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Chapter
Neurological emergencies in the elderly
18 Lauren M. Nentwich
Geriatric Emergency Medicine, ed. Joseph H. Kahn, Brendan G. Magauran Jr., and Jonathan S. Olshaker. Published by Cambridge University Press.
© Cambridge University Press 2014.
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Chapter 18: Neurological emergencies in the elderly
for arteriosclerosis and cardiac disease, and current medica- IV rt-PA, enrolled 44 patients with baseline age more than 80
tions, especially anticoagulants such as warfarin or dabigatran. (19 placebo and 25 IV rt-PA) [8,10]. Of the 25 patients ran-
In elderly patients presenting with fall and suspected stroke, it domized to IV rt-PA in this study, 4 experienced symptomatic
is important to obtain a history of trauma to the head, signii- intracranial hemorrhages within 36 hours of treatment, and
cant injury, or witnessed seizure. these older patients were 2.87 times more likely to experience
A rapid and thorough physical exam should be performed, a symptomatic intracranial hemorrhage within 36 hours when
including full vital signs, evaluation for any evidence of trauma compared with younger patients [10]. A follow-up study to the
or comorbidities, and a cardiac examination focusing on 1995 NINDS IV rt-PA trial that attempted to expand the hours
identifying concurrent myocardial ischemia, valvular condi- for treatment in AIS is the European Cooperative Acute Stroke
tions, irregular rhythm, or possible aortic dissection. A brief Study III (ECASS III), which treated patients with AIS with IV
but thorough neurological examination should be performed rt-PA within 3–4.5 hours ater the onset of stroke. Due to con-
and is enhanced by the use of a formal stroke score or scale, cern for increased risk of hemorrhagic complications, elderly
such as the National Institutes of Health Stroke Scale (NIHSS) patients of age greater than 80 years were excluded from enroll-
(Table 18.1). he NIHSS ensures that the major components ment in ECASS III [11]. Despite these apparent contradictions
of a neurological examination are performed in a timely fash- to treatment with IV rt-PA in elderly patients with AIS, mul-
ion, allows for rapid reassessment of the patient’s clinical sta- tiple studies have shown a beneit to thrombolysis with IV rt-PA
tus, and aids in facilitating communication between health care in patients older than 80 years who are treated within 3 hours
professionals. of symptom onset [9,12–14]. Given the current data, there is
Routine laboratory tests should be obtained in all patients no compelling reason to exclude elderly patients from receiv-
presenting with suspected AIS. A ingerstick blood glucose ing treatment with IV rt-PA if therapy can be started within 3
should be obtained on arrival, as hypoglycemia may cause hours of symptom onset. However, given the facts of increased
focal neurological signs and symptoms that mimic stroke. morbidity and mortality in elderly patients with AIS and the
Coagulation studies and platelets, especially in patients with increased risk of hemorrhagic complications, detailed discus-
concern for bleeding abnormality, thrombocytopenia, or sions should be held with the patient and family when decid-
coagulation use, are important as abnormal results will limit ing the proper course of treatment for older patients. hough
treatment. Given the increased incidence of cardiac arrhyth- IV rt-PA within 3 hours of symptom onset in elderly patients
mias and ischemia in the elderly, a 12-lead electrocardiogram is accepted treatment, current AHA guidelines do not recom-
(ECG), cardiac monitoring, and cardiac enzyme tests should be mend expanding the treatment window to 4.5 hours for elderly
performed in elderly patients with suspected AIS [5]. patients and do not endorse administering IV rt-PA to patients
An essential component in diagnosing AIS and diferen- older than 80 years outside of 3 hours of symptom onset [15].
