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Original Contribution
April 2006

Protracted Ictal Confusion in Elderly Patients

Author Affiliations

Author Affiliations: Departments of Neurology, University of Wisconsin–Madison (Drs Sheth and Hermann and Dr Gidal) and Mayo Clinic, Scottsdale, Ariz (Drs Drazkowski and Sirven).

Arch Neurol. 2006;63(4):529-532. doi:10.1001/archneur.63.4.529

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.