|Year : 2015 | Volume
| Issue : 2 | Page : 102-105
Retrospective chart review of elderly patients receiving electroconvulsive therapy in a tertiary general hospital
Mosam Phirke, Harshal Sathe, Nilesh Shah, Sushma Sonavane, Anup Bharati, Avinash DeSousa
Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
|Date of Web Publication||18-Jan-2016|
Carmel, 18, Street, Francis Road, Off S.V. Road, Santacruz West, Mumbai - 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Electroconvulsive therapy (ECT) is the one of the oldest and effective treatments in psychiatry today. It has been used in a wide variety of psychiatric disorders in both young and old patients.
Aims of the study: The present study is a retrospective chart review of geriatric patients receiving ECT as a treatment option in a tertiary care general hospital psychiatry setting.
Methodology: The study evaluated ECT records over a 5-year period between the years 2010 and 2014, and it was observed that 23 elderly patients (aged ≥60 years) had received ECT.
Results: The patients received modified bitemporal ECT using a brief pulse ECT machine and had no major complications. A total of 184 ECT treatments were administered at an average of 8 treatments per case. The major diagnoses of patients were schizophrenia and major depression. The main indications of ECT were intolerance to medication, suicidal behavior and aggression. Out of the 23 elderly patients, 18 (78.26%) showed a good response to ECT. The only complication noted was memory loss and confusion in 3 cases. Patients with medical illnesses like hypertension, diabetes and both together received ECT without any complications.
Conclusions: This study adds to the scarce database on the use of ECT in elderly patients in India and adds evidence to the fact that ECT is a safe and effective treatment in the elderly.
Keywords: Electroconvulsive therapy (ECT), elderly, side effects
|How to cite this article:|
Phirke M, Sathe H, Shah N, Sonavane S, Bharati A, DeSousa A. Retrospective chart review of elderly patients receiving electroconvulsive therapy in a tertiary general hospital. J Geriatr Ment Health 2015;2:102-5
|How to cite this URL:|
Phirke M, Sathe H, Shah N, Sonavane S, Bharati A, DeSousa A. Retrospective chart review of elderly patients receiving electroconvulsive therapy in a tertiary general hospital. J Geriatr Ment Health [serial online] 2015 [cited 2019 Nov 19];2:102-5. Available from: http://www.jgmh.org/text.asp?2015/2/2/102/174277
| Introduction|| |
Electroconvulsive therapy (ECT) has been a safe and effective treatment option used in the management of psychiatric disorders ever since its inception in the late 1930s.  ECT is a preferred mode of treatment in for the patients with geriatric psychiatric disorders as these patient often show low tolerability to medication with greater incidence of side effects, poor response to medication, and multiple drug interactions due to the use of multiple medications when treatment involves both psychiatric and comorbid medical conditions. , Other factors that lead to the use of ECT use the geriatric population includes increased sensitivity to the anticholinergic and orthostatic hypotensive side effects of psychotropic drugs where ECT might pose a relatively lesser risk than medication.  Studies have shown that older patients show a better treatment response to ECT than young patients with psychiatric disorders. , Many elderly patients with psychiatric disorders have concomitant neuropsychiatric conditions such as Parkinsonism More Details and catatonia due to medical causes that may also show a good response to ECT.  Recent studies even point to a role of ECT in reducing behavioral symptoms and aggression in dementia.  A large National Institute of Mental Health (NIMH) survey has revealed that ECT was the treatment of choice in 15.6% elderly patients who were depressed and no major side effects were noted with use of the treatment.  A previous study from India, on the use of ECT in the elderly (N = 56) revealed that amongst elderly who received ECT over a 8-year period in a tertiary general hospital, 96% had depression as a primary diagnosis. Of these 68% had not responded well to medication and 66% had medical comorbidity.  Other than this study, there is a scarcity of data with respect to the use of ECT in elderly patients in India. The present study is a retrospective chart review of the pattern of ECT usage in elderly patients in a tertiary general hospital psychiatric unit.
| Materials and methods|| |
The present study was a retrospective chart review of ECT use in elderly/geriatric patients (aged >60 years), who had received ECT in a tertiary general hospital in an Indian metropolis from 2010 to 2014. An approval from the Institutional Ethics Committee was obtained for the study prior to data collection.
