Non-epileptic seizures of the elderly

OBJECTIVE: To characterize non-epileptic seizures (NES) in the elderly and compare their features with NES of a younger control group. METHODS: The database of the epilepsy monitoring unit of the Cleveland Clinic Foundation (CCF) was searched for patients aged 60 years and older having undergone long-term video-/EEG monitoring between 1994 and 2002, with the subsequent diagnosis of NES. Videotapes of all events were evaluated by independent observers. NES were classified based on the clinical manifestations recorded on video, EEG and imaging data, and compared with a control group of younger adults with NES. RESULTS : Thirty-nine elderly patients were included. Seventeen of them (44%) had NES only, six (15%) had both epilepsy and NES. The control group consisted of 20 patients, two of them had NES and epilepsy. The NES were classified as physiological in 10 elderly patients (43%) and one control patient. They included TIA, syncope, movement disorders and sleep disorders. Psychogenic NES were found in 13 elderly and 19 control patients and were associated with somatoform disorders, anxiety disorders, mood disorders and reinforced behavior pattern. Psychogenic NES consisted of predominant motor activity in 8 (61%) elderly and 13 (68%) control patients, unresponsiveness in 4 (31%) elderly and 2 (11%) control patients and subjective symptoms in 1 (8%) elderly and 4 (21%) control patients. Twelve (71%) of the patients of each group without evidence for epilepsy were on anticonvulsant drugs at the time of admission. CONCLUSION: NES are a frequent problem in elderly patients referred to a comprehensive epilepsy center. In contrast to a younger control group, physiological and psychogenic NES are equally frequent in the elderly. Loss of responsiveness was seen in only 20% of patients with psychogenic NES. Although most of the patients did not have any evidence for epilepsy, more than two thirds of these patients had been placed on anticonvulsive drugs.     

Video/EEG monitoring in the evaluation of paroxysmal behavioral events: duration, effectiveness, and limitations

To establish the number of monitoring days needed to distinguish psychogenic nonepileptic seizures (PNES) from epileptic seizures (ES) in adult patients admitted for video/EEG monitoring (VEM), we performed a retrospective chart review on 199 consecutive admissions for behavioral event diagnosis with VEM. Of the 199 adult patients admitted for VEM, 83.9% (n = 167) had a clinical event during admission, and a definitive diagnosis was made in 75.9% (n = 151). Of patients who had clinical events, 87.7% (n = 143) had their first event on admission day 1 or 2. Factors associated with ES (vs PNES) included an abnormal baseline EEG (P < 0.001), an abnormal brain MRI (P = 0.01), and history of events lasting less than 1minute (P = 0.01). There was no association between time to first event and discharge diagnosis. VEM differentiated between ES and PNES in the majority of adult patients evaluated. Most behavioral events were characterized within 2 days of admission.     

The frequency of non-epileptic spells in children: Results of video-EEG monitoring in a tertiary care center.

RATIONALE: The diagnosis of non-epileptic spells (NES) in children can be challenging, even for experienced clinicians. Our objective was to describe the characteristics of such events. METHODS: This was a retrospective study conducted from January 2004 to December 2006. Inclusion criteria were age >1 month and <18 years and the diagnosis of NES established by video-EEG monitoring. RESULTS: Among 746 monitored children (1203 recorded video-EEG sessions), 109 (14.6%) had NES. The mean age of patients with NES was 6.6 years (range 0.1-18). Seventy patients were diagnosed with NES alone; the remaining 39 with both NES and epilepsy. Developmental delay was more frequent among patients with a co-morbid diagnosis of epilepsy (p<0.001). Similar clinical events were reported in both of these groups, save for crying spells/irritability which was more common in children with epilepsy. Frequent manifestations of NES included staring spells in preschool children, crying/irritability, tremor and eye deviation in young children and preschoolers, and limb shaking in adolescents. All of the patients with epilepsy and 19 (27%) of those without epilepsy were receiving antiepileptic drugs. CONCLUSION: Our data highlights the importance of accurate diagnosis of NES toward the appropriate treatment of affected children.     