tiating ischemic from hemorrhagic stroke is brain imaging
with either computed tomography (CT) or magnetic reson- Transient ischemic attack
ance imaging (MRI) (Figure 18.1). Imaging by CT or MRI is A transient ischemic attack (TIA) is deined as a transient epi-
necessary to exclude the presence of hemorrhage and may help sode of neurological dysfunction caused by focal brain, spinal
to guide therapy in patients with AIS. Non-contrast brain CT cord, or retinal ischemia, without acute infarction [16]. hough,
is typically the irst choice in imaging patients with suspected by deinition, the neurological dysfunction in patients sufer-
acute stroke due to its accuracy in excluding hemorrhage, ing a TIA is temporary, the risk of AIS ater TIA is high, par-
speed in acquisition, and general availability in most US EDs. ticularly in the irst few days. Up to 23% of all AIS are preceded
Additionally, many elderly patients have cardiac pacemakers by a TIA [17], and the pooled early risk of stroke ater TIA has
or certain ferromagnetic metallic implanted substances which been reported as 3.1–3.5% at 2 days, 5.2% at 7 days, 8.0% at
are absolute contraindications to undergoing MRI [6]. A full 30 days, and 9.2% at 90 days [18,19]. TIA incidence markedly
review of neuroimaging in AIS is beyond the scope of this chap- increases with increasing age, from 1–3 cases per 100,000 in
ter, but the American Heart Association (AHA) Guidelines rec- those younger than 35 years up to 600–1500 cases per 100,000
ommend that neuroimaging by CT or MRI in all patients with in those patients older than 85 years, making TIA an important
suspected AIS should be completed within 25 minutes of the disease in the geriatric population [16,20]. In addition to an
patient’s arrival to the ED and undergo expert interpretation increased stroke risk ater TIA, the risk of cardiac events is also
within 45 minutes of ED arrival [7]. elevated ater TIA, and equal numbers of patients with TIA will
Intravenous (IV) thrombolysis with recombinant tissue sufer a myocardial infarction or sudden cardiac death as will
plasminogen activator (rt-PA) is currently the only treatment have a cerebral infarction in the 5 years ater a TIA [21].
approved by the Food and Drug Administration for patients Given the high risk for early AIS ater TIA, elderly patients
presenting with AIS [8]. he beneit, safety, and frequency of presenting with symptoms suggestive of TIA should undergo
use of IV rt-PA in the elderly are uncertain. Elderly patients urgent triage and rapid evaluation by a physician. he diagno-
are at higher risk for stroke-related death and disability, which sis of TIA is clinical, and the history should focus on whether
makes them an important target group for acute treatment, but patients have abrupt onset of focal neurological deicits and the
they may also be at increased risk for hemorrhagic complica- duration of those symptoms [22]. Historical information may
tions from IV rt-PA [9]. he 1995 NINDS IV rt-PA trial, which be diicult to obtain from elderly patients, and family mem-
treated patients with symptoms of AIS less than 3 hours with bers or witnesses to the event should be interviewed to provide
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Adapted from National Institutes of Health, National Institute of Neurological Disorders and Stroke (accessed from http://stroke.nih.gov/resources/scale.htm).
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Chapter 18: Neurological emergencies in the elderly
clarifying or collaborating details. An accurate and full neuro- Non-traumatic intracranial hemorrhage
logical exam should be performed to determine whether base-
line neurological function has been restored, as a recent study Intracerebral hemorrhage
showed that one-quarter of patients referred to a same-day TIA Intracerebral hemorrhage (ICH) is deined as spontaneous,
clinic with reportedly resolved symptoms had persistent neuro- non-traumatic bleeding into the brain parenchyma [26]. ICH
logical deicits on the neurologist’s exam [23]. Auscultation of constitutes 10–15% of all irst-ever strokes and is a medical
the neck for carotid bruits and the heart for arrhythmias and emergency with a 30-day mortality rate of 35–52% and a high
valvular or structural heart lesions is also important. Routine morbidity rate, with only 20% of patients functionally inde-
laboratory testing, including a complete blood count, chemis- pendent at six months [27]. he incidence of ICH increases
try panel, and basic coagulation studies, is reasonable, though with increasing age, and the rate doubles each decade of life
oten low yield [16,22]. As the heart is a common source of ater 35 years of age [28]. Older age is an important risk fac-
emboli, cardiac evaluation is important in patients with TIA tor for ICH; additionally, other risk factors for ICH are oten
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endovascular specialists should be consulted to determine Table 18.2. Glasgow Coma Scale [87]
proper treatment of the aneurysm by either microsurgical clip- Score
ping or endovascular coiling depending on the characteristics
Best eye Spontaneous eye opening 4
of both the patient and aneurysm. hough the data are conlict-
response (E) Eye opening to verbal stimuli or
ing, some suggest that elderly patients older than 70 years of
command 3
age are ideal candidates for coiling rather than clipping [43].
