|Year : 2017 | Volume
| Issue : 2 | Page : 127-130
Electroconvulsive therapy in the elderly and nonelderly: 10 years' retrospective comparison
Ravishankar Vinutha, Venkata Lakshmi Narasimha, Nathan Deepa, Channaveerachari Naveen Kumar, Thirthalli Jagadisha, Sivakumar Thangaraju, Srikala Bharath, Mathew Varghese
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
|Date of Web Publication||29-Dec-2017|
Venkata Lakshmi Narasimha
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bengaluru - 560 029, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Although electroconvulsive therapy (ECT) is a well-established treatment modality worldwide for elderly with severe psychiatric disorders, literature is sparse in India. Materials and Methods: A retrospective chart review of patients aged 60 years and above (n = 90) who received a course of ECTs between April 2003 and 2013 in National Institute of Mental Health and Neurosciences, Bengaluru, a tertiary care neuropsychiatric institute, was carried out. For each elderly person, the next consecutive nonelderly ECT patient was selected as a control (n = 85). Clinical, demographic, and ECT variables were compared. Results: Depression (n = 57; 63.3%) was the most common diagnosis for ECT among the elderly while schizophrenia (n = 28; 32.9%) was most common among controls (P < 0.01); suicidal ideas were the most common indication (n = 25; 28.4%) among the elderly while aggression was the most common indication among controls (n = 28; 33.3%) (P = 0.004). Elderly received more number of ECTs (mean [standard deviation (SD)] 8.0 [3.0] vs. 6.4 [2.8]; P ≤ 0.01), had higher seizure threshold (mean [SD] 135.3 [76.9] mc vs. 81.3 [54.2] mc; P < 0.01), and experienced lesser duration of motor seizures (mean [SD] 38.48 [9.72] s vs. 48.90 [14.66]; P < 0.01). Immediate post-ECT cognitive deficits were more in the elderly (n = 19; 21.6% vs. n = 7; 8.3%; P = 0.02). Case records showed no between-group differences both at the end of 3-month (P = 0.40) and 6-month (P = 0.50) follow-up for cognitive complaints. Mean (standard deviation) Clinical Global Impression-Improvement scores at the end of ECT course were 2.3 (0.9) versus 2.4 (0.8) (P = 0.5) among elderly and nonelderly, respectively. These scores were comparable at the end of 3 as well as 6 months' follow-up. Conclusions: This retrospective chart review showed ECT to be safe and effective for geriatric patients with severe psychiatric disorders including cognitive adverse effects. However, prospective studies would help to better establish cognitive adverse effects of ECT.
Keywords: Electroconvulsive therapy in elderly, electroconvulsive therapy, India
|How to cite this article:|
Vinutha R, Narasimha VL, Deepa N, Kumar CN, Jagadisha T, Thangaraju S, Bharath S, Varghese M. Electroconvulsive therapy in the elderly and nonelderly: 10 years' retrospective comparison. J Geriatr Ment Health 2017;4:127-30
|How to cite this URL:|
Vinutha R, Narasimha VL, Deepa N, Kumar CN, Jagadisha T, Thangaraju S, Bharath S, Varghese M. Electroconvulsive therapy in the elderly and nonelderly: 10 years' retrospective comparison. J Geriatr Ment Health [serial online] 2017 [cited 2019 Jun 16];4:127-30. Available from: http://www.jgmh.org/text.asp?2017/4/2/127/221901
| Introduction|| |
Electroconvulsive therapy (ECT) has been an established mode of somatic treatments for various psychiatric illnesses, especially mood disorders in the elderly. Multiple studies have supported the safety and efficacy of ECT in elderly even in patients older than 75 years with multiple medical comorbidities and cognitive impairment in developed countries.
Utilization of ECT in developed countries like Australia has been primarily for the diagnosis of depression (75.2%). In contrast, schizophrenia forms the most common diagnostic indication in India and other developing countries. In addition, more number of young people get ECT in the latter.
