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Non-convulsive status epilepticus
in confused older patients
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Dr Henry J. Woodford
Consultant Geriatrician
Northumbria Healthcare NHS Trust
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Aims
discuss prevalence of non-convulsive
status epilepticus (NCSE) in confused
older people
 To describe clinical features that suggest
NCSE
 To discuss how to achieve a diagnosis
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 To
year old lady
 Clinically delirious
 No clear cause on assessment
 Bloods, ECG, CXR unremarkable
 CT head – atrophy and small vessel
ischaemia
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 83
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Scenario
an EEG?
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 Request
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 Clinical
 Delirium
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Common
Significant effect
Caused by anything – often multi-factorial
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Missing something?
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question
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Background
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 Jean-Martin
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Charcot
 1880s
 Somnambulism
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Lasting > 30 minutes
Seizure activity on EEG
Change in cognition/behaviour
No major motor signs
Presentation: coma to confusion
Potentially reversible
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NCSE
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Complex partial
 Absence
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How common is it?
universally accepted definition
 Wide range of estimates…
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1.5 per 100 000 adults per year
0.1% admitted to acute geriatric ward
3% attending ED with altered mental status
16% having EEG for undiagnosed confusion
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 No
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EEG
24/7, tolerance
 ‘epileptiform’ activity
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Metabolic disorders
Anoxic brain injury
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 Access
with antiepileptic drugs
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 Improvement
 History
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of previous epilepsy
43-69% all adults
35% aged 75-95
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at onset of confusion
 Prior neurological injury
 Recently stopped benzodiazepines
 Speech quality
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 Seizure
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History
 Subtle
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• Yawning, rubbing
• ? carphology / floccillation
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Twitching – eyelids, periorally, limb
extremities
Eye signs – nystagmus, hippus, eye deviation
Automatisms – repetitive, purposeless
movements
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motor features…
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Signs
Catalepsy
patients aged 65 or over with confusion
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Data from case series
female
 26% prior epilepsy
 34% dementia
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 82%
 Commonest
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Myoclonus / subtle jerking
Aphasia / interrupted speech
Automatisms
Staring
Perseveration / echolalia
Increased tone / catalepsy
Nystagmus / eye deviation
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clinical features
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Data 2
30%
26%
26%
22%
17%
13%
13%
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Data 3
patients no history of epilepsy or
clinical features suggestive of NCSE
1 recently stopped lorazepam
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Reversible cause of seizures
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Drugs / alcohol
Metabolic
Timely access to EEG?
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Female (?)
History of epilepsy / seizure at onset
Prior neurological injury
Benzodiazepine discontinuation
Signs – myoclonus, speech disturbance, automatisms
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Cause(s) of delirium identified?
Clinical features suggesting NCSE?
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Route to diagnosis
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Therapeutic trial?
year old lady
 Clinically delirious
 No clear cause on assessment
 Bloods, ECG, CXR unremarkable
 CT head – atrophy and small vessel
ischaemia
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 83
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Scenario
an EEG?
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 Request
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Reflections
how common is it?
 Suggestive features in history and on
examination
Targeted EEG
 Diagnosis
can be tricky
Therapeutic trial?
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 Just
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to Jim George and Margaret
Jackson
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 Thanks
Woodford HJ, George J, Jackson M. Non-convulsive
status epilepticus: a practical approach to diagnosis in
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confused older people. Postgrad. Med J. 2015; 91: 655661.