What is the management approach for a 60-year-old patient presenting with convulsions?

Management of a 60-Year-Old Patient with Convulsions

For a 60-year-old patient presenting with convulsions, immediately administer IV benzodiazepines (lorazepam or midazolam) as first-line therapy, followed by IV levetiracetam, fosphenytoin, or valproate as second-line agents if seizures persist—all three have equal efficacy (~47%) and should be selected based on patient-specific contraindications. 1

Immediate First-Line Treatment

• Administer IV benzodiazepines immediately as the cornerstone of acute seizure management 1, 2, 3

  • Lorazepam 0.1 mg/kg IV at no more than 2 mg/min, OR 3
  • Midazolam IM is equally or more effective than IV lorazepam and saves time in the prehospital/early ED setting 2
  • Diazepam is an alternative but less preferred due to shorter duration of action 4, 3

• Critical pitfall: Many patients receive inadequate benzodiazepine doses—ensure full weight-based dosing is administered 2

Second-Line Treatment for Benzodiazepine-Refractory Seizures

If seizures persist 5-30 minutes after adequate benzodiazepine dosing, the patient has established status epilepticus requiring second-line therapy. 1

Agent Selection (All Equally Effective)

The 2024 ACEP guidelines, based on the landmark ESETT trial, establish that fosphenytoin, levetiracetam, and valproate have equivalent efficacy (45-49% seizure cessation at 60 minutes) 1:

• Levetiracetam: 60 mg/kg IV (typically 3000-4500 mg) over 10 minutes 1

  • Preferred in elderly patients due to minimal cardiorespiratory effects (0.7% hypotension, 0.7% arrhythmias) 1, 5, 6
  • Lowest intubation rate (20%) compared to other agents 1, 5
  • No hepatic contraindications and minimal drug interactions 6

• Valproate: 30-40 mg/kg IV (typically 2000-3000 mg) over 10 minutes 1

  • Slightly higher hypotension risk (1.6%) 1, 5
  • Contraindicated in liver disease 6, 7
  • Requires monitoring for thrombocytopenia 6

• Fosphenytoin: 20 mg phenytoin equivalents/kg IV at ≤150 mg/min 1, 3

  • Highest cardiovascular complication rate (3.2% hypotension) 1, 5
  • Higher intubation rate (26.4%) 1
  • More drug interactions than levetiracetam 6

Algorithm for Agent Selection in a 60-Year-Old

1. First choice: Levetiracetam for most elderly patients due to superior safety profile 5, 6
2. Use valproate if: Patient has known levetiracetam failure or mood disorder comorbidity (mood-stabilizing properties) 7
3. Avoid valproate if: Liver disease present or suspected 6, 7
4. Use fosphenytoin only if: Both levetiracetam and valproate are contraindicated, as it has the worst safety profile 1, 5

Concurrent Diagnostic Evaluation

While treating the seizure, rapidly assess for reversible causes:

• Point-of-care glucose immediately—hypoglycemia is rapidly reversible 1

• Electrolytes (sodium, calcium, magnesium)—hyponatremia and hypocalcemia can present as new-onset seizures in elderly patients 1

• Non-contrast head CT urgently if:

  • Focal neurologic deficits present 1
  • Not returned to baseline within several hours 1
  • Age >60 increases risk of structural lesions (stroke, tumor) to 34-40% 1

• Consider lumbar puncture if: Fever, immunocompromised, or suspicion of CNS infection, though this is less common in immunocompetent elderly patients 1

Refractory Status Epilepticus (Third-Line)

If seizures continue after second-line agent, initiate general anesthesia with continuous EEG monitoring 3, 8:

• Pentobarbital, midazolam infusion, or propofol 3, 8
• Requires intubation and ICU-level care 3, 8
• Consult neurology/epilepsy specialist 8

Special Considerations for Elderly Patients

• Start maintenance antiepileptic drugs at 25-50% of standard adult doses and titrate slowly 6
• Monitor closely for cognitive impairment, dizziness, and ataxia which increase fall risk 6
• Avoid phenobarbital and phenytoin as maintenance therapy due to high risk of cognitive impairment and drug interactions 6
• Elderly patients have higher mortality from status epilepticus, particularly with acute symptomatic causes (stroke, anoxia) 8

Critical Pitfalls to Avoid

• Underdosing benzodiazepines—this is the most common error leading to treatment failure 2
• Delaying second-line therapy—administer within 5-30 minutes of benzodiazepine administration if seizures persist 1
• Using clinical observation alone—if patient doesn't regain consciousness, consider EEG monitoring for nonconvulsive status epilepticus 3, 9
• Missing psychogenic nonepileptic seizures (PNES)—these occur in elderly patients (particularly women >70) and present with motor symptoms; video-EEG can prevent unnecessary antiepileptic drug exposure 9