|Year : 2017 | Volume
| Issue : 2 | Page : 135-139
Chart review of electroconvulsive therapy practice from a tertiary care geriatric mental health set up
Akanksha Sonal, Shrikant Srivastava, SC Tiwari, Prateek Kumar Chaubey
Department of Geriatric Mental Health, King George Medical University, Lucknow, Uttar Pradesh, India
|Date of Web Publication||29-Dec-2017|
Department of Geriatric Mental Health, King George Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Electroconvulsive therapy (ECT) is frequently used treatment procedure, and is utilized more often for severe, treatment-resistant, or refractory psychiatric disorders. However, published data on the use of ECT is limited, more so for special population like older adults. Aim: The aim of the study was to explore the clinical, demographic, and diagnostic profiles of older adults, and the parameters of ECT treatment, in a tertiary care Geriatric Mental Health set up. Materials and Methods: Approval to review the case notes was obtained from the Institutional Ethical Committee. The individuals were aged 60 years and above and had received ECT between January 2014 and May 2017. The relevant details pertaining to the aims of the study were recorded in a spreadsheet. Results: Twenty-five courses (absolute number = 191) of ECT were given to 21 patients (mean age = 67.44 ± 9.8 years) with mean of 7.64 ± 3.6 ECT per patient. Majority of the patients belonged to age group 60–69 years, and were male (81%). Depression was the most common diagnosis for giving ECT (43%) in these individuals, and poor response to pharmacological treatment (81%) was the most common indication. The mean duration of the seizure elicited was 28.8 ± 13.2 s, and a therapeutic response was seen in 86% of cases. No major complications were noted during ECT treatment. Conclusion: When used judiciously and with trained staff, ECT is an effective and relatively safe mode of treatment even in older adults.
Keywords: Electroconvulsive therapy, India, older adults
|How to cite this article:|
Sonal A, Srivastava S, Tiwari S C, Chaubey PK. Chart review of electroconvulsive therapy practice from a tertiary care geriatric mental health set up. J Geriatr Ment Health 2017;4:135-9
|How to cite this URL:|
Sonal A, Srivastava S, Tiwari S C, Chaubey PK. Chart review of electroconvulsive therapy practice from a tertiary care geriatric mental health set up. J Geriatr Ment Health [serial online] 2017 [cited 2019 Aug 22];4:135-9. Available from: http://www.jgmh.org/text.asp?2017/4/2/135/221898
| Introduction|| |
Modification of convulsive therapy induction by von Meduna revolutionized psychiatric physical therapy. While electroconvulsive therapy (ECT) is the most utilized neuromodulation treatment modality for severe and/or treatment-refractory psychiatric disorders such as major depressive disorder and schizophrenia, its use is currently limited in special population groups like older adults, owing to societal pressures rather than medical reasons.
National Institute for Health and Care Excellence (NICE) UK guidelines recommend using ECT in depressive illness, schizophrenia, catatonia, and mania in those aged 18 years or more. ECT is only recommended as Step 4 intervention for severe and complex depression following the failure of multiple medications, high-intensity psychological interventions, combined treatments, and collaborative care. However, in developed countries, estimated 24%–50% of patient receiving ECT are older than 60 years, and majority who have received it are depressed.,,,,,, NICE also discourages the use of maintenance ECT (M-ECT) as the 'longer-term benefits and risks of ECT have not been clearly established' despite the evidence to the contrary.,
A literature search using the terms “India, ECT, elderly” came up with three retrospective studies.
Indian studies showing the prevalence of ECT use in older adult varies from 14.7% in Chanpattana 2005 to 15% in Jain et al. 2008 and near similar response from chart review of ECT practice in elderly by Phirke et al. 2016. Various factors leading to increased use of ECT in elderly are higher risk of self-harm, burden of multiple comorbid physical illnesses, vulnerability to physical and functional complications of mental illness like dehydration and malnutrition, complication and risk associated with pharmacological treatments.,, These indications make quite frequent use of ECT in this special group of population. However, still other than the above mentioned three studies there is no other study from India to document or support a pattern of use of ECT in this target population.
Thus, the present chart review is planned to illustrate the use of ECT, with respect to indications and technical details, in a Geriatric Mental Health Tertiary Centre.
| Materials and Methods|| |
The present study is a retrospective chart review of ECT use in elderly age 60 years, and above, from tertiary care Geriatric Mental Health setup. Institutional Ethics Committee approval was obtained for the data collection from the existing records.
Electro-convulsive therapy machine and administration
Brief-pulse, bilateral, modified ECT was administered to both in- and out-patients. The decision to administer ECT was taken individually for each patient, based on the type and severity of current symptoms, and the previous treatment history. A written informed consent was sought from patients and their main care giver before administering the ECT, and was repeated with every ECT procedure. Such patients had to go through thorough physical assessment and investigations, including but not limited to serum electrolytes, renal and liver function tests, ECG, and computed tomography brain. On the day of the ECT, the anesthetist also examined the patient before ECT administration.
Modified ECT was administered using spECTrum5000Q-from MECTA Corporation. Machine details can be collected from the link mentioned. Electrical dose was varied by changing any of the four parameter, current amount or duration, pulse width, frequency, or stimulus duration.
