Mental Mishaps

Errors in perceiving, remembering, and thinking.

Seizures and Postictal Psychosis in Alzheimer’s Disease: A Brief Glimpse of the Real Person?

Are Seizures and Postictal Psychosis Related in Alzheimer’s Disease?

Slowly and inexorably, Alzheimer’s disease steals a person away. Taking memory and cognitive abilities. Pilfering personality and social skills. Robbing a person of the ability to care for herself. But every now and then, Alzheimer’s disease relents – you get a brief glimpse of the person you know and love.

Sometimes these glimpses occur as part of the ebb and flow of the disease. Our recent gift occurred following a seizure. My wife and I are the primary care providers for a family member with Alzheimer’s disease. We have watched the disease progression. Sometimes it feels like the person we are caring for isn’t the same person we used to know. It isn’t just the cognitive difficulties. Instead, it’s the emotional and social losses. She has more difficulty tracking conversations, she can’t do the things she used to enjoy, and she interacts less with us. Not surprisingly, she isn’t as happy and joyful as she used to be.

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Like some people with Alzheimer’s disease, our relative suffers from occasional seizures. Grand mal seizures occur in about 20-25% of people with Alzheimer’s disease. Partial and petit mal seizures may occur more frequently but probably go unnoticed since small seizures can behaviorally appear as simply staring off into space. I’ve already written about our relative’s first known grand mal seizure and the horrors that followed her hospitalization (The Power of Narrative in Alzheimer's disease). She has had a few additional seizures since then and her recovery from her seizures has followed a consistent pattern, with a fascinating, unexpected, and brief period of changes in functioning.

As with most people, our relative is groggy, confused, and generally nonresponsive immediately following a seizure. She is unable to move independently for a few hours. Like most people, she sleeps for quite a while after a seizure. When she finally appears to be aware again, she has no memory of the experience. Her experience during the seizure aftermath (called the Postictal phase) is fairly typical of anyone experiencing a seizure.

Then the unusual postictal features appear. Our relative with Alzheimer’s disease has gone into a manic phase about 24 to 36 hours after the seizures. She is much more engaged and interactive. Her mood swings to euphoria. She laughs more and jokes with us. Following her most recent seizure, her elevated mood and increased social interaction lasted several days. This was a real gift – our loved one returned for a visit. It was as if the Alzheimer’s disease had released its hold on her for a few days.

Of course, there were a few other unusual symptoms that occurred as well. She experienced a clear increase in auditory hallucinations – both hearing music and apparently voices. She was possibly more confused than usual. And although she was more engaged, her conversation showed a series of thoughts bouncing all over the place. In addition, after her first major seizure when she was hospitalized, she experienced some delusions and paranoid responses.

These types of symptoms are known as Postictal Psychosis; that is psychotic symptoms for a period of time following a seizure. The displays of Postictal Psychosis vary among people who experience seizures associated with epilepsy. First, they don’t occur for all individuals with epileptic seizures – perhaps only 10% or so of people with grand mal seizures experience Postictal Psychosis. Second, the symptoms displayed vary but can include: mood changes (some euphoric, some depressed), hallucinations, delusions, disruptions to concentration, psychomotor excitement, suspiciousness/paranoia, and unusual thought content (Adachi et al., 2000; Luetmezer et al., 2003).

The postictal psychosis is a temporary event, generally lasting less than a week. For our relative, we enjoyed several days of her cognitive, emotional, and social visit. There was an odd sense it which the seizure blew away the cobwebs in her mind. Perhaps the seizure served as a reboot of her cognitive computer. Since then, she has gradually returned to her pre-seizure patterns.

I have not found any published reports of the frequency or symptom patterns for postictal psychosis for individuals with Alzheimer’s disease (the postictal psychosis information I have is based on the descriptions of people with epilepsy in non-Alzheimer’s disease cases). This could reflect the fact that seizures are not that common in Alzheimer’s disease. This could also reflect the nature of the postictal symptoms. If families and caregivers experience a happier, more engaged individual for a few days, then who would complain?

But here’s the interesting thing: Psychotic symptoms are common in Alzheimer’s disease. Some researchers estimate that 40-50% of individuals with Alzheimer’s disease suffer some psychotic symptoms, particularly delusions, paranoid delusions, and hallucinations (Hiron et al., 1998; Ropacki & Jeste, 2005; Sweet et al., 2010). Psychotic symptoms in Alzheimer’s disease are associated with increasing age, more severe cognitive deficits, and being female. But I have seen no reports concerning whether or not there is a link to seizure history. But seizures are common in Alzheimer’s disease and seizures cause psychotic symptoms during the postictal phase.

I write this blog post with the hope of encouraging people to notice and report changes following seizures in individuals with Alzheimer’s disease. Perhaps some diagnoses of psychosis reflect Alzheimer’s disease with seizures rather than simply Alzheimer’s disease.

Ira E. Hyman, Jr., Ph.D., is a Professor of Psychology at Western Washington University.

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