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Clinical  Management  Issues   2011; 5(1) 15

Clinical Management Issues

trauma; y
metabolic disorders; y
endocrine abnormalities; y
cerebrovascular accidents; y
seizure. y
Confusion and altered mental status are 

common problems in ED, and ictal con-
fusion, particularly if protracted, is often a 
diagnostic challenge. Behavioural and men-
tal state disturbances are common but often 
challenging problems in elderly patients, 
because seizures may present with nuances 
that are unique to this age group.

Nonconvulsive status epilepticus (NCSE), 
an important, and reversible cause of acu-
te confusion, is a possible explanation and 
probably is frequently missed. The elderly 
patient with altered mental status pose a dif-
ficult diagnostic challenge to the emergen-

IntroduCtIon

Altered mental status (AMS) in the el-
derly have numerous causes with signifi-
cant morbidity and mortality. In fact elderly 
patients usually suffer from comorbidities, 
and require more time and resources than 
younger ones.

The Emergency Department (ED) is the 
interface between community and health 
care institution, and AMS, being a complex 
symptom, is one of the major challenge for 
the emergency physician.

The first step consists in the patient eva-
luation, aimed at determining the cause of 
the complaints. The differential diagnosis 
for altered mental status is broad and in-
cludes:

toxins; y
infections; y

Corresponding author
Dr. Rocco Galimi
Department of Neurology
AOVV, Presidio 
Ospedaliero di Sondalo
Via Zubiani 33 
23039 Sondalo (SO)
glrocco@tiscalinet.it 

Gestione clinica

Abstract
In the elderly, new onset of epilepsy is often associated with vague complaints such as confusion, 
altered mental status, or memory problems. The absence of clinically apparent convulsions in 
association with an electroencephalogram showing continuous or recurrent seizure activity has 
been called nonconvulsive status epilepticus (NCSE). The purpose of this article is to describe the 
clinical and electroencephalographic features of NCSE in older adults. NCSE is an important, 
under-recognised and reversible cause of acute prolonged confusion. Although attempts have been 
made to define and classify this disorder, there is no universally accepted definition or classification 
yet that encompasses all subtypes or electroclinical scenarios. A urgent electroencephalogram is 
considered as the method of choice in the diagnostic evaluation of NCSE. Further researches 
are needed to better define NCSE.

Keywords: altered mental status, non-convulsive status epilepticus, absence status epilepticus, 
complex partial status epilepticus, elderly patient
Alterazione acuta dello stato mentale nell’anziano: lo stato epilettico non-convulsivo e il ruolo 
del Dipartimento di Emergenza
CMI 2011; 5(1): 15-25

1 Department of Neurology, 
Ospedale della Valtellina 
e della Valchiavenna. 
Presidio Ospedaliero di 
Sondalo

Rocco Galimi 1

Sudden altered mental state in 
the elderly: nonconvulsive status 

epilepticus and the role of the 
Emergency department



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Clinical  Management  Issues   2011; 5(1)16

Sudden altered mental state in the elderly

is a medical and neurological emergency 
that has been associated with significant 
morbidity and mortality. SE seems to occur 
more frequently in individuals older than 
60 years, and the morbidity and mortality 
of SE are significantly greater in this age 
group.

On the basis of another widely used clas-
sification, based solely on the presence or 
absence of convulsions, SE can be divided, 
from an operational and clinical viewpoint, 
into two main entities (Figure 1):

convulsive SE (CSE); y
non-convulsive status epilepticus (NCSE). y
NCSE is characterised by behavioural or 

cognitive change from baseline for at least 
30 minutes with EEG evidence of seizures. 
The main categories of NCSE are:

complex partial status epilepticus (CPSE); y
absence status epilepticus (ASE). y
Sustained or recurrent change from ba-

seline behaviour or mental status should be 
clinically evident. A physician unfamiliar 
with this kind of patients may not be able 
to differentiate baseline cognitive and beha-
vioural functions from ictal behavioural and 
mental state changes. As previously under-
lined, the detection of this disease may be 
particularly arduous in elderly subjects, and 
therefore, a high level of suspicion is essential 
to obtain an early diagnosis. NCSE is the 
ultimate condition in which the disciplines 
of neurology and psychiatry meet and, at 
times, overlap. Diagnosis is often delayed 
and mistaken for delirium, stupor, or other 
causes of confusion.