Verbal episodic memory in 426 multiple sclerosis patients: impairment in encoding, retrieval or both?

Episodic memory is frequently impaired in multiple sclerosis (MS) patients but the exact nature of the disorder is controversial. It was initially thought to be due to a retrieval deficit but some studies have demonstrated an encoding deficit, which could be linked to a slowing of information processing speed or to a deficit in elaboration of strategies. The main objective of this study is to assess the prevalence and the nature of verbal episodic memory (VEM) impairment in MS patients. We retrieved memory performances of 426 patients [314 F–112 M; mean age: 46.1 years; median Expanded Disability Status Scale (EDSS) score: 3.1] from a neuropsychological data base. VEM was assessed using the 16 words RL-RI 16 test. 66% MS patients present at least one recall impaired in VEM (37.2% from 2 to 5 recall). 14.2% MS patients present an impairment in encoding phase. We observed that 5% of patients presented recognition difficulties. Correlations were observed between VEM performances and EDSS, and disease duration but no group effect (ANOVA) is observed between form of MS and VEM performances. These results confirm the high prevalence of VEM impairment in MS patients. Deficits affect mainly information retrieval in early stage MS patients and are then linked to encoding as disability increases. Storage disorders are infrequent, so cognitive rehabilitation with mental imaging could be effective in MS patients.     

A Comprehensive Profile of Clinical, Psychiatric, and Psychosocial Characteristics of Patients with Psychogenic Nonepileptic Seizures

PURPOSE: To attain a comprehensive profile of clinical, psychiatric and psychosocial characteristics of patients with psychogenic nonepileptic seizures (NESs), and to assess the relation of these factors to NES outcome. METHODS: We administered a telephone-based structured questionnaire to 56 patients with NESs (16 male and 40 female patients; mean age, 35 years) at a mean follow-up time of 18 months after making the diagnosis of NES. RESULTS: Mean age of NES onset was 28 years with a mean duration of 8 years. Episodes resolved in 29 (51.8%) cases, decreased in 24 (42.9%), persisted unchanged in two (3.6%), and increased in frequency in one (1.8%). Thirty (53.6%) patients, including 13 (44.8%) of patients whose NESs resolved, were rehospitalized for NESs or for other symptoms. Twenty-nine (51.8%) had significant depressive symptoms, 22 (39.3%) had suicidal ideation, and 11 (19.6%) attempted suicide [including 6 (21%) of the patients whose NESs resolved]. Believing the NES diagnosis was associated with resolution or improvement of NES frequency (p<0.029), whereas anger in response to receiving the diagnosis did not predict a poorer outcome. Patients' perceptions of having good health (p<0.02) and good occupational functioning (p<0.04) were highly correlated with NES resolution. Only patients whose episodes resolved were employed at the time of follow-up. CONCLUSIONS: At a mean of 1.5 years, NES outcome was poor, with resolution in only half the group and with frequent rehospitalizations after NES diagnosis, even among patients whose NES resolved. Depressive symptoms, suicidal ideation, and suicide attempts were common. Believing the NES diagnosis and patient perceptions of having good health and good occupational functioning correlated well with NES resolution.     

Video-EEG monitoring in a geriatric veteran population.

Video-EEG monitoring is a standard tool to evaluate possible seizures. However, there are limited data available for the elderly population, and no data are available for the elderly veteran population. The records of 71 veterans ages 60 and older who underwent video-EEG monitoring at the Michael E. DeBakey Veterans Affairs Medical Center from 1999 to 2006 were reviewed. The average age was 68 years, and 94% were male. Typical events occurred in 34 of 71 patients (48%). Twelve patients (35%) had epileptic seizures; most were temporal lobe seizures (75%). The remaining 22 patients (65%) had a nonepileptic event. Of these, 10 (45%) had psychogenic nonepileptic seizures and 12 (55%) had other physiologic nonepileptic events. AEDs were previously prescribed in 14 of the 22 nonepileptic patients (64%). In our study, most events were nonepileptic, partly reflecting the unique nature of the VA population. There was a slightly higher number of physiologic nonepileptic events; however, psychogenic seizures are also frequently seen. Most of the patients with nonepileptic events were previously treated with AEDs. Most of the epileptic events captured were temporal lobe seizures. Video-EEG monitoring in the elderly is useful in the characterization of paroxysmal events.     

