A Comparative Study of Seizure in Elderly Male and Female Patients Pertaining to Etiology, Radiological Features, and Electroencephalographic Findings

Abstract

Background:

Seizures in elderly populations present unique challenges, with potential gender-specific variations in presentation and outcomes. This study aimed to compare the characteristics of seizures between elderly male and female patients, focusing on etiology, radiological features, and electroencephalographic (EEG) findings.

Methodology:

This observational cross-sectional study included 75 patients (40 males, 35 females) aged ≥60 years presenting with seizures at a tertiary care center. All patients underwent detailed clinical evaluation, neuroimaging (magnetic resonance imaging), and EEG studies. Gender-specific differences in various parameters were analyzed using appropriate statistical tests.

Results:

While cerebrovascular disease was the leading cause in both groups (40.0% males, 34.3% females), neurodegenerative disorders showed significantly higher prevalence in females (31.4% vs. 20.0%, P = 0.042). Radiological findings revealed higher rates of cortical infarcts in males (35.0%) and white matter changes in females (37.1%). EEG findings were comparable between genders, with focal epileptiform discharges being the most common (55.0% males and 51.4% females). Treatment outcomes were similar, with complete seizure control achieved in 65.0% of males and 68.6% of females.

Conclusions:

The study demonstrates significant gender-specific patterns in seizure etiology among elderly patients, particularly regarding neurodegenerative disorders. While radiological and EEG findings showed subtle differences, treatment outcomes were comparable between genders. These findings suggest the importance of gender-specific considerations in the evaluation and management of elderly patients with seizures.

INTRODUCTION

Seizures in the elderly population represent a significant neurological challenge that has gained increasing attention as global demographics shift toward an aging population.[1] The incidence of new-onset seizures is notably higher in individuals over 65 years of age compared to younger adults, with recent epidemiological studies indicating rates as high as 150 per 100,000 person-years in this age group, representing a 30% increase from previous decades.[2]

The etiology of seizures in the elderly presents a complex spectrum distinctly different from that observed in younger populations. While idiopathic seizures predominate in younger adults, elderly patients more commonly experience seizures secondary to identifiable pathologies.[3] Recent meta-analyses have confirmed cerebrovascular disease as the leading cause, accounting for approximately 45%–60% of cases, followed by neurodegenerative disorders, brain tumor, and metabolic disturbances.[4] Contemporary research has revealed significant gender-specific variations in these etiological patterns, with women showing a nearly twofold higher prevalence of seizures associated with Alzheimer’s disease and men demonstrating increased incidence of poststroke epilepsy, particularly in the 1^st year following the event.[5]

Radiological features play a crucial role in understanding and managing seizures in the elderly population. Recent advances in neuroimaging techniques, including high-resolution 7T magnetic resonance imaging (MRI) and advanced functional neuroimaging, have revealed previously undetectable structural and functional differences between male and female patients with seizures.[6] These differences extend beyond obvious pathological findings to include variations in network connectivity patterns, hippocampal subfield volumes, and region-specific patterns of cerebral atrophy. Modern quantitative imaging analyses have demonstrated gender-specific patterns in white matter integrity and cortical thickness that may influence seizure susceptibility and progression.[7]

Electroencephalographic (EEG) findings in elderly patients with seizures present unique characteristics and challenges in interpretation. Recent studies utilizing advanced EEG analysis techniques, including quantitative EEG and machine learning approaches, have revealed age-related changes in background activity that significantly impact the identification of epileptiform discharges.[8] Contemporary research has identified gender-specific variations in EEG patterns, including differences in seizure onset zones, network propagation patterns, and treatment responses, though these findings continue to evolve with advancing technology.[9]

The clinical presentation of seizures in the elderly often differs from that observed in younger populations, with recent large-scale studies highlighting a higher prevalence of subtle or atypical manifestations that can lead to delayed diagnosis or misdiagnosis.[10] These presentations may vary between males and females, potentially influenced by newly identified genetic factors, age-related pharmacokinetic changes, and gender-specific comorbidities.

Understanding these gender-specific differences in seizure characteristics among elderly patients has important implications for:

• Precision medicine approaches to diagnosis and treatment

• Optimization of advanced neuroimaging protocols

• Selection of antiepileptic medications based on gender-specific pharmacokinetics

• Management of comorbidities with consideration of gender-specific risk factors

• Implementation of targeted prevention strategies

• Prediction of long-term outcomes and quality of life.

