JNS-14925; No of Pages 5

Journal of the Neurological Sciences xxx (2016) xxxxxx

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Journal of the Neurological Sciences

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Clinical Short Communication

Status epilepticus in the elderly patients: A national data study

in Thailand
Somsak Tiamkao a,c, Sineenard Pranboon b,c, Kaewjai Thepsuthammarat d, Kittisak Sawanyawisuth a,e,f,
a
Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
b
Nursing Division, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand
c
Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
d
Clinical Epidemiology Unit, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
e
Research Center in Back, Neck Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University, Khon Kaen, Thailand
f
Non-communicable Diseases Research Group, Khon Kaen University, Khon Kaen, Thailand

a r t i c l e i n f o a b s t r a c t

Article history: There are limited data in terms of incidence, clinical features, and outcomes in elderly patients with status epilep-
Received 10 March 2016 ticus (SE) in national level. We retrospectively explored national data in Thailand for reimbursement of all SE in
Received in revised form 6 November 2016 elderly patients admitted in the scal year 20042012. SE in elderly patients (age N 60 years old) were diagnosed
Accepted 8 November 2016
and searched based on ICD 10 (G41) from the national database of from the National Health and Security Ofce.
Available online xxxx
There were 3326 SE in elderly patients. The national incidence of SE was highest at 8.78 patients/100,000/year in
Keywords:
2012. The average age was 72.02 years and most were males (1379 patients; 58.8%). At discharge, 66% of patients
Incidence had improved and in-hospital mortality rate was 14.5%. Predictors of poor outcomes were older age 80 years,
Status epilepticus being female, hospital levels, chronic renal failure, central nervous system infection, respiratory failure, pneumo-
Elderly nia, septicemia, shock, acute renal failure, and hyperkalemia. In conclusion, the number of cases of SE in elderly
Outcomes patients in Thailand has been increasing annually. Increasing age was associated with poor outcome in admitted
National elderly SE patients.
2016 Elsevier B.V. All rights reserved.

1. Introduction outcomes and prognostic factor and in-hospitalized mortality of SE in

The incidence rate of epilepsy may increase in the future due to a
higher.
proportion of elderly people in the population [1,2]. Epilepsy and its
complications may cause the elderly to suffer an increasing of economic
burden [2]. Status epilepticus (SE), a serious complication of epilepsy
and a major public health problem [3], may also be increasing in the el-
derly similar to epilepsy. SE in the elderly may be more intractable and
have high morbidity and mortality compared with the general popula-
tion [4].
Several studies have shown that the incidences of SE in people over
60 were higher than in the general population [47]. The incidence rate
of SE in the elderly (over 60 years old) was 39.2/100,000 population and
higher than that in the younger age group (2059 years) of 14.7/
100,000 population [5]. The SE incidence rates from Virginia (over
60 years old) and Minnesota (over 75) were 86/100,000 population
and 4/1000 population, respectively [6,8]. There are limited data in
term of incidence, characteristics, demographics, comorbidity,
Corresponding author at: Department of Medicine, Faculty of Medicine, Khon Kaen
University, Khon Kaen 40002, Thailand.
E-mail address: kittisak@kku.ac.th (K. Sawanyawisuth).
the elderly patients as longitudinal data at the national level.
2. Methods
2.1. Study design
A retrospective study explored national data from the National
Health and Security Ofce. The study period was from the scal years
2004 and 2012. Data from the reimbursement section of all admitted
SE in elderly patients aged 60 and over were studied. The ICD-10 code
(G41) was used to identify eligible patients. The G41 code indicated
Grand mal SE excluding epilepsia partialis continua, petit mal SE, com-
plex partial SE, other SE, and SE unspecied. Medical discharge forms
were used to retrieve clinical data, co-morbid diseases, complications,
procedures, and discharge status.
The Universal Health Coverage Insurance is the main health care in-
surance system in Thailand and is supported by the government. Ap-
proximately 77% of the entire Thai population is covered under this
plan. The other two health care insurance systems in Thailand are social
security system and civil servant medical benet system (CSMBS).One
person can have only one type of health insurance.
There were three hospital categories in Thailand including primary
or community, secondary, and tertiary hospitals. The primary or

http://dx.doi.org/10.1016/j.jns.2016.11.013
0022-510X/ 2016 Elsevier B.V. All rights reserved.