cy physician, especially in case of a patient 
with cognitive impairment at baseline (e.g., 
mental retardation or dementia) or with a 
previous history of psychiatric disorders. 
Knowing a patient’s baseline mental status 
is helpful (i.e., obtain this information when 
appropriate if cross-covering). In fact at least 
25% of all ED patients older than 65 years 
have some form of altered mental status.

As the population ages, the elderly will 
comprise a higher proportion of patients 
overall. The prevalence of epilepsy is 1% in 
individuals older than 60 years old and in-
crease with advancing age [1]. Nonetheless, 
epidemiological studies have revealed that 
epilepsy is most common among persons 
aged 75 and older [2,3].

The differential diagnosis of any person 
presenting with a sudden change in mental 
status should include epilepsy. Most epi-
leptic seizures in the elderly are partial with 
secondary generalisation. The clinical mani-
festations of seizures in the elderly may be 
different from those in younger adults and 
should be differentiated from other medical 
conditions that cause episodic spells.

One of the most serious complications of 
epilepsy is status epilepticus (SE).

SE can be defined as «continuous seizure 
activity longer than 30 minutes or two or 
more sequential seizures without full reco-
very of consciousness between the seizures». 
Elderly patients with SE often demonstrate 
either no convulsive activity or only mini-
mal motor movements that are often easily 
overlooked, or exhibit only a blunting of 
consciousness rather than frank coma. SE 

Figure 1
Classification of status 
epilepticus based on the 
presence or absence of 
convulsions

Status epilepticus (SE)
Situation longer than 30 minutes of continuous 
seizur activity or two or more sequential 
seizures without full recovery of consciousness 
between the seizures

Convulsive status epilepticus (CSE)
Similar to NCSE, but with a predominant 

motor component

non convulsive status epilepticus (nCSE)
Range of conditions in which electrographic 
seizures activity is prolonged and results in 

nonconvulsive clinical symptoms

Complex partial status epilepticus 
(CPSE)

Status that usually presents focal 
discharges and is considered the 

equivalent of prolonged or repetitive 
complex partial seizures

Absence status epilepticus (ASE)
Status characterised by generalised 

spike and slow wave discharges



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Clinical  Management  Issues   2011; 5(1) 17

R. Galimi

ChArACtErIStICS oF nCSE In thE 
EldErly

The geriatric population is at special risk 
for mental alterations for a myriad of rea-
sons. The most common cause of AMS in 
order of frequency are:

multifactorial causes; y
medications; y
infections; y
metabolic disorders; y
trauma; y
neoplasm; y
cardiovascular diseases; y
dehydration; y
nutritional abnormalities; y
seizure (epilepsy). y
Unfortunately, there is only a limited 

number of articles about the diagnosis of 
AMS in the ED.

In the following paragraphs, I will use 
“nonconvulsive status epilepticus” (NCSE) 
as a descriptive term denoting cases of SE 
with little or no clinical signs of ongoing 
seizure activity apart from obtundation or 
subtle motor phenomena.

NCSE has a heterogeneous presentation, 
is commonly underdiagnosed, and early de-
tection and treatment require a high level 
of suspicion. It consists of changes in basal 
mental status (confusion or depressed level 
of consciousness) for at least 30 min and 
EEG evidence of continuous or almost con-
tinuous epileptiform activity. Slight motor 
manifestations may be seen, such as eyelid 
myoclonia, automatisms, nystagmus, or di-
screte extremity dystonia, in the absence of 
evident convulsive activity [5].

