Video-EEG monitoring in the elderly: a review of 94 patients

PURPOSE: We sought to determine the utility and results of video-EEG monitoring in elderly patients. There is an increased incidence of epilepsy in the elderly population. Few studies have assessed the characteristics of epileptic and nonepileptic seizures in this age group. Diagnostic evaluation with video-EEG monitoring is a means to distinguish these different types of events. METHODS: The authors reviewed all patients aged 60 years and older who were admitted to the epilepsy monitoring unit at Columbia-Presbyterian Medical Center from January 21, 1991, to April 12, 1999. RESULTS: A total of 94 patients and 99 patient admissions were identified, accounting for 8% of all admissions. The average age was 70 years, and the mean length of stay was 3.8 days. Typical events were recorded in 75 of the 99 patient admissions. A total of 118 seizures was recorded in 46 patients, and 98 nonepileptic events were seen in 27 patients. Of the patients with nonepileptic events, 13 had psychogenic seizures. The majority of patients with nonepileptic events were taking antiepileptic medication. Whereas 76% of the patients with epileptic events had interictal epileptiform discharges, 26% of the patients with nonepileptic events had epileptiform discharges as well. CONCLUSIONS: Video-EEG monitoring in the elderly leads to a definitive diagnosis in the majority of patients in a relatively short time. Interictal recordings are inadequate in determining the nature of paroxysmal events. Nonepileptic events are common in the elderly, including psychogenic seizures, and these are often misdiagnosed and mistreated as epileptic seizures.     

Seizure semiology: value in identifying seizure origin

The diagnosis of epilepsy depends upon a number of factors, particularly detailed and accurate seizure history, or semiology. Other diagnostic data, consisting of electroencephalography, video-monitoring of the seizures, and magnetic resonance imaging, are important in any comprehensive epilepsy program, particularly with respect to lateralizing and localizing the seizure focus, if such a focus exists, and with respect to determining the type of seizure or seizure syndrome. The aim of this review is to present a survey of important semiologic characteristics of various seizures that provide the historian with observations, which help to lateralize and localize epileptic zones. Clinical semiology is the starting point of understanding a seizure disorder and making the diagnosis of epilepsy. While it may not provide unequivocal evidence of localization of the epileptic focus, nevertheless it usually directs subsequent investigations, whose concordance is necessary for the ultimate localization.     

New-onset mesial temporal lobe epilepsy in a 90-year-old: clinical and EEG features

Although there is a peak in the incidence of epilepsy in the elderly compared with the general population, complex partial seizures represent less than 15% of the seizure types reported. We report on a 92-year-old woman with a 2-year history of daily complex partial seizures. Prolonged video/EEG recording showed bilateral anterior mesial temporal interictal spikes, which predominated on the left, and two typical seizures arising from the left temporal area. Cranial MRI scanning showed multiple lacunar infarcts without temporal lobe involvement or mesial temporal atrophy. Our case appears to be oldest patient in the literature with newly diagnosed mesial temporal lobe epilepsy confirmed by video/EEG recording.     

Sensitivity of a Seizure Activity Detection Computer in Childhood Video/Electroencephalographic Monitoring

Summary: Purpose : Few data describe the sensitivity of a "Seizure Activity Detection Computer" (SzAC) in childhood video/EEG (VEEG) monitoring, especially for very young children. We examined the accuracy of SzAC in childhood VEEG monitoring in different pediatric age groups.
Methods : We visually analyzed VEEG monitoring samples for randomly designated subsets of 56 patients with childhood epilepsy, reviewing 335 visually detected electrographic seizures to analyze the sensitivity of SzAC for each age group as well as the electrographic characteristics affecting the sensitivity of automated computer-based seizure detection.
Results : SzAC was positive in 227 of 335 (67.8%) visually identified electrographic seizures in the entire study group. The SzAC sensitivity for infants (age 2 months to 2 years) was 59.7% (43 of 72 seizures); for young children (age 3–10 years), sensitivity 56.5% (91 of 161 seizures). In adolescents (age 11–18 years), SzAC was positive in 93 of 102 (91.2%) seizures- i.e., in a significantly greater number of seizures than in younger age groups. SzAC was significantly less sensitive in detecting electrographic seizures characterized as being of short duration or of low voltage.
Conclusions : The overall sensitivity of SzAC in detecting childhood electrographic seizures was 67.8%. The sensitivity was significantly less in younger age groups as compared with that in children aged >11 years. Electrographic seizures of relatively short duration or low voltage were often missed by SzAC.     

