Seizures are common in older adults and rank third among central nervous system disorders. Cryptogenic seizures reach a second peak in the elderly. Due to the increase of this age-related disorder and the growing aging population, there is a growing interest in the diagnosis and treatment of elderly patients. This article provides a review of the causes, types, and diagnostic criteria of EEG for nonacute seizure epilepsy in the elderly and briefly describes the treatment options. I. Incidence and aetiology of epilepsy in the elderly The incidence of epilepsy in the elderly increases gradually with age. The incidence of acute epilepsy is greater than 100/100,000 in older adults over the age of 60, and 50,000 new epilepsy cases occur each year in the U.S. Many central nervous system (CNS) disorders that can cause acute symptomatic seizures are the leading cause of recurrent seizures of unknown origin, with stroke being the leading cause of epilepsy onset in older adults. diagnosed after the age of 65 In patients with epilepsy after age 65, the most common causes were cerebrovascular disease (33%), degenerative disease (11.7%), and CNS tumors (4.5%).Hiyoshi and Yagi reported that half of those patients who developed epilepsy after age 50 without a family history of epilepsy had a stroke or head trauma as the cause. In a recent study of a continuous multicenter clinical trial, cerebrovascular accidents were found to be the leading cause of epilepsy in 40% of patients (>60 years of age) with new onset epilepsy. The incidence of post-stroke epilepsy ranged from 4% to 15%. Stroke-induced epilepsy has been reported to occur mostly 3 to 14 years later, but in most cases, post-stroke epilepsy occurs 3 months to 1 year after a cerebrovascular event. Seizures occur more often after a hemorrhagic stroke than after an ischemic stroke. Risk factors for the development of epilepsy after stroke include: stroke involvement of the cortex, history of seizures within two weeks of stroke, and hematoma involving the lobes of the brain. Some studies of pre-existing seizures and post-stroke recurrences have heralded a new progression of epilepsy. II. Types of seizures The types of seizures in older adults differ from those in younger adults. Compared with children, most older adults have partial seizures with or without secondary generalized tonic-clonic seizures. Complex partial seizures were the most common type (48%), followed by simple partial seizures, often with motor manifestations (13%). The incidence of generalized seizures (often with a history of hypoxia or degeneration) was considerably lower in older patients (29%) than in children under 15 years of age (50%). In a retrospective study of 190 elderly patients with epilepsy over 60 years of age (76% had seizures before the age of 50 years), it was found that 17.4% had full-blown seizures, 76.3% had partial seizures, and 6.3% had seizures of an unspecified nature. III. Diagnosis There are still many difficulties in the correct diagnosis of epilepsy in the elderly because we have not studied much about the symptomatology of seizures in this age group. The CCTV-EEG, which is extremely useful for the diagnosis and classification of epilepsy in younger patients, is difficult to use in the elderly because they are mostly unemployed, do not participate in social activities, live independently, and have fewer witnesses. Also, the self-description of symptoms by elderly patients can be masked by medications and concomitant psychiatric disorders. In addition, in a study of CCTV-EEG monitoring, it was found that adult patients with partial-onset seizures were often (30%) unaware of their seizures. Ramsay and Pryor concluded that elderly patients tend to have non-temporal lobe lesion epilepsy and therefore are less likely to have seizure aura commonly seen in younger patients, such as olfactory hallucinations, somatosensory seizures and complex partial seizures associated with the temporal lobe, including orofacial limbic automatism and wandering activity. In older patients, the aura is often described as “dizziness” and epileptic seizures are described as altered mental status, staring, unresponsiveness, temporary loss of consciousness, etc., and the post-ictal confusion may be prolonged, even lasting several days. In a retrospective study of 53 elderly patients over 60 years of age with long-standing epilepsy, generalized tonic-clonic seizures (GTCS) were found to be less common, and in some (20) cases, GTCS seizures became progressively milder. In addition, episodes accompanied by altered level of consciousness in the elderly should first exclude loss of consciousness due to cardiovascular disease, as neurological symptoms can occur in the form of arrhythmias, conduction blocks (A-Seizures), and blood pressure fluctuations. In elderly patients, common disorders such as syncope, TIA, transient generalized amnesia, and episodic vertigo are similar to seizures. In any population, a complete history statement from the patient and witnesses and a comprehensive and thorough neurological examination are the basis for the clinical diagnosis of epilepsy. Common ancillary tests include routine serum laboratory tests, neuroimaging (MRI is especially good), and EEG. In addition, appropriate cardiovascular examinations should be performed in the elderly. IV. EEG characteristics of epilepsy in the elderly Before discussing the role of EEG in the diagnosis of epilepsy in the elderly, it is important to understand the age-related changes in normal EEG, because age-related EEG changes are often mistaken as indicators of epileptic seizures. 