Status epilepticus in the elderly: differential diagnosis and treatment

Figures & data

Table 1 Available evidence for the initial pharmacologic management of status epilepticus

Author	N	Interventions	Outcome measures	Results	Comments
Alldredge et al^Citation11	205	IV diazepam (5 mg) vs IV lorazepam (2 mg) vs placebo	Termination of status, respiratory or circulatory complications	BZDs are safe and effective, lorazepam more effective than diazepam	Class I. Pre-hospital treatment of SE in adults
Leppik et al^Citation12	81	IV lorazepam (4 mg) vs IV diazepam (10 mg) with repeat dosing if needed	Termination of status, adverse effects	89% success with lorazepam, 76% with diazepam, no significant difference in adverse effects	Class II.
Treiman et al^Citation13	518	IV diazepam (0.15 mg/kg) + PHT (18 mg/kg) vs lorazepam (0.1 mg/kg) vs PHB (15 mg/kg) vs PHT (18 mg/kg)	Termination of status within 20 min of drug infusion and no return of seizure activity during next 40 min	Lorazepam superior to PHT in GCSE. No difference among drugs in NCSE.	Class I. No significant difference in lorazepam vs diazepam + PHT or lorazepam vs PHB, but lorazepam easier to use
Misra et al^Citation14	68	IV VPA (30 mg/kg) vs IV PHT (18 mg/kg)	Clinical seizure cessation after infusion and seizure freedom at 24 h	VPA was more effective than PHT in controlling GCSE, both as the first (66% vs 42%) and second choice (79% vs 25%)	Class III. Excluded NCSE, included children and adolescents, underpowered
Gilad et al^Citation15	74	IV VPA (30 mg/kg) vs IV PHT (18 mg/kg)	Clinical seizure cessation, drug tolerability	VPA effective in 87.8% and PHT effective in 88%. Side effects occurred in 12% of PHT group and none in VPA group.	Class III. Underpowered
Agarwal et al^Citation16	100	After failure of control with diazepam, IV VPA (20 mg/kg) vs IV PHT (20 mg/kg)	Termination of status within 20 min of drug infusion and no return of seizure activity during next 12 h	VPA effective in 88%, PHT in 84%.	Class III. 30% of patients were < 18 years old

Abbreviations: N, number of participants; IV, intravenous; BDZ, benzodiazepine; SE, status epilepticus; NCSE, nonconvulsive status epilepticus; GCSE, generalized convulsive status epilepticus; PHT, phenytoin; PHB, Phenobarbital; VPA, valproic acid.

Table 2 Treatment algorithm for status epilepticus in the elderly

Step 1 (0–5 minutes) Assess airway, apply oxygen and pulse oximetry Begin cardiac telemetry and hemodynamic monitoring Venipuncture to secure access with 2 large-gauge intravenous catheters Stat blood work: basic metabolic panel, liver function tests, calcium, magnesium, phosphate, complete blood count, toxicology screens, troponin, arterial blood gas, and antiepileptic drug levels if appropriate Check finger-stick glucose Begin normal saline drip Step 2 (6–10 minutes) Administer 100 mg thiamine IV Administer 50 mL of 50% dextrose IV if hypoglycemic, but withhold if normoglycemic Administer 0.1 mg/kg IV lorazepam (< 2 mg/min) ○ If seizures persist, may repeat initial dose of lorazepam once ○ Beware of sedation, respiratory depression, and hypotension If no IV access, consider rectal diazepam 10–20 mg ○ If seizures persist, may repeat initial dose of diazepam once ○ Beware of sedation, respiratory depression, and hypotension Step 3 (11 to 30 minutes) Administer 20 mg PE/kg IV fosphenytoin (< 150 mg PE/min) or IV 20 mg/kg phenytoin by slow push (< 50 mg/min) ○ Fosphenytoin ■ Beware of cardiac depression and arrhythmia, hypotension, parasthesias, and pruritis ■ Fosphenytoin is more expensive but can be infused at a faster rate, has a lower risk of peripheral infusion-site complications, and is compatible with glucose-containing IV fluids ○ Phenytoin ■ Beware of cardiac depression and arrhythmia, hypotension, infusion site soft tissue, and vascular injury (“purple-glove syndrome”) ■ Incompatible with glucose-containing solutions Monitor respiratory status, cardiac rhythm, and blood pressure and be prepared to adjust dosages and rates accordingly If seizures persist, give additional IV fosphenytoin or phenytoin to a maximum total dose of 30 mg/kg Step 4 (31–50 minutes) If seizures persist, order urgent EEG and neurologic consultation and transfer patient to intensive care unit Initiate intubation before using an anesthetic agent Consider using one of the following: ○ IV phenobarbital 20 mg/kg slow push (< 100 mg/min) ■ Then continuous infusion at 1 mg/kg/h to 4 mg/kg/h ■ Beware of respiratory and cardiac depression, prolonged sedation, allergy, and blood dyscrasias ■ Contraindicated in severe liver dysfunction ○ IV pentobarbital 5 mg/kg (< 50 mg/min) ■ Then continuous infusion at 0.5 mg/kg/h to 5 mg/kg/h ■ Beware of respiratory depression, sedation, and hypotension ○ IV midazolam 0.2 mg/kg (given over 20–30 seconds) ■ Dose may be repeated in 5 minutes if seizures persist ■ Then continuous infusion at 0.05 mg/kg/h to 2.0 mg/kg/h ■ Beware of respiratory depression, sedation, and hypotension ○ IV propofol 1 mg/kg bolus ■ May give repeated boluses every 3–5 minutes to a maximum dose of 10 mg/kg ■ Beware of sedation, hypotension, bradycardia, allergic reaction, and “propofol infusion syndrome” at high doses (metabolic acidosis, cardiac failure with dysrhythmia, rhabdomyolysis, hyperkalemia, and lipemia) ■ Monitor acid base status ■ Continuous infusion involves a large lipid and caloric load Non-sedating alternatives include: ○ IV valproate bolus of 25 mg/kg to 30 mg/kg (< 3 mg/kg/min) ■ Not FDA approved for SE ■ May be useful in patients who are awake, patients with primary generalized epilepsy, or in situations where intubation is to be avoided ■ Beware of dizziness, hyperammonemia, hypotension, hepatotoxicity, thrombocytopenia, and pancreatitis ■ Contraindicated in severe liver dysfunction, thrombocytopenia, and active bleeding ■ Monitor liver profile, amylase, lipase, and complete blood cell count ○ IV levetiracetam 20 mg/kg over 15 minutes ■ Not FDA approved for SE ■ May be useful in patients who are awake, patients with primary generalized epilepsy, patients with liver disease, or situations in which intubation is to be avoided ■ Beware of neuropsychiatric side effects ■ Dose must be lowered in those with impaired creatinine clearance ○ IV lacosamide ■ Not FDA approved for SE Step 5 If seizures persist, maintain continuous IV infusion of anesthetic agents and titrate dose to desired level of EEG suppression-burst as determined by the neurology consultant Defer to neurology consultant for choice of maintenance antiepileptic drug and appropriate dosing

Adapted with permission from Waterhouse E. Status epilepticus. Continuum Lifelong Learning Neurol. 2010:16(3):199–227.⁸

Abbreviations: SE, status epilepticus; PE, phenytoin equivalents.

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