Emergency Department Visits for Falls and First-Time Seizure

BACKGROUND AND OBJECTIVES: Unrecognized seizures occur in up to 77% of individuals with epilepsy, leading to delays in diagnosis with significant consequences including injury, mortality, impaired psychosocial functioning, and negative socioeconomic impacts. Falls are a common reason to present to the emergency department (ED) and may be a sentinel sign of an unrecognized seizure. Whether falls represent missed opportunities for earlier seizure recognition remains unknown. We therefore evaluated the temporal association between ED visits for falls and first-time seizure. METHODS: We conducted a retrospective case-crossover study using the State Inpatient Databases and State Emergency Department Databases from 11 states (Arkansas, Florida, Georgia, Iowa, Massachusetts, Maryland, Nebraska, New York, Utah, Vermont, and Wisconsin) between 2016 and 2021. Adults aged 18 years and older with an acute care visit for a first-time seizure were identified using ICD-10 codes. Using patients as their own controls, we applied conditional logistic regression to compare the odds of an ED visit for a fall during prespecified case periods preceding the seizure (1-7, 8-30, 31-90, and 91-180 days prior) vs corresponding control periods 1 year earlier. Prespecified intervals were selected to assess graded temporal proximity. RESULTS: There were 57,547 patients with a first-time seizure and 7,307 patients (mean age 49.3 years and 55.2% female) with at least one prior ED visit for a fall during the case or control periods. ED visits for a fall were more common in case compared with control periods, with the highest odds in the 7 days immediately before the acute care visit for first-time seizure (OR = 2.6, 95% CI 2.2-3.2). In a week-by-week analysis, the association persisted up to 22 weeks before seizure, demonstrating temporal attenuation as time from the event increased. These findings were consistent across age and sex strata and after excluding those who had traumatic brain injury. In analyses restricted to first-time status epilepticus, the association in the 7 days preceding seizure was most pronounced (OR = 4.5, 95% CI 2.5-9.0). DISCUSSION: ED visits for falls are more common immediately preceding first-time seizure, potentially representing missed opportunities for earlier diagnosis, evaluation, and intervention. Prospective studies are needed to clarify the underlying mechanisms and clinical implications.