Epilepsia, 49(Suppl.
1):45–49, 2008
doi: 10.1111/j.1528-1167.2008.01450.x
SUPPLEMENT - MANAGEMENT OF A FIRST SEIZURE
Special problems: Adults and elderly
Linda J. Stephen and Martin J. Brodie
Epilepsy Unit, Division of Cardiovascular and Medical Sciences, Western Infirmary, Glasgow, Scotland,
United Kingdom
SUMMARY
A first seizure out of a clear blue sky can be a
major life-changing event. Careful history-taking
and appropriate investigation together with a clear
explanation provided to patient and family are an
essential requirement. Although for most patients,
pharmacotherapy can be withheld and events
awaited, there are circumstances where introduc-
tion of antiepileptic drug (AED) therapy should be
considered. Medical causes of seizures should also
be sought and treated. In addition, a first seizure
A first seizure out of a clear sky can be a terrifying expe-
rience, particularly if it is a full-blown tonic–clonic event.
An individual’s life may be turned upside down in a matter
of minutes. Reduction in control, physical injury, and pro-
longed postictal symptoms can lead to loss of confidence
and impairment of independence. Longer-term sequelae in-
clude employment difficulties, rescinding of the driving
license, worry about having further events, and changes
in attitude among family and friends (Dworetzky et al.,
2000). Indeed, Lindsten and colleagues recently reported
that adults with a newly diagnosed unprovoked epileptic
seizure became significantly less physically active, traveled
abroad less frequently, and were generally less energetic
during their leisure time than sex- and age-matched refer-
ents (Lindsten et al., 2003). There has been much debate
about how to best manage a person who has suffered a first
seizure, which varies substantially among health-care sys-
tems throughout the world (Pohlmann-Eden et al., 2006).
Some objective advice can be gleaned from a variety of
guidelines (SIGN Guidelines, 2003; American Academy
guidelines 2003, 2004; NICE guidelines, 2004; Glauser et
al., 2006). Old age is now the commonest time to develop
seizures and, as the global elderly population swells, so
Address correspondence to Prof. Martin J. Brodie, Epilepsy Unit, West-
ern Infirmary, Glasgow G11 6NT, Scotland, United Kingdom. E-mail:
Martin.J.Brodie@clinmed.gla.ac.uk
Blackwell Publishing, Inc.

C International League Against Epilepsy
45
in HIV-positive patients and in those with underly-
ing neurocysticercosis should usually provoke the
introduction of AED therapy. Particular problems
can occur in patients with a single episode of pro-
voked status epilepticus, a first tonic–clonic seizure
during pregnancy and, particularly, an unprovoked
event in older and learning disabled people. Treat-
ment following a first seizure should balance risk
factors for recurrence with the informed opinion
of the patients and their family.
KEY WORDS: Elderly, Epilepsy, First seizure,
Investigation, Treatment.
too will the incidence of epilepsy (Forsgren et al., 2005).
This paper explores some of the issues that need to be con-
sidered in managing adults and senior citizens following
their first seizure. Details of the clinical trials exploring the
risks and consequences of additional seizures have been
discussed earlier in this supplement.
D IAGNOSIS
An adult who is suspected to have had a first seizure
should be referred to an epilepsy specialist for rapid assess-
ment (SIGN Guidelines, 2003). Diagnosis is based on the
history, ideally from a witness. Difficulties can arise with
partial seizures, which can have many varied presentations
from a brief sensory, autonomic or motor disturbance to
confusion and aggression lasting several minutes. Postictal
symptoms and signs such as exhaustion, headache, muscle
pain and Todd’s paresis can provide useful clues. A patient
presenting with a first convulsive seizure can, on occasion,
have undiagnosed epilepsy. It is worth asking about partial
events, absence seizures and myoclonic jerks. These may
have been occurring for many years without a diagnosis
having been made (Kwan & Brodie, 2000). It is essential
too to ensure that long QT syndrome, which can present
with a seizure, is excluded by obtaining a routine electro-
cardiogram (ECG) (Dunn et al., 2005).
