Clinical profile and etiological spectrum of acute symptomatic seizures in the elderly populace

Archana Verma; Alok Kumar; Divyata Sachan

doi:10.4103/jiag.jiag_62_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 18 | Issue : 4 | Page : 168-171

Clinical profile and etiological spectrum of acute symptomatic seizures in the elderly populace

Archana Verma¹, Alok Kumar², Divyata Sachan³
¹ Department of Neurology, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
² Department Forensic Medicine & Toxicology, UP University of Medical Sciences, Saifai, Uttar Pradesh, India
³ Department of Community Medicine, SMMH Medical Sciences, Saharanpur, Uttar Pradesh, India

Date of Submission	21-Nov-2022
Date of Decision	13-Dec-2022
Date of Acceptance	13-Dec-2022
Date of Web Publication	27-Dec-2022

Correspondence Address:
Dr. Archana Verma
Department of Neurology, All India Institute of Medical Sciences, Dalmau Road, Munshiganj, Raebareli - 229 405, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiag.jiag_62_22

Abstract

Aim: The current study aimed to analyze the etiology and the clinical spectrum of acute symptomatic seizures (ASS) and the predictors of in-hospital mortality in the elderly population. Materials and Methods: We evaluated 94 elderly (≥60 years of age) hospitalized patients with ASS for clinical profile, etiologies, and predictors of in-hospital mortality. Results: Mean age of onset of ASS was 67.63 ± 11.48 years. The main seizure type was focal seizure in 62 (59.7%) cases, followed by tonic-clonic seizures in 30 (31.9%) cases. The most common aetiologies in ASS were stroke in 61.7%, followed by infective cause in 30.9% of cases. In-hospital mortality in the ASS in the elderly was 21 (22.3%) in our series, and stroke was the most common cause of mortality. Conclusion: Stroke was the most common etiology of ASS in the elderly and was also related to mortality. It is necessary for us to analyze the causes of ASS in the elderly, to reduce in hospital mortality.

Keywords: Acute symptomatic seizures in the elderly, acute symptomatic seizures, etiology, in-hospital mortality

How to cite this article:
Verma A, Kumar A, Sachan D. Clinical profile and etiological spectrum of acute symptomatic seizures in the elderly populace. J Indian Acad Geriatr 2022;18:168-71

How to cite this URL:
Verma A, Kumar A, Sachan D. Clinical profile and etiological spectrum of acute symptomatic seizures in the elderly populace. J Indian Acad Geriatr [serial online] 2022 [cited 2023 Jan 29];18:168-71. Available from: http://www.jiag.com/text.asp?2022/18/4/168/365782

Introduction

Acute symptomatic seizures (ASS) are events that occur in close association with a central nervous system (CNS) insult. When seizures complicate acute neurological conditions, they add a layer of intricacy to patient management. ASS is more common in the youngest age and in the elderly. The incidence of ASS in patients elder than 60 years is ~100 per 100,000 and rises with each decade of advancing age.^[1],[2] Up to 30% of instances of elderly patients with ASS manifest as Status epilepticus (SE).^[3] The elderly account for around 25% of new cases of epilepsy.^[4] Epilepsy continues in one-third of patients with ASS.^[5] Due to the high prevalence of comorbidities, concomitant polypharmacy, and age- or disease-related alterations in pharmacodynamics and pharmacokinetics, the elderly represent a distinct treatment population when compared with adults.^[6] ASS have a clearly identifiable, proximate cause; the simultaneous management of the underlying cause and use of antiseizure medication are required for the treatment of ASS.

There is still a knowledge gap about the etiology and outcome among elderly patients who experience ASS, particularly those from developing countries. The current study aimed to (1) find the etiology and the clinical spectrum of ASS and (2) the predictors of in-hospital mortality.

Materials and Methods

We performed a hospital-based, cross-sectional study from July 2017 to September 2019 on the elderly (≥60 years of age) patients who were admitted to the neurology ward or intensive care unit (ICU) either with ASS or experienced ASS after being admitted for other neurological disorders were prospectively evaluated after obtaining their informed consent. Patients having pseudo seizures, a history of epilepsy, or epileptic seizures before 60 years were excluded from the study.

ASS was defined as clinical seizures episode in a close temporal relationship with an acute CNS insult, which may be vascular, metabolic, toxic, structural, infectious, or inflammatory.^[7] Out of 1976 elderly patients who were admitted with different neurological disorders during this period, 94 patients fulfilled the inclusion criteria.

Age, gender, seizure semiology, neurological findings, comorbidities, treatment, and length of hospital stay were all noted as clinical characteristics of the patients. Investigations that were pertinent were conducted, including complete blood count, liver and renal function tests, blood glucose and electrolyte levels, and blood gas analysis. Patients were also examined using chest X-rays, ultrasounds, abdomen, echocardiograms, and cerebrospinal fluid examination when deemed necessary. Magnetic resonance imaging and computed tomography scans of the brain were performed based on clinical recommendations. The 10–20 system of electrode placement was used to record the electroencephalogram for 30 min.

