General Hospital Psychiatry 36 (2014) 230.e3–230.e5
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Epileptic seizure presenting as dementia with Lewy bodies☆,☆☆ In Seok Park, M.D., Sang Won Yoo, M.D., Kwang-Soo Lee, M.D., Ph.D., Joong-Seok Kim, M.D., Ph.D. ⁎ Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
a r t i c l e
i n f o
Article history: Received 11 September 2013 Revised 22 October 2013 Accepted 22 October 2013 Keywords: Dementia with Lewy bodies Epileptic seizure
a b s t r a c t Psychotic symptoms and cognitive fluctuation are common manifestations of dementia with Lewy bodies (DLB). However, the differentiation of these symptoms is difficult because many psychiatric, neurologic, and medical conditions in addition to drug effects can mimic DLB in elderly people. We report on an 83-year-old woman who complained of vivid, recurrent visual hallucinations associated with fluctuating cognition. The patient was diagnosed as probable DLB. However, laboratory findings were consistent with an epileptic phenomenon and the patient improved completely with use of anti-epileptic drugs. This case illustrates the fact that epileptic seizure may cause symptoms that mimic DLB, and clinicians should consider an epileptic condition as a differential diagnosis for elderly patients with psychiatric symptoms and fluctuating cognition. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Psychiatric symptoms such as hallucinations and delusions increase in incidence with age. These symptoms are not uncommon and the prevalence in community samples ranges from 0.2% to 4.7% [1]. However, the causes of psychiatric symptoms are difficult to differentiate and several clinical conditions including delirium, dementia, metabolic disturbances, medication-induced psychosis and neurologic disorders should be kept in mind as possible causes [2]. Epileptic seizure is associated with a variety of psychiatric manifestations and impairment of cognition [3,4]. Seizure control with the use of appropriate anti-epileptic drugs prevent these psychotic symptoms. However, if typical seizure manifestations are not present, it can be difficult to appreciate epileptic seizures as the cause of the psychiatric symptoms. Furthermore, electroencephalography (EEG) may not be sufficiently sensitive to detect epilepsy in the absence of clinical suspicion [5]. We report the case of an elderly patient who presented with recurrent visual hallucinations and fluctuating cognition initially diagnosed as dementia with Lewy bodies (DLB) who was successfully treated with anti-epileptic drugs. 2. Case An 83-year-old woman was admitted with psychiatric symptoms and fluctuating cognitive impairment. Over the previous one month she ☆ Potential conflict of interest and financial disclosures related to this article: Nothing to report. ☆☆ For submission to: General Hospital Psychiatry, This draft on Oct. 22, 2013. ⁎ Corresponding author. Department of Neurology, The Catholic University of Korea, Seoul St. Mary’s Hospital, 505, Banpo-dong, Seocho-gu, Seoul, 137–701, South Korea. Tel.: +82 2 2258 6078; fax: +82 2 599 9686. E-mail address: [email protected] (J.-S. Kim). 0163-8343/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.10.015
had experienced intermittent but recurrent visual hallucinations. They occurred approximately three to four times per day. Each event appeared abruptly and lasted for several minutes which were in the range of about 1–5 minutes. Most of the phenomenon observed in the night but also during the daytime. The contents of the visual hallucinations were dominated by people. She complained of seeing someone hanging by their neck or holding a knife. When the hallucinations appeared, the consciousness of the patient was preserved, but she showed a lack of insight into the unreality of the hallucinations. Sometimes the visual hallucinations threatened the patient. She often did not recognize the person in the mirror as herself and talked to herself while looking in the mirror or window. During the same period, the patient and her family complained of impaired memory and fluctuating attention. The cognitive impairment fluctuated markedly in severity from day to day. She also had frequent daytime somnolence, lasting up to 1 hour, without obvious seizure activity. The patient’s spouse reported multiple episodes of violent injurious behavior during sleep, which developed more than 10 years ago. The patient had orthostatic intolerance, urinary incontinence and chronic constipation. She also had a 10-year history of hypertension, which was well controlled on a calcium channel blocker. There was no personal or family history of psychiatric or neurological diseases such as epilepsy, schizophrenia, depression or Parkinsonism. The patient was oriented and scored a 14 out of 30 on the Korean version of the Mini-Mental State Examination (MMSE) test. A neuropsychological investigation showed severe impairments in visuospatial memory and frontal executive functions. Her general and neurological examinations were unremarkable, with no Parkinsonian signs. There were no abnormalities of the visual system that were confirmed through a full ophthalmological examination. Laboratory examinations were normal, including homocysteine, vitamin B12, folate, thyroid, hepatic and renal function tests. Brain
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I.S. Park et al. / General Hospital Psychiatry 36 (2014) 230.e3–230.e5
Fig. 1. Electroencephalography shows ictal discharges that are composed of 6–7 Hz theta waves without a clear start point, and left temporal sharp waves “with phase reversals” (arrow).