Seizure semiology of lesional frontal lobe epilepsies in children

The aim of the study was to analyse the semiology of seizures in children with frontal lobe epilepsy (FLE) and to compare them with other paediatric cohorts described in the literature as well as with adult counterparts. We analysed 174 registered seizures of 18 cases under 12 years with lesional epilepsy whose frontal origin was defined by the concordance of neuroimaging and ictal electrographic findings, and confirmed by surgery in the six cases operated on. Seizures were generally short, with a high daily frequency and usually related to sleep. The most characteristic semiological pattern consisted of complex motor seizures, particularly hypermotor. Often seizures corresponded to a mixture of different semiological patterns (tonic, gelastic, automotor, hypermotor, versive) presenting in the same seizure, often as a unique type in the same patient. With regard to several aspects the semiology of FLE in our cohort looks like that reported in adult series, in particular as to the frequency of complex motor seizures. However, our cohort was also characterised by a more protean array of seizure semiology, stressing the occurrence of seizures typically present in adults (versive and complex motor) and of some seizure patterns more characteristic in children such as epileptic spasms; moreover, the rare occurrence of secondarily generalised tonic clonic seizures (SGTCS) was confirmed.     

Seizure semiology and neuroimaging findings in patients with midline spikes

PURPOSE: Midline epileptiform discharges are rare compared with discharges at other scalp locations. Neuroimaging results and semiologic seizure characteristics of patients with midline spikes are not adequately described. The aim of this study was to describe the neuroimaging findings and detailed seizure semiologies in patients with midline spikes. METHODS: We reviewed the EEG database of the University of Michigan Medical Center and identified 35 patients with midline spikes. Information about seizure types and neuroimaging results was obtained from a review of medical records. The seizures were classified according to the International League Against Epilepsy (ILAE) criteria and semiologic classification. RESULTS: Twenty-nine (83%) patients had a history of seizures. Complex partial seizures and simple partial seizures were the most common seizure types, experienced by 66% of patients. The age at seizure onset was within the first 10 years in 90% of patients. According to the semiologic seizure classification, automotor seizures and tonic seizures were the most common seizure types. Neuroimaging studies were abnormal in 45% of patients. When focal abnormalities were detected, they were lateralized to one of the frontal lobes in all cases. CONCLUSIONS: Our results indicate that in the majority of patients, midline spikes represent focal epileptiform activity rather than fragments of generalized discharges, and are most commonly associated with seizures of partial onset. Automotor seizures and tonic seizures are the most common semiologies. Focal radiologic abnormalities tend to be lateralized to one of the frontal lobes.     

Influence on ictal seizure semiology of rapid withdrawal of carbamazepine and valproate in monotherapy

PURPOSE: To quantify changes in ictal seizure semiology during rapid withdrawal of carbamazepine (CBZ) and valproate (VPA) from a monoregimen in presurgical evaluation. METHODS: Therapeutic intensive seizure analysis (TISA) with video-EEG monitoring was used in 33 patients with pharmacoresistant partial epilepsy undergoing complete withdrawal of CBZ (20 patients) or VPA (13 patients) from a monoregimen. Monitoring phases included a 3-day baseline phase, a 3-day rapid antiepileptic drug (AED) withdrawal phase, and another 3-day AED-free phase with AEDs in subtherapeutic levels. Seizure variables as complete processes and their various elements (ictal signs) were analyzed, including duration (seconds), intensity (on a scale of 0 to 3), frequency (number per 3 days), and total duration of seizures and ictal signs in 3 days (seconds). The localization of seizure patterns on ictal EEG recording (EEG seizure onset) and the first appearing clinical ictal phenomena (initial ictal signs) were recorded. RESULTS: A total of 188 seizures in the CBZ group and 57 seizures in the VPA group were investigated. Compared with the baseline phase, the CBZ group showed increases in duration, frequency of seizures, various ictal signs, and secondarily generalized tonic and clonic signs during the following two phases. Significantly increased values of the VPA group were observed in seizure duration and frequency of hypermotoric phenomena during the AED-free phase. More patients in the CBZ group had secondarily generalized clonic signs during the AED-free phase. EEG seizure onset and initial ictal signs showed no obvious changes between study phases. CONCLUSIONS: Withdrawal of CBZ is followed more quickly by an increase of seizure frequency and severity than is the case for VPA withdrawal. Both CBZ and VPA withdrawal influences seizure propagation rather than the seizure-onset characteristics, which speaks in favor of its use in presurgical evaluation.     

