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Successful ECT in Long-Term Care Residents
Successful ECT in Long-Term Care Residents Marc H. Zisselman, MD, Karen G. Kelly, MD, Terri Cutillo-Schmitter, MSN, RN, CS, David Payne, PhD, and Susan J. Denman, MD Introduction: Depression is common in long-term care (LTC) residents and causes increased mortality and morbidity. Treatment resistance or intolerance to antidepressants is not unusual. Electroconvulsive therapy (ECT) is a safe and effective alternative for older community-dwelling residents but has not been well studied in LTC residents. Methods: A retrospective chart review was made of all LTC residents who received ECT from a single academic 538-bed facility over a 3-year period. Demographic information, severity of medical illness as measured by the Cumulative Illness Rating Scale for Geriatrics (CIRSG), psychiatric diagnosis, earlier psychotropic drug trials, and MMSE before and after ECT were collected. ECT therapy was reviewed for number and types of treatments and complications. Outcome after ECT was rated with the Clinical Global Impression of Change scale (CGI). Results: Thirteen patients (4 men, 9 women ), mean age 81 years (range: 65-95), received ECT. All had a diagnosis of major depression, and 10 had associated psychotic features. All patients received at least two
There is increasing recognition that electroconvulsive therapy (ECT) can be performed safely and effectively in older adults. Research findings support treatment efficacy for depression, mania, psychotic schizophrenic exacerbations, and certain additional neuropsychiatric conditions such as neuroleptic malignant syndrome and alcoholic delirium.1– 4 In older persons, electroconvulsive therapy is utilized most commonly to treat major depression, especially when the patient has not been responsive to multiple trials of medications or when depression is accompanied by life-threatening complications such as severe weight loss or catatonia. The effectiveness does not diminish with age, and case reports attest to the safe use of ECT in patients as old as 102.1,4 – 6 Three recent prospective studies showed a trend toward greater improvement in the old-old compared with young-old Temple University Department of Psychiatry and Temple Continuing Care Center (M.H.Z. and T. C-S.) and Temple University Department of Medicine andTemple Continuing Care Center (K.G.K., D.P., and S.J.D.) Address correspondence to: Marc H. Zisselman, MD, Temple Continuing Care Center, 530l Old York Rd., Philadelphia, PA 19141.
Copyright ©2001 American Medical Directors Association 22 Zisselman et al.
psychotropic agents before receiving ECT (range: 2-11). Patients also had significant medical comorbidity, with a mean (CIRS-G) of 19.7 (range: 14-27). On average, patients received 5.7 ECT treatments in the hospital (range: 3-10), and 9 of 13 patients received bilateral stimuli. Nine patients (69%) were rated as improved, two (15%) were clinically unchanged, and two (15%) were rated as worse. Complications included transient atrial fibrillation in one patient, posttreatment headache in one patient, and delirium in one patient. Five patients had transient cognitive decline as measured by the MMSE, but all recovered fully by 1 month. Conclusions: ECT was a safe and effective treatment modality in this population of LTC residents with a significant medical comorbidity. 69% of patients exhibited clinical improvement despite previous medication resistance. Careful monitoring for delirium in this population is essential to prevent more protracted posttreatment confusion. (J Am Med Dir Assoc 2001; 2: 22–25) Keywords: ECT; long-term care
persons treated with ECT.7–9 Although major depression is not more common in older persons, ECT is used 6.7 times more frequently in patients older than age 65 compared with individuals aged 18 to 34 in inpatient settings.10 This may be caused by the increased prevalence of delusional depression, more severe medical comorbidity, and poor tolerance of psychotropic medications that may limit pharmacologic options in this population. The APA Task Force Report clearly states that ECT should not be considered a “last resort” intervention but rather a first line treatment when a rapid definitive response is needed, based on severe acute psychiatric and/or medical morbidity. Past response to ECT, particularly in the context of drug refractoriness or intolerance and patient preference, may also call for its primary use.1 To our knowledge, there have been no studies on the use of ECT for individuals residing in long-term care facilities. It is unclear whether the cognitive, physical, and functional status of long-term care residents would lend themselves to different outcomes with ECT treatment. It is known, however, that ECT can be utilized effectively in several conditions that are common among long-term care residents. For example, ECT can be administered to patients with Parkinson’s disease asJAMDA – January/February 2001