There is no universally accepted definition 
of NCSE. In a consensus workshop orga-
nised by the Epilepsy Research Foundation 
(amide at facilitating communication and 
research in this area), it has been defined 
as «a term used to denote a range of condi-
tions in which electrographic seizure activity 
is prolonged and results in non-convulsive 
clinical symptoms» [6].

In general, NCSE differs from CSE in the 
lack of a predominant motor component [7]. 
The definition of NCSE preferred by Shor-
von is «nonconvulsive status epilepticus is a 
term used to denote a range of conditions 
in which electrographic seizures activity is 
prolonged and results in nonconvulsive cli-
nical symptoms» [8].

NCSE is an epileptic condition lasting > 
30 minutes in which continuous or recur-
rent seizure activity on the electroencepha-
logram (EEG) is responsible for diverse 
clinical symptoms including impairment of 
consciousness, abnormal behaviour or per-
ception disturbances [4]. It requires EEG 
for confirmation.

Agitation in younger patients accessing 
the ED is much more likely to be the result 
of substance abuse or underlying psychiatric 
disease (psychotic or mood disorder), than in 
the elderly population. Post-ictal confusion 
may last as long as 1-2 weeks in an elderly 
patient, as opposed to minutes in younger 
individuals. Moreover, many elderly people 
have medical illnesses that can cause clinical 
deficits similar to NCSE, leading to the risk 
of misdiagnosis. NCSE is under-recognised, 
particularly in patients who have abnormal 
baseline cognitive abilities or multiorgan 
medical illnesses. However few studies have 
exclusively assessed NCSE in the elderly, 
and NCSE may be diagnosed incorrectly 
as metabolic abnormalities or psychiatric 
conditions. NCSE has been increasingly 
diagnosed given the higher index of suspi-
cion and recent advances in long-term EEG 
monitoring among patients with impaired 
level of consciousness.

Neurology of the older adult thus de-
mands a more holistic and multidisci-
plinary approach: distinguishing normal 
age-related changes from those that require 
treatment is a challenge. Altered mental 
status should not be attributed to psy-
chiatric causes until a careful history and 
evaluation have pointed out other aetiolo-
gies. The purpose of this article, therefore, 
is to describe some of the major principles 
of the diagnosis of NCSE in the elderly, 
in contrast to NCSE in younger patients. 
Geriatric assessment, multidisciplinary 
teams, observation units and geriatric ED 
have been described and tested to manage 
elderly ED patients or to shift them to-
wards alternative care sources. Even expe-
rienced physicians may not made the exact 
diagnosis during the whole course of the 
patient’s stay in the ED, despite using all 
possible means including laboratory and 
imaging studies. Physicians who develop 
expertise in recognising these nuances will 
make more timely diagnoses and be less 
likely to miss the diagnosis. Neurologists 
are ideally placed to manage SE, particu-
larly those with a knowledge of EEG, and 
should be consulted early.



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Clinical  Management  Issues   2011; 5(1)18

Sudden altered mental state in the elderly

[17]. Tumours and traumas may each ac-
count for another 5 to 10% of NCSE [18]. 
Neurodegenerative disorders in adults are 
progressively recognised as one of the major 
causes of epilepsy. Many of the remainders 
are multifactorial [19,20].

A history of seizures is not always present, 
nor is motor activity necessarily associated 
with NCSE. Primary generalised “absence” 
seizures occur in the elderly, usually after 
an earlier epilepsy diagnosis [21], or with 
de novo absence SE of late onset – often 
following benzodiazepine or other me-
dication withdrawal, even without earlier 
epilepsy [22]. NCSE can be precipitated by 
several toxic, metabolic, and epileptic trig-
gers. Triggering factors for situation-related 
ASE in the elderly are protean, including 
psychotropic and other seizure precipitating 
drugs such as aminophylline, benzodiaze-
pine withdrawal, metabolic imbalance, sy-
stemic infections and fever, alcoholism and 
dehydration [23].