Seizure semiology in leucine-rich glioma-inactivated protein 1 antibody-associated limbic encephalitis

ObjectiveThe objective of this study was to advance the characterization of seizure semiology in leucine-rich glioma-inactivated protein 1 (LGI1) antibody-associated limbic encephalitis (LE).MethodsEighteen patients diagnosed with LGI1 LE were identified. Seizure semiology, demographic features, MRI and fluorodeoxyglucose positron emission tomography (FDG-PET), electroencephalograms, and outcomes following immunotherapy were evaluated.ResultsPatients were divided into the following groups based on seizure semiology: faciobrachial dystonic seizure only (FBDS-only, n = 4), epileptic seizure without FBDS (Non-FBDS, n = 6), and FBDS plus epileptic seizure (FBDS +, n = 8). In the group with Non-FBDS, the majority of patients (5/6) manifested mesial temporal lobe epilepsy (MTLE) like semiology (i.e., fear, epigastric rising, staring, and automatisms) with a frequency of 7 ± 5 times per day and a duration of 15.3 ± 14.3 s. In the group with FBDS +, the distinctive symptom was FBDS followed by epileptic events, especially automatisms (7/8), with a frequency of 16 ± 12 times per day and a duration of 13.0 ± 8.0 s. In these cases, 67% and 50% of the patients showed abnormalities on MRI and FDG-PET, respectively, and the mesial temporal lobe structures were most often involved. Ictal discharges were observed in 0/4, 6/6, and 8/8 of the patients in the groups with FBDS only, Non-FBDS, and FBDS +, respectively. The temporal lobe was mainly affected. Immunotherapy had favorable therapeutic effects.SignificanceThe LGI1 LE should be considered as one disease syndrome with a series of clinical manifestation. Identifying types of unique semiology features will facilitate the early diagnosis and the timely initiation of immunotherapy.     

Seizure semiology and electroencephalography in young children with lesional temporal lobe epilepsy

PurposeThis study aimed to discuss the clinical features of seizure semiology and electroencephalography (EEG) in young children with lesional temporal lobe epilepsy (TLE).MethodChildren with lesional TLE received presurgical evaluation for intractable epilepsy. They were followed up for more than one year after temporal lobectomy. We reviewed the medical history and video-EEG monitoring of children with TLE to analyze the semiology of seizures and EEG findings and compared the semiology of seizures and EEG findings of childhood TLE and adult TLE.ResultsA total of 84 seizures were analyzed in 11 children (aged 23–108 months). The age of seizure onset was from 1 month to 26 months (a mean of 17.6 months). All of the patients exhibited prominent motor manifestations including epileptic spasm, tonic seizure, and unilateral clonic seizure. Seven children manifested behavioral arrest similar to an automotor seizure in adult TLE but with a shorter duration and higher frequency. The automatisms were typically orofacial, whereas manual automatisms were rarely observed. The EEG recordings revealed that diffuse discharge patterns were more common in younger children, whereas focal or unilateral patterns were more typical in older children. All of the patients were seizure-free after temporal lobectomy with more than one-year follow-up. All of the children had a mental development delay or regression; however, there was improvement after surgery, especially in those with surgery performed early.ConclusionIn contrast to TLE in adults, young children with lesional TLE probably represent a distinct nosological and probably less homogeneous syndrome. Although they had generalized clinical and electrographic features, resective epilepsy surgery should be considered as early as possible to obtain seizure control and improvement in mental development.     

Seizure semiology of anti‐LGI1 antibody encephalitis

Limbic encephalitis associated with anti‐LGI1 antibody (LGI1 encephalitis) presents with a variety of features, the most prominent of which include seizures and progressive disturbance of memory and behaviour. Although varied in semiology, recognition of the pattern of seizures in LGI1 encephalitis is important, as early diagnosis and definitive treatment may prevent subsequent development of cognitive impairment. We present a patient with LGI1 encephalitis and “faciobrachial dystonic seizures‐plus”, which began as classic faciobrachial dystonic seizures and progressed to focal seizures with impaired awareness, dacrystic/gelastic‐like outbursts, ictal speech, manual automatisms, and autonomic signs (tachycardia). Recognition of the broad range of seizure types associated with LGI1 encephalitis is crucial for early diagnosis and definitive treatment. [Published with video sequence on www.epilepticdisorders.com ]     