1, benign changes in the EEG of the elderly Previous literature is more controversial: what is the normal alpha rhythm of the elderly. Some authors consider frequencies less than 8 HZ to be abnormal. In people >50 years of age, background EEG activity similar to occipital alpha rhythms can be found in one or two temporal brain regions, generally those dominating the left side, with greater voltage for temporal alpha activity than for occipital alpha rhythms. The elderly EEG has a distinct periodic focal slow-wave activity, especially in the left temporal brain region. It has been reported that temporal lobe slow wave activity is a normal age-related manifestation. However, based on information collected from accurate video recordings of healthy older adults, many studies disagree with this view and suggest that focal periodic slow-wave activity accounts for only 1% to 2% of EEG recordings under normal conditions and includes more theta activity than alpha activity. “appear only singly or occasionally in pairs for a very short recording period (0-1%). Benign EEG variants with epileptiform waveforms can occur at any age and may be mistaken for indicators of seizure tendencies. The three benign variants that occur at higher frequencies in middle-aged and older adults include arcuate spikes, small sharp spikes, and adult subclinical rhythmic EEG emissions. Arching spikes are less common, with an incidence of 0.9%, occur more frequently in sleepy or light sleep states, morphologically resemble mu rhythms, and are commonly found in anterior and middle temporal brain regions, either bilaterally or unilaterally. Isolated arching spikes are often mistaken for temporal lobe epileptic waves, and when an arching spike occurs in isolation, the waves should be compared and analyzed as a series. If an isolated arching spike wave is similar to a series of arching spikes, the wave is not associated with the slow wave component that follows it and does not interfere with the EEG background, then the wave is not associated with epilepsy and is commonly seen in cerebrovascular disease. Small spike-like spikes (SSSs), also known as benign epileptiform transient sleep waves (BETS) or benign sporadic sleep spikes (BSSS), are common in adults during sleepy and non-rapidly moving light sleep periods and are typically low voltage (less than 50µV) and short duration (less than 50ms), monophasic or biphasic spikes, sometimes accompanied by a low voltage slow wave component, often with the highest It can occur in one hemisphere, or bilaterally if the EEG recording is long enough. The incidence of SSSs is 20% to 25% in normal and asymptomatic populations. In the past, SSSs were thought to be associated with cerebrovascular disease, syncope, mental disorders, and many other disorders. Some data suggest that SSSs are associated with the degree of seizures. There are also many EEG reports that suggest that SSSs are not significant in the diagnosis of seizures. Therefore, in clinical EEG, it is important to distinguish SSSs from the issuance of epileptic waves present in temporal lobe brain regions. In consecutive series of recordings, SSSs rarely repeat the same distribution and morphology. In deep sleep, the frequency of SSSs fades or disappears. sSSs do not interrupt background EEG activity and are not associated with slow-wave rhythmic activity. Subclinical rhythmic EEG emission in adults (SREDA) is a rare waveform that occurs in less than 0.05% of patients, mainly during hyperventilation in adults >50 years of age, but also during rest and sleepiness, and is a broad spike-like theta (4-7 Hz) rhythm with a sudden onset, often lasting 40-80 seconds, and can spread widely. It is often bilaterally symmetrical or unilaterally asymmetrical and is often mistaken for a seizure-like waveform. However, in adults, subclinical rhythmic EEG emissions occur during wakefulness, so the EEG technician can test the patient’s cognitive status to identify them. Unlike other episodic EEG activity with widespread diffusion, patients with adult subclinical rhythmic EEG emissions do not present with altered levels of consciousness. There is little difference in the frequency, amplitude, and distribution of subclinical rhythmic EEG emissions in adults compared with epileptic waveforms during seizures. The adult subclinical rhythmic EEG emissions often occur multiple times in sequence in a single lead. Subclinical rhythmic EEG in adults is not followed by the background EEG slowing activity typical of post-ictal seizures. 2. Epileptiform discharges in the EEG of older adults The presence of interictal epileptiform discharges in the EEG supports the diagnosis of epilepsy, as interictal epileptiform discharges rarely occur in normal subjects. Previous studies have shown that the frequency of interictal epileptiform discharges decreases with age, occurring in approximately 77% of patients with epilepsy in the first decade of life, decreasing to 39% in patients with epilepsy over the age of 40. In a retrospective study, Drury and Beydoun found that the number of people with early diagnosis of epilepsy based on interictal epileptiform activity (IEA) was significantly higher than the number of patients diagnosed after age 60. In 70 patients with seizures that started after age 60, only 26% presented with IEA (mean age 70 years), and in 55 patients with pre-existing epilepsy, the rate of IEA was 35% (mean age 65 years). Patients with >1 seizure/month were more prone to IEA. duration of epilepsy, cause and frequency of IEA were not related. sleep often initiated epileptiform discharges, but only 24% could be recorded on EEG, and this reduction in frequency