magnetic resonance imaging showed mild generalized atrophy. We tentatively diagnosed the patient with dementia with Lewy bodies [6]. However, myocardial 123I-metaiodibenzylguanidine scintigraphy showed normal postganglionic sympathetic innervation. An EEG revealed bilateral ictal epileptic discharges composed of 6– 7 Hz rhythmic theta waves that coincided with the onset of a vivid hallucination (Fig. 1). At that time, convulsive motor seizures were not detected. The patient was alert and responsive. Treatment was started with 100 mg zonisamide and the dose was increased to 200 mg per day. Four days after the dose increase, the psychotic symptoms, including visual hallucinations and fluctuating cognition and attention, were markedly improved. Follow up surface EEG performed after 1 month showed intermittent slow waves in the frontotemporal lobe and transient sharp wave activity in the left temporal lobe without ictal epileptic discharges. Cognitive function was improved beyond a state of no interference on daily activity and a follow-up MMSE was scored as 27 out of 30.
3. Discussion The patient had fluctuating cognitive impairment and recurrent, well-formed visual hallucinations, and other features such as REM sleep behavioral disorders and autonomic dysfunction. Although we did not perform pathologic study to confirm the definite diagnosis, these prominent features, in combination with other suggestive and supportive abnormalities, suggested a clinical diagnosis of DLB.
However, the origin of her recurrent hallucinations and fluctuating cognition were difficult to establish. A variety of psychiatric disorders (mania, depression, substance dependence, and schizophrenia) and neurologic disorders (migraine, epilepsy, delirium, dementia, tumor, and stroke) may be the cause of visual hallucination in elderly person [7]. The visual hallucinations that are related to epileptic seizures, are usually elementary visual hallucinations characterized as simple, brief, and usually consistent for each patient. Rarely more complex forms can occur [8]. These complex visual hallucinations may be associated with epilepsy originating in the temporal lobe and limbic structure and occipital and parietal lobe epilepsy often present with them [9]. Cognitive impairment can be associated with epilepsy and is influenced by a variety of factors such as epilepsy per se [4,10]. The most reported cognitive complaints in patients with epilepsy are mental slowness, memory impairment and attention deficits [11]. In our patient, cognitive fluctuation and recurrent visual hallucinations were the only symptoms associated with ictal episodes. The symptoms were relatively sudden and lasted only a short duration on EEG monitoring. Given that the emergence of symptoms occurred during an ictal period, and there was complete resolution of the cognitive symptoms with anticonvulsant treatment, the patient’s epileptic seizures were likely to have caused her DLB-mimicking symptoms and were not related to Lewy body pathology. This case demonstrates that epileptic seizures may present with symptoms mimicking DLB and clinicians should consider an epileptic condition as a possible cause of psychiatric symptoms and fluctuating cognition in the elderly.