Titration method  was used to assess the seizure threshold (ST) starting from 200 mC (this starting cutoff was set from our center experience), gradually increasing by 60 mC till ST achieved. Electrical dose was adjusted in subsequent sessions to compensate for rise in ST and fall in seizure duration. ECT was administered twice or thrice a week by a senior resident under the supervision of a consultant and with the help of an anesthetist. The pharmacological agents used were: atropine (0.2–0.3 mg) and glycopyrrolate (0.2–0.3 mg) as premedication, propofol (at rate of 1–1.5 mg/kg) preferred agent for induction with reasons being better hemodynamic stability; lesser incidence of post-procedure nausea and vomiting and smoother emergence , and Succinylcholine (0.3–1.1 mg/kg) for muscle relaxation. The cuff method was used to estimate seizure duration. Motoric seizure of at least 15 s was considered to be an effective ECT. Response to ECT was rated clinically. EEG recording was not practiced on routine basis.
ECT sessions were terminated either on remission or a plateau in the improvement after 2 consecutive treatments. The therapy was also discontinued in cases with no improvement in clinical state after 4–6 treatments, or if patient develop major complications (e.g., delirium) or patient or caregiver denied for further ECT.
All treatment details were documented in the patient's case notes and in the ECT register by the psychiatric resident administering the ECT. All sedative/hypnotic agents were normally withdrawn before administration of ECT. Other drugs were stopped only if they were judged to be interfering with ECT. If the patient had not responded to a particular antidepressant drug before receiving ECT, the drug was usually replaced by a drug of different class.
In view of limited sample size, only descriptive findings were analyzed in the results.
| Results|| |
A total of 191 ECTs (mean per patient = 7.64 ± 3.6) were given in 25 courses to 21 older adults (aged ≥60 years) during January 2014–May 2017. Two out of twenty-one patients had received more than one course of ECT. The mean seizure duration was 28.8 ± 13.2 s. The demographics and diagnoses are given in [Table 1]. The mean age of the patients was 67.44 ± 9.68, with majority n = 15 (71%) belonging to young old (60–69 years of age), and only one in oldest old (>80 years) age group. About 81% of the sample populations were male. The most common psychiatric diagnosis was depression (n = 9, 43%) with unipolar severe depression with psychotic features in 4 cases and 1 case of depression with severe suicidal ideas, and other 4 were cases of recurrent depression. Tvhis was followed by schizophrenia (n = 4, 19%), catatonia (n = 4, 19%) and mania (n = 4, 19%). Most common medical comorbidity was hypertension (n = 7, 29%), followed by diabetes mellitus (n = 5, 24%) and hypothyroidism (n = 2, 10%) and 1 patient with history of coronary artery disease. Eleven patients had a history of tobacco abuse.
The patients were on variety of medications – either single or multiple drug therapy, which included newer antidepressants, typical and atypical antipsychotics, mood stabilizers, and benzodiazepines.
Indications for ECT were poor medication response (n = 17, 81%), with or without prior good response to ECT (n = 8, 38%), refusal to take drugs (n = 3, 14%), and self-injurious behavior (n = 2, 10%). The mean and standard deviation for each ECT parameters for different conditions were mentioned in [Table 2] and [Figure 1].
|Table 2: Electro-convulsive therapy parameters observed across the four groups|
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|Figure 1: Electroconvulsive therapy parameters for the different diagnostic groups|
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In all the cases, the anesthetic agent used for induction was propofol (mean dose 76 mg ± 7.8), succinylcholine (mean dose 60 mg ± 8.9) was used as muscle relaxant.
In 18 cases (86%), ECT sessions were ended with the desired therapeutic response. In the remaining 3 individuals, ECT sessions were discontinued before a therapeutic response was seen of which – 2 withdrew consent, and 1 had sustained seizures (during the first ECT itself, probably due to multiple medical comorbidities).
In the immediate recovery phase, 4 patients reported memory loss and confusion. In these cases, the ECTs was restarted once the confusion subsided. However, this was not recorded on any rating scale. No adverse side effects including major cardiac events were observed during any of the treatment apart from initial rise of blood pressure in 6 cases, which was successfully controlled with drugs. No hypoglycemia or bone injury was noted in any of the patients.
Maintenance electroconvulsive therapy
Initially, 4 patients were advised for M-ECT: 2 cases of catatonia (psychosis) and 1 each of recurrent depressive disorder and paranoid schizophrenia. After 8–10 ECTs, 3 patients maintained remission with oral drugs, while 1 patient of catatonia still continued with M-ECT.
| Discussion|| |
ECT although being most commonly practiced somatic treatment modality, but still lacks nation based data on its use. The situation is even worse when it comes to special population like elderly. The present study is a small step to fill this gap.
Higher age does not seem to be a barrier to successful use of ECT. Even an elderly male of 82 years of age was successfully treated with ECT. Male preponderance (81%) among patient receiving ECT in this study goes well with Indian survey of Chanpattana 2005. However, western literature documents female predominance ,, reasons being they were more likely to seek treatment, with or without cultural bias in prescribing ECT.
The most common diagnosis being depression was again supported by western and Indian literature., The indications of ECT were poor response to drugs, suicidal risk, refusal of food and water, and behavioral disturbances such as catatonia and agitation. These make older adults more prone to inpatient admission(s), and use of ECT as therapeutic agent.,, Only 3 patients did not show therapeutic response to ECT as the treatment had to be terminated early for various reasons already mentioned. Other Indian and western studies have also reported a favorable response in 70%–90% of the older adults treated with ECT.,,,,
The limitations of this study are small sample size, single-center retrospective study. There was lack of proper scale to assess improvement and cognitive outcomes during and after the ECT. The study does demonstrate the safety and efficacy of ECT as a treatment modality in older adults when used judiciously with proper indications and by trained personnel.,,
| Conclusion|| |
When used with caution ECT is an effective and relatively safe mode of treatment even in elderly. ECT is well-accepted treatment modality for late-life depression and can also be used for refractory cases of mania, schizophrenia, and catatonia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]