The present study aims to address current knowledge gaps by conducting a comparative analysis of seizures in elderly male and female patients, with particular emphasis on etiological factors, radiological features, and EEG findings. This comprehensive evaluation will contribute to our understanding of gender-specific aspects of seizures in the elderly and potentially inform more targeted therapeutic approaches in the era of precision medicine.

METHODOLOGY

Study design and setting

This observational cross-sectional study was conducted in the Department of Medicine at our tertiary care center over 18 months. The study protocol was approved by the Institutional Ethics Committee, and written informed consent was obtained from all participants or their legal guardians.

Study population

A total of 75 elderly patients (aged 60 years and above) presenting with seizures were included in the study. The study population was divided into two groups based on gender. Patients with a history of psychogenic nonepileptic seizures, those unable to undergo MRI, and those refusing consent were excluded from the study.

Sample size and sampling method

The sample size of 75 was calculated based on previous studies with similar objectives, considering a confidence interval of 95% and a margin of error of 5%. A consecutive sampling technique was employed to recruit eligible patients who presented to the neurology outpatient department or emergency services.

Data collection

A detailed clinical history was obtained from all patients using a structured proforma. The collected data included:

• Demographic details

• Seizure characteristics (type, frequency, duration)

• Past medical history

• Family history

• Current medications

• Associated comorbidities

• Physical and neurological examination findings.

Clinical assessment

All patients underwent comprehensive neurological examination by experienced neurologists. Seizure classification was performed according to the International League Against Epilepsy 2017 classification system. The etiology was determined based on clinical findings, laboratory investigations, imaging studies, and other relevant investigations.

Laboratory investigations

Standard laboratory investigations were performed for all patients, including:

• Complete blood count

• Serum electrolytes

• Blood glucose

• Liver and renal function tests

• Thyroid function tests

• Serum calcium and magnesium levels.

Radiological assessment

All patients underwent radiological evaluation including:

• MRI of the brain (1.5 Tesla) with standard protocols

• Computed tomography scan of the brain (when indicated)

• MR spectroscopy and contrast studies (in selected cases).

The MRI sequences included T1-weighted, T2-weighted, fluid-attenuated inversion recovery, diffusion-weighted imaging, and gradient echo images. Two experienced neuroradiologists, blinded to the clinical details, independently evaluated the imaging findings. Any discrepancies were resolved through consensus.

Electroencephalographic recording and analysis

Digital EEG recordings were performed using a 32-channel EEG system following the international 10–20 system of electrode placement. Both routine and sleep-deprived EEG recordings were obtained when indicated. Each EEG recording lasted for a minimum of 30 min and included:

• Standard activation procedures (hyperventilation and photic stimulation)

• Both awake and drowsy states

• Natural sleep when possible.

EEG analysis was performed independently by two qualified neurophysiologists who were blinded to the clinical and radiological findings. The following parameters were assessed:

• Background activity

• Presence and type of epileptiform discharges

• Focal versus generalized abnormalities

• Post-ictal changes

• Sleep architecture (when applicable).

Data analysis

Statistical analysis was performed using SPSS version 25.0 (IBM corporation, Armonk, Newyork, USA). Descriptive statistics were presented as frequencies, percentages, means ± standard deviations, and medians with interquartile ranges as appropriate. Comparative analysis between male and female groups was performed using:

• Chi-square test for categorical variables

• Student’s t-test for normally distributed continuous variables

• Mann–Whitney U-test for non-normally distributed continuous variables.

P < 0.05 was considered statistically significant. Multivariate analysis was performed to adjust for potential confounding factors.

Quality control measures

To ensure data quality and reliability:

• Standardized data collection forms were used

• Regular calibration of EEG and imaging equipment was performed

• Independent assessment by multiple specialists

• Regular data audits

• Adherence to standard operating procedures.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki and Good Clinical Practice guidelines. Patient confidentiality was maintained throughout the study period. Patients were free to withdraw from the study at any time without affecting their standard of care. All investigations were performed as part of routine clinical care, and no additional financial burden was placed on the patients.