In India, there have been very few studies on ECT use in the elderly. A retrospective review of elderly who received ECT  showed that majority (96%) had depression. About 68% had not responded to adequate psychotropic treatment before ECT. Comorbid medical illnesses were present in 66% and were associated with cognitive side effects. There were no serious untoward events caused by ECT. About 80% showed some response to treatment. Phirke et al. reported that among 23 elderly patients (aged >60 years) who received ECT, schizophrenia was the most common diagnosis followed by depression; 18 (78.26%) patients showed good response to ECT. Grover et al. have observed that elderly patients with severe mental disorders have poor knowledge, and a significant proportion of them have a negative attitude toward ECT. Hence, it is important that medical professionals should impart proper information about ECT to elderly patients to increase the acceptability of ECT in this age group who more often respond well to ECT.
Studies done outside India, which looked at the safety and efficacy, have revealed that ECT is safe and effective even in patients more than 75 years. Greater cognitive dysfunction has been seen in patients with preexisting cognitive and neurological defects.
The current study brings to light the various clinical and demographic profiles of elderly patients who received ECTs and highlights the differences in ECT variables when compared to those among the younger population.
| Materials and Methods|| |
Setting and referral pattern of patients to electroconvulsive therapy
National Institute of Mental Health and Neurosciences is a tertiary care hospital which caters to the treatment of patients with various psychiatric, neurological, and neurosurgical ailments. All the patients who present with psychiatric complaints are screened and evaluated in detail, and treatment strategies are formulated which are tailor made and need based. Indications for starting a patient on ECT are based on the clinical condition.
Electroconvulsive therapy procedure at National Institute of Mental Health and Neurosciences
The standard practice in the institute is to evaluate all patients posted for ECT with detailed history, mental status and neurological examination, complete blood picture, metabolic workup, and electrocardiogram. Written informed consent is obtained from either the patients or from their relatives or both. Preanesthetic evaluation is obtained for all patients before starting ECT. ECT is administered in a dedicated ECT suite with state of the art facilities. ECTs are generally administered thrice weekly using the NIVIQURE machine (Technonivilac, Bengaluru, Karnataka, India) with or without EEG monitoring. Brief-pulse square-wave stimulation with constant current at 800 mA, 125 bidirectional pulses per se cond with pulse width of 1.5 ms, is used. All ECTs were administered under anesthetic modification (thiopentone 2–4 mg/kg and succinylcholine 0.5–1 mg/kg). For bitemporal ECTs, electrodes are placed on the perpendicular line 3 cm above the midpoint of the line joining the outer canthus of each eye with the ipsilateral external auditory meatus. In bifrontal ECTs, electrodes are placed bilaterally 5 cm above the outer angle of orbit. During the first ECT session, the seizure threshold is determined by titration method. From the second session, onward, patients receive stimuli at 1.5 times their threshold. Seizure duration (motor) is monitored using the cuff method. After the motor seizure ceases, patients are shifted to the recovery room for monitoring of the vitals. Once stable, they are shifted back to the ward.
We reviewed case files of 90 patients (aged 60 years and above) who received a course of ECTs between April 2003 and 2013. This group was compared with a control arm that received ECTs during the same period. For each elderly person, the next consecutive nonelderly (18–60 years) ECT patient was chosen as a control. For the latter, we included only such patients who had complete records (n = 85).
The following details were obtained from the file: sociodemographic details, clinical details including diagnosis, duration of illness, course of the illness, details of psychotropic medications when posted for ECT, comorbid medical illness, ECT-related procedure - number of ECTs, past ECT response, mode of ECT, seizure threshold and average motor seizure duration, number of failed ECTs, immediate adverse effects, and cognitive side effects. Cognitive side effects (scored as present/absent) were noted for the following time points: just before the first ECT, just after the completion of ECT course, at the end of 3 months' follow-up, and at the end of 6 months of follow-up. These were deemed to be present if there was any mention of the same in the file. No specific scale was used. For this paper, if there was no mention of adverse effects in the case file, it was taken as absent. Same time points were taken into consideration for Clinical Global Impression (CGI)-Improvement  scoring as well. However, no interrater reliability exercise was carried out. All the statistical analysis was done using Epi Info™, using t-statistics for the continuous variables and Chi-square for discrete variables.