I.S. Park et al. / General Hospital Psychiatry 36 (2014) 230.e3–230.e5
References [1] Targum SD, Abbott JL. Psychoses in the elderly: a spectrum of disorders. J Clin Psychiatry 1999;60:S4–10. [2] Targum SD. Treating psychotic symptoms in elderly patients. Prim Care Companion J Clin Psychiatry 2001;3:156–63. [3] Nadkarni S, Arnedo V, Devinsky O. Psychosis in epilepsy patients. Epilepsia 2007;48:S17–9. [4] Vijayaraghavan L, Natarajan S, Krishnamoorthy ES. Peri-ictal and ictal cognitive dysfunction in epilepsy. Behav Neurol 2011;24:27–34. [5] Raybould JE, Alfers C, Cho Y, Wang H, Shara NM, Epstein SA, et al. EEG screening for temporal lobe epilepsy in patients with acute psychosis. J Neuropsychiatry Clin Neurosci 2012;24:452–7.
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[6] McKeith IG, Dickson DW, Lowe J, Emre M, O'Brien JT, Feldman H, et al, Consortium on DLB. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2005;65:1863–72. [7] Norton JW, Corbett JJ. Visual perceptual abnormalities: hallucinations and illusions. Semin Neurol 2000;20:111–21. [8] Elliott B, Joyce E, Shorvon S. Delusions, illusions and hallucinations in epilepsy: 2. Complex phenomena and psychosis. Epilepsy Res 2009;85:172–86. [9] Bien CG, Benninger FO, Urbach H, Schramm J, Kurthen M, Elger CE. Localizing value of epileptic visual auras. Brain 2000;123:244–53. [10] Elger CE, Helmstaedter C, Kurthen M. Chronic epilepsy and cognition. Lancet Neurol 2004;3:663–72. [11] van Rijckevorsel K. Cognitive problems related to epilepsy syndromes, especially malignant epilepsies. Seizure 2006;15:227–34.
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Epileptic seizure presenting as dementia with Lewy bodies☆,☆☆ In Seok Park, M.D., Sang Won Yoo, M.D., Kwang-Soo Lee, M.D., Ph.D., Joong-Seok Kim, M.D., Ph.D. ⁎ Department of Neurology, College of Medicine, The Catholic University of Korea, Seoul, Korea
a r t i c l e
i n f o
Article history: Received 11 September 2013 Revised 22 October 2013 Accepted 22 October 2013 Keywords: Dementia with Lewy bodies Epileptic seizure
a b s t r a c t Psychotic symptoms and cognitive fluctuation are common manifestations of dementia with Lewy bodies (DLB). However, the differentiation of these symptoms is difficult because many psychiatric, neurologic, and medical conditions in addition to drug effects can mimic DLB in elderly people. We report on an 83-year-old woman who complained of vivid, recurrent visual hallucinations associated with fluctuating cognition. The patient was diagnosed as probable DLB. However, laboratory findings were consistent with an epileptic phenomenon and the patient improved completely with use of anti-epileptic drugs. This case illustrates the fact that epileptic seizure may cause symptoms that mimic DLB, and clinicians should consider an epileptic condition as a differential diagnosis for elderly patients with psychiatric symptoms and fluctuating cognition. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Psychiatric symptoms such as hallucinations and delusions increase in incidence with age. These symptoms are not uncommon and the prevalence in community samples ranges from 0.2% to 4.7% [1]. However, the causes of psychiatric symptoms are difficult to differentiate and several clinical conditions including delirium, dementia, metabolic disturbances, medication-induced psychosis and neurologic disorders should be kept in mind as possible causes [2]. Epileptic seizure is associated with a variety of psychiatric manifestations and impairment of cognition [3,4]. Seizure control with the use of appropriate anti-epileptic drugs prevent these psychotic symptoms. However, if typical seizure manifestations are not present, it can be difficult to appreciate epileptic seizures as the cause of the psychiatric symptoms. Furthermore, electroencephalography (EEG) may not be sufficiently sensitive to detect epilepsy in the absence of clinical suspicion [5]. We report the case of an elderly patient who presented with recurrent visual hallucinations and fluctuating cognition initially diagnosed as dementia with Lewy bodies (DLB) who was successfully treated with anti-epileptic drugs. 