The value of home video with ambulatory EEG: A prospective service review

PurposeThe demand for long term EEG monitoring is increasing with the emphasis on recording patients’ attacks. Outpatient ambulatory EEG is relatively inexpensive and widely available. The main disadvantage of the technique is the lack of video which can make interpretation of an ictus difficult. We investigated whether patients, if offered home video equipment, would take it, if this resulted in simultaneous EEG-video capture of an ictus and if interpretation of the recording was facilitated by the video.MethodAll ambulatory EEG patients, adults and children, were offered a camcorder to take home during a 17-month study period.Results130 patients/carers were offered a camcorder (93 adults, 37 children), 45 patients (35%) accepted; the main reason for not accepting was that attacks were considered too brief to record. An ictal event occurred in 34 patients (76%) with a camcorder; in 17 (50%) of these an attack was captured successfully on video. The main reasons for failure to capture events were that attacks were too brief, or that the camcorder was not operated successfully. Attacks were captured with greater success in children (14/23, 61%) than adults (3/11, 27%). Of the 17 video recordings, 14 (82%) were helpful in aiding interpretation of the ambulatory EEG.ConclusionIn our study, home video facilities aided interpretation of ambulatory EEG recordings in approximately one third of patients. Technological advances and familiarity with portable recording devices will improve this figure and patients and their carers should be encouraged to use such facilities when available.     

Alcohol and cognition in the elderly: a review

Consumption of large amounts of alcohol is known to have negative effects, but consumption in smaller amounts may be protective. The effect of alcohol may be greater in the elderly than in younger adults, particularly with regard to cognition. However, the drinking pattern that will provide optimal protection against dementia and cognitive decline in the elderly has not been systematically investigated. The present paper is a critical review of research on the effect of alcohol on cognitive function and dementia in the elderly. Studies published from 1971 to 2011 related to alcohol and cognition in the elderly were reviewed using a PubMed search. Alcohol may have both a neurotoxic and neuroprotective effect. Longitudinal and brain imaging studies in the elderly show that excessive alcohol consumption may increase the risk of cognitive dysfunction and dementia, but low to moderate alcohol intake may protect against cognitive decline and dementia and provide cardiovascular benefits. Evidence suggesting that low to moderate alcohol consumption in the elderly protects against cognitive decline and dementia exists; however, because of varying methodology and a lack of standardized definitions, these findings should be interpreted with caution. It is important to conduct more, well-designed studies to identify the alcohol drinking pattern that will optimally protect the elderly against cognitive decline and dementia.     

The value of long term EEG monitoring in children: A comparison of ambulatory EEG and video telemetry

PurposeOutpatient ambulatory EEG may be followed by inpatient video telemetry EEG when investigating children for possible seizures and for classification of epilepsy. We investigated the value of ambulatory EEG and subsequent video telemetry recording in our centre.MethodThe departmental EEG database was interrogated retrospectively for children undergoing ambulatory recording followed by inpatient video telemetry within an 18-month period.Results30 patients fitted these criteria, 21 females, 9 males, age range 3–16 years. The mean interval between studies was 9 months. For ambulatory recordings 93% of studies were undertaken to ascertain if behaviours were epileptic. 66% of ambulatory recordings studies captured an event of interest and 63% were able to answer the question asked of the test. In video telemetry recording 80% of studies were aimed at ascertaining if events were epileptic or not, 20% were undertaken for classification of seizure type. 70% of recordings captured an ictus and were considered helpful in addressing the clinical question. Pooled together 90% of patients had a paroxysmal event captured and the clinical question answered by the recording techniques. In patients for whom ambulatory recording failed to capture an attack or answer the clinical question, 70% went on to have a successful video telemetry recording.ConclusionBoth ambulatory EEG and inpatient video telemetry are effective tools for diagnosis of seizures. The majority of patients with failed ambulatory recordings go on to have successful video telemetry. Combining the two resources provides useful clinical information in nearly all instances.     