With an increasingly ageing population, 
and age itself being an independent risk fac-
tor for stroke, the incidence and prevalence 
of post-stroke seizure and post-stroke epi-
lepsy are likely to increase. Cerebrovascular 
disease is the most common underlying 
cause, although as many as 25-40% of new 
epilepsy cases in the elderly have no obvious 
underlying aetiology [24].

Most NCSE in the elderly are not pri-
marily generalised but of focal onset, com-
plex partial status (CPSE), with possible 
secondary generalisation. Older patients 
were more likely to have focal discharges, 
again indicating that NCSE in the elderly 
tends to be “symptomatic” or arise from a 
focal lesion [18,25,26]. The term “sympto-
matic” indicates that the seizure activity is 
a secondary phenomenon or a symptom of 
an underlying disease process.

Almost 75% of patients older than 40 are 
women [27,28], and ASE over the age of 
50 is predominantly a female disorders [29]. 
Globally, NCSE appears to have a worse 
prognosis in the elderly (NCSE mortality 
in elderly patients ranges up to 57% [30]), 
with more severe underlying processes in-
cluding infections [31].

The mortality rates for SE, which are not 
uniform across age groups, are about 40% for 
patients aged older than 60 years and exceed 
60% for those older than 80 [32,33].

The use of a classification based on the 
age at which NCSE occurs has recently 
been suggested [5,34]. Rare neuropathologic 

The two types of NCSE have different fe-
atures: absence SE (ASE) is characterised by 
generalised spike and slow wave discharges, 
while complex partial SE (CPSE) usually 
presents focal discharges and is considered 
the equivalent of prolonged or repetitive 
complex partial seizures (Figures 2 and 3).

Absence status was reported to occur de 
novo in later life as a situation-related, sin-
gle event.

ASE may be considered those cases si-
milar to «status epilepticus in petit mal» 
described by Schwab [9].

CPSE is NCSE with a presumed focal 
onset.

CPSE was reported less often than absen-
ce SE until recently, perhaps because of some 
very stringent definitions. Clinical manife-
stations include an «epileptic twilight state» 
with a lack of responsiveness or confusion, 
and bizarre, and particularly fluctuating, be-
haviour [10,11]. Most recently, a classifica-
tion proposed by the International League 
Against Epilepsy (ILAE) has subdivided 
focal NCSE (focal; CPSE) into aura conti-
nua (non-convulsive simple partial SE with 
maintained consciousness) and dyscognitive 
SE (with impaired consciousness) of mesial 
temporal or neocortical origin. While the 
forms originating from the mesial temporal 
lobe regions may be summarised as “limbic 
status” manifesting with limbic sensations, 
the manifestations of the neocortical forms 
reflect the region of origin involved [12].

As stated in the Introduction, both the in-
cidence and prevalence of epilepsy are high 
among the elderly. The incidence of SE has 
a bimodal distribution, with the highest in-
cidences during the first year of life and after 
the age of 60 [13]. Among adults, patients 
older than 60 had the highest risk of deve-
loping SE, with an incidence of 86/100,000 
persons per year [14-16].

NCSE may constitute one quarter of all 
SE in patients over 60 years old, and up to 
40% of all SE occurs in the elderly. Today 
the estimated frequency of NCSE is around 
32-85 cases/100,000/year [5]. Older adults’ 
increased risk for stroke, metabolic abnor-
malities, and comorbid conditions contri-
butes to the frequency of seizures in this 
population.

Cerebrovascular disease is the most com-
monly identified cause of SE in the elderly 
and accounts for the majority of NCSE. 
About 7% of acute strokes provoke at least 
one epileptic seizure, and about one fifth of 
these result in SE, somtimes nonconvulsive 



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Clinical  Management  Issues   2011; 5(1) 19

R. Galimi

ly is also a relatively common setting for 
NCSE [42]) are common and may lead, 
in absence of EEG evaluation, to misdia-
gnosis of NCSE as a psychiatric condition 
[43]. Thus, NCSE is a highly pleomorphic 
condition and should be considered in all 
older patients with unexplained mood di-

case reports have described neuropatholo-
gic changes associated with SE in humans 
[35,36]. This correlates with neuronal loss 
within the hippocampus, especially in the 
CA1 and CA4 regions, as well as neuronal 
loss in more diffuse brain regions [37].

