Functional Seizures in the Elderly: Accurate Diagnosis Can Reduce Iatrogenic Harm

An 87-year-old man with multiple vascular risk factors presented to the emergency department four times in eighteen months with new, recurrent paroxysmal events, without loss of awareness and able to recall the events. FS are common, with one report indicating 12% of patients referred to neurology for loss of consciousness received this diagnosis.2 Functional seizures are much more common in younger patients, with the median age of onset being 28 years.3 However, FS are not uncommon in the elderly.4–6 Among patients diagnosed with FS, 10% were older than 60 years.4 Men have an approximately equal rate of developing FS across the age range.3 A number of studies have been published characterizing features of the final diagnosis of patients over 60 years admitted for VEM, finding approximately half of patients experiencing non-epileptic events had FS.5,6 In many cases, a diagnosis of epilepsy was revised to FS, highlighting the importance of pursuing VEM to establish this diagnosis. Misdiagnosis of FND as other conditions places patients at significant risk of iatrogenic harm related to medications and interventions, invasive diagnostic tests, hospital admissions, inclusion in research trials, and lack of access to appropriate treatment.7 These risks are even greater in elderly patients, who are more susceptible to adverse events.