2. Case An 83-year-old woman was admitted with psychiatric symptoms and fluctuating cognitive impairment. Over the previous one month she ☆ Potential conflict of interest and financial disclosures related to this article: Nothing to report. ☆☆ For submission to: General Hospital Psychiatry, This draft on Oct. 22, 2013. ⁎ Corresponding author. Department of Neurology, The Catholic University of Korea, Seoul St. Mary’s Hospital, 505, Banpo-dong, Seocho-gu, Seoul, 137–701, South Korea. Tel.: +82 2 2258 6078; fax: +82 2 599 9686. E-mail address: [email protected] (J.-S. Kim). 0163-8343/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.genhosppsych.2013.10.015
had experienced intermittent but recurrent visual hallucinations. They occurred approximately three to four times per day. Each event appeared abruptly and lasted for several minutes which were in the range of about 1–5 minutes. Most of the phenomenon observed in the night but also during the daytime. The contents of the visual hallucinations were dominated by people. She complained of seeing someone hanging by their neck or holding a knife. When the hallucinations appeared, the consciousness of the patient was preserved, but she showed a lack of insight into the unreality of the hallucinations. Sometimes the visual hallucinations threatened the patient. She often did not recognize the person in the mirror as herself and talked to herself while looking in the mirror or window. During the same period, the patient and her family complained of impaired memory and fluctuating attention. The cognitive impairment fluctuated markedly in severity from day to day. She also had frequent daytime somnolence, lasting up to 1 hour, without obvious seizure activity. The patient’s spouse reported multiple episodes of violent injurious behavior during sleep, which developed more than 10 years ago. The patient had orthostatic intolerance, urinary incontinence and chronic constipation. She also had a 10-year history of hypertension, which was well controlled on a calcium channel blocker. There was no personal or family history of psychiatric or neurological diseases such as epilepsy, schizophrenia, depression or Parkinsonism. The patient was oriented and scored a 14 out of 30 on the Korean version of the Mini-Mental State Examination (MMSE) test. A neuropsychological investigation showed severe impairments in visuospatial memory and frontal executive functions. Her general and neurological examinations were unremarkable, with no Parkinsonian signs. There were no abnormalities of the visual system that were confirmed through a full ophthalmological examination. Laboratory examinations were normal, including homocysteine, vitamin B12, folate, thyroid, hepatic and renal function tests. Brain
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I.S. Park et al. / General Hospital Psychiatry 36 (2014) 230.e3–230.e5
Fig. 1. Electroencephalography shows ictal discharges that are composed of 6–7 Hz theta waves without a clear start point, and left temporal sharp waves “with phase reversals” (arrow).
magnetic resonance imaging showed mild generalized atrophy. We tentatively diagnosed the patient with dementia with Lewy bodies [6]. However, myocardial 123I-metaiodibenzylguanidine scintigraphy showed normal postganglionic sympathetic innervation. An EEG revealed bilateral ictal epileptic discharges composed of 6– 7 Hz rhythmic theta waves that coincided with the onset of a vivid hallucination (Fig. 1). At that time, convulsive motor seizures were not detected. The patient was alert and responsive. Treatment was started with 100 mg zonisamide and the dose was increased to 200 mg per day. Four days after the dose increase, the psychotic symptoms, including visual hallucinations and fluctuating cognition and attention, were markedly improved. Follow up surface EEG performed after 1 month showed intermittent slow waves in the frontotemporal lobe and transient sharp wave activity in the left temporal lobe without ictal epileptic discharges. Cognitive function was improved beyond a state of no interference on daily activity and a follow-up MMSE was scored as 27 out of 30.