Eye opening to pain 2
hough approximately 20 years ago, elderly patients sufering
No eye opening 1
an aSAH were treated conservatively on the basis of advanced
age alone and subsequently sufered a poor outcome, the man- Best verbal Oriented 5
response (V) Confused 4
agement of aSAH has considerably changed in recent years with
a more aggressive approach for elderly patients with improved Inappropriate words 3
results. If elderly patients are carefully selected, endovascular Incomprehensible speech 2
coiling or microsurgical clipping can lead to a positive outcome No verbal response 1
[41]. All patients with aSAH should be admitted to an ICU, Intubated T
preferentially a neurologic critical care unit, to optimize care Best motor Obeys commands 6
and monitor closely for common complications. Neurologic response (M) Localizing response to pain 5
complications are common ater aSAH and include symptom- Withdrawal response to pain 4
atic vasospasm, hydrocephalus, rebleeding, and seizures [40]. Flexion to pain (decorticate posture) 3
Due to their advanced age and resulting comorbidities, eld- Extension to pain (decerebrate
erly patients sufering an aSAH are at increased risk for both posture) 2
neurologic and general complications and should be moni- No motor response 1
tored closely [41]. Total score 3–15 (T)
Traumatic brain injury elderly patients as well as in those who have sufered moder-
Traumatic brain injury (TBI) is an important health problem ate to severe TBI. Abnormalities found on imaging of patients
in the US afecting about 1.5 million people per year with high who have sufered a TBI may include: skull fractures, diasta-
morbidity, accounting for approximately 1.2 million ED visits sis of the skull, intracranial hemorrhage (epidural hematoma,
and 220–290 thousand hospitalizations per year, and high mor- subdural hematoma, intracerebral hematoma, intraventricular
tality with approximately 50 thousand deaths per year. hough hemorrhage, brain contusion, traumatic subarachnoid hemor-
TBI rates are highest among infants and young children, TBI rhage), cerebral edema, pneumocephalus, traumatic infarction,
hospitalizations and death rates are highest among older adults and difuse axonal injury [47,48]. All patients with moderate
65 years of age and older, making TBI an important disease to severe TBI (GCS <13) should undergo immediate head CT
state in the elderly population [44]. Falls are the leading cause given a higher likelihood of abnormal indings on neuroimag-
of TBI for older adults, accounting for 51% of all geriatric TBI ing studies [47]. In adult patients with minor TBI (GCS 13–15),
patients, and motor vehicle accidents (both driver/passenger neuroimaging is generally recommended only for patients who
and pedestrians struck) are the second leading cause account- meet certain criteria, with older age being one of the most
ing for 9% [45]. Additionally, older age is associated with wors- important for ordering brain imaging. hree decision rules:
ening outcome ater TBI [46]. the Canadian CT Head Rule, the New Orleans Criteria, and the
TBI is caused by a high-energy acceleration or deceleration National Emergency X-Radiography Utilizations Study-II have
of the brain within the cranium or with penetration of the been derived to indicate which patients sufering a minor TBI
brain. It is classiied as either focal or difuse; focal injuries tend should undergo CT to most eiciently identify acute abnormal-
to occur at the site of impact with resulting focal neurologic ities on CT; elderly patients, age >60 or >65, are excluded from
deicits in those areas, whereas difuse shearing of axons may these decision rules due to a higher rate of acute intracranial
occur in the cerebral white matter, gray–white junction, cor- abnormalities in such patients [49–51]. Geriatric patients with
pus callosum, and/or brainstem causing both nonlateralizing blunt minor TBI are more likely to have an acute abnormality
neurologic deicits and/or focal deicits. TBI is oten classiied on head CT which may require neurosurgical intervention, and
by severity, which is usually based on the Glasgow Coma Scale liberal use of head CT is recommended in this patient popula-
(GCS) (Table 18.2). GCS evaluates best motor response, verbal tion [48,52]. It is generally recommended to obtain neuroim-
response, and eye opening in patients who have sufered acute aging in all elderly patients who sufer acute head trauma and
trauma. Mild TBI is deined as an isolated head injury with a sustain a TBI, regardless of the severity of the injury or the ini-
GCS score of 13–15. Patients with moderate TBI have a GCS tial clinical presentation.