sociated with depressed mood.11,12 ECT can also effectively treat both depressive and psychotic symptoms in Parkinson patients, often inducing a concurrent improvement in the motor symptoms of the disease.13 Additionally, depression is common in individuals with Alzheimer’s disease and often represents a treatable source of excess disability. Studies reveal that demented patients treated with ECT achieve comparable reductions in their depressive symptoms compared with their nondemented counterparts.14 There is a growing body of case reports describing successful ECT treatment for individuals with more advanced dementia and severe agitation that has been refractory to other treatment modalities.15,16 ECT may also be a particularly valuable treatment for patients with cerebrovascular disease other than discrete stroke. Patients with subcortical hyperintensities on MRI – particularly in the deep white matter, basal ganglia, and pontine reticular formation – seem to demonstrate increased resistance to antidepressant pharmacotherapy. Studies suggest bilateral ECT maybe the most effective treatment for these individuals.17,18 Several studies have also found ECT treatment can be performed safely, without mortality or sustained morbidity, in older persons with advanced cardiovascular disease.19,20 This retrospective case series sought to examine ECT response and complications in long-term care residents. We also sought to make some preliminary observations regarding demographic or clinical factors that may influence ECT treatment outcome. METHODS Temple Continuing Care Center is a 538-bed, universityaffiliated, long-term care facility containing skilled and intermediate-level beds. The residents are predominately women (77%) with a mean age of 88 years. We reviewed retrospectively the long-term care and hospital records of all patients (n ⫽ 13) from the long-term care facility who received ECT between July 1996 and January 2000. One geriatric psychiatrist (M.Z.) practiced full time in the facility during the study period and made all referrals for ECT. All patients were hospitalized on a geropsychiatry unit for their index ECT treatment course. Demographic information, DSM-IV psychiatric diagnosis, number of psychotropic medications/drug trials, and Mini Mental State Exam (MMSE) scores before and after ECT were all obtained from the LTC facility records. The Cumulative Illness Rating Score for Geriatrics (CIRS-G) was also calculated using information from the LTC facility records. The CIRS-G is a measure of severity of medical illness and rates 14 separate organ systems on a 5-point scale (0 ⫽ no problem to 4 ⫽ extremely severe).21 Information about the ECT treatment course was obtained by direct review of the hospital records and by face-to-face discussion with the treating psychiatrist. Chart review included a thorough reading of all physician and nursing notes from the hospitalization looking specifically for complications of ECT such as cognitive and cardiac changes. Number and type (unilateral vs. bilateral) of treatments and complications were recorded. All psychotropic medications were tapered to ORIGINAL STUDIES
the extent possible before ECT was started. Treatment was performed according to the clinical judgment of the hospital psychiatrist. The outcome of the ECT course was rated by the geriatric psychiatrist at the time of readmission to the LTC facility using the Clinical Global Impression of Change Scale (CGIC), a 7-point scale ranging from very much improved (1) through very much worse (7). The use of continuation ECT was also recorded. We performed Pearson product moment correlations to assess relationships between ECT treatment outcome and demographic and clinical variables. RESULTS Of the 13 patients who received ECT, nine (69%) were women and four (31%) were men; mean age was 81 years (range 65–95). All received ECT for major depression, and 10 had associated psychotic features. Four of the patients had long-standing bipolar disorder, but all were diagnosed as depressed at the time of ECT. All patients had received treatment with at least two psychotropic agents before ECT (range 2–11; mean 5.1). These medications included antidepressants, antipsychotics, and mood stabilizers alone and in combination. All but one patient had at least one adequate antidepressant treatment trial, based on