Diagnosis of a first seizure in old age can be partic-
ularly challenging and it may take some time before an
46
L. J. Stephen and M. J. Brodie
Table 1. Differential diagnoses of seizures
in elderly people
Neurological Endocrine/metabolic
• Transient ischemic attack • Hypoglycemia
• Transient global amnesia • Hyponatremia
• Migraine • Hypokalemia
• Narcolepsy
• Restless legs syndrome Sleep disorders
Cardiovascular • Obstructive sleep apnea
• Vasovagal syncope • Hypnic jerks
• Orthostatic hypotension • Rapid eye movement sleep
• Cardiac arrhythmias disorders
• Structural heart disease Psychological
• Carotid sinus syndrome • Psychogenic seizures
accurate clinical picture can be pieced together (Brodie &
Kwan, 2005). The patients may remember little or noth-
ing of the episode and, if they live alone, there may be no
witness. A history of trauma with physical damage such as
bruises, cuts, and burns can be helpful as can the timescale
of the episode (Stephen & Brodie, 2000). It is important
to consider the many differential diagnoses, which may
mimic or coexist with seizure activity in this population
(Table 1). Syncope, particularly, can occur without warning
in elderly people. Physical examination should concentrate
on the neurological and cardiovascular systems. Investiga-
tions such as full blood count, serum electrolytes, renal pa-
rameters, and random blood glucose are important, as well
as an ECG and chest radiograph (Stephen & Brodie, 2000).
Prolonged ECG recording, carotid and basilar ultrasonog-
raphy, orthostatic blood pressure measurement may also be
necessary. Tilt table testing can be useful to detect barore-
ceptor and vasopressor dysfunction or sympathetic failure
due to autonomic neuropathy in older people (McKeon et
al., 2006).
M EDICAL C AUSES
Around 8–10% of seizures are provoked by an acute
precipitating stimulus such as a brain insult, metabolic or
toxic disturbance, systemic illness, opportunist infection
or a cryptic cancer (Annegers et al., 1995). Many drugs
carry high epileptogenic potential, particularly meperidine,
sevoflurane, clozapine, phenothiazines, and cyclosporin
(Ruffmann et al., 2006). Alcoholics can have a seizure
as a result of excessive alcohol intake, abstinence compli-
cations of their alcoholism, or an underlying seizure dis-
order (American College of Emerging Physicians, 1997).
Recreational drug use, particularly with cocaine, phen-
cyclidine, amphetamines, and heroin, can also produce
seizures (Henry et al., 1992; Koppel et al., 1996). Specific
enquiry should be made regarding these lifestyle issues
following a potentially unprovoked tonic–clonic seizure.
Epilepsia, 49(Suppl. 1):45–49, 2008
doi: 10.1111/j.1528-1167.2008.01450.x
Other treatable causes of symptomatic seizures, such as
malaria, hypertensive encephalopathy, systemic lupus ery-
thematosus, and acute intermittent porphyria, should be
considered in the appropriate clinical setting (Delanty et
al., 1998).
Because seizures are likely to recur in patients infected
with HIV and because they are a poor prognostic indica-
tor, it is generally recommended that all HIV seropositive
patients experiencing a first seizure without a recognizable
and reversible cause be treated with a nonenzyme-inducing
antiepileptic drug (AED) (Romanelli & Ryan, 2002). Sim-
ilarly, a first seizure in a patient with underlying neuro-
cysticercosis should probably be treated, as the progno-
sis for the epilepsy is usually excellent (Riley & White,
2003). Patients with concomitant treated depression may
also benefit from early introduction of AED therapy be-
cause of the increasingly recognized overlap between the
neurobiological bases of these common disorders (Kanner,
2006).