Cortical processing during smartphone text messaging

ObjectiveThe objective of this study was to report the EEG features of text messaging using smartphones.MethodsOne hundred twenty-nine patients were prospectively evaluated during video-EEG monitoring (VEM) over 16 months. A reproducible texting rhythm (TR) present during active text messaging with a smartphone was compared with passive and forced audio telephone use, thumb/finger movements, cognitive testing/calculation, scanning eye movements, and speech/language tasks in patients with and without epilepsy. Statistical significance was set at p < 0.05.ResultsTwenty-seven patients with a TR were identified from a cohort of 129 (93 female, mean age: 36; range: 18–71) unselected VEM patients. Fifty-three out of 129 patients had epileptic seizures (ES), 74/129 had nonepileptic seizures (NES), and 2/129 were dual-diagnosed. A reproducible TR was present in 27/129 (20.9%) specific to text messaging (p < 0.0001) and present in 28% of patients with ES and 16% of patients with NES (p = NS). The TR was absent during independent tasks and audio cellular telephone use (p < 0.0001). Age, gender, epilepsy type, MRI results, and EEG lateralization in patients with focal seizures were unrelated (p = NS).ConclusionsOur results suggest that the TR on scalp EEG represents a novel technology-specific neurophysiological alteration of brain networks. We propose that cortical processing in the contemporary brain is uniquely activated by the use of PEDs.SignificanceThese findings have practical implications that could impact industry and research in nonverbal communication.     

The usefulness of video-EEG monitoring in elderly patients with seizure disorders.

The purpose of this paper was to evaluate the use of inpatient video-EEG (VEEG) monitoring in the evaluation of seizure disorders in elderly subjects. We retrospectively identified 36 patients aged 60 years old or over from a total of 849 patients studied at the VEEG unit of the Tampere University Hospital. Sixteen of the patients (44%) experienced at least one habitual seizure during the recording. Seven patients had epileptic seizures including two cases with status epilepticus. Nine patients had various non-epileptic disorders. VEEG had a clinically significant impact on the diagnosis and treatment in 14 of the 16 patients in whom paroxysmal events were recorded and proved to be useful in the evaluation of seizure disorders in elderly subjects.     

The value of video-EEG monitoring to diagnose juvenile myoclonic epilepsy

ObjectiveA diagnostic accuracy of conventional electroencephalography (EEG) is approximately 50% at best. We aimed to determine the accuracy of video-EEG monitoring (VEM) for a correct diagnosis and the feasibility of its clinical application. The data from all 55 patients (M:F = 31:24) with juvenile myoclonic epilepsy (JME) who underwent VEM were reviewed according to the clinical history, brain imaging and video-EEG findings.ResultsAge at seizure onset ranged from 10 to 25 (15.5 ± 2.7 years). The age at VEM ranged from 15 to 46 (21.8 ± 5.8 years) and 57% (29/51) showed seizures. Of those, 20 patients (69%) showed myoclonic jerks alone, whereas 3 (10%) showed generalized seizures alone. Both of these conditions were observed in 6 patients (21%). Interictal abnormalities alone without clinical seizures were detected in 16 patients (31%). Atypical semiologies such as asymmetric myoclonus or versive seizures were observed in 18 patients (35%) during video monitoring. Interestingly three patients complained of visual aura on history. The duration of VEM ranged from 1 to 6 days (1.8 ± 1.1). Overall, 88% of patients showed an EEG abnormality with/without seizure, concordant with JME. Among 10 patients with a normal conventional EEG before VEM, 9 showed interictal or ictal EEG abnormalities during approximately 1-day of VEM.ConclusionsVEM for 1 or 2 days is appropriate for making a correct diagnosis of JME, especially in patients having an atypical semiology and a normal result on the conventional EEG.     