treatment duration, oral dose, and compliance, in accordance with the Antidepressant Treatment History form.22 Patients had significant medical comorbidity, with a mean CIRS-G score of 19.7 (range 14 –27). Patients received, on average, 5.7 ECT treatments in the hospital (range 3–10). Nine of 13 patients received some treatments using bilateral stimulation. Outcome Nine (69%) patients were rated as improved after the hospital treatment course, two (15%) were clinically unchanged and two (15%) were rated as worse. Of the nine who improved, five were rated as very much improved, two much improved, and two minimally improved. Of the two who became worse, one was rated as minimally worse and one as much worse. ECT treatment was continued in eight of 13 patients. The two patients who became worse did not respond to subsequent ECT treatments. Higher baseline MMSE score correlated with positive ECT treatment outcome (r ⫽ [minus]0.63, P ⫽ 0.045). Only one of the four patients whose initial MMSE was less than 20 responded to ECT, whereas eight of nine with a pretreatment MMSE of more than 20 had a positive response. There was no relationship between age, sex, number of prior pharmacologic treatments, severity of medical illness, and number and type of ECT treatments with ECT treatment outcome. Complications of Treatment There was no mortality during the treatment course or in the first 90 days after treatment. One patient had transient atrial fibrillation after several treatments, eventually leading to the family’s decision to halt ECT. One patient had urosepsis and a DVT during the psychiatric hospitalization and Zisselman et al. 23
was transferred to a medical floor. One patient was treated for post-ECT headache. Mental Status Changes Mini-Mental State Exam scores before ECT treatment ranged from 8 to 30. Although delirium was diagnosed formally in only one patient, transient confusion and decline in MMSE scores were seen in five patients. All had full cognitive recovery; by 1 month after ECT, no patient had a persistent decline in MMSE. DISCUSSION This study is consistent with other research supporting the safety and efficacy of ECT in older adults while extending the results to a population of medically complex, long-term care residents with major depression. In addition to their severe psychiatric problems, our patients were medically complex, with a median CIRS-G greater than 19. A recent series of older community dwellers had a median CIRS-G of 14, whereas all of our patients had scores of 14 or higher.9 Our population had a 69% positive response to a course of ECT despite earlier failures of adequate drug trials in all but one case. Patients who have failed drug therapy are considered to be more likely to be resistant to ECT, so our patients constitute a group who might be expected to be difficult to treat successfully. A recent multi-site study documented ECT response rates of 63% immediately post treatment and 48% 1 week after treatment cessation in a group of mixed-age, medication-resistant patients.22 Despite their advanced age, medical complexity, and general frailty, our patients tolerated ECT without permanent sequelae. There was no mortality during or within 3 months of the ECT treatment course. Only one patient had a significant cardiac arrhythmia after ECT, and it was transient and did not affect treatment response although it did lead to family refusal to allow further ECT. One patient had postECT headache which has been noted to be a side effect in other studies.23 The most significant complication was change in mental status. In one case, delirium was formally diagnosed-term recovery was noted. This is not surprising because many of the risk factors for delirium are common in our population (such as advanced age, cognitive and functional impairment).24 Our results suggest that mental status changes will be common in this population, but with appropriate reduction of ECT treatment frequency they will resolve. Increased attention has recently focused on the use of high dosage right unilateral ECT to achieve equivalent treatment benefit and less cognitive side effects compared with bilateral electrode placement.25 Careful monitoring for delirium during the course of ECT is clearly essential to prevent more protracted posttreatment confusion. This is a preliminary study that is retrospective in nature. All patients described were deemed by a geriatric psychiatrist to be appropriate ECT candidates. Likewise, the geriatric psychiatrist who performed the post-ECT assessment was not blinded to the treatment. This possible selection bias and rater bias limit the scope of our conclusions and the general24 Zisselman et al.
