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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 143-145

Comorbid bipolar depression and dementia managed with electroconvulsive therapy: A case report and review of the evidence


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_10_17

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  Abstract 

Patients with bipolar disorder (BD) can have a range of comorbid psychiatric disorders, and clinical studies have reported BD to be a putative risk factor for the development of dementia. In this case report, we present a case of a 62-year-old female, who had been suffering from BD since early adulthood, developed symptoms of dementia at the age of 60 years, which led to diagnostic issues at the time of relapse of BD. At the time of presentation, she had a depressive relapse with catatonic symptoms and was managed with electroconvulsive therapy during the acute phase, and lithium was used for maintenance treatment.

Keywords: Bipolar disorder, dementia, electroconvulsive therapy


How to cite this article:
Grover S, Sahoo S. Comorbid bipolar depression and dementia managed with electroconvulsive therapy: A case report and review of the evidence. J Geriatr Ment Health 2017;4:143-5

How to cite this URL:
Grover S, Sahoo S. Comorbid bipolar depression and dementia managed with electroconvulsive therapy: A case report and review of the evidence. J Geriatr Ment Health [serial online] 2017 [cited 2019 Sep 20];4:143-5. Available from: http://www.jgmh.org/text.asp?2017/4/2/143/221896




  Introduction Top


The prevalence of dementia in the general population is on the rise worldwide.[1] Studies that have tried to evaluate bipolar disorder (BD) as a putative risk for the development of dementia had found that individuals with a history of BD have a significantly higher risk of developing dementia.[2],[3],[4],[5] A recent meta-analysis revealed that BD leads to cognitive impairment and dementia.[6] Dementia in BD can lead to further impairment in functioning, greater disability, and poorer quality of life.[7] Development of dementia in an individual with BD can not only worsen the course of BD, but it can also pose a challenge to treatment. Self-recognition of cognitive deficits in patients with BD at an early stage of cognitive decline can precipitate depression.[8],[9] Major depressive episode in an elderly individual with BD often becomes severe and usually takes a longer time to respond to conventional treatment. Further, development of bipolar depression among patients with comorbid dementia can lead to a difficulty in recognizing symptoms of depression and further impairment in cognitive functions which in turn may cause delay in treatment and increase in severity of depression.

Hence, relapse of mood episode among patients of BD with comorbid dementia poses several treatment challenges, as most of the psychotropics have to be used judiciously due to both age factor and dementia. In cases of extreme severe depression or mania in an elderly individual with dementia, electroconvulsive therapy (ECT) has been found to be a relatively safe and beneficial option.[10],[11] ECT has also found to be useful to benefit severe agitation in cases of elderly individuals with advanced dementia.[12],[13],[14] Similarly, there is evidence of improvement of catatonia in dementia patients with ECT.[15],[16],[17]

In this report, we present the case of a 62-year-old female, who had been suffering from BD since early adulthood, developed symptoms of dementia at the age of 60 years, and presented to us with depressive catatonia. She was managed with ECT during the acute phase, and lithium was used for maintenance treatment.


  Case Report Top


Mrs. R, 62 years old, primary passed, homemaker, from lower socioeconomic status, rural background, with a family history of recurrent depressive disorder, presented with an episodic illness of 43 years' duration fulfilling the criteria of bipolar affective disorder with current episode severe depression with psychotic symptoms for the last 8 months. Detailed exploration of history revealed that she was poorly treated for her bipolar illness during the initial years. However, for the past 5 years, she was maintaining well on psychotropic medications, details of which could not be ascertained. About 2 years prior to presentation to our center (i.e., age 60 years), she was noticed to be forgetful, especially would have difficulty in recollecting recent events. She would forget as to who visited her 1 or 2 days back or what she had cooked the previous day. When corrected or reminded, she would not show much reaction. Over the next 3–4 months, the symptoms of forgetfulness increased, and she was noticed to forget days of the week and could not remember the appropriate day for the fasting/religious festivals, which she was doing over the years. In addition, she was also noticed to have difficulty in recalling names of relatives, had difficulty in wearing clothes and slippers, and would forget recent events. However, her remote memory was relatively preserved. On few occasions, she lost her way back to her home and went to her neighbor's home. Over the period, these symptoms kept on progressing. She would occasionally express distress about her failing cognition.

About 8 months prior to presentation to our center, in addition to forgetfulness, she gradually developed depressive features in the form of low mood, anhedonia, lethargy, low self-esteem, ideas of hopelessness, nihilism, poverty, poor interaction, decreased sleep, decreased appetite, and more often started making mistakes in household work. Later on, about 3 months prior to presentation, additionally, she developed urinary and fecal incontinence, staring, and refusal to feed. She also lost a significant amount of weight due to poor intake. She was brought to our center due to complete refusal to feed for 5 days.