Please cite this article as: S. Tiamkao, et al., Status epilepticus in the elderly patients: A national data study in Thailand, J Neurol Sci (2016), http://
dx.doi.org/10.1016/j.jns.2016.11.013
2 S. Tiamkao et al. / Journal of the Neurological Sciences xxx (2016) xxxxxx

community hospitals serve at the district or community levels and usu- Table 2
ally have 1030 beds. The secondary hospitals provide healthcare at the Co-morbid conditions of status epilepticus in elderly patients admitted
throughout Thailand during the 9-year study period from 2004 to 2012.
provincial level, while the tertiary hospitals, such as university hospitals
or large provincial hospitals, are referral centers. Co-morbid conditions Numbers (%)
Attending physicians categorized the discharge statuses of all admit- Hypertension 1072 (32.2)
ted patients as follows: complete recovery, improved, not improved, Diabetes mellitus 543 (16.3)
and death. The rst two categories were classied as improved or Previous stroke 423 (12.7)
Chronic renal failure 219 (6.6)
good outcomes, while the latter two were not improved or poor out-
Traumatic brain injury 45 (1.4)
comes. All eligible patients were divided into two groups based on Cirrhosis 43 (1.3)
whether they their outcomes were considered good or poor. CNS infection 38 (1.1)
Schizophrenia 24 (0.7)
Brain tumor 21 (0.6)
2.2. Statistical analysis Psychosis 12 (0.4)
Depression 8 (0.2)
Descriptive statistics were used to analyze the baseline data. The in-
cidence rates of SE in each year were calculated and adjusted by the
structure of population in the year of 2012. Three age groups were 3.4. Outcomes of treatment
used as reference values (age group 6069, 7079, and 80 and over).
Factors associated with discharge status were calculated by descriptive The most cases of treatment of SE in elderly patients were classi-
statistics. Univariate and multivariate logistic regression analyses were ed as having good outcomes 66.6% (2215 patients; categorized as
used to identify signicant factors associated with poor discharge status. complete recovery 17 patients or 0.5% and improved 2198 patients
All data analyses were performed by STATA software version 10 (Col- or 66.1%), while poor outcomes accounted for 33.4% (1111 patients;
lege Station, Texas, USA) on a personal computer. A p value of b 0.05 categorized as not improved 630 patients or 18.9% and dead 481 pa-
was considered statistically signicant. tients or 14.5%). The mean (SD) hospital stay was 7.74 (16.36) days.
Predictors of poor outcome were age N 80 years, female sex and hos-
pital levels.
3. Results
Out of 11 co-morbid conditions, chronic renal failure and central
nervous system infection were signicantly associated with poor out-
3.1. Demographics
comes. Additionally, six complications including respiratory failure,
pneumonia, septicemia, shock, acute renal failure, and hyperkalemia.
There were 3326 Elderly SE patients examined in the study period.
There were 251 patients who received at least one treatment proce-
1957 of the patients were male (58.8%) and 1369 were female
dures such as Foley catheterization, or cardiopulmonary resuscitation.
(41.2%). The mean age (SD) was 72.02 years (7.55) (range 61
Only cardiopulmonary resuscitation was a signicant factor of poor out-
103 years). Most were admitted into tertiary care (1701 patients;
comes as shown in Table 3.
51.1%) followed by secondary care (967 patients; 29.1%) and primary
The mortality rate was slightly increasing by years (Table 4). No
care (658 patients; 19.8%).
death was reported in 2004. The age group of 80 years had highest
mortality rate except in 2006; highest in 2005 (26.92%).
3.2. National incidence of SE