89例首发住院老年期抑郁症的临床特征分析

目的　研究首发住院老年期抑郁症的临床特征。方法　应用自编一般资料调查表 ,回顾 1994～ 2 0 0 1年 89例住院首发老年期抑郁症患者的临床特征 ,并与同期住院的 2 4 9例非老年期首发抑郁症比较。结果　老年期组男性有自杀观念者多于女性 ,并发躯体疾病者少于女性 (P <0 0 0 5 ) ;老年期组并发躯体疾病多于非老年期组 ,精神焦虑比青年组多 ,自杀观念和自杀行为比老年前期少 ,较多单一使用麦普替林 (P <0 0 5 ) ;临床疗效和非老年期无显著差异。结论　老年期抑郁症有较多的精神性焦虑。充分的治疗可以取得满意的疗效     

Seizure semiology in temporal lobe vs. temporal plus epilepsy using intracranial EEG monitoring

Objectives:To utilize our tertiary center’s experience with Temporal lobe epilepsy (TLE) and Temporal plus epilepsy (TPE) cases and determine whether a correlation exists between ictal semiology signs, their localization/lateralization value after intracranial electroencephalography (EEG) monitoring, and surgical outcomes.Methods:A retrospective study was conducted among epilepsy patients who underwent resective surgery for TLE or TPE after intracranial EEG monitoring between January 2008 and December 2018 at King Faisal Specialist Hospital in Riyadh, Saudi Arabia. Data were retrieved for 464 patients; 181 had intracranial electrode monitoring.Results:Forty-eight patients with a mean age of 27 years (SD=8.4) were included; 15 patients had TPE. Auras were frequently reported, emotional auras, in the form of fear (35%). The localization/lateralization value of aura was statistically significant for TPE patients, including visual hallucinations and vertigo, lateralized to the left and right temporo-occipital, respectively (p=0.009 and <0.001). Early-onset ictal manual automatism, oral automatism, late-onset dystonic posture, and late head-turning were significant for TLE without significant lateralization value. The ictal onset zone’s localization was significant between the scalp and intracranial EEG findings in mesial TLE patients. The probability of seizure freedom (Engel class I) was 74%, 60%, and 67% at 2-year follow-up for mesial, lateral TLE, and TPE, respectively.Conclusion:Our results are consistent with previous studies and confirm the importance of ictal semiology signs in TLE and TPE. The addition of intracranial EEG monitoring in these cases helped improve the surgical outcomes.

Epilepsy is one of the most common neurological disorders, affecting approximately 70 million people globally.¹ Thirty percent of these patients have drug-resistant epilepsy,² and most cases referred for epilepsy surgery involve temporal lobe epilepsy (TLE).³ However, after standard temporal lobectomy, around 40% of these patients will experience recurrent seizures.⁴ A variety of explanations have been proposed for these surgical failures, including incomplete removal of the epileptogenic zone, additional contralateral focus (bilateral TLE), dual pathology (mesial and neocortical), and extended epileptogenic focus to the neighboring structures, including extratemporal or temporal plus epilepsy (TPE).⁵The TPE is defined as focal epilepsy with a complex epileptogenic network involving the temporal lobe and the surrounding areas, such as the orbitofrontal cortex, insula, operculum, and temporo-parieto-occipital junction.⁶ A thorough presurgical evaluation is required to delineate the epileptogenic zone for successful resective surgery. In phase I assessment, scalp video electroencephalography (EEG) monitoring, brain magnetic resonance imaging (MRI), and neuropsychological evaluation are needed. Further non-invasive investigations can be included if the initial results are discordant. To reach a well-demarcated epileptogenic focus requires intracranial monitoring, including the subdural grid, strips, and depth, which is known as phase II assessment.⁷ Seizure semiology is the first step in a presurgical evaluation, and ictal semiology and scalp-EEG results play a valuable role in distinguishing TLE from TPE.⁸ Patients with TLE are more likely to experience abdominal auras, ictal gestural automatism, and post-ictal amnesia. However, TPE patients are more likely to experience gustatory hallucinations, rotatory vertigo, auditory illusions, contralateral eye and head versions, piloerection, and ipsilateral tonic posturing. Similar findings were highlighted in a review of TPE cases.4 Furthermore, laryngeal and throat constriction and the atypical distribution of somatosensory symptoms at seizure onset have been found.4Although some studies have found a correlation between seizure semiology and intracranial EEG monitoring in TLE (mesial vs. lateral) vs. TPE, none evaluated lateralization values. This study aims to utilize our tertiary center’s experience with TLE and TPE cases and determine whether a correlation exists between ictal semiology signs, their localization/lateralization value after intracranial electroencephalography (EEG) monitoring and surgical outcomes. We also highlight the process of phase I presurgical assessment (including ictal/interictal scalp EEG, MRI, positron emission tomography [PET], and neuropsychology) in our center.     