Evidence That Emotional Maladjustment Is Worse in Men Than in Women with Psychogenic Nonepileptic Seizures

The purpose of this study is to examine the effects of gender on adjustment and cognition in patients with psychogenic nonepileptic seizures (NES) and on patients with epilepsy. We compared 57 women and 27 men, all at least 16 years old, with only NES as documented by long-term EEG-video monitor studies, to equal numbers of randomly selected women and men with only epileptic seizures. Variables examined included age, age of onset, education, scales from the MMPI, the WAIS-R, and the number of tests outside normal limits from the Neuropsychological Battery for Epilepsy. We found no significant differences in mean age, intelligence, or percentage of neuropsychological tests outside normal limits across the four groups. Women and men with NES had significantly later age of onset of attacks compared with subjects of either gender with epilepsy (26 years vs 13 years, P < 0.001) and men with NES had greater educational achievement than women with NES or patients with epilepsy (P < 0.02). However, the most important findings were seen on the MMPI. Men with NES exhibited significantly greater elevations on multiple scales (especially Hysteria, Depression, Hypochondriasis, Psychoasthenia, Schizophrenia) compared with men with epilepsy or women with either epilepsy or NES. We conclude that men with NES have significantly worse patterns of emotional adjustment, as measured by the MMPI, than women with NES or subjects of either gender with epilepsy.     

Non-epileptic seizures: delayed diagnosis in patients presenting with electroencephalographic (EEG) or clinical signs of epileptic seizures.

The clinical differentiation between epileptic seizures (ES) and non-epileptic seizures (NES) is often difficult and mostly based on the presence or absence of widely recognized features of ES such as tongue biting, falling, incontinence or concomitant epileptic abnormalities in the electroencephalogram (EEG). We retrospectively analysed the records of all patients referred to our Epilepsy Centre for refractory epilepsy and finally diagnosed with NES between 1980 and 1999 ( n= 103), half of them also exhibiting ES. The mean time-lapse between first attack and NES diagnosis was 8.7 +/- 1.3 years and 16.5 +/- 1.4 years for the NES and NES + ES groups respectively. At least one of the usual signs associated with generalized tonic-clonic seizures (tongue biting, falling or incontinence) was reported by 66% and 60% of patients with NES or NES + ES respectively. Interictal EEG abnormalities were recorded in 16% of NES patients vs. 80% of NES + ES patients. In the NES group, delay before establishing the correct diagnosis was significantly longer when the patients exhibited > or =1 symptom(s) of generalized seizures, or when patients exhibited interictal EEG abnormalities. Upon admission, 72% of NES patients and all NES + ES patients were being treated with antiepileptic drugs (AEDs).We conclude that EEG or clinical abnormalities suggestive of epileptic seizures are common in undiagnosed NES patients. Such diagnostic pitfalls, besides considerably delaying NES diagnosis, also considerably delay appropriate treatment implementation.     

Fibromyalgia and seizures

The purpose of this case‐matched study was to determine how frequently fibromyalgia is associated with different paroxysmal neurological disorders and explore the utility of fibromyalgia as a predictor for the diagnosis of psychogenic non‐epileptic seizures. The billing diagnosis codes of 1,730 new, non‐selected patient encounters were reviewed over a three‐year period for an epileptologist in a neurology clinic to identify all patients with historical diagnoses of fibromyalgia. The frequency with which epileptic seizures, psychogenic non‐epileptic seizures, and physiological non‐epileptic events were comorbid with fibromyalgia was assessed. Age and gender case‐matched controls were used for a between‐group comparison. Wilcoxon tests were used to analyse interval data, and Chi‐square was used to analyse categorical data (p<0.05). Fibromyalgia was retrospectively identified in 95/1,730 (5.5%) patients in this cohort. Females represented 95% of the fibromyalgia sample (age: 53 years; 95% CI: 57, 51). Forty‐three percent of those with fibromyalgia had a non‐paroxysmal, neurological primary clinical diagnosis, most commonly chronic pain. Paroxysmal events were present in 57% of fibromyalgia patients and 54% of case‐matched controls. Among patients with fibromyalgia and paroxysmal disorders, 11% had epileptic seizures, 74% had psychogenic non‐epileptic seizures, and 15% had physiological non‐epileptic events, compared to case‐matched controls with 37% epileptic seizures, 51% psychogenic non‐epileptic events, and 12% physiological non‐epileptic events (p = 0.009). Fibromyalgia was shown to be a predictor for the diagnosis of psychogenic non‐epileptic seizures in patients with undifferentiated paroxysmal spells. However, our results suggest that the specificity and sensitivity of fibromyalgia as a marker for psychogenic non‐epileptic seizures in a mixed general neurological population of patients is less than previously described.     