Important differential diagnoses of NCSE 
are:

metabolic encephalopathy; y
migraine aura; y
posttraumatic amnesia; y
prolonged post-ictal confusion; y
psychiatric disorders; y
substance de- or intoxication; y
transient global amnesia; y
transient ischemic attack [38]. y
From a electroencephalographic point of 

view, a clear development with a build-up of 
rhythmic activity or generalised spike-wave 
discharges at 3 Hz or faster and decremen-
tal features with flat periods associated with 
clinical seizure activity strongly indicate 
NCSE [39].

thE SPECtruM oF thE ClInICAl 
FEAturES oF nCSE In thE 
EldErly

As previously noted, NCSE diagno-
sis is difficult, due to its heterogeneous 
presentation, which is undistinguishable 
from other causes of altered awareness: 
its clinical manifestations can include the 
full spectrum of mental status changes; pa-
tients may only show subtle clinical signs 
of seizure activity such as mild myoclonic 
movements; and presentation is very in-
consistent, varying in intensity from mild 
personality changes, such as drowsiness 
and difficulty in concentration, lethar-
gy, agitation, blinking, confusion, facial 
twitching, automatisms, to severe mani-
sfestations such as coma [40]. Since all the 
symptoms may be improved by treatment, 
some investigators consider the clinical 
and electrographic response to antiepi-
leptic drugs, especially benzodiazepines, 
an important aspect for the diagnosis of 
NCSE. However, the response to these 
medications may not be immediate, occur-
ring many days after the beginning of the 
treatment, precluding its inclusion among 
major diagnostic criteria [41].

Behavioural disturbances related to these 
confusional states (confusion in the elder-

Figure 2
Electroencephalogram 
in an absence status 
epilepticus patient

Figure 3
Electroencephalogram 
in a complex partial 
status epilepticus patient 
with focal discharges

sturbance, behavioural changes, language 
disturbances, cortical blindness, confabula-
tion, psychotic states, sensory phenomena, 
autonomic disturbances and psychic phe-
nomena. In one larger series of patients 
with NCSE seen in emergency rooms, 
agitation, lethargy, disruptive behaviour, 
mutism or other language disturbances, 
delirium, staring, oral automatisms, inap-
propriate laughter or crying, rigidity, and 
several other types of bizarre behaviour 
were presenting signs [44].

Thomas et al. noted that status could be 
present from 8 hours to 5 days before being 
diagnosed, and described clinical features 
such as «interrupted speech, catatonia, slow 
and ataxic gait». Many of the elderly patients 
diagnosed with NCSE have not had epilepsy 



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Clinical  Management  Issues   2011; 5(1)20

Sudden altered mental state in the elderly

dIAGnoStIC APProACh to nCSE

Clinical examination

The number of accesses to Emergency 
Departments has substantially increased 
during the past few years, especially for pa-
tients aged 65 years and older.

The ageing of the general population is 
a well known trend. By the year 2020, it is 
estimated that, every second, one person in 
Germany will be older than 50 years old, 
and some 7% of the population will be 80 
or older [51]. The US government predicts 
that by 2030 there will be 70 million adults 
over age 65 in the United States. Whereas 
this segment made up 12.4% of the popu-
lation in 2000, it will account for about 20% 
by 2030 [52].

Furthermore, current demographic tren-
ds will lead to an increased prevalence of 
epilepsy in the general population, leading 
to the necessity of a major effort aimed at 
improving our understanding of the clini-
cal course and optimal treatment of epilep-
sy in this rapidly growing segment of the 
population.

