Explanation of Development: Seizure Observation Checklist
Based on Source Material
The SeizureSafe™ Seizure Observation Checklist was developed by drawing directly from a comprehensive review of academic literature on seizures in neurodegenerative diseases, particularly Alzheimer’s disease (AD) and other dementias. Seagull Health LLC is committed to providing evidence-based tools, and this checklist reflects a synthesis of current scientific understanding to aid in the challenging task of identifying subtle seizure activity.
The Challenge Addressed
The literature consistently highlights the diagnostic challenge posed by seizures in individuals with dementia. Key considerations from the source materials include:
- Subtle and Non-Motor Presentations: Seizures in dementia are frequently non-motor and subtle, making them difficult to distinguish from the underlying cognitive and behavioral symptoms of the disease (Asadollahi et al., 2019; Cretin et al., 2017; Vossel et al., 2017).
- Risk of Misdiagnosis: These subtle manifestations can be easily missed by caregivers or misdiagnosed as other common events in dementia, such as syncope, delirium, transient ischemic attacks, or simply fluctuating cognitive states (Kinney et al., 2018).
- Impact of Unrecognized Seizures: Unrecognized or untreated seizures can contribute to accelerated cognitive decline and increased morbidity (Vossel et al., 2016; Chen et al., 2024).
- Importance of Structured Observation: Given the limitations of standard EEG in some cases and the atypical presentations, detailed and structured observation by informed caregivers is crucial for gathering information that supports accurate clinical diagnosis (Faught, 2021; Cretin et al., 2017).
Methodology for Checklist Item Derivation
The structure of the checklist and the specific observational items were derived by synthesizing descriptions of seizure semiologies (the signs and symptoms of seizures) as presented across numerous peer-reviewed articles. The aim was to create a proforma that encourages systematic observation to avoid overlooking subtle phenomena, thereby enhancing the quality of information provided to clinicians.
Rationale for Checklist Categories and Items (Based on Synthesized Literature)
- Changes in Awareness/Responsiveness:
- Multiple sources describe seizures as involving “transient manifestation of signs and/or symptoms” and note that seizures in neurodegenerative disorders are often “of non-motor type, and may be subtle” (Adan et al., 2021; Horváth et al., 2016).
- Specific manifestations cited include transient episodes of unresponsiveness, loss of awareness, blank stares (often associated with absence seizures, a non-convulsive type), loss of contact with the environment, episodic confusion, increased drowsiness, and sudden altered mental states (Chen et al., 2021; Pandis & Scarmeas, 2012; Rao et al., 2009).
- Repetitive Behaviors/Movements (Automatisms):
- While gross motor activity is less subtle, the literature notes that automatisms (involuntary repetitive movements) such as mouth movements (lip smacking, chewing), eyelid movements (blinking, fluttering), and purposeless hand/limb movements (fumbling, picking) can be ictal phenomena (Horváth et al., 2018; Cretin et al., 2015). General rhythmic or jerking movements, even if subtle, are also recognized seizure symptoms.
- Motor Symptoms (subtle):
- Several sources specifically associate myoclonus (sudden, brief muscle jerks) with AD and other dementias (Beagle et al., 2017).
- Increased clumsiness, subtle body stiffening or posturing (which can be brief or localized), and sudden, unexplained falls are also documented as potential seizure manifestations in this population (Amatniek et al., 2006; Rao et al., 2009).
- Changes in Communication:
- Seizure activity, particularly when originating in or affecting temporal or temporoparietal regions (areas commonly implicated in AD pathophysiology), can manifest as language or memory disturbances (Noebels, 2011; Tombini et al., 2021).
- Described semiologies include verbal fluency impairment, loss of language, verbal memory impairment, verbal amnesia, and episodic memory dysfunction (Cretin et al., 2015). The concept of “epileptic amnesic syndrome,” involving transient memory loss, is also relevant (Cretin et al., 2017).
- Sudden Unexplained Behavioral/Emotional Changes:
- Seizures can present as sudden behavioral changes. Fluctuations in cognition are explicitly mentioned as a potential presentation of seizures in AD (Vossel et al., 2013).
- Visuo-constructive apraxia and visuospatial dysfunction (sudden difficulty with visual-spatial tasks) have been observed as seizure semiologies (Cretin et al., 2015).
- While subjective auras (like fear) are difficult for an observer to confirm, if an “ascending aura” has observable behavioral correlates (e.g., sudden expressions of fear or distress), it warrants notation.
- Other Unusual or Sudden-Onset Symptoms:
- General seizure symptoms like trouble breathing and incontinence, if sudden and unexplained by other causes, could indicate a seizure (Adan et al., 2021).
- Transient global amnesia-like events are also noted as a potential semiology (Cretin et al., 2015).
- Contextual Information (Episode Details, Pre-Event, Post-Event):
- Recording the estimated duration is vital as seizures are typically transient events (Pandis & Scarmeas, 2012).
- Noting frequency is important for understanding patterns of potential recurrent seizures, which are common in patients with dementia (Vöglein et al., 2020).
- Observing activity before the event and identifying potential triggers (e.g., certain medications, such as some antipsychotics/antidepressants that may lower the seizure threshold, infections, and metabolic issues) can provide important diagnostic clues (Mauritz et al., 2022; Adan et al., 2021).
- Documenting the post-event (postictal) state, including confusion, fatigue, or prolonged altered mental states, helps characterize the episode and differentiate it from other conditions (Horváth et al., 2016).
This checklist, by providing a structured approach rooted in the scientific literature, serves as a vital tool for enhancing the detection of seizures in dementia. It supports improved patient care and outcomes, aligning with Seagull Health LLC’s mission to advance seizure management through evidence-based practices and innovation.