Brief Answer:
Convulsive Syncope following Orthostatic Hypotension

Detailed Answer:
Good evening. Thank you for your concerns. The most common reason for someone such as your mother to have the type of terrible hypotension you are referring is medication interactions (generally patients are Over-medicated with agents that cause lowered blood pressure).

If I were her physician I would do what is called a modified Aminoff protocol which the neurologist should clearly know how to do. Essentially, your mother's blood pressure and pulse are measured in different positions or postures and what one is looking for is either a reduction in BP of 20-30mm in the systolic (Top number), a reduction of 12-15 mm. in the bottom number or an increase in heart-rate in any position of greater than 15 Beats Per Minute. If the patient cannot even tolerate doing the entire test because of dizziness, vertigo, or in some cases faints then, the patient is clearly what we call ORTHOSTATIC and then, the determination needs to be made as to whether it is due to a problem in their autonomic system that controls blood pressure, heart rate, and other vital signs and functions, medications (most commonly), low volume or poor nutritional status (2nd most common reason), or other medical problems.

I am suspicious of what you are describing as a SEIZURE which is occurring after breakfast and medication because she may as well be having what is called a vasovagal reaction and what appears to be a seizure may look like epileptic activity but it may be on the basis of a sudden drop in blood pressure and circulating volume to the brain that results in this phenomenon but without any electrical correlate to classify it as a seizure. Therefore, I am wondering about the original validity of the seizures for which she is receiving Keppra in the first place then, on top of that an increase in Keppra based upon the type of picture you're describing with may be orthostatically induced which we refer to as CONVULSIVE SYNCOPE or perhaps PRESYNCOPE if she doesn't actually fall and due to the shaking thing.

And then, she is on Sinemet (and I think the dose of her medication is fairly high for only having PD for 3 years) as well which itself can cause ORTHOSTASIS.

Now, here's one more thing to consider which is an entity called MULTISYSTEM ATROPHY (MSA) which is a condition that can be mistaken as Parkinson's Disease. MSA is much more common in men compared to women by nearly 2 fold but it's something to consider in her with everything else that is going on. Also, has she been ruled out for Normal Pressure Hydrocephalus (NPH). Again, the neurologist should have a good sense of what that entity is and how to go about distinguishing it from Parkinson's Disease. Sometimes it can be difficult in the first few years to tell it apart from MSA and because people move very slowly it tends to be called Parkinson's.

Bottom line is that I believe your mother needs another diagnostic revision (2nd opinion) from a neurologist and potentially internist with the goal of:

1. Validating the diagnosis of an epileptic condition requiring a DOUBLING of the dose of her antiepileptic which I believe could be done more slowly and thus avoid potential complications that she is now apparently having. Has she had an EEG performed that clearly shows an epileptic focus or foci? Was the EEG read by a certified epileptologist or was it performed and read by the same neurologist who himself may not be a subspecialist in epilepsy.

2. Validating the diagnosis of PD and the need for double dose Sinemet compared to the majority of patients especially when in the face of her apparent orthostatic problems.

3. Reviewing her metabolic and medication status to be sure that there are no problems that she could be corrected on such as volume status, nutritional status, hormones (thyroid and cortisol)

My prediction is that her episodes of both passing out or nearly passing out as well as her "seizure" episodes will get worse now that medications have been increased unless she gets a review of her medications and even a 2nd opinion consult from another neurologist...preferably somebody at an Academic Center who may be more accustomed to seeing cases who are mistakenly diagnosed with epilepsy when they in fact have convulsive syncope or some other type of issue that may LOOK like seizures but aren't.

I believe she also needs to find an internist or PRIMARY CARE PROVIDER who can better recognize when things are going too far to the left or right and make some kind of move to bring the situation back to center.

If I've adequately answered your questions could you do me a huge favor by CLOSING THE QUERY and being sure to include some fine words of feedback along with a 5 STAR rating if you feel my suggestions have helped? Again, many thanks for posing your question and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 75 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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