Unfortunately, there are documented pro-
blems with the quality and continuity of care 
provided to older ED patients, including 
failure to recognise problems that could be-
nefit from more careful assessment, failure 
to refer to appropriate community services, 
and failure to timely communicate to the 
primary physician the problems identified 
and interventions implemented at the ED 
visit. This may represent a consistent pro-
blem in the management of acute mental 
change, which must be evaluated in rapid 
sequence or simultaneously while using the 
tools of basic resuscitation, history, clinical 
assessment, laboratory evaluation and radio-
logical assessment.

A tool that can help in reminding the 
reasons why a patient can show an altered 
mental status is common mnemonic called 
AEIOU-TIPSM (Table I).

Besides, it is important to remember that 
elderly patients with SE often demonstrate 
either no convulsive activity or only mini-
mal motor movements that are often ea-
sily overlooked, or exhibit only a blunting 
of consciousness rather than frank coma. 
The patient may be able to walk and carry 
out simple activities, but acute fluctuating 
confusion associated with agitation, bizarre 
behaviour, staring, increased tone, mutism 
or subtle myoclonus are features that sug-
gest this diagnosis [53,54]. Thus, accurate 

earlier in life but have had benzodiazepine 
withdrawal or other significant effects of 
medications on the brain [22]. Visual hal-
lucinations and visual loss similar to those of 
migraine can be an unusual manifestation of 
focal NCSE [45]. Catatonia [46] and atonia 
[47] have been described as manifestations 
of NCSE. Speech difficulties due to dysar-
thria rather than aphasia can be caused by 
SE arising in the opercular regions [48]. 
NCSE presenting as a progressive aphasia 
that developed insidiously over 5 weeks has 
been described [49]. There are often severe 
language disturbances, with mutism and 
verbal perseveration. Frequent features are 
bizarre behaviour, agitation, aggressiveness, 
emotional liability, and hallucinations [50]. 
Occasionally automatisms such as chewing 
and compulsive handling of objects have 
been noted, and on examination, frontal re-
lease signs and a Babinski reflex have been 
documented [50].

Furthermore, it may become especially 
difficult to diagnose CPSE (dyscognitive 
SE) in elderly patients in whom it is as fre-
quent as of 40%. In fact, as already remarked 
in this article, the differentiation of this type 
of dyscognitive SE from nonepileptic con-
ditions without EEG and by pure clinical 
means may become challenging even for the 
skilled epileptologist

Typical psychiatric manifestations of dy-
scognitive SE include delirium, stupor or 
catatonia, mental slowing, cognitive decli-
ne, aggressive behaviour and psychotic de-
pression. When spreading to the neocorti-
cal areas of the temporal lobes, auditory or 
visual hallucinations may occur. The EEG 
of dyscognitive SE is characterised by irre-
gular or regular focal spikes or spike-wave 
activity similar to the one observed in aura 
continua; however, the ictal activity in dy-
scognitive SE tends to involve a larger area 
which increases the likelihood to detect it 
by surface EEG [12].

A Alcohol, other toxins, drugs
E Endocrine, electrolytes
I Insulin, diabetes-related, hypoglycaemia
o Oxygen, opiates
u Uremia
t Trauma, temperature
I Infection
P Psychiatric, poisoning, porphyria
S Stroke, seizure, shock, subarachnoid haemorrhage
M Metabolic: hyperammonia

table I
Meaning of the 
mnemonic AEIOU-
TIPSM



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Clinical  Management  Issues   2011; 5(1) 21

R. Galimi

zure activity strongly indicate NCSE [39]. 
In ambulatory patients, the most common 
EEG patterns associated with NCSE are 
generalised spike-and-wave or generalised 
polyspike-and-wave discharges in the case 
of ASE, or rhythmic focal discharges in the 
case of CPSE [57]. Absence status and focal 
NCSE can be distinguished easily by EEG, 
the former being characterised by generali-
sed 2 to 4 Hz spike and wave activity and 
the latter by more or less focalised dischar-
ges generally associated with the temporal 
or frontal lobe.