The number of SE in elderly patients was increasing every year from 4. Discussion
113 patients in 2004 to 717 patients in 2012. The national incidence rate
of SE was lowest at 1.84 patients/100,000/year in 2004 and highest at This study showed the trend of SE incidence rates in the elderly
8.78 patients/100,000/year in 2012 as shown in Table 1. over a nine-year period based on the national data. SE incidences
and mortality rate increased slightly over this period (Table 1).
3.3. Comorbidities and in-hospital complications The incidence rates in this study were lower than previous reports
from the Western countries [410]. In 2012, the incidence rate of
The three most common comorbidities were hypertension, diabetes SE in the Thai elderly population was 8.78/100,000 population,
mellitus and previous stroke (Table 2), while the three most common while a study from California found an incidence rate there of
complications were respiratory failure, pneumonia and septicemia 22.3/100,000 population in a generalized tonic clonic SE in the el-
(Table 3). derly aged 75 years and older [10]. The reported SE incidence
rates in the Thai elderly population may be under-reported mainly
due to the limited number of laboratories and epileptologists [11,
Table 1
Incidence rates of status epilepticus (SE) in elderly patients admitted throughout Thailand 12]. Nonconsulvive SE may be difcult to diagnose, particularly in
during the 9-year study period from 2004 to 2012. the elderly. Electroencephalography (EEG) and experienced neu-
rologists or epileptologists are required to examine SE patients
Years SE, n Age group Age group Age group Rate/100,000
6069 7079 80 populationsa
who have subtle or minor symptoms of SE. Clinical suspicion of
SE is crucial and the lack of clinical suspicion may lead to misdiag-
2004 113 65 33 15 1.84
nosis. EEG is not available in all healthcare facilities. Additionally,
2005 166 76 64 26 2.63
2006 174 78 68 28 2.67 the low incidence of SE in this study may be due to source of data
2007 241 115 90 36 3.60 in this study. We collected data from discharge documents which
2008 356 149 149 58 5.14 depended on summary by attending physicians and also correct
2009 413 170 174 69 5.74
code for SE. These errors may slightly result in lower incidence of
2010 556 216 243 97 7.40
2011 590 247 242 101 7.55 SE.
2012 717 304 264 149 8.78 The present study indicated that SE in Thai elderly patients had
Total 3326 1420 1327 579 good outcomes (66.6%) and in-hospital mortality was 14.5%. Com-
a
The rate was adjusted by three age groups (6069, 7079, and 80 and over) by using pared with other studies in Thailand, the mortality rate in this
the population of each age group in the year of 2012 as the reference. study was somewhat lower [1315]. In a study from the southern

Please cite this article as: S. Tiamkao, et al., Status epilepticus in the elderly patients: A national data study in Thailand, J Neurol Sci (2016), http://
dx.doi.org/10.1016/j.jns.2016.11.013
 S. Tiamkao et al. / Journal of the Neurological Sciences xxx (2016) xxxxxx 3

Table 3
Factors affecting discharge status of status epilepticus in elderly patients admitted throughout Thailand during the 9-year study period from 2004 to 2012.

Variables Discharge Status Total n (%) Adjusted odds ratios (95%CI) p-value

Good n (%) Poor n (%)

Age group b0.001

6070 years 1016 (45.9) 404 (36.4) 1420 (42.7) 1
7080 years 863 (39.0) 464 (41.8) 1327 (39.9) 1.19 (0.99, 1.44)
80 years 336 (15.2) 243 (21.9) 579 (17.4) 1.58 (1.26, 1.99)
Gender b0.001
Male 1379 (62.3) 578 (52.0) 1957 (58.8) 1
Female 836 (37.7) 533 (48.0) 1369 (41.2) 1.52 (1.29, 1.80)
Hospital level b0.001
Primary care 383 (17.3) 275 (24.8) 658 (19.8) 1
Secondary care 654 (29.5) 313 (28.2) 967 (29.1) 0.29 (0.23, 0.38)
Tertiary care 1178 (53.2) 523 (47.1) 1701 (51.1) 0.22 (0.17, 0.28)
Co-morbid conditions
Hypertension 719 (32.5) 353 (31.8) 1072 (32.2) 0.91 (0.75, 1.09) 0.323
Diabetes mellitus 362 (16.3) 181 (16.3) 543 (16.3) 0.85 (0.66, 1.08) 0.181
Previous Stroke 261 (11.8) 162 (14.6) 423 (12.7) 1.17 (0.91, 1.49) 0.203
Chronic renal failure 111 (5.0) 108 (9.7) 219 (6.6) 1.79 (1.30, 2.47) b0.001
Traumatic brain injury 27 (1.2) 18 (1.6) 45 (1.4) 1.55 (0.76, 3.17) 0.238
Cirrhosis 26 (1.2) 17 (1.5) 43 (1.3) 1.44 (0.72, 2.88) 0.335
CNS infection 18 (0.8) 20 (1.8) 38 (1.1) 2.18 (1.07, 4.44) 0.029
Schizophrenia 16 (0.7) 8 (0.7) 24 (0.7) 0.97 (0.36, 2.57) 0.964
Brain tumor 16 (0.7) 5 (0.5) 21 (0.6) 0.64 (0.21, 1.92) 0.460
Psychosis 9 (0.4) 3 (0.3) 12 (0.4) 0.88 (0.21, 3.61) 0.964
Depressive 7 (0.3) 1 (0.1) 8 (0.2) 0.45 (0.05, 4.15) 0.471
Complications
Respiratory failure 884 (39.9) 672 (60.5) 1556 (46.8) 2.37 (1.94, 2.90) b0.001
Pneumonia 310 (14.0) 259 (23.3) 569 (17.1) 1.35 (1.08, 1.69) b0.001
Septicemia 109 (4.9) 278 (25.0) 387 (11.6) 5.24 (4.03, 6.81) b0.001
Pressure sore 58 (2.6) 43 (3.9) 101 (3.0) 1.03 (0.65, 1.63) 0.865
Shock 24 (1.1) 49 (4.4) 73 (2.2) 3.49 (1.99, 6.12) b0.001
Acute renal failure 51 (2.3) 122 (11.0) 173 (5.2) 3.24 (2.20, 4.78) b 0.001
Hyperkalemia 51 (2.3) 70 (6.3) 121 (3.6) 2.04 (1.33, 3.14) 0.001
Hyperglycemia 26 (1.2) 26 (2.3) 52 (1.6) 1.87 (0.99, 3.55) 0.057
Procedures*
Foley's catheter 100 (4.5) 70 (6.3) 170 (5.1) 0.88 (0.60, 1.29) 0.600
CPR 9 (0.4) 83 (7.5) 92 (2.8) 15.54 (7.52, 32.10) b0.001