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.     

Nonepileptic Seizures After Head Injury

Summary: Purpose: To examine the role of head injury as a risk factor in the development of nonepileptic seizures (NES). Specifically, we will determine the relative frequency of head injury among NES patients referred to our center and will describe several pertinent clinical features and personal characteristics.
Methods: Retrospective record review of patients referred to our center for evaluation of seizures over a 4-year period. All patients with NES were evaluated as in a previously described protocol, which included intensive video EEG monitoring, provocation by suggestion, and psychiatric interview. All NES patients with a history of head injury were extracted for this report.
Results: Of 102 patients with NES, nearly one-third (32%) had an antecedent head injury; 52% were male, mean age was 34 years, and 12% had coexisting epilepsy. Multiple psychiatric disorders were not uncommon (79%), and a history of abuse was found in 35%. All but four patients had documented financial gain from their injury. Follow-up at 1 year found poor long-term outcome with lasting disability; despite that, the majority (91%) of head injuries were minor.
Conclusions: Our preliminary findings suggest that prior head injury is associated with the development of NES and may contribute to the pathogenesis of NES in vulnerable patients. Head injury and sexual or physical abuse appear to occur in comparable proportions in patients with NES. This suggests that head injury and abuse may be equally important risk factors in the development of NES.     

EEG dipole source localisation of interictal spikes acquired during routine clinical video-EEG monitoring

OBJECTIVE: We investigated the feasibility of electroencephalography (EEG) dipole source localisation of interictal epileptiform discharges from data acquired during routine clinical inpatient video-EEG monitoring (VEM) and compared a 19-channel 'routine montage' with a 29-channel 'surgical montage' that includes an additional row of 10 inferior temporal electrodes. METHODS: Twenty consecutive patients who had VEM for the presurgical evaluation of medically refractory partial epilepsy were screened. Thirteen of the patients had focal interictal spikes recorded, and in 11 (85%) these were technically satisfactory for source localisation. Fourteen spike foci were analysed as 3 patients had bilateral independent spikes. EEG data was acquired with 29 electrodes including an inferior temporal row (surgical montage). For comparison, the 10 additional electrodes were excluded from analysis (routine montage). Using NEUROSCAN Source 2.0 software, a computed dipole source localisation of averaged spikes was performed utilising a magnetic resonance imaging-based finite element model. Dipole localisation was compared with that of the Comprehensive Epilepsy Program (CEP) evaluation. RESULTS: Using the surgical montage dipole source localisation was consistent with the CEP spike localisation for 13/14 spikes (93%, P<0.005), compared with only 5/14 spikes (36%) using the routine montage. CONCLUSIONS: Data derived from routine clinical inpatient VEM using a routine montage can yield accurate EEG dipole source localisation, but significantly more accurate localisation is obtained using the surgical montage.     