score of 9–12. Severe TBI is deined as a patient who presents Ater sustaining a TBI, elderly patients tend to sufer worse
acutely with a GCS of 8 or less or any patient with an intracra- outcomes with higher mortality and worsened neurologic
nial contusion, hematoma, or laceration [47]. outcomes [53]. Elderly patients have twice the mortality of
Many young patients with TBI may have normal younger patients (30 versus 14%) and increased poor func-
head imaging with no acute abnormalities found on CT. tional outcome in survivors (13 versus 5%) [54]. he mech-
Abnormalities on brain imaging are much more common in anism by which advanced age is an independent predictor
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threshold for trauma activation should be used for elderly brain shit. Neuroimaging should precede LP in patients with:
trauma patients who are evaluated at trauma centers and for new-onset seizures, immunocompromised state, signs suspi-
transferring older patients at acute care hospitals without a cious for space-occupying lesions including papilledema, or
dedicated trauma service to designated trauma centers for their moderate-to-severe alteration in level of consciousness. Best
care [59]. practice dictates that if neuroimaging is performed before LP,
Adequate IV access should be obtained and proper labs antibiotic therapy should be initiated before the patient is sent
sent, especially a complete blood count and coagulation param- for neuroimaging [65].
eters, to assess for any potential coagulopathy that needs to be he predominant bacterial organisms found in eld-
reversed [57]. Warfarin-related coagulopathy, which is more erly patients with community-acquired bacterial meningi-
common in the geriatric population, increases the risks of post- tis include: Streptococcus pneumoniae, Neisseria meningitidis,
injury hemorrhage. All elderly patients with suspected head and Listeria monocytogenes. As such, empiric antibiotic ther-
injury on anticoagulants should be evaluated by head CT as apy that should be started in elderly patients prior to knowing
soon as possible ater ED arrival. In elderly patients on warfarin the organism from Gram stain or culture is vancomycin plus
with intracranial bleeding, the INR should be rapidly corrected a third-generation cephalosporin plus ampicillin. Additionally,
to a value of less than 1.6 with IV vitamin K and FFP or PCCs. due to a proven mortality beneit, adjunctive dexamethasone
Depending on their injuries and clinical status, patients should therapy should be initiated in patients with suspected bacterial
be admitted to the intensive care unit or trauma service [59]. meningitis before or with the irst dose of antibiotics [65,66].
Admission to the hospital is recommended for all patients with
suspected bacterial meningitis, and respiratory isolation for 24
CNS infections hours is indicated for patients with suspected meningococcal
Infections in the elderly are typically more frequent and more infection [65].
severe than in younger patients and are associated with wors- Advanced age is associated with unfavorable outcome in
ened outcome. Additionally, in this population, infection tends patients with bacterial meningitis [67], and complications are
to have a more subtle presentation with fewer symptoms. Fever, more likely to occur in older patients than younger patients
a cardinal sign of infection in younger patients, is absent or [64]. Early recognition and treatment are important to reduce
blunted in 20–30% of severe infections in the elderly. he most the high morbidity and mortality of infectious diseases in older
common signs of infection in the elderly are very nonspeciic, adults, and bacterial meningitis is always a medical emergency
such as falls, delirium, anorexia, or generalized weakness [60]. [63]. In addition, although this section addresses community-
his is true of most infections in the elderly, but particularly acquired bacterial meningitis in older patients, nosocomial
infections of the CNS. Two important CNS infections to be meningitis is a distinct disease that should also be considered
aware of in elderly adults are meningitis and spinal epidural in the elderly patient, especially those presenting with fever and
abscess. altered level of consciousness with a history of neurosurgery, a
distant focus of infection, or following penetrating trauma or
Community-acquired bacterial meningitis basilar skull fracture [62,66].
