 5 (8.6%) patients out of which 2 (5.4%) were in the age group of 60–70 years, 2 (12.5%) were in the age group of 71–80 years, and 1 (20%) was in the age group of >80 years.
Among 4 (6.9%) patients with gliosis, 3 (8.1%) patients were in the age group of 60–70 years and 1 (20%) was in the age group of >80 years. Among 4 (6.9%) patients with uremic encephalopathy and neuroinfection, all were in the age group of 60–70 years.
Among 3 (5.2%) patients with CVA-hemorrhage, 2 (5.4%) patients were in the age group of 60–70 years and 1 (6.3%) was in the age group of 71–80 years. Among 2 (3.4%) patients with sepsis, 1 (2.7%) patient was in the age group of 60–70 years and 1 (6.3%) was in the age group of 71–80 years.
Only 1 (1.7%) Cerebral venous thrombosis (CVT) patient was in the age group of 71–80 years.
Only 1 (1.7%) subdural hygroma patient was in the age group of >80 years.
Among 1 (1.7%) patient each with hypocalcemia and neurocysticercosis was in the age group of 60–70 years.
Out of the 37 patients in the age group of 60–70 years, 83.8% of patients had GTCS followed by FSSG 6 (16.2%).
87.5% of the patients in the age group of 71–80 years had GTCS, only 12.5% of patients had focal seizures, and no patients were with FSSG. Among the age group of >80 years, 80% had GTCS. The P value of this analysis is 0.038 which is statistically significant. GTCS is the most common type of seizures, among all the age groups above 60 years.
Stroke was the major cause which contributes 39.7% with respect to total subjects. metabolic cause contributes 32.6% with respect to total subjects, cryptogenic cause was found in 8.6% of total subjects, CNS infection were 8.6%. CNS Tumour and Miscellaneous contributes 1.7% & 8.6% respectively. Causes of seizures were not different in both sexes.
In our study, 42 (72.4%) patients had comorbidities and 16 (27.6%) patients were without comorbidities. Among patients with comorbidities, 9 (15.5%) had diabetes and hypertension (HTN) each. Patients with both diabetes and HTN amounted to 21 (36.3%). 3 (5.1%) patients had comorbidities other than diabetes mellitus and HTN.
Among patients presented with GTCS, 8 (16.3%) were only diabetic, 6 (12.2%) were hypertensive, and 17 (34.7%) were both diabetic and hypertensive.
Among patients presented with FSSG, 1 (16.7%) was only diabetic, 2 (33.3%) were hypertensive, and 3 (50.0%) were both diabetic and hypertensive.
In our study, 56 subjects underwent imaging; 67.2% of patients revealed abnormal CT/MRI findings of which 27.5% of patients had multi-infarct state. 20.68% of the patients had acute infarct. Gliosis and hemorrhage accounted for 8.6% and 5.1%, respectively. Other findings were subdural hygroma, CVT, and neurocysticercosis [Table 3].
| Discussion|| |
Number of case of new-onset seizures above 60 years studied in our study was 58.
Cerebrovascular disease has become frequently reported risk factors for seizure in the elderly patients. The present study also shows cerebrovascular disease as the most common cause of seizure in the elderly seen in 23 (39.7%) patients. This finding is consistent with other studies as mentioned in the [Table 4]. In our study, metabolic etiology of seizure was 19 (32.6%) comprising hypoglycemia in 6 (10.3%), hyponatremia in 6 (10.3%), uremic encephalopathy in 4 (6.9%), sepsis in 2 (3.4%), and hypocalcemia in 1 (1.7%).
Other causes included in our study were cryptogenic contributing 5 (8.6%), CNS infection contributing 5 (8.6%), CNS tumor contributing 1 (1.7%), and gliosis contributing 4 (6.9%), and one subject had CVT. 1 (1.7%) seizure case was found to have infectious causes, such as neuroinfection and neurocysticercosis.
EEG was done in 13 (22.4%) subjects. Out of that, only 4 were abnormal and rest 9 were normal. In our study, EEG could not be done in 45 (75.6%) patients, due to lack of easy accessibility and feasibility due to patients unstable conditions.
In our study, imaging was done in 56 patients, and 67.2% of patients revealed abnormal findings of which 27.5% of patients had multi-infarct state which was the major finding in our study group. 20.68% of patients had acute infarct. Gliosis and hemorrhage accounted for 8.6% and 5.1%, respectively. Other findings were subdural hygroma, CVT, and neurocysticercosis. In a study by Pandey et al., neuroimaging abnormality was found in 71% of cases, of which 80.39% of patients with GTCS had abnormalities and 61.22% of patients with focal seizures had abnormalities. Sarmah et al. found CT abnormality in 61.7% of patients and MRI abnormality in 59.7% of cases which is comparable to our study.
32.6% of patients had deranged metabolic parameters. 10.3% of patients had hyponatremia, 10.3% had hypoglycemia, 6.9% had uremia, 2 patients (3.4%) had sepsis, and only 1.7% of patients had hypocalcemia. Another study by Pandey et al. showed 12% of patients with metabolic causes.
In our study, 8.6% of patients had cryptogenic cause for seizures. Cryptogenic cause was found in 16.3% of patients in Sarmah et al.'s study, 22% in Granger et al.'s study, and 25% in Lühdorf et al.'s study.
| Conclusion|| |
- Among newly diagnosed seizures in the elderly, the most common age group was 60–70 years
- Cerebrovascular accident was the most common cause of seizures in the elderly. Infarct was the common cause among CVA in both males and females
- Associated comorbidities such as diabetes and HTN itself were the risk factors for ischemic stroke
- Metabolic causes including hyponatremia and hypoglycemia were important since they were correctable
- GTCS was the most common type of seizures in the elderly.
Sample size was small and this was a single-center study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]