izability of our findings. We examined only the short-term effectiveness of ECT and did not assess the effectiveness of continuation ECT. Continuation ECT has been shown to be a cost-effective intervention in other depressed populations.26,27 Likewise, our patient sample included only patients with major depression. We did not examine responses to other potential indications for ECT, such as dementia with severe agitation. Our finding that moderate to severe cognitive impairment – as evidenced by MMSE ⬍ 20 – seemed to reduce the likelihood of response to ECT is based on only a few patients and, thus, requires replication. Depression is common in dementia and is thought to be a reversible cause of added disability. Other studies and reports have shown improvement in depression in patients with comorbid dementia treated with ECT.28 –30 This small study supports the use of ECT in appropriately selected, long-term care residents, especially those whose MMSE is greater than 20, even if they have failed medication trials. It can be done safely with careful monitoring for delirium. The adverse effects of depression on this population mandate effective programs within long-term care facilities to identify and treat depressed patients. ECT is a useful modality, even in long-term care residents, and should be considered an appropriate component of the treatment armamentarium. ACKNOWLEDGMENTS The authors thank Arlene Smuckler for editorial assistance. REFERENCES 1. American Psychiatric Association. The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging. Washington, DC: APA Press, 1990. 2. American Psychiatric Association. The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging, 2nd Ed. Washington, DC: APA Press, 2000. 3. Fink M, Abrams R, Bailine S, et al. Ambulatory electroconvulsive therapy: Report of a task force of the Association for Convulsive Therapy. Convulsive Ther 1996;12:42–55. 4. Kelly KG, Zisselman M. Update on ECT in older adults. J Am Geriatr Soc 2000;48: 560 –566. 5. Greenberg RM. ECT in the elderly. In: Schneider, L, ed. Developments in Geriatric Psychiatry. San Francisco, CA: Jossey-Bass, 1997. 6. Tomac TA, Rummans TA, Pileggi TS, et al. Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psychiatry 1997;5:126 –130. 7. Folkerts HW, Tolle R, Schonaver K, et al. Electroconvulsive therapy vs. paroxetine in treatment-resistant depression–A randomized study. Acta Psychiatr Scand 1997;96:334 –342. 8. Wesson ML, Wilkinson AM, Anderson DN, et al. Does age predict the long-term outcome of depression treated with ECT? A prospective study of the long-term outcome of ECT-treated depression with respect to age. Int J Geriatr Psychiatry 1997;12:45–51. 9. Tew JT, Mulsant BH, Haskett RF, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry 1999;156: 1865–1870. 10. Olfson M, Marcus S, Sackheim HA, et al. Use of ECT for the inpatient treatment of recurrent major depression. Am J Psychiatry 1998;155:22–29. 11. Moellentine C, Rummans T, Ahlskog JE, et al. Effectiveness of ECT in patients with Parkinsonism. J Neuropsychiatry Clin Neurosci 1998;10: 198 –193. 12. Pridmore S, Polland C. Electroconvulsive therapy in Parkinson’s disease: 30 month follow-up. J Neurol Neurosurg Psychiatry 1996;61: 693–700. JAMDA – January/February 2001
13. Hotten WM, Melin G, Richardson JW. Response of the Parkinsonian symptoms of multiple system atrophy to ECT. Am J Psychiatry 1998; 155:1628. 14. Zwil AS, Pelchat RJ. ECT in the treatment of patients with neurological and somatic disease. Int J Psychiatry Med 1994;24:1–29. 15. Holmberg SK, Tariot PN, Challapalli R. Efficacy of ECT for agitation in dementia. Am J Geriatr Psychiatry 1996;4:330 –334. 16. Caryle W, Killick L, Ancill R. ECT. An effective treatment in the screaming demented patient. J Am Geriatr Soc 1991;39:181–190. 17. Simpson S, Baldwin RC, Jackson A, et al. Is subcortical disease associated with a poor response to antidepressants? Neurological, neuropsychological and neuroradiological findings in late-life depression. Psychol Med 1998;28:1015–1026. 18. Coffey CE. Brain morphology in primary mood disorders: Implications for electroconvulsive therapy. Psychiatr Ann 1996;26:713–716. 19. Tomac TA, Rummans TA, Pileggi TS, et al. Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psychiatry 1997;5:126 –130. 20. Rice EH, Sombrotto LB, Markowitz JC, et al. Cardiovascular morbidity in high-risk patients during ECT. Am J Psychiatry 1994;151:1637–1641. 21. Parmelee PA, Thuras PD, Katz IR, et al. Validation of the Cumulative Illness Rating Scale in a geriatric residential population. J Am Geriatr Soc 1995;43:130 –137.
ORIGINAL STUDIES
22. Prudic J, Haskett RF, Mulsant B, et al. Resistance to antidepressant medications and short-term clinical response to ECT. Am J Psychiatry 1996;153:985–992. 23. Weiner SJ, Ward TN, Ravaris CL. Headache and electroconvulsive therapy. Headache 1994;155–159. 24. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. JAMA 1996;275:852– 857. 25. Sackeim HA, Prudic J, Devanand DP, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000; 57:425– 434. 26. Dubin WR, Jaffe R, Roemer R, et al. The efficacy and safety of maintenance ECT in geriatric patients. J Am Geriatr Soc 1992;40:706 –709. 27. Swartz T, Lowenstein J, Isenberg KE. Maintenance ECT: Indications and outcome. Convulsive Ther 1995;11:14 –23. 28. Nelson JP, Rosenberg DR. ECT treatment of demented elderly patients with major depression: A retrospective study of efficacy and safety. Convulsive Ther 1991;7:157–165. 29. Frances A, Weiner RD, Coffey CE. ECT for an elderly man with psychotic depression and concurrent dementia. Hosp Commun Psychiatry 1989;40:237–239. 30. Greenwald BS, Kramer-Ginsberg E, Marin DB, et al. Dementia with coexistent major depression. Am J Psychiatry 1989;146:1472–1478.