Results

A total of 94 elderly patients with ASS were recruited. Of which, 62 (66.6%) cases were male and the mean age of onset of ASS in years (mean ± standard deviation [SD]) was 67.63 ± 11.48 years. Age ranged from 60 to 90 years. The main seizure type was focal seizure in 62 (59.7%) cases, in which focal with bilateral convulsive seizures were the most common presentation, 30 (31.9%), followed by tonic-clonic seizures in 30 (31.9) cases. The most common etiologies in ASS were stroke in 61.7% (acute infarct in 43.6% and hemorrhagic stroke in 18.1%), followed by infective cause in 30.9% of cases. The mean duration of hospital stay in days (mean ± SD) was 6.49 ± 3.53 days. The clinical characteristics of the patients are shown in [Table 1].

Table 1: The clinical characteristics of the patients with acute symptomatic seizures

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In-hospital mortality in the ASS in the elderly was 21 (22.3%) in our series. Among them, stroke was the most common cause of mortality (n = 13), followed by CNS infections (n = 7) and metabolic causes in 1 case. Factors such as gender, socioeconomical status, seizure semiology, etiology, comorbidities, and duration of stay in the hospital, were not significantly associated with mortality on multivariate analysis [Table 2].

Table 2: Risk factors for mortality: Multiple logistic regressions

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Discussion

Although ASS cannot technically be classified as epilepsy, they are a common symptom in elderly patients and raise the likelihood that they may develop epilepsy.

In our study, ASS was experienced in 4% of the elderly patients hospitalized in neurology wards and ICU with various acute neurological diseases. In another study, 2.1% of admissions were related to new-onset seizures occurring with acute neurological disorders in patients aged ranged from 6 months to 80 years.^[8] New-onset seizures were observed in 0.8% of patients admitted to medical and surgical ICUs, according to a retrospective research from the Mayo Clinic.^[9] A review by Bleck et al.^[10] noted that 3.5% of patients with critical medical illness had new-onset seizures. Due to the study's inclusion of exclusively elderly patients, ASS occurred more frequently in our study.

In our study, stroke was the most frequent cause of ASS in the elderly, accounting for 61% of cases. The incidence of stroke increases markedly with increasing age. The most frequent cause of ASS in the elderly is cerebrovascular disease, accounting for 28%–58% of cases.^[11],[12] In another neuroimaging study on a cohort of 201 elderly patients with new-onset seizures; focal lesions were predominantly present in 98 (48.8%) cases, among them common etiologies were infarcts (45), hemorrhages (18), and granuloma (16).^[13] In ischemic strokes, the degree of the initial neurological deficit, the degree of long-term disability, the involvement of many sites or a larger lesion, cortical damage, and hippocampal involvement all indicate the likelihood of having poststroke seizures.^[14] Early poststroke seizures are known to be at increased risk due to embolic stroke.^[15]

In our analysis, infectious causes accounted for 36.2% of cases, making them the second-most frequent cause of ASS. In another study, CNS infections accounted for 32% (n = 21/66) of the etiology.^[8] One study from south India found that 36% of cases of ASS were caused by neuro infection, the majority of which was neurocysticercosis.^[16]

In our series, in-hospital mortality in the ASS in the elderly was 22.3% and stroke was the most common cause of mortality. Similar to this, there is a high short-term risk of death associated with ASS (about 20% in the 1^st month after ASS). Compared to younger people (17.7% in Washington Heights and 11.2% in Rochester), mortality was significantly more prevalent in those 65 years and older (28.4% in Washington Heights and 40.5% in Rochester).^[17] A study has shown that ASS is the most common risk factor of SE and/or cluster seizures in the elderly, which is a neurologic emergency;^[18] this phenomenon increases the risk of neurologic emergency for the elderly.

The study population was from the neurology ward and ICU and did not include all the etiology related to neurosurgery and the obstetrician department. It was a single-center, hospital-based study, and it does not represent the general population.

Conclusion

To conclude, ASS was experienced in 4% of the elderly patients hospitalized in the neurology ward and ICU. In-hospital mortality in the ASS in the elderly was 22.3% in our series. Stroke was the most frequent etiology of ASS in the elderly and was also related to mortality. Therefore, to reduce in hospital mortality, it is necessary for us to analyze the causes of ASS in the elderly.

Ethical approval and consent to participate

Taken.

Consent for publication

Taken.

Availability of supporting data

Present.

Authors' contribution

Dr. Archana Verma – Diagnosis, management, and data collection
Dr. Alok Kumar –- Data collection and writing of manuscript
Dr. Divyata Sachan – Statistical analysis of data.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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