Management of Recurrent Tonic-Clonic Seizures

Immediate Acute Management

• Administer benzodiazepines immediately if seizures are ongoing or recur, as status epilepticus is defined by seizure activity lasting more than 5 minutes or recurrent seizures without return to baseline, with a mortality rate of 5-22% if left untreated 1
• Status epilepticus carries a significant mortality rate, making prompt treatment critical, with a mortality rate of up to 65% if refractory 1

Urgent Diagnostic Workup

• Immediately check ionized calcium, magnesium, sodium, glucose, and renal function, as hypocalcemia can trigger seizures at any age, even without prior history 3, 2
• Hyponatremia and other electrolyte abnormalities are common seizure precipitants in elderly patients 2
• Evaluate for aspiration pneumonia with chest X-ray and complete blood count, given the patient's dysphagia and frequent aspirations 1

Long-Term Antiepileptic Drug Selection

• The American Academy of Neurology recommends levetiracetam as a preferred long-term antiepileptic medication for patients with generalized tonic-clonic seizures 2

Management of Underlying Precipitants

• Hypocalcemic seizures may resolve with calcium and vitamin D supplementation alone without long-term antiepileptics, but given the patient's history of seizures, initiate antiepileptic therapy while correcting calcium 3, 2
• Treat infection aggressively if aspiration pneumonia is present, as this represents an acute symptomatic seizure trigger 1, 2

Disposition and Follow-Up

• The patient requires hospital admission given the frequency of seizures, multiple comorbidities, need for metabolic workup and treatment, and aspiration risk 1, 2
• Ensure medication compliance monitoring, as non-compliance is a major seizure precipitant 2
• Coordinate care with neurology, psychiatry, and primary care 1