With the success of the Haemophilus inluenzae type b (Hib)
and pneumococcal vaccines, the rates of bacterial meningitis Spinal epidural abscess
have decreased over the past 15 years. he age group with the Spinal epidural abscess (SEA) represents the accumulation of
highest incidence of bacterial meningitis in the US is children purulent material in the space between the dura mater and
less than 2 years, but elderly patients aged 65 years and above the osseo-ligamentous conines of the vertebral canal. It is an
comprise the group with the second highest incidence of bac- uncommon disease with a relatively high rate of morbidity
terial meningitis with 1.92 cases per 100,000 people in 2006– and mortality and prognosis that is oten determined by early
2007. In addition to being more common in older patients, diagnosis and initiation of appropriate therapy [68]. SEA is a
bacterial meningitis causes increased mortality in geriatric diicult diagnosis to make in general as most patients do not
patients with an overall mortality rate that increases linearly present with the classic triad of back pain, fever, and neuro-
with age (8.9% in patients 18–34 years versus 22.7% in patients logical deicit, and misdiagnosis and delayed diagnosis is com-
over 65 years) [61]. mon [69]. A dangerous infection that is more common in
Elderly patients with bacterial meningitis may present with elderly patients, diagnosis of SEA in the geriatric population is
a myriad of symptoms, including: fever, altered mental sta- further complicated by the fact that elderly patients frequently
tus, neck stifness, headache, seizure, shock, or focal neuro- present to the ED with back pain from degenerative disease
logic abnormalities. Neck stifness and headache are found [70]. Most patients with SEA have one or more predisposing
to occur less frequently in older people, and a much larger conditions, and many of these conditions are common in eld-
proportion of elderly patients presented with altered mental erly patients, including: underlying diabetes mellitus or alco-
status or focal neurological abnormalities [62–64]. If bacter- holism, a spinal abnormality such as degenerative joint disease
ial meningitis is suspected, LP is indicated. Due to the risk of or trauma, spinal intervention such as surgery, placement of
brain herniation as a complication of diagnostic LP in select stimulators or catheters, or a potential source of infection such
patients with bacterial meningitis, neuroimaging by CT or as skin and sot-tissue infections, osteomyelitis, urinary tract
MRI prior to LP is recommended in selected patients to detect infection, sepsis, indwelling vascular access, epidural analgesia,
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Chapter 18: Neurological emergencies in the elderly
or nerve block [71]. Additionally, though the disease can afect the abscess. Myelography followed by CT is useful when MRI
any age group, SEA seems to have increased in incidence over is contraindicated, but it is less speciic than MRI and cannot
the past 25 years and one of the potential reasons is thought to distinguish SEA from other lesions that compress the thecal
be aging of the general population [68]. sac [68].
In SEA, the spinal cord is injured by the infection either Emergent surgical depression and drainage of the abscess,
directly by mechanical compression or indirectly as a result together with systemic antibiotics is the treatment of choice for
of vascular occlusion caused by septic thrombophlebitis. An the vast majority of patients diagnosed with SEA. Since the pre-
established staging system by Heusner outlines the progres- operative neurologic function is the most important predictor
sion of symptoms of SEA: stage 1, back pain at the level of of inal outcome and the rate of progression of neurologic
the afected spine; stage 2, nerve root pain radiating from the impairment is diicult to predict, decompressive surgery and
involved spinal area; stage 3, motor weakness, sensory def- debridement of infected tissues should be performed as soon as
icit, and bladder and bowel dysfunction; and stage 4, paralysis possible ater diagnosis. Immediate consultation with a spine
[71,72]. he most common presenting symptoms include back surgeon is necessary, and hospitals without qualiied spine sur-
pain (present in about 70–90% of patients), fever (documented geons should immediately transfer the patient to an appropriate
in 60–70% of patients), and neurological dysfunction (noted spine center. Pending results of the cultures, empiric antibiotic
in approximately 33–70% of patients). Other complaints in therapy should provide coverage of the most common causa-
patients presenting with SEA may include paravertebral mus- tive organisms (i.e., Staphylococcus and Streptococcus spp.),
cle spasm, limited spinal motion, paresthesias, weakness, and with additional coverage for Gram-negative organisms espe-
diiculty ambulating [68,71]. cially in patients who are immunocompromised, have a history
Diagnosis of SEA is suspected on the basis of clinical ind- of IV drug abuse, or have had recent infection or manipulation
ings and supported by laboratory data and imaging studies. of the genitourinary tract [68,70,71].
