Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 428
  • Home
  • Print this page
  • Email this page

 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 153-155

Electroconvulsive in a 75-year-old patient with severe agitated behavior and dementia


Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Avinash Desousa
Carmel, 18 St., Francis Road, Off S. V. Road, Santacruz West, Mumbai - 400 054, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_49_16

Rights and Permissions
  Abstract 

Various drugs have been used in the management of behavioral and psychotic symptoms including aggression and agitation in dementia. However, the risk of side effects and sedation limits the use of higher doses of many agents. Electroconvulsive therapy (ECT) has been used in the management of behavioral symptoms related to dementia although sparingly and rare. We report the case of a 75.year.old male patient with moderate Alzheimer's dementia and severe agitated behavior and aggression which failed to respond to pharmacological treatment and whom we treated using seven ECT sessions with success. Significant clinical improvement was noted and no cognitive decline or worsening of the dementia in any form was reported. The patient was followed up 6 months post the ECT sessions. This case report demonstrates the safety and efficacy ECT use patients with Alzheimer's dementia when behavioral problems and aggression or agitation fail to respond to medications.

Keywords: Aggression, agitated behavior, Alzheimer's, cognitive decline, dementia, electroconvulsive therapy


How to cite this article:
Sathe H, Phirke M, Shah N, Sonavane S, Desousa A. Electroconvulsive in a 75-year-old patient with severe agitated behavior and dementia. J Geriatr Ment Health 2017;4:153-5

How to cite this URL:
Sathe H, Phirke M, Shah N, Sonavane S, Desousa A. Electroconvulsive in a 75-year-old patient with severe agitated behavior and dementia. J Geriatr Ment Health [serial online] 2017 [cited 2019 Aug 22];4:153-5. Available from: http://www.jgmh.org/text.asp?2017/4/2/153/221906




  Introduction Top


Behavioral and psychotic symptoms are common features in dementia and may be seen at any stage of the disorder.[1] Agitation in patients with dementia may involve excessive psychomotor activity, aggressive behavior, irritable mood, disinhibited behavior, abusive behavior, and emotional symptoms.[2] These behavioral problems are often seen in patients with all forms of dementia as the illness progresses and affect the quality of life of the patient, but also are quite distressing for both the patients and their caregivers.[3] A number of psychopharmacological and nonpharmacological approaches have been used in the management of these symptoms.[4],[5] The role of psychopharmacological treatments reduces when the patient is nonresponsive to the medication or due to ensuing side effects and sedation which is common in this group.[6] Most studies using antipsychotics and other medications have shown minimal to moderate effects when compared in controlled trials to other drugs or placebo and the US Food and Drug Administration black box warning when using these drugs exists.[7] The risk of falls in patients with dementia in old age is another factor that limits the use of sedating medication.[8]

Electroconvulsive therapy (ECT) has been used widely in the management of various psychiatric disorders and its safety and efficacy is well established.[9] Cognitive side effects are common with ECT but are reversible in weeks, especially with the advances in the use of brief pulse ECT.[10] Studies have demonstrated the safety of ECT in the elderly subjects when used in the management of depression, mania, and late onset psychosis.[11],[12],[13],[14] ECT has also been used in the management of depression that may be a part of or comorbidity to dementia.[15] ECT has also been reported to be safe in patients with dementia in various anecdotal case reports and case series.[16],[17],[18],[19] We report here the case of a 75-year-old male patient with moderate Alzheimer's dementia and severe agitated behavior and aggression which failed to respond to pharmacological treatment and was treated using seven ECT sessions with success without cognitive decline or worsening of the dementia in any form.


  Case Report Top


The patient was a 75-year-old, right-handed man with 8 years history of gradual onset Alzheimer's dementia initially diagnosed clinically and later confirmed on magnetic resonance imaging. The patient was brought to us with a history of agitated behavior, aggression, abusive behavior and throwing things, shouting, crying, and laughing when shouting and decreased night time sleep for the past 3 months. The patient was taking donepezil 10 mg at night and vitamin supplements at the time of examination. We had admitted the patient for observation and in the ward the patient demonstrated severe agitation, screaming and shouting, crying, resisting care and treatment offered, pacing, and abusive behavior. The patient even attempted to assault the doctor and nursing staff at times. Verbal communication with the patient was reduced due to noncomprehensibility by the patient and talking irrelevant when asked questions including repeating the same statements and abusing. The patient was not cooperative for Mini Mental Status Examination and other cognitive tests and these could not be performed. A mini mental state examination (MMSE) carried out 6 months before admission had a score of 22/30. The patient needed assistance with all activities of daily living but did not cooperate and even got aggressive when someone tried to assist him leading to deterioration in his personal hygiene. The patient had no history suggestive of major medical illnesses such as hypertension or diabetes and all the routine blood investigations performed in the ward (blood count, urine routine, blood glucose, serum lipids, serum B12, serum folate, thyroid function, renal and liver function calcium, Vitamin D) were within normal limits.

