Protracted ictal confusion in elderly patients

Background: Ictal confusion, particularly if protracted, often presents a diagnostic challenge. Objectives: To define protracted ictal confusion in elderly patients and to characterize its features and outcome. Design: Case series. Setting: Neurology outpatient and emergency departments at 2 tertiary care centers. Patients: Consecutive series of 22 ambulatory patients with acute ictal confusion. Main Outcome Measures: Duration of ictal confusion was correlated with age and lesions noted on cerebral images and videoelectroencephalographic studies. Results: The ictal basis underlying confusion was not recognized for up to 5 days in 22 patients (mean±SD age, 70±8.5 years). Twenty patients had partial complex status epilepticus, and 2 patients had newly diagnosed primary generalized status epilepticus. Motor movements were not present in either group, although reduced mood states and ictal neglect were noted in some patients. Fifteen patients had previous episodes (2-10) of protracted ictal confusion. Once identified, treatment reversed confusion, and eventually patients were discharged to home, although a few patients sustained persistent reduction in baseline cognition. Conclusions: Protracted ictal confusion is often not considered in the ambulatory elderly patient, with resulting delay in diagnosis. Electroencephalographic and videoelectroencephalographic studies performed while the patient is experiencing symptoms are crucial to early diagnosis and timely management.