When an older adult presents with a first unprovoked seizure and MRI shows no lesion, the diagnosis often stops at 'late-onset epilepsy' and an antiseizure drug. Yet a proportion will later develop cognitive decline, and some already have early Alzheimer pathology.
A short cognitive screen at the first visit gives a baseline against which later complaints can be judged, and helps choose an antiseizure drug with less cognitive burden.
- Record a brief cognitive screen (MoCA or similar) at diagnosis.
- Prefer antiseizure drugs with low cognitive side effects in older adults, such as levetiracetam or lamotrigine.
- Ask the family about memory or behaviour change over the past year.
- Repeat cognitive screening at follow-up, especially if seizures are hard to control.
Why it matters
Seizures may be the first visible sign of a neurodegenerative process that no one is yet looking for.
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