Note. CNS: central nervous system; CPR: cardiopulmonary resuscitation; *only 251 patients received at least one treatment procedure.

Thailand, the rates poor outcomes and mortality were 62.2% and
26.7%, respectively [13], while studies from central and northeastern
Thailand reported mortality rates of 25% and 35% [14,15]. However,
there have been several studies that have found similar SE mortality
rates as were found in this study (range 14.5%16%) [1618]. Note
that populations examined in the above studies were not limited to
elderly patients. These three studies were conducted in university
or referral hospitals which may have more severe SE patients. The re-
sults of this study should be more generalized for Thailand in overall.
Only 45% of the patients in the study from central Thailand were 60
90 years of age [14]. We found the national mortality rate of SE to be
11.96% for all age groups [19], which was lower than in this elderly
population (14.5%).
Several factors were independently associated with poor out-
comes at discharge (Table 3). Age was one signicant positive factor,
with the rate of poor outcomes increasing with the age of the pa-
tients. Patients 7080 years old had an adjusted OR of 1.24 (1.03,
1.49), while those over 80 had higher the adjusted OR of 1.67 (1.33,
2.10). These ndings were similar to previous studies with smaller
sample sizes [18,2026]. Elderly patients over 75 years old had unfa-
vorable outcomes in 50% of cases if the patients had experienced de-
terioration of mental status [21]. Female gender was also another
poor prognostic factor as previously reported [23]. The mortality
rate increased by 34% (95% CI 1.041.73) in females [23], while the
adjusted OR in this study was quite similar at 1.53 (95% CI 1.29,
1.80) as shown in Table 3.
Hospital category was also signicantly associated with poor out-
comes. The tertiary care hospitals had the highest rate of poor outcomes
compared with secondary or primary care hospitals (24.8% vs 28.2% vs
47.1%) as shown in Table 3. These ndings were mainly explained by
the fact that there were more severe cases at tertiary hospital level.
But, the adjusted odds ratios for secondary and tertiary care hospitals
were b1 (Table 3). In other words, the secondary and tertiary care hos-
pitals may have better outcomes. These ndings may be due to better

Table 4
Mortality rates of status epilepticus (SE) in elderly patients admitted throughout Thailand during the 9-year study period from 2005 to 2012.

Years Age group 6069, n (%) Age group 7079, n (%) Age group 80, n (%) Total death, n SE, n Mortality rate Mortality/100,000 populationsa

2005 8 (10.53%) 9 (14.06%) 7 (26.92%) 24 166 14.46% 0.38

2006 16 (20.51%) 14 (20.59%) 3 (10.71%) 33 174 18.97% 0.51
2007 14 (12.17%) 7 (7.78%) 8 (22.22%) 29 241 12.03% 0.43
2008 17 (11.41%) 25 (16.78%) 11 (18.97%) 53 356 14.89% 0.77
2009 16 (9.41%) 24 (13.79%) 16 (23.19%) 56 413 13.56% 0.78
2010 33 (15.28%) 43 (17.70%) 23 (23.71%) 99 556 17.81% 1.32
2011 30 (12.15%) 31 (12.81%) 23 (22.77%) 84 590 14.24% 1.08
2012 37 (12.17%) 39 (14.77%) 27 (18.12%) 103 717 14.37% 1.26
a
The rate was adjusted by three age groups (6069, 7079, and 80 and over) by using the population of each age group in the year of 2012 as the reference.