U NPROVOKED S EIZURE
In some people, seizure type can be determined ac-
cording to the clinical (ideally witnessed) history. A
young adult who presents with an unprovoked tonic–clonic
seizure, which occurs without warning or witnessed pro-
drome, may be developing an idiopathic primary gener-
alized epilepsy syndrome. Other markers of this include
seizures on awakening, during sleep deprivation or in the
early morning. Juvenile myoclonic epilepsy (JME) is the
commonest syndrome in this population and, although
amenable to treatment, it is often a life-long condition
(Specchio & Beghi, 2004). Photosensitivity will be present
in around 5% of epilepsies. Photosensitive epilepsies gen-
erally have a good prognosis and there is a 14–37% prob-
ability that the seizures will remit spontaneously (Verrotti,
2004).
For people with focal-onset seizures, prognosis depends
on whether the seizures are idiopathic, cryptogenic, or re-
mote symptomatic in nature. Remote symptomatic seizures
carry an increased risk of mortality (Beghi et al., 2005).
Patients found to have a progressive neurological disor-
der are highly likely to reseizure and should, therefore, be
considered for early AED treatment. On the other hand,
there is no evidence that AED therapy following a pro-
voked seizure, such as after a traumatic head injury, will
prevent later unprovoked episodes and the subsequent de-
velopment of epilepsy (Temkin et al., 2001).
S TATUS E PILEPTICUS
Status epilepticus de novo is a frequent occurrence
in adults (56%) and elderly (70%) patients who have
not previously suffered from epilepsy (DeLorenzo et al.,
1996). In this population, there is a significant risk of

developing epilepsy (Hesdorffer et al., 1998). The under-
lying etiology is the most important determining factor
(Rossetti et al., 2006). This is particularly the case for
adults where damaging pathology, such as acute vascular
events, trauma, encephalitis, or a rapidly growing neoplas-
tic lesion, can cause serious brain damage as well as status
epilepticus. It is therefore important to consider long-term
AED therapy in these patients as well as treating the under-
lying cause.
E LDERLY P EOPLE
A first seizure in an older person can have profound
physical and psychological consequences. For those who
develop epilepsy, morbidity and mortality are high (Luh-
dorf et al., 1987) as are rates of sudden unexpected death
(Jallon et al., 1999). Old age was found to be a signifi-
cant predictor for seizure recurrence by the FIRST Seizure
Trial Group (Musicco et al., 1997). It is usually assumed
that underlying cerebral pathology is responsible for ictal
generation. Magnetic resonance imaging (MRI) is not al-
ways tolerated in this age group and computerized tomog-
raphy (CT) may be preferred by some patients (Tallis et
al., 2002). In our elderly population of 117 patients with
newly diagnosed epilepsy, 66% had abnormal neuroimag-
ing. Of the 61% of patients who had an interictal EEG,
epileptiform discharges were seen in just 28% (Stephen et
al., 2006). As with younger adults, however, there were no
differences in outcome for those with normal and abnormal
brain imaging. The prognosis in this population, however,
is better than for patients under 65 years of age (Mohanraj
& Brodie, 2006). This, in itself, may be a good reason for
starting AED therapy in the elderly, which is often readily
accepted by a patient already taking a number of drugs for
other indications.
L EARNING D ISABILITIES
Around 1–2.5% of people in the Western world have
a learning disability (Gillberg & Soderstrum, 2003). Of
these, 14–44% will have epilepsy, with rates highest oc-
curring in those with the most severe disabilities (Jones
et al., 2002). There are no specific data regarding man-
agement of a first seizure in this population (Bowey &
Kerr, 2000). Clinicians therefore have to rely on infor-
mation pertaining to outcomes in those with established
epilepsy. Given that these patients are likely to have under-
lying cerebral pathology, those with a first remote symp-
tomatic seizure fall into a poor prognostic category (Beghi
et al., 2005). Learning disability is associated with seizure
clusters, more prolonged seizures, status epilepticus, and
sudden unexpected death in epilepsy (SUDEP) (Hannah &
Brodie, 1998). Early introduction of treatment may there-
fore be warranted in these individuals to minimize the risk
of complications assuming, of course, that the diagnosis
47
Special Considerations: Adults and the Elderly
of epilepsy is secure. As the history is crucial, the patient
must be accompanied by a carer who knows him or her
very well and has witnessed the presenting event. Problems
can arise differentiating epileptic seizures from repetitive
stereotyped behavior. In this setting, investigations such as
EEG or brain imaging are rarely helpful. With specialist su-
pervision, over 40% of this population can become seizure-
free with AED treatment (Kelly et al., 2004).
