What is the initial management for a 79-year-old patient with new onset seizure?

Initial Management of New Onset Seizure in a 79-Year-Old Patient

For a 79-year-old patient with new onset seizure, the initial management should include serum glucose and sodium testing, neuroimaging with CT head, and consideration for admission based on clinical findings and test results. 1

Initial Laboratory Evaluation

• Determine serum glucose and sodium levels as these are the most frequent abnormalities identified in patients with new-onset seizures 1, 2
• Consider an expanded electrolyte panel, including calcium, magnesium, and phosphate testing, especially in patients with known renal insufficiency, malnutrition, or those taking diuretics 2
• A drug of abuse screen should be considered, though evidence for routine use is limited 1, 2
• For immunocompromised patients, a lumbar puncture is recommended after head CT 1, 3

Neuroimaging

• CT head without contrast should be performed in the emergency setting to rapidly identify structural pathology such as intracranial hemorrhage, stroke, vascular malformation, hydrocephalus, and tumors 1, 4
• CT is particularly important in elderly patients as they have a higher incidence of acute symptomatic seizures, with stroke being a common etiology 5
• MRI is the preferred imaging modality when not in an emergent situation due to superior sensitivity (detecting up to 55% of abnormalities vs. 18-30% with CT) 4
• Be aware that CT has limited sensitivity (approximately 30%) for detecting epileptogenic lesions 4

Risk Assessment and Disposition

• Consider admission if any of the following are present: persistent abnormal neurologic examination results, abnormal investigation results, or if the patient has not returned to baseline 1
• Older adults (≥60 years) have the highest incidence of seizures of all age groups and require a tailored approach 5
• Acute symptomatic seizures can represent half of the new-onset seizures in older adults and have a higher short-term mortality rate (1.6 to 3.6 times higher than younger adults) 5
• Hospitalized elderly patients are at increased risk of provoked seizures, with exposure to proconvulsant drugs being a major risk factor 6

Treatment Considerations

• Patients with a normal neurologic examination, normal test results, and no structural brain disease do not require immediate antiepileptic medications 7, 8
• If antiepileptic therapy is indicated based on risk assessment, consultation with a neurologist is recommended 8
• For patients requiring antiepileptic medication, valproate may be considered at an initial dose of 10 to 15 mg/kg/day, with dosage increases of 5 to 10 mg/kg/week to achieve optimal clinical response 9
• Be cautious with medication dosing in elderly patients, as they may have reduced protein binding of drugs like valproate, affecting clearance 9

Common Pitfalls to Avoid

• Failing to identify metabolic abnormalities such as hypoglycemia or hyponatremia that may be causing the seizure 1
• Missing structural lesions by not performing appropriate neuroimaging 1
• Assuming a normal CT excludes structural abnormality, as MRI may still reveal significant pathology 4
• Prescribing antiepileptic drugs without meeting International League Against Epilepsy diagnostic criteria for epilepsy 6
• Overlooking the possibility of provoked seizures in elderly patients, especially those on medications with proconvulsant properties 5, 6

Follow-up Recommendations

• Electroencephalography (EEG) is recommended for all patients presenting with a first seizure, though it may be less sensitive in older adults than in younger adults 1, 5
• Consider MRI follow-up if CT is normal but seizures persist or if there are focal neurologic findings 4
• Approximately 30% of older adults with acute symptomatic seizures subsequently develop epilepsy, requiring careful follow-up 5