Seizure Evaluation and Management in Elderly Patients with Fall, Drooling, Urinary Incontinence, and Confusion

Immediate Recognition and Assessment

The combination of drooling, urinary incontinence, and post-event confusion following a fall from bed represents the classic triad of a generalized tonic-clonic seizure, according to the American College of Emergency Physicians 1, 2
Perform a comprehensive head-to-toe trauma evaluation immediately, as post-ictal patients who fall can sustain "occult" injuries that present without classic signs, as recommended by the American College of Emergency Physicians 1, 2

Maintain high suspicion for blunt head trauma with intracranial hemorrhage, spinal fractures, tongue lacerations, and shoulder dislocation or posterior fracture-dislocation, as suggested by the American College of Emergency Physicians 1, 2
Obtain the following tests to identify reversible and life-threatening causes: EKG, complete blood count, comprehensive metabolic panel, head CT without contrast, and measurable medication levels, as recommended by the American College of Emergency Physicians 1, 2

Admit to hospital if first-time seizure requiring workup, intracranial hemorrhage or other acute injury identified, persistent altered mental status, unable to safely ambulate, or patient safety cannot be ensured at home, according to the American College of Emergency Physicians 1, 2
Require physical therapy and occupational therapy evaluation for all admitted patients who fell, as recommended by the American College of Emergency Physicians 1

Ask specifically about witnessed seizure activity, time spent on floor, loss of consciousness, previous seizures or epilepsy history, and recent medication changes, as suggested by the Journal of the American Geriatrics Society 4
Perform focused assessment for mental status using validated screening tool, focal neurologic deficits, peripheral neuropathy, proximal motor strength, and orthostatic vital signs, as recommended by the American College of Emergency Physicians 1, 2

Do not treat asymptomatic bacteriuria even if urinalysis shows pyuria and bacteria, as this causes harm without benefit, according to the Infectious Diseases Society of America 3
Avoid placing Foley catheter unless retention documented, as it increases UTI risk after 48 hours, as recommended by the Infectious Diseases Society of America 3