The ECT form where the ECT record of each patient is maintained was reviewed, and data were recorded. No human subjects were interviewed during the course of the study. In the center where the study was carried there is a standard procedure for administration of ECT to elderly patients. A senior psychiatrist decides on the use of ECT in such patients and the indication for ECT use is mentioned in the records. All routine investigations are carried out at baseline and ECT fitness is obtained from the anesthetist prior to the start of the ECT course. ECT is normally administered bitemporally to all patients and in cases where memory loss or confusion may ensue, a right unilateral application or bifrontal approach may be considered. A written informed consent after thorough explanation of the procedure along with all risks and complications is obtained from the legally acceptable relative of the patient. All treatments are administered after hyperoxygenation for at least 1 min with 100% oxygen under mask anesthesia with atropine (0.5-1.0 mg/kg), propofol (1.5-2.0 mg/kg), and succinylcholine (0.7 mg/kg), which are all delivered intravenously. Blood pressure, heart rate, pulse oximetry, and two-lead electrocardiogram (ECG) are monitored. Modified ECT is given using a brief pulse ECT machine (Medicaid Systems, Chandigarh, India). All patients had received ECT using a brief pulse, constant energy machine. Electrical dose is calibrated in joules (range, 36Y135 J). The machine has settings for adjusting the duration of current passed (0.1-5 s with increments of 0.1 s), frequency between 20 Hz and 90 Hz (settings of 20 Hz, 40 Hz, 50 Hz, 60 Hz, 70 Hz, and 90 Hz), and adjusting the pulse width from 0.1 s to 1.5 s (0.1 s, 0.2 s, 0.5 s, 1 s, 1.2 s, and 1.5 s). Electrical dose is varied by changing the duration of current while keeping the frequency and pulse width constant. In elderly subjects, the initial duration of current is kept at 1 s. If the patient does not have an adequate seizure (motor seizure of 15-s duration measured by the cuff method), the duration is increased in increments of 0.1 s until the patient achieves a seizure of adequate duration. Thrice weekly ECT sessions are administered to the patients. ECT seizure duration (motor seizure) is noted for every patient and all details are mentioned for each ECT treatment received. Electroencephalographic monitoring of the ECT seizure is done in high-risk cases. A normal ECT course involves 6-8 ECTs and may extend to 12-14 ECTs till the patient achieves remission.
Data were extracted from the ECT record of the patients and were entered into the case record form. Demographic parameters of all patients were noted along with psychiatric diagnosis, anesthetic agent used, total number of ECTs given, any complications during the ECT course, medical comorbid illnesses if any, details of concomitant psychotropic medication prescribed, and substance use if present. Seizure duration and strength of charge used to induce a seizure were not included in the analysis because data in some of the records were unclear. All patients received bitemporal brief pulse ECT. Since this was a chart review, descriptive statistics and percentages were used to describe the data.
The data were then analyzed and presented.
A total of 23 elderly patients (aged ≥60 years) received ECT during the period 2010-2014. The mean age of the patients was 63.17 (SD 9.68; range: 60-72) years. Twenty-one patients (91.3%) belonged to age group 61-70 years and the rest were between 71 and 75 years age. Majority of the patients were male (N = 14, 60.86%). The most common psychiatric diagnosis was schizophrenia (N = 11), followed by depression (N = 9), and bipolar mood (mania) disorder (N = 2). One patient with obsessive compulsive disorder received ECT. Eight patients had hypertension while six suffered from diabetes mellitus. Four patients of these had both hypertension and diabetes. Nine patients had comorbid tobacco dependence (39.15%).
The patients were on variety of medications ranging from antidepressants to both typical and atypical antipsychotics and mood stabilizers. It was interesting to note that one patient was on lithium (dosage not recorded) and one was on clozapine (100 mg per day).
Indications for ECT were suicidality (N = 12), poor medication response (N = 6), aggression not responding to medication (N = 8), and previous favorable response to ECT (N = 1). Some patients had more than one indication for receiving ECT.
A total of 184 ECT treatments were administered to 23 patients at an average of 8 (SD- 3.6; range 4-12) ECTs per case. Propofol was the anesthetic agent in all cases. The mean seizure duration was 29.33 ± 13.2 s.
Out of the 23 elderly patients, 18 (78.26%) showed a good response to ECT. No standardized rating scales were used to measure the same.
Memory loss and confusion was noted in three patients. In these cases, the ECTs were spaced out and the restarted once the confusion subsided. In one case, the ECT course was stopped due to confusion at the end of four treatments as relatives were unwilling for further treatments. No cardiac events or side effects were observed during any of the treatments. No hypoglycemia was noted in any of the patients. No bone injuries or fractures were noted either. Many patients were suffering from medical comorbidities such as hypertension (N = 8) and diabetes mellitus (N = 6). One of the patients who received ECT suffered from glaucoma and was administered mannitol intravenously before each ECT.
