Epilepsy in older adults

A 75-year-old female is seen in the emergency department (ED) due to a subacute onset of severe back pain. The pain is centered in the mid-thoracic area of the back without radiation and is easily exacerbated by movement. She is an established patient and has a history of localization-related epilepsy with recurrent focal seizures. The seizures were caused by a previous stroke that occurred almost a decade ago. The typical seizure manifests as a generalized convulsion. In the past, they had been sporadic and had occurred in both the day and nighttime. The patient also reports persistent imbalance and a feeling of chronic dizziness. She has been adherent to her current dosage of phenytoin taken as directed by her neurologist. She is taking 300 mg per day with a recent serum level of 10 mg/dl. The patient had been on a higher dose of phenytoin in the past but complained that she experienced significant problems with her balance. In the ED, following clinical assessment, a radiograph of the thoracic spine was performed. The interpretation suggested a compression deformity in the appropriate area. An MRI is performed and reveals the following (Fig. 18.1):