How to manage seizures in a 67-year-old woman?

Question

Hello doctor,

My 67-year-old mother started having seizures three months ago, completely out of nowhere, and was really scared. She has had five seizures total, the first one happened while she was cooking dinner, and she fell and hit her head on the counter.

The neurologist did an EEG and MRI, but everything looked normal except for some small vessel changes. Started her on Levetiracetam 500 mg twice daily, but she still had two more seizures last month. Her seizures always start with her staring blankly, then her right arm starts twitching, then she loses consciousness for about two minutes.

Afterwards, she is confused for 30 to 45 minutes and cannot remember what happened. Worried because she lives alone and drives to the grocery store and doctors' appointments. Should she stop driving until seizures are controlled? Also concerned about her medications, she's on Warfarin for atrial fibrillation, Lisinopril for blood pressure, and Atorvastatin.

Can any of these interact with seizure medicines? The seizures seem to happen more often when she's tired or stressed.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I can understand your concern.

Your concern is very valid – new-onset seizures in someone at 67 years old are always something we take seriously. The pattern you described (blank staring, right arm twitching, then loss of consciousness, confusion afterwards) sounds like focal onset seizures spreading to generalized seizures. Since she is still having seizures despite being on Levetiracetam 500 mg twice a day, I would suggest you speak to the neurologist again. Sometimes the dose needs to be increased (the usual effective dose can go up to 1500 mg twice daily). There are other options also if she does not respond.

She must not drive until she is completely seizure-free for at least six months (sometimes even 12 months, depending on state/country rules). Driving right now is unsafe both for her and for others.

As for her medicines:

Warfarin does not have any major interaction with Levetiracetam (unlike some older anti-epileptics). Still, INR (international normalized ratio) monitoring must continue regularly.
Lisinopril and Atorvastatin are also safe with Levetiracetam.
The main thing is to watch for mood changes, excessive sleepiness, and irritability, which can happen with Levetiracetam in the elderly.

You are right, lack of sleep, stress, missed doses can trigger seizures, so try to keep her routine regular, avoid alcohol, and avoid sudden stress if possible.

The probable causes:

New-onset focal epilepsy is likely due to structural brain changes (age-related small vessel disease can lower seizure threshold).
It could be post-traumatic as well (from the head injury after the first seizure).

Investigations to be done:

Repeat EEG (sometimes the first one can be normal).
MRI (magnetic resonance imaging) with epilepsy protocol, if not already done.
Basic laboratory tests: electrolytes, kidney and liver function, thyroid, and vitamin B12.
INR monitoring is regular because she is on Warfarin.

Differential diagnosis:

• Focal epilepsy (most likely).
• TIA (transient ischemic attack) (less likely because of post-ictal confusion and motor twitching).
• Arrhythmia-related syncope (but twitching and post-ictal confusion point to seizure more).

Probable diagnosis:

Focal epilepsy with secondary generalization, likely age-related structural or post-traumatic.

Treatment plan:

Escalate or optimize anti-seizure medication under neurologist guidance.

Strict medication adherence.
No driving until seizure-free for months as per guidelines.
Maintain regular INR monitoring due to Warfarin.
Maintain good sleep hygiene and reduce stress.

Regarding follow-up:

Follow up with the neurologist soon – do not wait, since she is still having seizures. Take note of each episode (timing, duration, what happens before and after) and share with the doctor.

Preventive measures:

Regular sleep, avoid alcohol.
Avoid missing medications.
Keep home safe (padding sharp corners, avoiding cooking alone until seizures are under control).
Have someone check in on her daily if she lives alone.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.