| Results|| |
Depression (n = 57; 63.3%) was the most common diagnosis among the elderly while schizophrenia (n = 28; 32.9%) was common among younger patients (P = 0.001). Suicidal ideation was the most common symptomatic indication (n = 25; 28.4%) among the elderly while aggression was most common symptomatic indication among the younger patients (n = 28; 33.3%; P= 0.004). About 67% elderly had medical comorbidity such as diabetes, hypertension, hypothyroidism, and ischemic heart disease. The results are represented in [Table 1].
|Table 1: Comparison of demographic and clinical details between elderly and nonelderly|
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[Table 2] shows that as compared with the nonelderly, elderly received more number of ECTs, had higher seizure thresholds, and had lesser duration of motor seizures and more number of failed induction attempts. [Table 2] also shows that immediate post-ECT cognitive side effects were more in the elderly (n = 19/90; 21.6% vs. n = 7/85; 8.3%; P= 0.02). However, this difference had disappeared both at the end of 3 months (P = 0.4) and at 6 months (P = 0.5) of follow-up. [Table 3] illustrates comparative CGI severity and improvements of both groups. [Table 4] illustrates that even when depression alone was considered, elderly echoed similar findings. About 21.4% of depressed elderly had cognitive side effects immediately after ECT while none from the younger (P = 0.04) population.
|Table 4: Comparison of electroconvulsive therapy correlates in patients with depression|
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| Discussion|| |
Commensurate with the Western literature, our retrospective study shows ECT to be both safe and effective for the elderly with severe psychiatric disorders. This was so despite the elderly having significantly higher medical comorbidities. It has been shown that ECT in special populations with coexisting medical conditions is safe if appropriate precautions are taken., Lack of any serious complication despite the presence of comorbid medical illness in 67% of the elderly patients in our study is in keeping with this observation.
Depression (63.3%) was the most common diagnosis among the elderly while schizophrenia (32.9%) was common among nonelderly patients (P = 0.001). This is in keeping with the previous studies the world over.,,,
Elderly in our study received more number of ECTs than younger population (7.9 vs. 6.3) (P < 0.001) which is at variance with the Jain et al.'s study (8.53 vs. 9.77 [P > 0.05]). This could be explained by the differences in diagnostic profile and the symptomatic indication. Majority of the elderly had depressive disorders where the aim generally would be to attain clinical remission and consequently will require more number of ECTs. On the contrary, the nonelderly group had schizophrenia in which the aim is not so much to achieve clinical remission but to target specific symptom domains such as aggression, catatonia, self-harm, and food refusal.
Majority of the sample in our study received bilateral ECT. This is in keeping with the trend of use of bilateral ECTs in the developing countries. This may be a concern for the cognitive side effects noted in the elderly. In fact, more research needs to come with respect to the efficacy and adverse effects of unilateral ECTs, especially in the elderly.
Adverse effects with the use of ECT deserve a special discussion whenever the discussion of safety of ECTs in elderly is focused upon. In our study, though the elderly had significantly more cognitive side effects immediately post-ECT (21.6% vs. 8.3%; P= 0.02), these had settled down by 3 months (P = 0.4). This is consistent with the literature that the cognitive side effects are transient in the elderly., Even in the study by Phirke et al., confusion was noted in just three cases (13.04%). However, in this study too, a comprehensive tool for assessment of cognitive functions was not used. However, it may be noted that this was a retrospective chart review yielding itself to limited conclusions about the cognitive safety in the elderly. Systematic prospective assessments can give us better answers to this issue.
One of the strengths of this study was the employment of a control arm that helped to view the benefits of ECT in a better context. The results of this study (being a retrospective chart review) need to be viewed in the background of all the limitations of such a design.
| Conclusion|| |
Despite the various limitations, this study has shown that ECT in the elderly is a safe and effective treatment for those with severe psychiatric disorders. These results need better validation in future prospective designs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]