Leukocytosis is only detected in about two-thirds of patients, Of patients diagnosed with SEA, 10–23% die due to the
but inlammatory markers (erythrocyte sedimentation rate and disease process [68]. Of those who survive, irreversible paraly-
C-reactive protein) are almost uniformly elevated. Bacteremia sis is the most feared complication of SEA afecting 4–22% of
as the cause of or arising from SEA is detected in about 60% all patients. he single most important predictor of the inal
of patients, and can provide identiication of the causative neurologic outcome is the patient’s pre-surgical neurologic sta-
pathogen [71]. When SEA is suspected, gadolinium-enhanced tus [71]. Diagnostic delays oten lead to irreversible neurologic
MRI of the spine should be obtained emergently (Figure 18.5), deicits [73], and a high index of suspicion is required to make
as this imaging modality is highly sensitive and highly spe- the diagnosis, especially in elderly patients.
ciic and can accurately delineate the extent and location of
Seizures
New seizures
Nearly 25% of irst epileptic seizures occur in patients who are
60 years of age or older [74], and the geriatric population has a
higher incidence of new-onset seizures and epilepsy than any
other age group [75]. he causes, clinical presentations, and
prognosis of irst seizures in elderly patients difer from those in
younger patients, afecting the acute work-up and management
in older patients. New seizures may be either the result of acute
symptomatic seizures (deined as provoked seizures occurring
at the time of a systemic insult or in close temporal associ-
ation with a documented brain insult) or unprovoked seizures
(deined as seizures occurring in the absence of precipitating
factors and may be caused by a static or progressing injury).
Unprovoked seizures may be single or recurrent, and epilepsy
is deined as at least one unprovoked seizure in the presence of
an enduring predisposition to further seizures. Both types of
new seizures predominate in the very young (less than 1 year of
age) and the elderly [76,77]. However, there is usually a cause
for seizure found in elderly patients, and almost no idiopathic
epilepsies start in patients over 60 years of age [78].
Approximately 25% of elderly patients who sufer a seizure
have seizures of unknown etiology. Known etiological factors of
seizures in elderly patients include: stroke and cerebrovascular
Figure 18.5. T2-weighted MRI of a spinal epidural abscess within the disease, intracranial hemorrhage, head injury, infection, brain
posterior spinal canal centered at L4–L5. tumor or vascular malformation, neurodegenerative disorders
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(i.e., Alzheimer’s dementia), neuropsychiatric disorders (i.e., treatment as indicated [76,81]. Due to frequent comorbidities,
depression, anxiety), toxic and metabolic abnormalities, and the changed physiology of elderly patients, and the interac-
normal aging [75,76,79]. Diagnosing seizures and epilepsy in tions with concomitant medications, the decision on whether
the elderly is diicult due to the subtle manifestations of par- to start anti-epileptic drug treatment in the elderly patient is
tial seizures, as well as the presence of age-related cognition complicated and should be made only ater consultation with
diiculties, comorbid conditions, and medications. hough a neurologist and an extensive discussion with the patient and
generalized tonic–clonic seizures are more easily diagnosed, family about the risks and beneits. Anti-epileptic medications
complex partial seizures in the elderly are a more elusive diag- with a more favorable proile in elderly patients include: lev-
nosis [76]. Most new seizures in elderly patients are partial in etiracetam, pregabalin, lamotrigine, and oxcarazepine [78,82].
