This article is first seen at Medscape.
Contributed by: Mohammed Kays Alattiya; Anwar I. Joudeh; Riyadh Ali Hammamy
Citation: J Med Case Reports. 2023;17(170)
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Introduction
The complexity of diagnosing and managing the initial occurrence of seizures in elderly individuals arises from the unclear symptoms of seizure activity and the high frequency of both provoked and spontaneous seizures within this age bracket. Previous research indicated a connection between epilepsy in older adults, a faster decline in cognitive function, and an increased five-year mortality rate. It’s crucial to distinguish between seizures triggered by external factors and those that occur spontaneously to prevent future episodes and unnecessary use of antiepileptic drugs.
Among the elderly population, drugs are a frequent instigator of provoked seizures. This can be attributed to various factors including compromised kidney and/or liver function, the use of multiple medications, and coexisting neurological conditions. Several types of medications have been linked to sudden symptomatic seizures in the elderly, including antibiotics, cancer treatments, opioid painkillers, and psychiatric drugs, among others. Interestingly, certain over-the-counter drugs like pseudoephedrine and caffeine act as stimulants for the central nervous system, potentially reducing the seizure threshold in older adults. In the following case study, we examine an instance of an older individual who experienced a first-time seizure after taking a few tablets of over-the-counter cold medicine.
Case Summary
An 83-year-old male patient of Arabic origin arrived at a public hospital in Qatar’s emergency department. He had a temporary episode of altered consciousness accompanied by involuntary urination. Earlier that day, he was experiencing symptoms of an upper respiratory tract infection, such as a runny nose and cough. In response, he took one tablet of loratadine/pseudoephedrine (10 mg/240 mg) and two tablets of paracetamol/caffeine (500 mg/65 mg). Subsequently, his family found him snoring loudly in his wet bed. When they tried to wake him, he was disoriented and dizzy, which caused him to fall from the bed. He sustained no head or bodily injuries. During his time in the emergency department, he had a witnessed tonic-clonic seizure that lasted for 2 minutes. There was no fever, recent travel, or contact with sick individuals in his history. His medical background revealed a 20-year history of type 2 diabetes mellitus and hypertension. He was on a regular regimen of medications including linagliptin, rosuvastatin, metformin, and lisinopril. He was a non-smoker and non-drinker.
Upon examination, his vital signs were stable, but he appeared pale. He displayed confusion regarding his surroundings, time, and identity. However, there were no other observable focal neurological issues or signs of irritation of the meninges. The rest of the physical examination did not reveal anything noteworthy. Initial tests indicated a mild case of anemia (hemoglobin at 10.3 g/dL), a normal sodium level (134 mEq/L), a serum glucose level of 8.3 mmol/L, and a normal white blood cell count. Diagnostic assessments like an electrocardiogram and a brain computed tomography (CT) scan came back normal. After the witnessed seizure in the emergency department, the patient was administered 1 g of levetiracetam, but no further doses were given. He was admitted to the hospital for one day for observation and further investigations, during which his condition remained stable.
A brain magnetic resonance imaging (MRI) was conducted, revealing bilateral small white-matter hyperintensities on T2, indicative of chronic small vessel ischemic changes. However, the electroencephalogram (EEG) did not detect any focal or generalized epileptiform discharges, even with hyperventilation or intermittent photic stimulation.
At this point, the most likely diagnosis for this patient was a seizure induced by medication. He was discharged without the initiation of antiepileptic drugs but was educated about seizures and advised to follow up in the clinic.
Discussion
We presented a case involving an elderly patient who experienced his first seizure after taking a few over-the-counter medications for a runny nose. The patient underwent thorough inpatient assessments, all of which yielded no remarkable findings. Consequently, he was discharged without being prescribed antiepileptic medications. There were no subsequent seizure incidents reported up to around 6 months post the initial attack.