Evaluating the use of prolonged video-EEG monitoring to assess future seizure risk and fitness to drive

ObjectiveThe use of prolonged video-electroencephalography monitoring (VEM), rather than routine electroencephalography (EEG), in predicting the risk of future seizures in patients with epilepsy is not well studied. A longer period of monitoring could be more likely to capture either ictal or interictal epileptiform activity. This information may better assist clinical decision making on driving fitness. The goal of this study was to evaluate the use of 6-hour prolonged VEM versus routine EEG in the assessment of future seizure risk and driving fitness for patients with epilepsy.MethodsData on consecutive patients referred for 6-hour prolonged VEM were retrospectively analyzed. Criteria were developed that combined EEG findings and clinical factors to determine each patient's fitness to drive. Seizure relapse outcomes were followed over 2 years.ResultsOf 34 patients, 27 were considered safe to drive following prolonged VEM. Five (19%) of these 27 patients had seizure relapses; all had an obvious precipitant(s) identified including sleep deprivation, excessive alcohol, and missed medication doses. Seven of the 34 patients were deemed unsafe to drive. All seven (100%) had seizure relapses, with unprovoked seizures in four patients. The relative risk of seizure in patients deemed unfit to drive was 5.4 (P = 0.00015). If only the routine EEG component of the recordings were used with the criteria, the relative risk would have been 3.4 (P = 0.037), with nearly double the number of active drivers having seizures. The majority of patients (76%) in this study had idiopathic generalized epilepsy, with a relative seizure risk of 4.0 (P = 0.002) for patients deemed unfit to drive in this subgroup. The focal epilepsy group was small (eight patients) and did not quite achieve statistical significance.ConclusionSix-hour VEM improves the evaluation of driving fitness by better predicting the risk of subsequent seizure relapse for idiopathic generalized epilepsy and possibly focal epilepsy. Prolonged monitoring is superior to routine EEG. Ongoing avoidance of seizure-provoking factors remains paramount to driving safety.     

Clinical Features and Prognosis of Nonepileptic Seizures in a Developing Country

PURPOSE: To determine the predictive value of clinical features and medical history in patients with nonepileptic seizures (NESs). METHODS: One hundred sixty-one consecutive ictal video-EEGs were reviewed, and 17 patients with 41 NESs identified. NES diagnosis was defined as paroxysmal behavioral changes suggestive of epileptic seizures recorded during video-EEC without any electrographic ictal activity. Clinical features, age, sex, coexisting epilepsy, associated psychiatric disorder, social and economic factors, delay in reaching the diagnosis of NES, previous treatment, and correlation with outcome on follow-up were examined. RESULTS: The study population included 70% female patients with a mean age of 33 years. Mean duration of NESs before diagnosis was 9 years. Forty-one percent had coexisting epilepsy. The most frequent NES clinical features were tonic-clonic mimicking movements and fear/anxiety/hyperventilation. The most common psychiatric diagnosis was conversion disorder and dependent and borderline personality disorder. Seventy-three percent of patients with pure NESs received antiepileptic drugs (AEDs), and 63.5% of this group received new AEDs. Fifty-nine percent of the patients received psychological/psychiatric therapy. At follow-up, 23.5% were free of NESs. CONCLUSIONS: All seizure-free patients had two good prognostic factors: having an independent lifestyle and the acceptance of the nonepileptic nature of the episodes. Video-EEG monitoring continues to be the diagnostic method to ensure accurate seizure classification. Establishing adequate health care programs to facilitate access to new technology in public hospitals as well as the implementation of continuous education programs for general practitioners and neurologists could eventually improve the diagnosis and treatment of patients with NESs.     

Nonepileptic seizures in children

PURPOSE: To determine if the clinical characteristics of nonepileptic seizures (NES) are different in children younger than 13 years age as compared to adolescents. METHODS: Retrospective review of medical records and video-EEGs (VEEG) of all patients with NES confirmed on VEEG monitoring was performed. RESULTS: Sixty-eight (3.5%) of 1,967 patients monitored with VEEG had a clinical diagnosis of NES. Fifty-nine of 68 patients had their habitual event recorded. Mean age at the time of the VEEG diagnosis was 13 years 4 months. Twenty-two patients were less than 13 years (group A) and 37 were 13 years and older (group B). The male to female ratio was equal in group A, with female predominance seen in group B. NES commonly manifested as subtle motor activity in group A (p < 0.01) and prominent motor activity in group B (p < 0.001). Difficulties at school, family discord, and interpersonal conflicts, were frequent stressors in both groups. Sexual abuse was the least frequent. Depression was more common in group B; cognitive dysfunction (p < 0.001) and epilepsy (p < 0.01) were more common in group A. CONCLUSIONS: Differences in clinical semiology and predisposing factors may help identify young children and adolescents who might be at risk for the development of NES.     