Zisselman et al. 25
There is increasing recognition that electroconvulsive therapy (ECT) can be performed safely and effectively in older adults. Research findings support treatment efficacy for depression, mania, psychotic schizophrenic exacerbations, and certain additional neuropsychiatric conditions such as neuroleptic malignant syndrome and alcoholic delirium.1– 4 In older persons, electroconvulsive therapy is utilized most commonly to treat major depression, especially when the patient has not been responsive to multiple trials of medications or when depression is accompanied by life-threatening complications such as severe weight loss or catatonia. The effectiveness does not diminish with age, and case reports attest to the safe use of ECT in patients as old as 102.1,4 – 6 Three recent prospective studies showed a trend toward greater improvement in the old-old compared with young-old Temple University Department of Psychiatry and Temple Continuing Care Center (M.H.Z. and T. C-S.) and Temple University Department of Medicine andTemple Continuing Care Center (K.G.K., D.P., and S.J.D.) Address correspondence to: Marc H. Zisselman, MD, Temple Continuing Care Center, 530l Old York Rd., Philadelphia, PA 19141.
Copyright ©2001 American Medical Directors Association 22 Zisselman et al.
psychotropic agents before receiving ECT (range: 2-11). Patients also had significant medical comorbidity, with a mean (CIRS-G) of 19.7 (range: 14-27). On average, patients received 5.7 ECT treatments in the hospital (range: 3-10), and 9 of 13 patients received bilateral stimuli. Nine patients (69%) were rated as improved, two (15%) were clinically unchanged, and two (15%) were rated as worse. Complications included transient atrial fibrillation in one patient, posttreatment headache in one patient, and delirium in one patient. Five patients had transient cognitive decline as measured by the MMSE, but all recovered fully by 1 month. Conclusions: ECT was a safe and effective treatment modality in this population of LTC residents with a significant medical comorbidity. 69% of patients exhibited clinical improvement despite previous medication resistance. Careful monitoring for delirium in this population is essential to prevent more protracted posttreatment confusion. (J Am Med Dir Assoc 2001; 2: 22–25) Keywords: ECT; long-term care
persons treated with ECT.7–9 Although major depression is not more common in older persons, ECT is used 6.7 times more frequently in patients older than age 65 compared with individuals aged 18 to 34 in inpatient settings.10 This may be caused by the increased prevalence of delusional depression, more severe medical comorbidity, and poor tolerance of psychotropic medications that may limit pharmacologic options in this population. The APA Task Force Report clearly states that ECT should not be considered a “last resort” intervention but rather a first line treatment when a rapid definitive response is needed, based on severe acute psychiatric and/or medical morbidity. Past response to ECT, particularly in the context of drug refractoriness or intolerance and patient preference, may also call for its primary use.1 To our knowledge, there have been no studies on the use of ECT for individuals residing in long-term care facilities. It is unclear whether the cognitive, physical, and functional status of long-term care residents would lend themselves to different outcomes with ECT treatment. It is known, however, that ECT can be utilized effectively in several conditions that are common among long-term care residents. For example, ECT can be administered to patients with Parkinson’s disease asJAMDA – January/February 2001
sociated with depressed mood.11,12 ECT can also effectively treat both depressive and psychotic symptoms in Parkinson patients, often inducing a concurrent improvement in the motor symptoms of the disease.13 Additionally, depression is common in individuals with Alzheimer’s disease and often represents a treatable source of excess disability. Studies reveal that demented patients treated with ECT achieve comparable reductions in their depressive symptoms compared with their nondemented counterparts.14 There is a growing body of case reports describing successful ECT treatment for individuals with more advanced dementia and severe agitation that has been refractory to other treatment modalities.15,16 ECT may also be a particularly valuable treatment for patients with cerebrovascular disease other than discrete stroke. Patients with subcortical hyperintensities on MRI – particularly in the deep white matter, basal ganglia, and pontine reticular formation – seem to