In perhaps the best study of the EEG in 
NCSE, Granner and Lee evaluated NCSE 
patients who responded well to antiepileptic 
drugs [26]. NCSE patients who responded 
well to antiepileptic drugs EEG discharges 
were often generalised, but many became 
focal once the medication has been initiated. 
The researchers found a wide variety of dif-
ferent alterations such as typical or atypical 
spike wave discharges, multiple or polyspike 
wave discharges, and also rhythmic delta ac-
tivity with some spikes. Waveform morpho-
logies were remarkably variable; discharge 
frequencies were generally from 1.0 to 3.5 
Hz (mean 2.2). Most of these changes appe-
ared to be generalised but some were focal.

In NCSE, ongoing seizure activity, whe-
ther focal or generalised, with clearly defined 
spike-slow-wave discharges usually more 
than 2 Hz, often waxing and waning, is 
usually diagnostically straightforward [30]. 
The EEG borderlands of what represent sei-
zures versus what are postictal or interictal 
patterns, periodic epileptiform discharges 
(PEDs), and triphasic waves (TWs), have 
been the subject of some study with incom-
plete consensus. PEDs have been referred to 
as an “irritative” pattern found in temporal 
proximity to seizures proper; the footprints 
rather than the animal itself [58].

The clinician should look for signs that 
would point to potential localisations of a 
brain disturbance such as focal paresis, focal 
sensory deficits, or aphasia. In parallel, it is a 
good idea to look for signs of conditions that 
could produce symptoms that mimic seizu-
res, but are not seizures, for example irregular 
heart rates or cardiac murmurs suggesting 
the risk of syncope. In order to put the pa-
tient’s presentation into the proper context, 
a careful medical history should be taken 
and standard laboratory tests performed to 
exclude other possible diagnoses.

I suggest making the diagnosis of the 
NCSE only if, in addition to the electro-

diagnosis is often delayed and appropriate 
intervention may not be initiated. The dia-
gnosis of NCSE is important because it is 
potentially reversible. It is difficult to treat 
this pathology appropriately if the diagnosis 
does not come to mind.

Certain clinical features that are more 
likely to be present in patients in NCSE 
compared with other types of encephalopa-
thy (e.g. waxing and waning state of prolon-
ged seizures, unassociated with major motor 
activity such as convulsions). Either remote 
risk factors for seizures or ocular movement 
abnormalities were seen in all patients in 
NCSE. If these tipical features are present, 
an EGC urgently be performed [55].

Electroencephalographic evaluation

The definite diagnosis of NCSE is depen-
dent on electroencephalographic confirma-
tion. Electroencephalographic and videoe-
lectroencephalographic studies performed 
while the patient is experiencing symptoms 
are crucial to early diagnosis and timely ma-
nagement [56].

Since NCSE in the elderly is of focal onset 
[18,25,26], neuroimaging can be taken into 
consideration in order to identify any under-
lying structural abnormalities. The hallmark 
of NCSE is a change in behaviour or mental 
state that is associated with diagnostic EEG 
changes. EEG evaluation is vital to confirm 
the diagnosis of NCSE and may also be use-
ful to exclude other potential explanations 
for the clinical signs, such as metabolic di-
sorders, infections of the nervous system, 
transient ischaemic events or in the case of 
syndromes whose clinical presentation is 
dominated by behavioural and psychiatric 
symptoms.

A number of EEG patterns have been 
described in NCSE, and many of these are 
controversial, particularly if they are ictal. 
There seems to be agreement that the ove-
rall picture of the electroencephalographic 
discharge and its evolution in time and space 
is helpful in differentiating the electroence-
phalography of encephalopathies from that 
of NCSE. The EEG findings of NCSE are 
heterogeneous; generalised or focal (tempo-
ral, temporo-frontal) spike-and-slow wave 
complexes, polyspike discharges, irregular 
sharp or slow waves may be seen. A clear 
development with a build-up of rhythmic 
activity or generalised spike-wave discharges 
at 3 Hz or faster and decremental features 
with flat periods associated with clinical sei-



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Clinical  Management  Issues   2011; 5(1)22

Sudden altered mental state in the elderly

or fosphenytoin is subsequently given. Blood 
pressure and cardiac rhythm must be moni-
tored continuously during a rapid infusion, 
and if adverse effects occur, the infusion rate 
should be slowed.

