As with younger patients, the most useful history is that provided by the patient, supplemented by a reliable observer for any period during which the patient was unconscious or confused.

To evaluate a possible first seizure in seniors, it is critical to inquire about:

  • ongoing illnesses
  • medications
  • position and activities at the time of the event
  • nature and rate of onset of symptoms
  • skin color changes
  • motor activity
  • duration of ictal and postictal periods, if identifiable

Other elements of the patient's history that should be elicited include:

  • any prenatal or perinatal difficulties
  • febrile seizures in childhood
  • staring spells or myoclonus in childhood or adolescence
  • inflammatory, vascular, or neoplastic disease
  • head trauma

Examination and testing

Physical and neurologic examinations should address mainly the issues of cardiovascular function, metabolic-endocrine status, and prior neurologic insults.

In emergencies, metabolic studies (electrolytes, calcium, magnesium, glucose, renal and liver function tests), a toxicology screen, and a complete blood count should generally be performed. If symptoms or signs of infection are present, a lumbar puncture should be done, generally after a neuroimaging procedure. Noncontrast computed tomography (CT) is adequate to rule out hemorrhage or a large mass lesion.

In non-emergencies, MRI is indicated because of its high sensitivity to potentially treatable structural lesions, particularly small neoplasms.


Electroencephalography is a noninvasive, relatively inexpensive test that can:

  • provide additional data to support or refute the seizure diagnosis
  • help confirm the relevance of a minor structural lesion
  • demonstrate focality when no localizing findings are seen on examination or neuroimaging
  • raise the possibility of late presentation of a primary generalized disorder (rarely)

In the acute setting, if full recovery does not follow promptly after the seizure apparently terminates, EEG is necessary to rule out ongoing nonconvulsive status epilepticus.53

The EEG usually need not be obtained immediately, but the yield of interictal epileptiform discharges and diagnostic postictal slowing is maximal if the test is done soon after the event. In some situations, such as if encephalitis is suspected, the EEG can be crucial to early diagnosis.54

Epileptiform findings on EEG—particularly periodic lateralized epileptiform discharges—are also highly predictive of the development of seizures after stroke even if no seizures have been observed.55

If diagnosis remains uncertain or frequent events are occurring despite treatment, long-term video-EEG monitoring, perhaps with additional ECG and polysomnography, is indicated.

The electroencephalographer must be familiar with the effects of normal aging on the EEG, particularly temporal slowing, which is often asymmetric (L > R), and with normal variants that could be mistaken for epileptiform abnormalities.54-56

Adapted from: Bromfield EB. Epilepsy and the elderly. In: Schachter SC, Schomer DL, eds. The comprehensive evaluation and treatment of epilepsy. San Diego, CA: Academic Press; 1997. p. 233-254.
With permission from Elsevier (www.elsevier.com).

Authored By: 
Edward Bromfield MD
Steven C. Schachter MD
Donald L. Schomer MD