demonstrate increased resistance to antidepressant pharmacotherapy. Studies suggest bilateral ECT maybe the most effective treatment for these individuals.17,18 Several studies have also found ECT treatment can be performed safely, without mortality or sustained morbidity, in older persons with advanced cardiovascular disease.19,20 This retrospective case series sought to examine ECT response and complications in long-term care residents. We also sought to make some preliminary observations regarding demographic or clinical factors that may influence ECT treatment outcome. METHODS Temple Continuing Care Center is a 538-bed, universityaffiliated, long-term care facility containing skilled and intermediate-level beds. The residents are predominately women (77%) with a mean age of 88 years. We reviewed retrospectively the long-term care and hospital records of all patients (n ⫽ 13) from the long-term care facility who received ECT between July 1996 and January 2000. One geriatric psychiatrist (M.Z.) practiced full time in the facility during the study period and made all referrals for ECT. All patients were hospitalized on a geropsychiatry unit for their index ECT treatment course. Demographic information, DSM-IV psychiatric diagnosis, number of psychotropic medications/drug trials, and Mini Mental State Exam (MMSE) scores before and after ECT were all obtained from the LTC facility records. The Cumulative Illness Rating Score for Geriatrics (CIRS-G) was also calculated using information from the LTC facility records. The CIRS-G is a measure of severity of medical illness and rates 14 separate organ systems on a 5-point scale (0 ⫽ no problem to 4 ⫽ extremely severe).21 Information about the ECT treatment course was obtained by direct review of the hospital records and by face-to-face discussion with the treating psychiatrist. Chart review included a thorough reading of all physician and nursing notes from the hospitalization looking specifically for complications of ECT such as cognitive and cardiac changes. Number and type (unilateral vs. bilateral) of treatments and complications were recorded. All psychotropic medications were tapered to ORIGINAL STUDIES
the extent possible before ECT was started. Treatment was performed according to the clinical judgment of the hospital psychiatrist. The outcome of the ECT course was rated by the geriatric psychiatrist at the time of readmission to the LTC facility using the Clinical Global Impression of Change Scale (CGIC), a 7-point scale ranging from very much improved (1) through very much worse (7). The use of continuation ECT was also recorded. We performed Pearson product moment correlations to assess relationships between ECT treatment outcome and demographic and clinical variables. RESULTS Of the 13 patients who received ECT, nine (69%) were women and four (31%) were men; mean age was 81 years (range 65–95). All received ECT for major depression, and 10 had associated psychotic features. Four of the patients had long-standing bipolar disorder, but all were diagnosed as depressed at the time of ECT. All patients had received treatment with at least two psychotropic agents before ECT (range 2–11; mean 5.1). These medications included antidepressants, antipsychotics, and mood stabilizers alone and in combination. All but one patient had at least one adequate antidepressant treatment trial, based on treatment duration, oral dose, and compliance, in accordance with the Antidepressant Treatment History form.22 Patients had significant medical comorbidity, with a mean CIRS-G score of 19.7 (range 14 –27). Patients received, on average, 5.7 ECT treatments in the hospital (range 3–10). Nine of 13 patients received some treatments using bilateral stimulation. Outcome Nine (69%) patients were rated as improved after the hospital treatment course, two (15%) were clinically unchanged and two (15%) were rated as worse. Of the nine who improved, five were rated as very much improved, two much improved, and two minimally improved. Of the two who became worse, one was rated as minimally worse and one as much worse. ECT treatment was continued in eight of 13 patients. The two patients who became worse did not respond to subsequent ECT treatments. Higher baseline MMSE score correlated with positive ECT treatment outcome (r ⫽ [minus]0.63, P ⫽ 0.045). Only one of the four patients whose initial MMSE was less than 20 responded to ECT, whereas eight of nine with a pretreatment MMSE of more than 20 had a positive response. There was no relationship between age, sex, number of prior pharmacologic treatments, severity of medical illness, and number and type of ECT treatments with ECT treatment outcome. Complications of Treatment There was no mortality during the treatment course or in the first 90 days after treatment. One patient had transient atrial fibrillation after several treatments, eventually leading to the family’s decision to halt ECT. One patient had urosepsis and a DVT during the psychiatric hospitalization and Zisselman et al. 23