Please cite this article as: S. Tiamkao, et al., Status epilepticus in the elderly patients: A national data study in Thailand, J Neurol Sci (2016), http://
dx.doi.org/10.1016/j.jns.2016.11.013
4 S. Tiamkao et al. / Journal of the Neurological Sciences xxx (2016) xxxxxx
diagnosis and management in higher hospital levels. The tertiary care
hospitals have experienced neurologists, while the primary care hospi-
tals do not. Additionally, non-convulsive SE requires an EEG to diagnose,
and is quite difcult to control seizures particularly if a referral process
is delayed. Generally, elderly people with epilepsy have 23 times
greater mortality than the general population [27]. SE was presented
in 30% of acute seizures in the elderly with a mortality rate of 40% par-
ticularly refractory SE [8,20,28,29]. In addition, primary care hospitals
have a limited amount of anti-epileptic drugs to control refractory or
non-convulsive SE [17,19,30].
The most common co-morbid conditions of SE in elderly patients
were cerebrovascular disease at 45%50% [2,5,31]. Our nationwide
data showed that the three most common co-morbid conditions were
hypertension (32.2%), diabetes mellitus (16.3%), and previous stroke
(12.7%). These factors may not be the primary cause of SE in the elderly
patients. However, they may be a contributing factor for other SE-relat-
ed conditions such as stroke instead. Therefore, elderly people who de-
velop new-onset seizures should undergo assessment for the presence
of cerebrovascular risk factors and treat these conditions accordingly
with the aim of stroke prevention [2].
Common SE complications were respiratory failure (46.8%), pneu-
monia (17.1%) and septicemia (11.6%) as shown in Table 3. These fac-
tors, once again, related with poor outcomes as previously reported by
Hocker et al.. [20]. SE, particularly non-convulsive SE in elderly patients
was associated with a high rate of hospital-acquired infections [32]. The
study of non-convulsive SE on 25 elderly patients found a mortality rate
of 52% and death was associated with the number of acute life-threaten-
ing medical problems [32].
Our study found that the mean (SD) hospital stay was 7.74 (16.36)
days. The length of hospital stay was longer than adult SE patients at
the national level at 5.48 (SD 11.44) days [30]. These results conrmed
that cases of SE in the elderly were more severe and required longer
hospitalizations than the general population. The mortality rate tends
to increase by years (Table 4). These ndings may be due to elderly
community in Thailand. Even though the healthcare is better, the elder-
ly patients had more co-morbid diseases. Additionally, the mortality
rates tended to be higher in age group of N 80 years in almost all years
(Table 4). Advanced age is one factor associated with mortality other
than disability status [33].
The strengths of this study were large sample size at the national
level and longitudinal data over a nine-year period. This study is a
subgroup analysis of the previous study [31]. Another national
study included all adult SE patients with all types of health insurance
and treated in 2010 [19] which may be a part of this study. Some lim-
itations exist, however. The patients enrolled in this study were only
those who were admitted and reimbursed through the national in-
surance system. However, these populations accounted for N77% of
Thai population. Due to retrospective data collection, some specic
clinical factors, such as laboratory results, were not included in the
analysis. Additionally, data were collected from discharge summary
forms. Some factors were not recorded such as duration of seizure,
anticonvulsant therapy, or depth of coma. Finally, even though dis-
charge summary form was routinely double checked or audited ac-
cording to the standard of the hospital accreditation, using the ICD
code in the discharge summary may not have the 100% accuracy.
The sensitivity and specicity for epilepsy by the ICD-code were
98.8% and 69.6%, respectively [34].
SE in the elderly had a high rate of incidence and severity. Factors as-
sociated with poor outcomes in admitted SE in elderly patients were
age, sex, hospital level, co-morbid conditions, complications of SE, and
procedural intervention by the national data.
Financial disclosure
None declared by all authors.
Please cite this article as: S. Tiamkao, et al., Status epilepticus in the elderly patients: A national data study in Thailand, J Neurol Sci (2016), http://
dx.doi.org/10.1016/j.jns.2016.11.013
Conicts of interest
None declared by all authors.
Acknowledgement
The authors would like to thank Mr. Dylan Southard for his English
language editing and the Thailand Research Fund (TRF) for their kind
support (IRG 5780016). This research was also funded in part by grants
from the Higher Education Research Promotion National Research Uni-
versity Project of Thailand Ofce of the Higher Education Commission
through the Health Cluster (SHeP-GMS), Thailand; the Faculty of Medi-
cine, Khon Kaen University grant number TR57201; and the TRF Senior
Research Scholar Grant, Thailand Research Fund grant number
RTA5880001.
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Please cite this article as: S. Tiamkao, et al., Status epilepticus in the elderly patients: A national data study in Thailand, J Neurol Sci (2016), http://
dx.doi.org/10.1016/j.jns.2016.11.013