ConCluSIonS

AMS remains a symptom that carries a 
significant degree of morbidity and mor-
tality, especially in elderly patients with 
neurological aetiologies (in the elderly 22-
39% of AMS are secondary to medications 
[60]). NCSE, as a complex of symptoms, is 
and will remain one of the major causes of 
access to ED. It represents a pleomorphic 
condition of patient without overt convul-
sions [30].

Although relatively frequent, NCSE is 
a poorly understood and under-diagnosed 
condition. NCSE should be suspected whe-
never cases of fluctuating consciousness or 
abrupt cognitive or behavioural changes are 
noted. The often unspectacular and unspeci-
fic clinical manifestation of NCSE makes it 
important to “think of it at all” in any patient 
presenting with unexplained new onset of 
behavioural changes, impaired consciousness 
and/or focal, non-convulsive neurological 
deficits [61].

NCSE is one of the most important 
neurological emergencies requiring rapid 
diagnosis, being confirmed by EEG and 
treated without delay and with appropriate 
aggressiveness.

Finally, elderly patients with confusion 
should undergo diagnostic EEG, particular-
ly if the confusion is episodic or there have 
been previous episodes of protracted ictal 
confusion. If EEG is not performed during 
the symptomatic period, the diagnosis is li-
kely to be missed.

More research is needed to determine the 
effectiveness of screening and intervention 
strategies targeting at-risk older ED pa-
tients. Future research should be targeted 
to investigate and manage this symptom 
complex.

dISCloSurE

The Author declares that he has no finan-
cial competing interests.

encephalographic changes, there is clinical 
evidence from the patient’s history.

trEAtMEnt

Treatment focuses on correcting un-
derlying pathologic abnormalities such as 
hyponatremia or drug toxicity, and initiating 
pharmacologic therapy.

From a clinical point of view, the treat-
ment of NCSE in the elderly population is 
complicated by several major factors such as 
altered pharmacokinetics (i.e. altered drug 
metabolism and excretion) and comorbidity, 
related to the risk of interaction with con-
comitant medications. In treating epilepsy, 
the choice of antiepileptic drug (AED) is 
usually dictated by seizure type and tolera-
bility and maybe complicated by comorbi-
dities or age-associated differences in AED 
pharmacokinetics. The objective should be 
complete control of seizures, with enhanced 
quality of life.

Treatment of NCSE in the elderly is stri-
kingly easy in some and impressively difficult 
in others. The choice of AED should focus 
on avoidance of side effects and adverse 
drug-drug interactions. Patients with prima-
ry generalised, absence SE usually respond to 
modest doses of benzodiazepines and often 
do not need long-term AED maintenance. 
CPSE is typically due to some underlying 
lesion and often requires long-term medica-
tion. CPSE has a mortality of approx. 30% 
in the elderly, simple partial SE 40%, and 
generalised status 90% [25]; many of the 
patients with generalised NCSE are those 
mentioned earlier with severe medical and 
neurological illnesses and prolonged electro-
graphic SE. The treatment of NCSE needs 
to be tailored to the perceived urgency and 
morbidity of the condition.

Because prognosis varies depending on 
the causes, and may be a by-product of the 
morbidity conferred by the inciting brain 
insult, some experts advocate oral or intra-
muscular treatment, or supplementation 
with antiepileptic; others recommend careful 
monitored use of iv benzodiazepines [30]. 
The benzodiazepines are considered the first 
line treatment for both ASE and CPSE [59]. 
The initial recommended treatment consists 
of intravenous diazepam or lorazepam. If 
seizures persist, a loading dose of phenytoin 



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Clinical  Management  Issues   2011; 5(1) 23

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