P REGNANCY
On occasion, a woman will present with a first un-
provoked seizure during pregnancy. This is a reasonably
rare occurrence. Provoked seizures secondary to eclamp-
sia are the commonest reason for seizure activity during
pregnancy (SIGN Guidelines, 2003). The management of
the seizure requires balancing the well-being of the fetus
with the health of the mother. After a generalized tonic-
clonic seizure, alterations in fetal heart rate compatible
with acidosis have been reported (Crawford, 2001). In gen-
eral, however, tonic-clonic seizure activity does not appear
to adversely affect fetal outcome (Crawford, 2001). Even
status epilepticus appears to have a better prognosis for
mother and child than previously thought (EURAP, 2006).
Routine inter-ictal EEG appears to be safe in pregnancy,
although it would seem sensible to avoid provocation pro-
cedures, such as photic stimulation and sleep deprivation.
Brain MRI is preferable to CT scanning given that it does
not involve exposure to radiation. Some practitioners pre-
fer to wait until after the first trimester, although there is no
conclusive evidence that MRI can lead to fetal problems.
Indeed, brain imaging can have a direct effect on the man-
agement of pregnancy. For example, a woman with a high-
pressure vascular malformation could be at risk of rupture
during labor and thus may benefit instead from an elective
cesarean section.
Given their teratogenic potential, many clinicians prefer
to delay AED treatment, where possible, until well into the
second trimester (Shorvon, 2002; Tomson et al., 2004). Ex-
ceptions may be patients presenting with a first episode of
status epilepticus or seizures secondary to a rapidly pro-
gressive neurological disorder.
T HE PATIENT ’ S P ERSPECTIVE
When considering whether or not to treat a first seizure,
it is important to take into consideration the patient’s views
of the situation and that of their family. To this end, it is
vital that everyone concerned is provided with a clear ex-
planation of what has happened and what are the likely
consequences. For patients who are anxious not to have
another seizure, early introduction of treatment may be
the best course of action. These patients may rely on their
ability to drive for their work and lifestyle. Those with a
family history of epilepsy may be more inclined to accept
Epilepsia, 49(Suppl. 1):45–49, 2008
doi: 10.1111/j.1528-1167.2008.01450.x
48
L. J. Stephen and M. J. Brodie
long-term treatment. Occasionally, a person will have a rel-
ative who has succumbed to a seizure-related death and
will, therefore, gain peace of mind by starting medica-
tion. At the opposite end of the spectrum, some patients
will choose not to start treatment even after a number of
seizures because they dislike taking medication. Others
may have a problem with the stigma of the diagnosis of
epilepsy and all that this entails. Treatment may be dif-
ficult in people who have problems with drug or alcohol
abuse or who are unwilling or unlikely to take medica-
tion. These individuals should be counseled appropriately
and be made aware of the implications of further seizure
activity, including the risk of SUDEP (Mohanraj et al.,
2006).
C ONCLUSIONS
The management of an adult with a first seizure can
be complicated and is best undertaken by an epilepsy
specialist. Patients at particular risk of seizure recur-
rence include those presenting with provoked or unpro-
voked status epilepticus, remote symptomatic seizures,
and those with progressive underlying neurological pathol-
ogy. Elderly patients and those with learning disabilities
may be at a higher risk of seizure recurrence. Treatment
following a first seizure should balance these risk fac-
tors with the informed opinion of the patient and their
family.
Disclosure of Conflicts of Interest: MJB has acted as a paid con-
sultant to Pfizer, UCB, Eisai, Johnson & Johnson, Schwarz, Jazz
and Shire and has received research funding from Pfizer, UCB
and Eisai. LJS declares no conflicts of interest.
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