It is also noteworthy to mention that two patients were advised maintenance ECT after the course due to low tolerance to medication. One who suffered from schizophrenia received a total of 47 ECTs till date. He is maintained on just one antipsychotic medication (risperidone), and maintenance ECT was administered fortnightly. One patient with depression had received a total of 70 ECTs in his lifetime and had received 12 ECTs after completing the age of 60 years. The indication of maintenance ECT in the patient with schizophrenia was noncompliance with the medication and relapses due to the same in the past.
| Discussion|| |
With advances in anesthesia and the use of brief pulse, ECT is a safe procedure with low complication rates of 0.08% per ECT and deaths being as low as 1 per 1 lakh ECTs as reported in a huge study.  It is well known from ECT literature that older patients respond better and faster to ECT than to pharmacotherapy, and they also experience fewer complications with the former.  ECT has in fact been regarded as the treatment of choice for geriatric depression in patients who are nonresponsive to medication  and have psychotic features.  ECT when combined with pharmacotherapy has been shown to yield better results than pharmacotherapy alone.  There is a need to consider the role of ECT as a synergistic treatment to pharmacological and nonpharmacological treatments in the management of psychiatric disorders in the elderly. 
Our study adds to the scarce database on ECT use in the elderly from India. Confusion was noted in just three cases (13.04%) while cognitive side effects in previous studies have been reported in 45% cases with medical illnesses and 17% cases without medical illnesses. Aches and pains were not documented in any of our cases while 32% cases have reported the same in a previous study. 
The lack of major complications across 184 ECT treatments in elderly emphasizes the low complication rate of ECT in the elderly.
Being a retrospective chart review, our study was marred by nonuse of a tool that could have rated cognitive outcomes after and during the course of ECT. No rating scales were used in the patients to monitor treatment response and improvement. However, that does not undermine the safety of ECT as a procedure. In India, psychiatrists working in the area of geriatric mental health need to recognize the potential of ECT as a useful treatment modality in treatment algorithms when treating elderly patients with major psychiatric illness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Payne NA, Prudic J. Electroconvulsive therapy Part 1: A perspective on the evolution and current practice of ECT. J Psychiatr Pract 2009;15:346-68.
Payne NA, Prudic J. Electroconvulsive therapy Part 2: A biopsychosocial perspective. J Psychiatr Pract 2009;15:369-90.
Flint AJ, Gagnon N. Effective use of electroconvulsive therapy in late life depression. Can J Psychiatry 2002;47:734-41.
Rapoport MJ, Mamdani M, Herrmann N. Electroconvulsive therapy in older adults: 13-year trends. Can J Psychiatry 2006;51:616-9.
Dombrovski AY, Mulsant BH, Haskett RF, Prudic J, Begley AE, Sackeim HA. Predictors of remission after electroconvulsive therapy in unipolar major depression. J Clin Psychiatry 2005;66:1043-9.
Tomac TA, Rummans TA, Pileggi TS, Li H. Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psychiatry 1997;5:126-30.
Raveendranathan D, Narayanaswamy JC, Reddi SV. Response rate of catatonia to electroconvulsive therapy and its clinical correlates. Eur Arch Psychiatry Clin Neurosci 2012;262:425-30.
Ujkaj M, Davidoff DA, Seiner SJ, Ellison JM, Harper DG, Forester BP. Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia. Am J Geriatr Psychiatry 2012;20:61-72.
Thompson JW, Weiner RD, Myers CP. Use of ECT in the United States in 1975, 1980, and 1986. Am J Psychiatry 1994;151:1657-61.
Jain G, Kumar V, Chakrabarti S, Grover S. The use of electroconvulsive therapy in the elderly: A study from the psychiatric unit of a north Indian teaching hospital. J ECT 2008;24:122-7.
Watts BV, Groft A, Bagian JP, Mills PD. An examination of mortality and other adverse events related to electroconvulsive therapy using a national adverse event report system. J ECT 2011; 27:105-8.
Williams JH, O′Brien JT, Cullum S. Time course of response to electroconvulsive therapy in elderly depressed subjects. Int J Geriatr Psychiatry 1997;12:563-6.
Mcdonald WM, Phillips VL, Figiel GS, Marsteller FA, Simpson CD, Bailey MC. Cost-effective maintenance treatment of resistant geriatric depression. Psychiatr Ann 1998;28:47-52.
Philibert RA, Richards L, Lynch CF, Winokur G. Effect of ECT on mortality and clinical outcome in geriatric unipolar depression. J Clin Psychiatry 1995;56:390-4.
Prudic J, Olfson M, Sackeim HA. Electro-convulsive therapy practices in the community. Psychol Med 2001;31:929-34.
Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatr (London) 2014; 4:33-54.