onset, with or without secondary generalization [80]. Complex Many elderly patients require smaller doses than younger
partial seizures in the elderly may manifest as simple motor patients, and adverse efects may be minimized by starting with
or sensory symptoms, memory lapses, episodes of confusion, a lower dose and titrating slowly [78]. Elderly patients seem
periods of inattention, apparent syncope, or a blank stare with to respond better to treatment with anti-epileptic medications
transient disturbance of consciousness [76,81]. Oten seizures than younger patients, and up to 80% of patients with seizure
in the elderly are misdiagnosed as altered mental status, con- onset in old age remain seizure free on anti-epileptic medica-
fusion, or syncope, and a high degree of suspicion for seizure tion, though treatment is generally lifelong [82].
should be maintained in elderly patients presenting with these
symptoms [76]. In almost half of all elderly patients who are Status epilepticus
ultimately diagnosed with epilepsy, epilepsy is not the initial Although exact deinitions vary, status epilepticus (SE) is typ-
suspected diagnosis [78]. ically deined as seizures that persist for 20–30 minutes, which
Work-up of irst seizures in the elderly can be diicult and is the estimated time to cause injury to CNS neurons. However,
time intensive. A reliable history and a witnessed event by an given that physicians should not wait 20–30 minutes prior to
observer are invaluable in making the diagnosis, but may not treating a patient with seizure, an operational deinition of SE
always be available as many elderly live alone and may remem- is continuous seizures persisting for at least ive minutes or
ber little or nothing about the event. In the elderly, many dis- two or more discrete seizures between which there is incom-
orders may mimic or co-exist with seizure activity, and the plete recovery of consciousness. SE is a medical emergency
diferential diagnosis is broad, including: cardiac arrhythmias, with a high mortality rate of approximately 20% and should
transient global amnesia, transient ischemic attacks, migraine, be intervened upon rapidly [83]. SE can be classiied according
hypoglycemia, hyperglycemic non-ketotic states, hyponatremia, to clinical spectrum, type of seizure (convulsive versus non-
orthostatic hypotension, carotid sinus sensitivity, adverse drug convulsive), or on the basis of EEG features (partial versus gen-
efects, and vasovagal episodes. Electrocardiogram with cardiac eralized) [84]. Up to 30% of acute seizures in elderly patients
monitoring, full vital signs including orthostatic vital signs, and present as SE, with an associated higher mortality rate of up to
full laboratory testing including thyroid-stimulating hormone 50% [78,82,84]. Additionally, in the elderly, partial SE with sec-
can help to diferentiate these disorders from seizure [78,81]. ondary generalization is the most common presentation, fol-
Brain imaging with head CT or MRI is recommended in eld- lowed by partial, and then generalized tonic–clonic [84].
erly patients presenting with new seizure, as there is a high In older patients, SE is usually caused by stroke, hypoxia,
rate of abnormalities found in this patient population and an metabolic insults, and low anticonvulsant drug concentra-
identiied intracranial lesion may elucidate the etiology of the tions. When an elderly patient presents in SE, general acute
seizure [78,82]. MRI is more sensitive than CT for detection of treatment actions should be taken, including: monitoring and/
relevant anatomical abnormalities [81], but may be diicult to or establishing an airway, monitoring vital signs and oxygen-
obtain in elderly patients especially if they are unstable or have ation, obtaining IV access, measuring blood glucose levels,
altered mental status. Abnormalities found on brain imaging and checking basic laboratory studies including anti-epileptic
more commonly in elderly patients can include: strokes, small drug levels. here is no established protocol for the manage-
vessel disease, cerebral atrophy, encephalomalacia, or tumor ment of SE in elderly patients, but treatment generally follows
[78,82]. Electroencephalography (EEG) is less speciic and sen- the widely accepted guidelines for all adults presenting with
sitive than neuroimaging in the evaluation of elderly people SE. Benzodiazepines (e.g., lorazepam, diazepam) are typically
with seizure. With advancing age, 12–38% of patients develop irst-line agents for aborting SE as they have rapid onset and
EEG abnormalities in the absence of a seizure and fewer elderly are efective for all seizure types. Phenytoin or fosphenytoin
patients with seizures have abnormal interictal EEGs [78]. should be administered immediately ater benzodiazepines
Treatment for provoked seizures should be directed toward when seizures persist or even when they have been aborted; it
the underlying cause [81]. In general, a irst, single unprovoked is important to monitor the ECG and BP in the elderly when
seizure is not considered epilepsy and treatment with an anti- giving these medications [84]. Valproate or levitiracetam may
epileptic medication is usually not recommended. However, in also be considered as an alternative to IV phenytoin/fospheny-
the older patient, a irst, unprovoked seizure carries a higher toin or in addition to phenytoin/fosphenytoin if the seizure is
risk for recurrent seizures than in younger adults, and any not halted by the initial medications.