3. Discussion The patient had fluctuating cognitive impairment and recurrent, well-formed visual hallucinations, and other features such as REM sleep behavioral disorders and autonomic dysfunction. Although we did not perform pathologic study to confirm the definite diagnosis, these prominent features, in combination with other suggestive and supportive abnormalities, suggested a clinical diagnosis of DLB.
However, the origin of her recurrent hallucinations and fluctuating cognition were difficult to establish. A variety of psychiatric disorders (mania, depression, substance dependence, and schizophrenia) and neurologic disorders (migraine, epilepsy, delirium, dementia, tumor, and stroke) may be the cause of visual hallucination in elderly person [7]. The visual hallucinations that are related to epileptic seizures, are usually elementary visual hallucinations characterized as simple, brief, and usually consistent for each patient. Rarely more complex forms can occur [8]. These complex visual hallucinations may be associated with epilepsy originating in the temporal lobe and limbic structure and occipital and parietal lobe epilepsy often present with them [9]. Cognitive impairment can be associated with epilepsy and is influenced by a variety of factors such as epilepsy per se [4,10]. The most reported cognitive complaints in patients with epilepsy are mental slowness, memory impairment and attention deficits [11]. In our patient, cognitive fluctuation and recurrent visual hallucinations were the only symptoms associated with ictal episodes. The symptoms were relatively sudden and lasted only a short duration on EEG monitoring. Given that the emergence of symptoms occurred during an ictal period, and there was complete resolution of the cognitive symptoms with anticonvulsant treatment, the patient’s epileptic seizures were likely to have caused her DLB-mimicking symptoms and were not related to Lewy body pathology. This case demonstrates that epileptic seizures may present with symptoms mimicking DLB and clinicians should consider an epileptic condition as a possible cause of psychiatric symptoms and fluctuating cognition in the elderly.
I.S. Park et al. / General Hospital Psychiatry 36 (2014) 230.e3–230.e5
References [1] Targum SD, Abbott JL. Psychoses in the elderly: a spectrum of disorders. J Clin Psychiatry 1999;60:S4–10. [2] Targum SD. Treating psychotic symptoms in elderly patients. Prim Care Companion J Clin Psychiatry 2001;3:156–63. [3] Nadkarni S, Arnedo V, Devinsky O. Psychosis in epilepsy patients. Epilepsia 2007;48:S17–9. [4] Vijayaraghavan L, Natarajan S, Krishnamoorthy ES. Peri-ictal and ictal cognitive dysfunction in epilepsy. Behav Neurol 2011;24:27–34. [5] Raybould JE, Alfers C, Cho Y, Wang H, Shara NM, Epstein SA, et al. EEG screening for temporal lobe epilepsy in patients with acute psychosis. J Neuropsychiatry Clin Neurosci 2012;24:452–7.
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[6] McKeith IG, Dickson DW, Lowe J, Emre M, O'Brien JT, Feldman H, et al, Consortium on DLB. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2005;65:1863–72. [7] Norton JW, Corbett JJ. Visual perceptual abnormalities: hallucinations and illusions. Semin Neurol 2000;20:111–21. [8] Elliott B, Joyce E, Shorvon S. Delusions, illusions and hallucinations in epilepsy: 2. Complex phenomena and psychosis. Epilepsy Res 2009;85:172–86. [9] Bien CG, Benninger FO, Urbach H, Schramm J, Kurthen M, Elger CE. Localizing value of epileptic visual auras. Brain 2000;123:244–53. [10] Elger CE, Helmstaedter C, Kurthen M. Chronic epilepsy and cognition. Lancet Neurol 2004;3:663–72. [11] van Rijckevorsel K. Cognitive problems related to epilepsy syndromes, especially malignant epilepsies. Seizure 2006;15:227–34.