This case underscores the challenges in identifying seizure activity among the elderly, where the symptoms can be unclear and hard to distinguish. Initially, the patient exhibited confusion, urinary incontinence, and a fall, which are nonspecific manifestations frequently encountered in the elderly population. These symptoms could have been linked to the medications he had taken earlier that day. The subsequent tonic-clonic seizure he experienced in the emergency department was pivotal in confirming the diagnosis of a seizure, although motor manifestations of seizures are unusual in the elderly. Research by Rowan et al. indicates that focal seizures with impaired awareness are the most common form of seizures in the elderly. Furthermore, if auras occur, they tend to be nonspecific, such as dizziness or confusion. Additionally, post-ictal confusion can be prolonged for days. It’s worth noting that generalized-onset seizures are rare among the elderly and may suggest underlying cerebral aging, neurodegenerative conditions, or environmental triggers, as seen in this case.
Considering the distinct presentation of seizures in the elderly, it’s crucial to promptly rule out other neurological emergencies with similar symptoms. Conditions like cerebrovascular events, intracerebral hemorrhages, and delirium may present similarly in elderly patients. Swift diagnosis and intervention are essential to mitigate potential mortality and morbidity risks. Alongside initial clinical and laboratory evaluations to exclude metabolic imbalances, arrhythmias, and orthostatic hypotension, neuroimaging plays a vital role in both ruling out differential diagnoses and identifying focal lesions that could trigger seizure activity.
In this instance, an emergency noncontrast CT scan didn’t uncover significant intracranial issues, while a subsequent brain MRI revealed a few nonspecific white-matter lesions indicative of chronic small vessel ischemic changes. According to Borja et al., abnormal findings on head CT scans for adults experiencing their first seizure can vary significantly, but CT scans remain essential in the emergency setting to rapidly rule out bleeding, intracranial masses, and substantial infarcts. However, head MRI offers a more comprehensive assessment of brain tissue, including focal lesions, infarctions, tumors, microhemorrhages, and gliosis.
Reports in pediatric literature have repeatedly detailed neurological and cardiovascular adverse events, including fatalities, associated with both therapeutic and excessive doses of over-the-counter cough and cold medications. However, such occurrences have been less documented in adults. For instance, İsmailoğulları et al. described a case of nonconvulsive status epilepticus in a seemingly healthy 31-year-old woman after using cough and cold medications containing pseudoephedrine, dextromethorphan, paracetamol, and chlorpheniramine for 10 days. Unlike our patient, this woman had previously experienced a single episode of complex partial seizure at the age of 8, but was not under any pharmacological treatment for it.
The case presented here also involves the use of caffeine, which possesses a complex relationship with seizures. A systematic review and qualitative analysis of 105 studies revealed that caffeine can induce seizures in individuals with and without a history of epilepsy. Even a single high dose of caffeine can potentially lower the seizure threshold. Furthermore, caffeine can interact with antiepileptic drugs, particularly topiramate, potentially diminishing their effectiveness. However, animal studies suggest that chronic low doses of caffeine may actually protect against seizures. Consequently, it’s important to inquire about dietary and over-the-counter caffeine use when assessing patients presenting with new-onset seizures or changes in seizure patterns.
Given the aging population and the intricacies of examining elderly individuals, the significance of obtaining a detailed medical history and information about drug usage cannot be overstated. Patients and healthcare providers must be aware of the potential neurophysiological side effects associated with nonprescription sympathomimetic medications, including pseudoephedrine and caffeine. More research is needed to fully understand the link between specific over-the-counter cough and cold medications and the precipitation of seizures. Such studies can aid in predicting risk levels and shaping regulatory guidelines for the use of these commonly employed medications.
Conclusion
This document presented a situation where an elderly person with no previous seizure history experienced a generalized seizure triggered by exposure to a low dose of pseudoephedrine and caffeine. When evaluating older individuals who have recently had their first seizure, it’s important to thoroughly examine their medical history, including both prescribed and non-prescribed medication usage. The consumption of specific over-the-counter medications that act as sympathomimetics can carry significant health hazards for the elderly. Therefore, these medications should be approached with care when used by older patients.
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