RESULTS

The study included 75 elderly patients with seizures, comprising 40 males and 35 females. The demographic data showed comparable characteristics between genders, with mean ages of 68.5 ± 6.2 years for males and 70.2 ± 5.8 years for females (P = 0.245). The duration of epilepsy was similar in both groups (males: 4.2 ± 2.8 years; females: 3.8 ± 2.5 years; P = 0.512). Common comorbidities were similarly distributed, with hypertension being the most prevalent (70.0% in males, and 71.4% in females) [Table 1].

Table 1.

Demographic and clinical characteristics

Characteristic	Males (n=40)	Females (n=35)	P
Age (years)*	68.5±6.2	70.2±5.8	0.245
Duration of epilepsy (years)*	4.2±2.8	3.8±2.5	0.512
Comorbidities, n (%)
Hypertension	28 (70.0)	25 (71.4)	0.892
Diabetes mellitus	22 (55.0)	20 (57.1)	0.854
Coronary artery disease	18 (45.0)	12 (34.3)	0.342
Dyslipidemia	15 (37.5)	14 (40.0)	0.824

*Values presented as mean±SD. SD=Standard deviation

Regarding etiology, cerebrovascular disease was the leading cause in both groups (40.0% males, and 34.3% females). Notably, neurodegenerative disorders showed a significant gender difference, being more prevalent in females (31.4%) compared to males (20.0%) (P = 0.042). Other etiologies, including brain tumors, metabolic disorders, and posttraumatic causes, showed no significant gender differences [Table 2].

Table 2.

Etiology of seizures

Etiology	Males (n=40), n (%)	Females (n=35), n (%)	P
Cerebrovascular disease	16 (40.0)	12 (34.3)	0.608
Neurodegenerative disorders	8 (20.0)	11 (31.4)	0.042*
Brain tumors	6 (15.0)	4 (11.4)	0.645
Metabolic disorders	4 (10.0)	3 (8.6)	0.834
Posttraumatic	3 (7.5)	2 (5.7)	0.756
Cryptogenic	3 (7.5)	3 (8.6)	0.867

*Statistically significant

MRI findings revealed cortical infarcts as the most common radiological finding in males (35.0%), whereas white matter changes were most prevalent in females (37.1%). Brain atrophy was more common in females (34.3%) compared to males (25.0%), although this the difference wasn’t statistically significant [Table 3].

Table 3.

Radiological findings on magnetic resonance imaging

Finding	Males (n=40), n (%)	Females (n=35), n (%)	P
Cortical infarcts	14 (35.0)	10 (28.6)	0.545
White matter changes	12 (30.0)	13 (37.1)	0.512
Brain atrophy	10 (25.0)	12 (34.3)	0.378
Mass lesions	6 (15.0)	4 (11.4)	0.645
Hippocampal sclerosis	3 (7.5)	4 (11.4)	0.567
Normal imaging	2 (5.0)	1 (2.9)	0.632

EEG findings showed similar patterns between genders. Normal background activity was observed in 37.5% of males and 34.3% of females. Focal epileptiform discharges were the most common abnormality in both groups (males: 55.0%, females: 51.4%) [Table 4].

Table 4.

Electroencephalographic findings

EEG parameter	Males (n=40), n (%)	Females (n=35), n (%)	P
Background activity
Normal	15 (37.5)	12 (34.3)	0.772
Mild slowing	14 (35.0)	13 (37.1)	0.845
Moderate slowing	8 (20.0)	7 (20.0)	1.000
Severe slowing	3 (7.5)	3 (8.6)	0.867
Epileptiform discharges
Focal	22 (55.0)	18 (51.4)	0.756
Generalized	8 (20.0)	7 (20.0)	1.000
None	10 (25.0)	10 (28.6)	0.723

EEG=Electroencephalographic

The distribution of seizure types was comparable between genders, with focal impaired awareness seizures being most common in both groups (males: 37.5%, females: 40.0%) [Table 5].

Table 5.

Seizure types and characteristics

Characteristic	Males (n=40), n (%)	Females (n=35), n (%)	P
Seizure type
Focal aware	12 (30.0)	10 (28.6)	0.892
Focal impaired awareness	15 (37.5)	14 (40.0)	0.824
Focal to bilateral tonic-clonic	8 (20.0)	7 (20.0)	1.000
Generalized onset	5 (12.5)	4 (11.4)	0.887
Seizure frequency
<1 per month	18 (45.0)	16 (45.7)	0.952
1–4 per month	14 (35.0)	12 (34.3)	0.948
>4 per month	8 (20.0)	7 (20.0)	1.000

Treatment response patterns were similar between genders, with most patients responding to monotherapy (males: 60.0% and females: 62.9%). Complete seizure control was achieved in 65.0% of males and 68.6% of females, with no significant gender differences in treatment outcomes [Table 6].