The patient was maintained on donepezil and was started on memantine 5 mg which was increased to 10 mg later and quetiapine 25 mg at night which was increased to 50 mg in 2 days and 100 mg but the patient still slept only 5 h and the agitated behavior continued. The patient was tried on multiple pharmacological agents separately and some in combination such as risperidone (4 mg/day), olanzapine (10 mg/day), divalproex sodium (750 mg/day), amisulpride (200 mg/day), aripiprazole (15 mg/day), and escitalopram (10 mg/day). These were stopped and started based on effects and side effects. The aim was to get a combination of pharmacological agents that worked and reduced the agitation. Affective worsening was noted with Escitalopram and tremors were noted with Risperidone. Lorazepam (3 mg at night) and Mirtazapine (30 mg) were tried and achieved just 4–5 h of sedation at night. The patient was noncooperative for psychological and behavioral interventions as well as occupational therapy sessions and even playing music (that he liked) regularly had no effect on him. On a thorough evaluation of the agitation and factors antecedent to the same, no triggers could be elucidated. This carried on for a 10 weeks period in the ward and due to the lack of response the relatives were psychoeducated and ECT was considered as a treatment option. The consent was taken from the wife due to the patient's inability to give consent.

To minimize the side effects of ECT a right unilateral electrode placement as per the standard methods [20] was considered and a twice a week course was followed compared to the routine thrice a week protocol. We could have considered bilateral electrode placement with probable faster results but did not want to risk the patient to developing any further cognitive deterioration. The patient was examined and fitness for anesthesia was obtained. The patient was administered using propofol (1 mg/kg) and Succinylcholine and Atropine was used before ECT. The patient's seizure threshold was determined in the first session itself and a pulse width of 0.25 ms was used. The seizure threshold of the patient was <50 mC and all subsequent sessions were administered at 100 mC. Post-ECT the patient was evaluated daily for confusion and change in behavior clinically and MMSE till the next ECT session. The last two sessions (6th and 7th) were given at 150 mC as per the dose titration. Sufficient seizure duration was noted as per the cuff method. Within 3 treatments, the patient showed over 70% reduction in all his symptoms and was very manageable and cooperative in the ward. The aggression and agitated behavior reduced markedly, night sleep was better and patient was receptive to help in activities of daily living with the staff and relatives while memory and cognitive deficits continued as before showing no further deterioration. The family members mentioned that the patient was responsive to them though he did not follow their commands at times but was cooperative in all activities of daily living. The ECT course was tolerated well with no side effects and cognitive decline noted. The patient was discharged 4 days after the seven ECT session. The improvement in agitation symptoms was present on hospital discharge. The relatives refused maintenance ECT as the patient was going to the village and would now stay there. The daughter followed up with us for medication (donepezil 10 mg, mirtazapine 30 mg, and aripiprazole 10 mg) and over 6 months follow up mentioned that the patient was maintained as he was post seven ECT sessions with no behavioral problems and further cognitive decline (MMSE 22/30).


  Discussion Top


One of the reasons for the lack of response to medications in behavioral symptoms related to dementia is the poor understanding of its neurobiology and the varied of response of different patients to the same drug.[21] ECT in its mechanism of action relies upon antidepressant and antipsychotic actions and agitation and aggression in dementia are associated with psychotic symptoms which may bear neurobiological similarities to an agitated mood disorder or psychosis.[22] In our patient, the improvement was sustained over 6 months and the course of ECT was uneventful from a side effect point of view. Our findings correspond to that reported in previous case reports of ECT in patients with dementia.[16],[17],[18],[19] ECT is known to have long lasting effects and in our case this was attributed to positive effect of ECT rather than any permanent change in personality or behavior brought about by it. The change of home environment and setting may have also played a supportive role in the patient's well-being while the caregivers remained the same. ECT is under used in the geriatric population with a fear of side effects and cognitive decline. Our case demonstrates that ECT does have a role in the management of psychiatric symptoms related to dementia, especially when patients may be nonresponsive to medication and when intolerant due to side effects. One must however be cautious when administering ECT to older patients due to the medical complications that may ensue as well as the medical disorders that may co-exist in this population.[18] Further larger studies are however need to corroborate the findings of this case report.

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.