elderly patient with a new-onset seizure should be rapidly If SE continues despite treatment with benzodiazepines
referred to an epilepsy specialist for evaluation and initiation of and one anti-epileptic drug, it is considered refractory status
180
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Chapter 18: Neurological emergencies in the elderly
epilepticus (RSE), and mortality for RSE is about three times or absent in 20–30% of geriatric patients with severe
higher than for non-refractory SE. In general, anesthetic infection.
agents such as pentobarbital, midazolam, or propofol are rec- • New-onset idiopathic epilepsy in patients over 60 years
ommended for patients in RSE. Patients in RSE who receive of age is extremely rare, and all elderly patients with new
these agents will require intubation. hese patients should also seizure should undergo a thorough evaluation to identify
undergo an urgent neurology consult for further management a cause.
and treatment for continued seizures [84–86].
Non-convulsive status epilepticus (NCSE) is characterized
by a clinically evident alteration in mental status or behavior
Pitfalls
from baseline, without signs of convulsions, lasting at least • Delaying immediate work-up, including neuroimaging
30 minutes, with a pattern of seizure activity on the EEG that and neurology consultation, of a patient sufering a
disappears with the treatment and recovery of consciousness. transient ischemic attack, given the high risk of acute
Elderly patients in NCSE oten present with no convulsive ischemic stroke in the days and months following a
activity or less apparent clinical manifestations that go unrecog- transient ischemic attack.
nized [84]. NCSE is particularly diicult to diagnose in elderly • Failure to rapidly reverse warfarin-associated
patients and should be considered in patients with unexplained coagulopathy and treat severe hypertension in patients
coma or prolonged confusional state, even if there is no past sufering an intracerebral hemorrhage.
history of epilepsy. Due to the lack of motor indings, diagnosis • Failure to obtain expert consultation regarding the
is oten delayed. Altered mental status is a key feature of NCSE, consideration of endovascular coiling or microsurgical
and an early high degree of suspicion and early EEG is required clipping in elderly patients sufering an aneurysmal
for prompt recognition, especially in elderly patients [82]. It is subarachnoid hemorrhage.
important to consider an EEG in the evaluation of acute mental • Failing to consider intravenous recombinant tissue
and behavioral changes in the geriatric population [78,84]. plasminogen activator in elderly ischemic stroke
patients within 3 hours of symptom onset simply due to
Conclusion advanced age.
Neurological emergencies are common in the geriatric popula- • Not obtaining neuroimaging in elderly patients greater
tion. Due to the physiologic changes of aging as well as increased than 60 years of age who sufered a minor traumatic
comorbidities in elderly patients, neurological diseases in geri- brain injury and potentially missing an acute intracranial
atric patients are generally more diicult to diagnosis and man- abnormality.
age and are associated with increased morbidity and mortality • Failure to consider spinal epidural abscess in elderly
than in younger patients. When caring for older patients with patients presenting with back pain, especially if these
suspected neurological emergencies, it is important to maintain patients have a fever, potential infectious source or
a high degree of suspicion and obtain urgent expert consult- comorbid diabetes, spinal abnormality, or prior spinal
ation in order to provide geriatric patients with the best possible intervention.
care and ofer them the best chance for a positive outcome.
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