What treatment is recommended for an 87-year-old patient with seizure-like episodes, urinary tract infection (UTI), and confusion, who has stable blood pressure and no known allergies?

From the Guidelines

I strongly recommend starting the patient on a low dose of an antipsychotic medication such as quetiapine 25mg orally at bedtime for management of confusion and sleep disturbance, while avoiding benzodiazepines due to their potential to worsen confusion and increase fall risk 1. For the UTI, an appropriate antibiotic such as nitrofurantoin 100mg twice daily for 7 days (if renal function is adequate) or trimethoprim-sulfamethoxazole DS twice daily for 7 days would be appropriate pending urine culture results, as antimicrobial treatment of UTIs in older people generally aligns with the treatment for other patient groups, using the same antibiotics and treatment duration unless complicating factors are present 1. The patient should be monitored closely for worsening confusion or new neurological symptoms, as the seizure-like episodes may be related to the UTI causing metabolic encephalopathy. Key considerations in management include:

• Ensuring adequate hydration
• Considering a urinary catheter if the patient has urinary retention
• Regular neurological assessments to monitor for improvement or deterioration
• Using the lowest effective dose of antipsychotic medication to minimize side effects, particularly in elderly patients. It is also important to assess for other causes of the patient's symptoms and carefully observe rather than immediately treating with antimicrobials, as recommended for older patients with functional and/or cognitive impairment with bacteriuria and delirium or falls without local genitourinary symptoms or other systemic signs of infection 1.

From the Research

Patient Presentation

The patient is an 87-year-old male presenting with seizure-like episodes and a urinary tract infection (UTI). He is confused, and his family is seeking help to calm him down and improve his sleep. The patient has no known allergies, and his blood pressure is stable at 121/64.

Relevant Studies

• The study 2 highlights the risk of ciprofloxacin-associated seizures, particularly in patients with underlying conditions such as thyrotoxicosis.
• Another study 3 reports a case of cefepime-induced encephalopathy in a patient treated for a urinary tract infection, emphasizing the need for caution when administering antibiotics.
• A review of the association between infections, seizures, and drugs 4 notes that various medications, including antibiotics, can cause CNS disturbances ranging from seizures to encephalopathy.
• A study on seizures and epilepsy in the acute medical setting 5 provides guidance on the presentation and management of patients with seizures.
• A clinical overview of epilepsy 6 emphasizes the importance of accurate diagnosis and treatment, as well as consideration of special situations such as status epilepticus and safety issues.

Potential Causes of Seizure-Like Episodes

• UTI: The patient's UTI may be contributing to his seizure-like episodes, as infections can cause CNS disturbances 4.
• Antibiotic use: The patient may be at risk of antibiotic-induced seizures or encephalopathy, particularly if he is taking medications such as ciprofloxacin or cefepime 2, 3.
• Underlying medical conditions: The patient's confusion and seizure-like episodes may be related to an underlying medical condition, such as thyrotoxicosis or another neurologic disorder 2, 6.