was transferred to a medical floor. One patient was treated for post-ECT headache. Mental Status Changes Mini-Mental State Exam scores before ECT treatment ranged from 8 to 30. Although delirium was diagnosed formally in only one patient, transient confusion and decline in MMSE scores were seen in five patients. All had full cognitive recovery; by 1 month after ECT, no patient had a persistent decline in MMSE. DISCUSSION This study is consistent with other research supporting the safety and efficacy of ECT in older adults while extending the results to a population of medically complex, long-term care residents with major depression. In addition to their severe psychiatric problems, our patients were medically complex, with a median CIRS-G greater than 19. A recent series of older community dwellers had a median CIRS-G of 14, whereas all of our patients had scores of 14 or higher.9 Our population had a 69% positive response to a course of ECT despite earlier failures of adequate drug trials in all but one case. Patients who have failed drug therapy are considered to be more likely to be resistant to ECT, so our patients constitute a group who might be expected to be difficult to treat successfully. A recent multi-site study documented ECT response rates of 63% immediately post treatment and 48% 1 week after treatment cessation in a group of mixed-age, medication-resistant patients.22 Despite their advanced age, medical complexity, and general frailty, our patients tolerated ECT without permanent sequelae. There was no mortality during or within 3 months of the ECT treatment course. Only one patient had a significant cardiac arrhythmia after ECT, and it was transient and did not affect treatment response although it did lead to family refusal to allow further ECT. One patient had postECT headache which has been noted to be a side effect in other studies.23 The most significant complication was change in mental status. In one case, delirium was formally diagnosed-term recovery was noted. This is not surprising because many of the risk factors for delirium are common in our population (such as advanced age, cognitive and functional impairment).24 Our results suggest that mental status changes will be common in this population, but with appropriate reduction of ECT treatment frequency they will resolve. Increased attention has recently focused on the use of high dosage right unilateral ECT to achieve equivalent treatment benefit and less cognitive side effects compared with bilateral electrode placement.25 Careful monitoring for delirium during the course of ECT is clearly essential to prevent more protracted posttreatment confusion. This is a preliminary study that is retrospective in nature. All patients described were deemed by a geriatric psychiatrist to be appropriate ECT candidates. Likewise, the geriatric psychiatrist who performed the post-ECT assessment was not blinded to the treatment. This possible selection bias and rater bias limit the scope of our conclusions and the general24 Zisselman et al.
izability of our findings. We examined only the short-term effectiveness of ECT and did not assess the effectiveness of continuation ECT. Continuation ECT has been shown to be a cost-effective intervention in other depressed populations.26,27 Likewise, our patient sample included only patients with major depression. We did not examine responses to other potential indications for ECT, such as dementia with severe agitation. Our finding that moderate to severe cognitive impairment – as evidenced by MMSE ⬍ 20 – seemed to reduce the likelihood of response to ECT is based on only a few patients and, thus, requires replication. Depression is common in dementia and is thought to be a reversible cause of added disability. Other studies and reports have shown improvement in depression in patients with comorbid dementia treated with ECT.28 –30 This small study supports the use of ECT in appropriately selected, long-term care residents, especially those whose MMSE is greater than 20, even if they have failed medication trials. It can be done safely with careful monitoring for delirium. The adverse effects of depression on this population mandate effective programs within long-term care facilities to identify and treat depressed patients. ECT is a useful modality, even in long-term care residents, and should be considered an appropriate component of the treatment armamentarium. ACKNOWLEDGMENTS The authors thank Arlene Smuckler for editorial assistance. REFERENCES 1. American Psychiatric Association. The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging. Washington, DC: APA Press, 1990. 