Cases That Test Your Skills

A 95-year-old man with treatment-resistant depression

Current Psychiatry. 2018 January;17(1):49-53

References

1. Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry (London). 2014;4(1):33-54.
2. Dombrovski AY, Mulsant BH. The evidence for electroconvulsive therapy (ECT) in the treatment of severe late-life depression. ECT: the preferred treatment for severe depression in late life. Int Psychogeriatr. 2007;19(1):10-14,27-35; discussion 24-26.
3. Olfson M, Marcus S, Sackeim HA, et al. Use of ECT for the inpatient treatment of recurrent major depression. Am J Psychiatry. 1998;155(1):22-29.
4. Salzman C, Wong E, Wright BC. Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review. Biol Psychiatry. 2002;52(3):265-284.
5. Kellner CH, Husain MM, Knapp RG, et al; CORE/PRIDE Work Group. A novel strategy for continuation ect in geriatric depression: phase 2 of the PRIDE study. Am J Psychiatry. 2016;173(11):1110-1118.
6. Tew JD Jr, 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(12):1865-1870.
7. Dombrovski AY, Mulsant BH, Haskett RF, et al. Predictors of remission after electroconvulsive therapy in unipolar major depression. J Clin Psychiatry. 2005;66(8):1043-1049.
8. Charles K. UpToDate. Unipolar major depression in adults: indications for efficacy of electroconvulsive therapy (ECT). https://www.uptodate.com/contents/unipolar-major-depression-in-adults-indications-for-and-efficacy-of-electroconvulsive-therapy-ect. Updated May 16, 2017. Accessed November 26, 2017.
9. 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(5):425-434.
10. UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet. 2003;361(9360):799-808.
11. Lisanby SH. Electroconvulsive therapy for depression. N Engl J Med. 2007;357(19):1939-1945.
12. Stoppe A, Louzã M, Rosa M, et al. Fixed high dose electroconvulsive therapy in elderly with depression: a double-blind, randomized comparison of efficacy and tolerability between unilateral and bilateral electrode placement. J ECT. 2006;22(2):92-99.
13. Geduldig ET, Kellner CH. Electroconvulsive therapy in the elderly: new findings in geriatric depression. Curr Psychiatry Rep. 2016;18(4):40.
14. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry. 2000;157(suppl 4):1-45.
15. Rhebergen D, Huisman A, Bouckaert F, et al. Older age is associated with rapid remission of depression after electroconvulsive therapy: a latent class growth analysis. Am J Geriatr Psychiatry. 2015;23(3):274-282.
16. Philibert RA, Richards L, Lynch CF, et al. Effect of ECT on mortality and clinical outcome in geriatric unipolar depression. J Clin Psychiatry. 1995;56(9):390-394.
17. 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(2):126-130.
18. Verwijk E, Comijs HC, Kok RM, et al. Short and long-term neurocognitive functioning after electroconvulsive therapy in depressed elderly: a prospective naturalistic study. Int Psychogeriatr. 2014;26(2):315-324.
19. Flint AJ, Gagnon N. Effective use of electroconvulsive therapy in late life depression. Can J Psychiatry. 2002;47(8):734-741.
20. Bjolseth TM, Engedal K, Benth JS, et al. Speed of recovery from disorientation may predict the treatment outcome of electroconvulsive therapy (ECT) in elderly patients with major depression. J Affect Disord. 2016;190:178-186.
21. Sackeim HA, Prudic J, Nobler MS, et al. Ultra-brief pulse ECT and the affective and cognitive consequences of ECT. J ECT. 2001;17(1):77.
22. Bjolseth TM, Engedal K, Benth JS, et al. Baseline cognitive function does not predict the treatment outcome of electroconvulsive therapy (ECT) in late-life depression. J Affect Disord. 2015;185:67-75.
23. de Carle AJ, Kohn R. Electroconvulsive therapy and falls in the elderly. J ECT. 2000;16(3):252-257.
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Neurocognitive effects

Reports on the effects of ECT on neurocognitive functioning have varied. In some studies, performance improved or did not change in severely depressed older patients who received ECT.^18,19 In older people who receive ECT, MMSE scores often return to baseline by the end of treatment.²⁰ There often is only mild transient cognitive impairment in patients with late-life depression who receive ECT. Areas of concern include attention span, orientation, and speed of mental processing.²⁰ Physicians should conduct cognitive tests before, during, and after ECT sessions to monitor their patient’s mental status.²⁰

Cognitive stability can be maintained by administering ECT twice a week; applying right-sided, unilateral electrode placement; and using short, ultra-brief stimulus pulse width parameters.²¹ Cognitive impairment induced by ECT is not associated with age in geriatric patients with depression.²² Older adults who experienced longer postictal reorientation time periods have better outcomes than others who reach orientation faster; their intellectual impairment returned to baseline.²⁰ Falling is another complication associated with ECT. A longitudinal cohort study found the incident of falls among patients receiving ECT was 13%.²² Risk factors for falls during a course of ECT include the number of treatments and the presence of coexisting Parkinson’s disease.²³

OUTCOME Improvement

Mr. R receives 8 sessions of right-sided, unilateral ECT with an individualized dosage titration method. Treatments are completed with a stimulus intensity at 6 times seizure threshold, with an ultra-brief pulse width at 0.3 milliseconds. Mr. R’s mood and affect begin to improve after 3 ECT sessions. His MMSE score increases to 28/30 (Figure). His clinical improvement is progressively sustained; he develops an increasingly jovial attitude and experiences less anxiety. Mr. R’s confidence, appetite, and sleep also improve. There are no complications with treatment, and Mr. R has no complaints. After 8 ECT sessions, Mr. R has no affective symptoms and does not experience any cognitive impairment.

The authors’ observations

Depression among older people is a growing public health concern. It is a leading cause of disability, and often leads to nursing home placement.²⁴ ECT is a safe, effective treatment for late-life depression, but is underutilized in patients age >75 because of concerns for cognitive impairment.⁶ However, there is evidence that response rates to ECT are higher in patients ages 45 to 85, compared with young individuals ages 18 to 45.²⁵ ECT is a viable intervention for older depressed patients, particularly for those who do not tolerate or fail to respond to pharmacotherapy. Many of these patients are at risk for drug-induced toxicities or interactions or suicide.¹

Bottom Line

Electroconvulsive therapy (ECT) is a safe, effective treatment for depression. Although there are only a few case reports of patients in their 90s who have received ECT, evidence supports ECT as an appropriate intervention for geriatric patients with depression.

Related Resources

Salzman C, Wong E, Wright BC. Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review. 2002;52(3):265-284.
Blumberger DM, Hsu JH, Daskalakis ZJ. A review of brain stimulation treatments for late-life depression. 2015;2(4):413-421.

Drug Brand Names

Buspirone • Buspar
Escitalopram • Lexapro
Mirtazapine • Remeron
Quetiapine • Seroquel
Risperidone • Risperdal