Nonconvulsive status epilepticus in the elderly: a case-control study

BACKGROUND: Nonconvulsive status epilepticus (NCSE) is a usually underdiagnosed and potentially treatable cause of altered awareness in the elderly. To assess etiologies, associations with other medical problems, and prognosis of NCSE in a population aged >75 years we performed a nested case-control study. METHODS: We retrospectively evaluated the clinical manifestations and EEG findings in 19 consecutive elderly patients (mean age 83.3 years) presenting with NCSE and compared them with 34 elderly patients (mean age 83.3 years) with altered mental status but without EEG evidence of NCSE. The variables compared included brain lesions on CT or MRI, number of concomitant chronic active diseases, previous neurological disorders, acute medical problems, the use and withdrawal of medications, and outcome. Statistical analysis was performed using chi-square test, t-test, Fisher's exact two-tailed test, and Wilcoxon rank sum test. RESULTS: The etiology of NCSE was epilepsy in 2, acute medical disorders in 14, and a cryptogenic cause in 4. The NCSE group had a more frequent history of epilepsy, 35% versus 8.8% (p = 0.028); tramadol use, 31% versus 0% (p = 0.00151); longer hospitalization, 25 days versus 7 days (p = 0.0004); and unfavorable outcome, 50% versus 5.8% (p = 0.00031). No significant differences were found in the other variables. Unfavorable outcome was associated with a higher number of comorbidities (>2) and to a severely altered mental status. CONCLUSIONS: NCSE is a serious cause of altered mental status in the elderly. Although its direct role in brain damage is controversial, elderly patients with NCSE have higher morbidity and worst prognosis than those with altered mental status without NCSE.     

48例老年谵妄临床特征分析

目的：了解老年谵妄的临床特征：方法：收集48例老年谵妄病人的一般资料及生物学资料，实验室检查等各项辅助检查，并使用谵妄评定方法中文修订版（the Chinese revision of confusion assessment method,CAM-CR)测评。结果：谵妄的核心症状是意识障碍，谵妄的特点是急性起病，症状的波动性明显。其它常见症状为注意障碍，不同程度的定向力障碍，记忆障碍，行为障碍和睡眠－觉醒周期改变等。结论；年龄大，患有多种躯体疾病，肺部感染，用药，酒精滥用等与谵妄发生有关系。     

SPASE-I: a multicenter observational study on pharmacological treatment of acute stroke in the elderly

We investigated the clinical outcome and current therapeutic management of ischemic stroke in elderly patients in different neurological wards throughout Italy. Twelve centers in 10 Italian regions were involved. The clinical and instrumental data were prospectively collected for 335 patients 65 years or older, presenting in a 12-months period. At the multivariate analysis, death was associated with the presence of total anterior circulation infarct and the use of antiedema agents. Stroke-related disability was related to female sex, unified stroke scale (USS) scores at entry and mini-mental state examination (MMSE) scores at the 1-months follow-up. The majority of patients (70%) received antiplatelets to prevent stroke recurrence. Very elderly (≥80 years) patients had worse presentation and prognosis than less elderly stroke victims (<80 years). Age played an important role in the therapeutic approach to stroke: while antiplatelets were widely used, oral anticoagulants were underused even when specifically indicated. Received: 6 November 2001 / Accepted in revised form: 28 February 2002     

Atypical antipsychotics in the elderly

INTRODUCTION: Although their primary purpose is to treat psychosis, antipsychotics are commonly prescribed for the elderly to treat the behavioural disturbances and agitation associated with dementia. Such use is controversial. Atypical antipsychotics cause fewer extrapyramidal sideeffects than the older drugs in younger adults, but the evidence base for their efficacy and tolerability in the elderly is poor. The aims of this study were to determine the prevalence of atypical antipsychotic prescribing for the elderly, the indications for use and documented side-effects. METHOD: The medication cards of all patients from 19 Trusts, occupying a psychiatric bed for the over 65s, were screened during one week in March 2000. Data were collected by pharmacists from the clinical notes. RESULTS: Half of those prescribed an antipsychotic received an atypical, and risperidone was the one most commonly prescribed. Half the sample had a diagnosis of dementia. Documented side-effects from the atypical were uncommon. CONCLUSION: Atypicals are frequently prescribed as first-line antipsychotics for behavioural problems associated with dementia, despite the poor evidence base for their efficacy and safety in this population. Undermonitoring of side-effects may remain a problem.