2. American Psychiatric Association. The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging, 2nd Ed. Washington, DC: APA Press, 2000. 3. Fink M, Abrams R, Bailine S, et al. Ambulatory electroconvulsive therapy: Report of a task force of the Association for Convulsive Therapy. Convulsive Ther 1996;12:42–55. 4. Kelly KG, Zisselman M. Update on ECT in older adults. J Am Geriatr Soc 2000;48: 560 –566. 5. Greenberg RM. ECT in the elderly. In: Schneider, L, ed. Developments in Geriatric Psychiatry. San Francisco, CA: Jossey-Bass, 1997. 6. Tomac TA, Rummans TA, Pileggi TS, et al. Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psychiatry 1997;5:126 –130. 7. Folkerts HW, Tolle R, Schonaver K, et al. Electroconvulsive therapy vs. paroxetine in treatment-resistant depression–A randomized study. Acta Psychiatr Scand 1997;96:334 –342. 8. Wesson ML, Wilkinson AM, Anderson DN, et al. Does age predict the long-term outcome of depression treated with ECT? A prospective study of the long-term outcome of ECT-treated depression with respect to age. Int J Geriatr Psychiatry 1997;12:45–51. 9. Tew JT, Mulsant BH, Haskett RF, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry 1999;156: 1865–1870. 10. Olfson M, Marcus S, Sackheim HA, et al. Use of ECT for the inpatient treatment of recurrent major depression. Am J Psychiatry 1998;155:22–29. 11. Moellentine C, Rummans T, Ahlskog JE, et al. Effectiveness of ECT in patients with Parkinsonism. J Neuropsychiatry Clin Neurosci 1998;10: 198 –193. 12. Pridmore S, Polland C. Electroconvulsive therapy in Parkinson’s disease: 30 month follow-up. J Neurol Neurosurg Psychiatry 1996;61: 693–700. JAMDA – January/February 2001
13. Hotten WM, Melin G, Richardson JW. Response of the Parkinsonian symptoms of multiple system atrophy to ECT. Am J Psychiatry 1998; 155:1628. 14. Zwil AS, Pelchat RJ. ECT in the treatment of patients with neurological and somatic disease. Int J Psychiatry Med 1994;24:1–29. 15. Holmberg SK, Tariot PN, Challapalli R. Efficacy of ECT for agitation in dementia. Am J Geriatr Psychiatry 1996;4:330 –334. 16. Caryle W, Killick L, Ancill R. ECT. An effective treatment in the screaming demented patient. J Am Geriatr Soc 1991;39:181–190. 17. Simpson S, Baldwin RC, Jackson A, et al. Is subcortical disease associated with a poor response to antidepressants? Neurological, neuropsychological and neuroradiological findings in late-life depression. Psychol Med 1998;28:1015–1026. 18. Coffey CE. Brain morphology in primary mood disorders: Implications for electroconvulsive therapy. Psychiatr Ann 1996;26:713–716. 19. Tomac TA, Rummans TA, Pileggi TS, et al. Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psychiatry 1997;5:126 –130. 20. Rice EH, Sombrotto LB, Markowitz JC, et al. Cardiovascular morbidity in high-risk patients during ECT. Am J Psychiatry 1994;151:1637–1641. 21. Parmelee PA, Thuras PD, Katz IR, et al. Validation of the Cumulative Illness Rating Scale in a geriatric residential population. J Am Geriatr Soc 1995;43:130 –137.
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22. Prudic J, Haskett RF, Mulsant B, et al. Resistance to antidepressant medications and short-term clinical response to ECT. Am J Psychiatry 1996;153:985–992. 23. Weiner SJ, Ward TN, Ravaris CL. Headache and electroconvulsive therapy. Headache 1994;155–159. 24. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. JAMA 1996;275:852– 857. 25. Sackeim HA, Prudic J, Devanand DP, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000; 57:425– 434. 26. Dubin WR, Jaffe R, Roemer R, et al. The efficacy and safety of maintenance ECT in geriatric patients. J Am Geriatr Soc 1992;40:706 –709. 27. Swartz T, Lowenstein J, Isenberg KE. Maintenance ECT: Indications and outcome. Convulsive Ther 1995;11:14 –23. 28. Nelson JP, Rosenberg DR. ECT treatment of demented elderly patients with major depression: A retrospective study of efficacy and safety. Convulsive Ther 1991;7:157–165. 29. Frances A, Weiner RD, Coffey CE. ECT for an elderly man with psychotic depression and concurrent dementia. Hosp Commun Psychiatry 1989;40:237–239. 30. Greenwald BS, Kramer-Ginsberg E, Marin DB, et al. Dementia with coexistent major depression. Am J Psychiatry 1989;146:1472–1478.
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