 
  References Top

1.
Thompson C, Brodaty H, Trollor J, Sachdev P. Behavioral and psychological symptoms associated with dementia subtype and severity. Int Psychogeriatr 2010;22:300-5.  Back to cited text no. 1
[PUBMED]    
2.
Howard R, Ballard C, O'Brien J, Burns A; UK and Ireland Group for Optimization of Management in Dementia. Guidelines for the management of agitation in dementia. Int J Geriatr Psychiatry 2001;16:714-7.  Back to cited text no. 2
    
3.
Naglie G. Quality of life in dementia. Can J Neurol Sci 2007;34 Suppl 1:S57-61.  Back to cited text no. 3
[PUBMED]    
4.
Liperoti R, Pedone C, Corsonello A. Antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Curr Neuropharmacol 2008;6:117-24.  Back to cited text no. 4
[PUBMED]    
5.
Yamaguchi H, Maki Y, Yamagami T. Overview of non-pharmacological intervention for dementia and principles of brain-activating rehabilitation. Psychogeriatrics 2010;10:206-13.  Back to cited text no. 5
[PUBMED]    
6.
Pollock B, Forsyth C, Bies R. The critical role of clinical pharmacology in geriatric psychopharmacology. Clin Pharmacol Ther 2009;85:89-93.  Back to cited text no. 6
[PUBMED]    
7.
Nelson JC, Delucchi K, Schneider LS. Efficacy of second generation antidepressants in late-life depression: A meta-analysis of the evidence. Am J Geriatr Psychiatry 2008;16:558-67.  Back to cited text no. 7
[PUBMED]    
8.
Eriksson S, Gustafson Y, Lundin-Olsson L. Risk factors for falls in people with and without a diagnose of dementia living in residential care facilities: A prospective study. Arch Gerontol Geriatr 2008;46:293-306.  Back to cited text no. 8
[PUBMED]    
9.
Payne NA, Prudic J. Electroconvulsive therapy: Part I. A perspective on the evolution and current practice of ECT. J Psychiatr Pract 2009;15:346-68.  Back to cited text no. 9
[PUBMED]    
10.
Ingram A, Saling MM, Schweitzer I. Cognitive side effects of brief pulse electroconvulsive therapy: A review. J ECT 2008;24:3-9.  Back to cited text no. 10
[PUBMED]    
11.
van Schaik AM, Comijs HC, Sonnenberg CM, Beekman AT, Sienaert P, Stek ML. Efficacy and safety of continuation and maintenance electroconvulsive therapy in depressed elderly patients: A systematic review. Am J Geriatr Psychiatry 2012;20:5-17.  Back to cited text no. 11
[PUBMED]    
12.
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.  Back to cited text no. 12
[PUBMED]    
13.
Wilkins KM, Ostroff R, Tampi RR. Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: A review of the literature. J Geriatr Psychiatry Neurol 2008;21:3-11.  Back to cited text no. 13
[PUBMED]    
14.
Phirke M, Sathe H, Shah N, Sonavane S, Bharati A, De Sousa A. Retrospective chart review of elderly patients receiving electroconvulsive therapy in a tertiary general hospital. J Geriatr Ment Health 2015;2:102-5.  Back to cited text no. 14
  [Full text]  
15.
Hausner L, Damian M, Sartorius A, Frölich L. Efficacy and cognitive side effects of electroconvulsive therapy (ECT) in depressed elderly inpatients with coexisting mild cognitive impairment or dementia. J Clin Psychiatry 2011;72:91-7.  Back to cited text no. 15
    
16.
Oudman E. Is electroconvulsive therapy (ECT) effective and safe for treatment of depression in dementia? A short review. J ECT 2012;28:34-8.  Back to cited text no. 16
[PUBMED]    
17.
Sutor B, Rasmussen KG. Electroconvulsive therapy for agitation in Alzheimer disease: A case series. J ECT 2008;24:239-41.  Back to cited text no. 17
[PUBMED]    
18.
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.  Back to cited text no. 18
[PUBMED]    
19.
Tielkes CE, Comijs HC, Verwijk E, Stek ML. The effects of ECT on cognitive functioning in the elderly: A review. Int J Geriatr Psychiatry 2008;23:789-95.  Back to cited text no. 19
[PUBMED]    
20.
Kellner CH, Tobias KG, Wiegand J. Electrode placement in electroconvulsive therapy (ECT): A review of the literature. J ECT 2010;26:175-80.  Back to cited text no. 20
[PUBMED]    
21.
Balthazar ML, Pereira FR, Lopes TM, da Silva EL, Coan AC, Campos BM, et al. Neuropsychiatric symptoms in Alzheimer's disease are related to functional connectivity alterations in the salience network. Hum Brain Mapp 2014;35:1237-46.  Back to cited text no. 21
[PUBMED]    
22.
Merkl A, Heuser I, Bajbouj M. Antidepressant electroconvulsive therapy: Mechanism of action, recent advances and limitations. Exp Neurol 2009;219:20-6.  Back to cited text no. 22
[PUBMED]    




 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
References

 Article Access Statistics
    Viewed964    
    Printed41    
    Emailed0    
    PDF Downloaded84    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]