The clinical spectrum of laryngeal dystonia includes dystonic cough: Observations of a large series

Laryngeal dystonia is a movement disorder of the muscles within the larynx, which most commonly manifests as spasmodic dysphonia (SD). Rarer reported manifestations include dystonic respiratory stridor and dyscoordinate breathing. Laryngeal dystonia has been treated successfully with botulinum neurotoxin (BTX) injections since 1984. We reviewed prospectively collected data in a consecutive series of 193 patients with laryngeal dystonia who were seen at St. Vincent's Hospital between 1991 and 2011. Patient data were analyzed in Excel, R, and Prism. Laryngeal dystonia manifested as SD (92.7%), stridor (11.9%), dystonic cough (6.2%), dyscoordinate breathing (4.1%), paroxysmal hiccups (1.6%), and paroxysmal sneezing (1.6%). There were more women (68.4%) than men (31.6%), and the average age at onset was 47 years. A positive family history of dystonia was present in 16.1% of patients. A higher incidence of extra‐laryngeal dystonia (ie, torticollis and blepharospasm) and concurrent manifestations of laryngeal dystonia were present in patients with dystonic cough, dyscoordinate breathing, paroxysmal sneezing, and hiccups than in other patients (P = 0.003 and P < 0.0001, respectively). The average starting dose of BTX decreased from 2.3 to 0.5 units between 1991 and 2011. The median treatment rating was excellent across all subgroups. Patients with adductor SD, stridor, extra‐laryngeal dystonia and male patients had relatively better treatment outcomes. Technical failures were rare (1.1%). Dysphonia secondary to vocal cord paresis followed 38.7% of treatments. Laryngeal dystonia manifests predominantly as SD, but other manifestations include stridor, dyscoordinate breathing, paroxysmal cough, hiccups, and sneezing. BTX injections are very effective across all subgroups. Severe adverse events are rare. © 2014 International Parkinson and Movement Disorder Society     

Profile of psychiatric disorders and life events in medically ill elderly: experiences from geriatric clinic in Northern India

BACKGROUND: Morbidity among elderly people has an important influence on their psychological well-being. Evaluation of the morbidity profile and its determinants, which have implications for management of medical problems of elderly people, are scarce in developing countries. Even the physicians' detection rate of mental distress in elderly populations is low in medical outpatient clinics. This could be due to the large caseloads and also, importantly, underestimation of psychological concerns of the elderly. The objective of this study was to study the psychiatric co-morbidity and life events among elderly medical outpatients. METHODS: One hundred medically ill elderly (>60 years) patients attending the Geriatric Clinic at Bikaner (North India) constituted the study population. The physical diagnosis was made by a physician based on reported illness, clinical examination and medical records. Psychiatric diagnosis was made by detailed clinical psychiatric interview using ICD-10 guidelines. Life events were assessed by the Indian adaptation of Presumptive Stressful Life Events Scale. RESULTS: Hypertension was the most commonly reported physical diagnosis (50%), other specific medical illnesses were osteoarthritis (15%), diabetes (13%) and constipation (8%). The study found 18% subjects had depression and 11% had other mental disorders. Patients with mental disorders had suffered more recent stressful life events. Among life events, conflicts in family (16%); unemployment of self or children (9%) was reported by elderly psychiatric patients. Other reported life events in psychiatric diagnosed elderly were conflict in family (7%), illness of self (6%) or family members (5%) and death of family members (5%) or close relatives (4%). CONCLUSION: Mental disorders are common among medically ill elderly patients, but they are poorly recognized and treated. Assessment of the psychiatric morbidity will help in strengthening psycho-geriatric services and thus, improve the quality of life of the elderly.