At the time of presentation, she was found to be thin built, emaciated, and dehydrated. Further physical examination revealed pallor, presence of bilateral pedal edema. No abnormality was detected in the cardiovascular and respiratory system and abdominal examination. A detailed neurological examination also did not reveal any abnormality. Mental status examination was characterized by the presence of marked psychomotor retardation, staring, marked decreased speech output, perseveration, increased reaction time, sadness of mood, ideas of hopelessness, poverty, nihilism, impaired recent memory, and partial insight. Based on the available history, a diagnosis of bipolar affective disorder, current episode severe depressive episode with psychotic symptoms (catatonia), dementia (Alzheimer's/nutritional deficiencies), and malnutrition was considered. Her Bush Francis Catatonia Rating scale score was 14, and on Hamilton Depression Rating Scale, she scored 32. All routine hematological and biochemical investigations (renal function test, liver function test, ultrasound abdomen, thyroid function test, fasting blood sugar, lipid profile) did not reveal any abnormalities except for the evidence of anemia and hypokalemia. Her serum Vitamin D levels were found to be low (<3 units). Her magnetic resonance imaging study revealed mild cerebral atrophy with small vessel ischemic changes. Initially, she was given appropriate nutritional supplements in the form of ferrous sulfate, Vitamin D, calcium, Vitamin B12, folic acid, and high protein diet to correct the nutritional deficiencies. Appropriate measures were also taken to correct hypokalemia. Given the severe depression and catatonia, she was started on ECT. She received 14 sessions of bilateral ECT, with which her depressive symptoms improved significantly. Later, she was started on lithium 600 mg/day after all the prerequisite investigations along with tablet olanzapine 7.5 mg/day and memantine 10 mg/day. Her Mini–Mental State Examination score increased from 10 at presentation to 18 after resolution of depression. Detailed cognitive function assessment 2 weeks after resolution of depression revealed significant impairment in memory and perceptuomotor functions. She has been maintaining well in terms of affective symptoms for the past 2.5 years on lithium 600 mg/day with regular monitoring of serum lithium along with olanzapine 5 mg/day and memantine 10 mg/day. There was no major further deterioration of dementia with Mini–Mental State Examination scores varying from 15 to 19, over the period of follow-up.


  Discussion Top


The recent meta-analysis [6] which had evaluated the risk of dementia in individuals with BD had revealed that the estimated risk of dementia in BD is larger than reported in meta-analyses of unipolar major depression (risk estimates ranging from 1.65 to 2.0).[18],[19] Unlike unipolar depression, individuals with BD have been found to have high pro-inflammatory activity, reduced neurotropic support, and high oxidative stress burden which elevate their risk of developing dementia in later life.[20],[21] Various other clinical factors such as strong genetic susceptibility, more number of affective episodes, earlier age of onset, and greater medical and psychiatric comorbidities also add on to the cognitive impairment in individuals with BD.[22] In the index case, there were several of these clinical factors such as positive family history of affective illness and age of onset of BD in the early 20s, with poorly treated episodes leading to frequent relapses in the initial years. All these could have been the possible risk factors for development of dementia in the index case.

Several studies have reported that depression in late life is not only a potential risk factor for dementia but also a prodrome/forerunner of dementia.[23] In this regard, though it has been well studied whether a depressive relapse in elderly individuals with BD poses an additional threat to development of dementia, it can be postulated that every mood episode, more particularly depression, leads to further cognitive decline as evident from the studies which have tried to evaluate the association of number of affective episodes and dementia among patients with BD.[22] The index case with BD was unique as she developed dementia first and subsequently had a depressive relapse which possibly could have led to worsening of cognitive symptoms.

Previous studies have reported that lithium has some neuroprotective effect against the development of dementia in patients with BD.[5],[24],[25] It has been hypothesized that lithium by inhibiting the transcription of the glycogen synthasekinase-3 gene may inhibit crucial processes in the overproduction of amyloid-b and tau hyper-phosphorylation [26] which are the main pathogenic mechanisms of dementia. In this line, few studies have suggested that long-term lithium treatment may have disease-modifying properties on the core pathophysiologic features in the development of dementia, particularly Alzheimer's dementia, and deliver a marginal clinical benefit, mostly if started at the earlier stages of the disease process.[5],[27] In the index case, we could not find any past history of treatment with lithium. However, addition of lithium possibly prevented further worsening of cognitive symptoms during follow-up period of 2.5 years, suggesting that lithium could have played some role in preventing further progression of dementia.

There has been substantial evidence on the beneficial effect of ECT in elderly individuals with both unipolar and bipolar depression.[28],[29] Role of ECT in comorbid dementia and depression though not extensively studied, few studies have reported ECT to be quite effective and safe with rapid resolution of depressive symptoms with no significant change in the existing cognitive impairment.[10],[30],[31] Treatment with ECT has been reported to be well tolerated, though post-ECT delirium and confusion are the two most common adverse side effects in depressed, demented individuals.[10] Existing literature in this regard is limited to few case series,[11] and only five prospective studies (sample size ranging from 19 to 105) on the use of ECT in individuals with depression superimposed on dementia are available in which the mean number of ECT sessions had been around nine and there was no reported worsening of cognitive impairment too.[32] In the index case, 14 sessions of bilateral ECT were used for the management of catatonia and depression with a substantial degree of improvement.


  Conclusion Top


The present case reflects that patients with BD can develop dementia. Further, the case shows that lithium can have some neuroprotective effect in the presence of dementia and may prevent further progression of dementia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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