Table 6.

Treatment response

Parameter	Males (n=40), n (%)	Females (n=35), n (%)	P
AED usage
Monotherapy	24 (60.0)	22 (62.9)	0.798
Dual therapy	12 (30.0)	10 (28.6)	0.892
≥3 AEDs	4 (10.0)	3 (8.6)	0.834
Seizure control
Complete control	26 (65.0)	24 (68.6)	0.743
Partial control	10 (25.0)	8 (22.9)	0.828
Poor control	4 (10.0)	3 (8.6)	0.834

AED=Antiepileptic drug

DISCUSSION

The present study reveals important gender-specific patterns in seizure characteristics among elderly patients, with notable findings regarding etiology, radiological features, and treatment outcomes. These findings contribute to our understanding of age and gender-related aspects of epilepsy in the elderly population.

The predominance of cerebrovascular disease as the primary etiology in both genders (40.0% males and 34.3% females) aligns with recent epidemiological data. Stefanidou et al.[5] in their cohort study reported that cerebrovascular disease (hypertension) increases 2- to 2.5-fold the risk of developing late-onset epilepsy. This consistency across studies emphasizes the crucial role of vascular health in seizure prevention among older adults.

The significantly higher prevalence of neurodegenerative disorders in females (31.4% vs. 20.0%, P = 0.042) corresponds with findings from recent research. Lyou et al.[11] demonstrated in their 10-year cohort study that women over 60 have a higher association between Alzheimer’s disease and seizure occurrence, with a reported hazard ratio of 0.859 (95% confidence interval: 0.782–0.944). This gender disparity may be partially explained by the higher life expectancy in women and the increased prevalence of neurodegenerative conditions in elderly females.

Radiological findings in our study revealed distinct patterns between genders, with cortical infarcts predominating in males (35.0%) and white matter changes in females (37.1%). These findings align with recent work by Galovic et al.,[12] who identified gender-specific patterns in poststroke epilepsy development and associated imaging characteristics. The higher prevalence of brain atrophy in females (34.3% vs. 25.0%) warrants further investigation, particularly given emerging evidence about gender-specific patterns in brain aging.

The EEG findings showed consistency between genders, with focal epileptiform discharges being the predominant abnormality (males: 55.0%, females: 51.4%). This aligns with findings from Aanestad et al.,[13] who reported similar EEG patterns across genders in late-onset epilepsy, though they noted subtle differences in background activity that merit further investigation.

Treatment responses showed encouraging similarity between genders, with comparable rates of complete seizure control (65.0% males, 68.6% females). These findings support recent work by Sen A et al.,[14] who demonstrated that despite pharmacokinetic variations between elderly males and females, clinical outcomes remain similar with appropriate dosing strategies. The high rate of response to monotherapy in both groups (60.0% males and 62.9% females) suggests that single-drug regimens may be sufficient for many elderly patients, regardless of gender.

The high prevalence of comorbidities, particularly hypertension and diabetes, emphasizes the complexity of managing seizures in elderly populations. Recent research by Lattanzi S et al.[15] highlights the importance of considering these comorbidities in treatment selection, suggesting that a comprehensive approach to managing concurrent conditions may improve overall outcomes.

A notable limitation of our study is the relatively small sample size, which may have masked subtle gender-specific differences. Additionally, the cross-sectional nature of the study prevents analysis of long-term outcomes and disease progression patterns. Future longitudinal studies with larger cohorts are needed to better understand the temporal aspects of gender-specific differences in elderly-onset seizures.

CONCLUSIONS

The study reveals significant gender-specific patterns in the etiology of seizures among elderly patients, particularly in the prevalence of neurodegenerative disorders. While cerebrovascular disease remains the predominant cause in both genders, females showed a higher association with neurodegenerative conditions. Radiological and EEG findings demonstrated subtle gender differences, though treatment outcomes were comparable. These findings suggest the need for gender-specific considerations in the evaluation and management of elderly patients with seizures.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.