was seen in both generalized and partial seizures. In the Continuous VA Collaborative Study, the presence of epileptiform activity in routine EEG was found to be 37% in patients ≥60 years of age with new-onset epilepsy and excluded those with progressive neurological disease (including dementia and primary brain tumors). Portable digital EEG recordings can significantly improve the diagnostic rate of EEG in these populations due to the substantially longer recording time. Even if epileptiform activity is not detected on conventional EEG, the diagnosis of epilepsy should be considered in elderly patients with seizure manifestations. A portable or CCTV-EEG with long-duration monitoring is a valuable diagnostic tool in determining the diagnosis of epilepsy in elderly patients. This monitoring device is also used to identify psychiatric abnormalities caused by the application of other therapeutic agents or AEDS. In a retrospective analysis of 17 patients >60 years of age considered to have a concomitant altered state of consciousness with petit mal seizures, 11 patients were found to be free of epileptic events and 10 had seizures due to therapeutic drugs and psychiatric abnormalities, including cerebrovascular events (3), pseudoseizures (3), complex migraine (1), hypotension (1), syncope (1), systemic infection (1), and Addison’s disease (1 case). Lancman et al. studied the application of CCTV-EEG monitoring in 20 patients >60 years of age. The patients were divided into a diagnostic group and a characteristic group. In the diagnostic group, 9 patients were routinely diagnosed with epilepsy, CCTV-EEG was useful in 7 cases, most without epileptic events, 2 suffered from obstructive sleep apnea, 2 had psychogenic seizures, 1 had convulsive syncope, and 2 were diagnosed with epilepsy and started on AEDs. in the characteristic group, 11 patients who were earlier diagnosed with refractory epilepsy were monitored to determine their seizure type, and in 4 patients CCTV-EEG monitoring was valuable and guided their treatment and management. drury retrospectively analyzed the application of CCTV-EEG monitoring in 18 patients with primary epilepsy >60 years of age. 5 cases were recorded as complex partial seizures, 4 of which had a history of seizures but clinical events related to psychiatric disorders. This monitoring established the diagnosis in 5 patients and started the application and adjustment of AEDs. In the remaining 10, 8 patients who had applied AEDs before the diagnosis was established were excluded from epilepsy and thus discontinued AEDs in order to find a more appropriate treatment plan. Other diagnoses included normal pressure hydrocephalus, depression, primary brain tumor, and cardiac arrhythmia. All authors agree that CCTV-EEG monitoring is valuable in the elderly population, but it is currently too rarely used and should be routinely used in patients with petit mal seizures of unknown origin. V. Treatment of epilepsy in the elderly Drug therapy remains the basis for preventing recurrences. Compared with the effect and tolerance of AEDs application in adults, it is more difficult to adhere to AEDs treatment in elderly patients, where dyskinesia, tremor, visual disturbance, and sedative effects are common disadvantages. Another therapeutic barrier is the interaction between some medications, which is due to the fact that the application of multiple medications due to other diseases is very common at this age. In addition, changes in the absorption, distribution, metabolism, and excretion of AEDs due to age-related physiological changes and diseases can also cause the effects of AEDs to differ from those of younger adults when applied. Blood concentration monitoring, particularly of free blood concentrations of highly protein-bound AEDs, can be very useful in adjusting the level of drug therapy in older patients, which is not very relevant to the range of drug therapy in younger patients. In addition to pharmacological interactions, pharmacodynamic drug-drug interactions should be taken into account. There are no studies with large samples to fully evaluate the use of novel AEDs in the treatment of epilepsy in the elderly. Based on the pharmacological and pharmacodynamic merits of the drugs, Ramsay believes that early application of GBP, LTG, and TGB should be used in elderly patients with epilepsy.Faught believes that CBZ, VPA, GBP, and LTG are the best options for the treatment of AEDs in elderly patients. Consecutive VA collaborative studies on the treatment of epilepsy in the elderly have recommended CBZ, GBP, and LTG for patients >60 years of age with new-onset epilepsy, as well as some other alternative therapies, including surgery and vagus nerve stimulation, but these treatments have not been studied in depth in elderly patients. Several studies have shown that surgical treatment is more effective in elderly patients without associated memory or IQ reduction. VI. Summary The prevalence of epilepsy is higher in the elderly, and the most common cause of new-onset epilepsy in the elderly is stroke. Epileptic seizures in the elderly are different from those in younger people and should also be distinguished from other drug-induced seizures.EEG is an important tool for epilepsy diagnosis, and interictal epileptiform abnormal discharges are higher than in younger patients. Long-duration EEG monitoring is very useful in establishing the diagnosis of epilepsy, excluding non-epileptic causes, and guiding treatment. Research on the best and most effective treatment is needed because of the higher incidence of epilepsy in the elderly and the rapidly growing aging population.