Electroconvulsive therapy in the elderly: Retrospective analysis from an urban general hospital psychiatry unit

Dimple D Dadarwala; Jahnavi S Kedare; Amey G Pusalkar; Alka A Subramanyam; Ravindra M Kamath

doi:10.4103/jgmh.jgmh_6_17

ORIGINAL ARTICLE

Year : 2017 | Volume : 4 | Issue : 2 | Page : 123-126

Electroconvulsive therapy in the elderly: Retrospective analysis from an urban general hospital psychiatry unit

Dimple D Dadarwala, Jahnavi S Kedare, Amey G Pusalkar, Alka A Subramanyam, Ravindra M Kamath
Department of Psychiatry, Nair Hospital, Mumbai, Maharashtra, India

Date of Web Publication

29-Dec-2017

Correspondence Address:
Dimple D Dadarwala
65, Aakash Apartment, Mamalatdar Wadi, Cross Road No. 4, Malad-West, Mumbai - 400 064, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jgmh.jgmh_6_17

Abstract

Introduction: The number of elder patients with severe psychiatric illnesses other than depression is increasing. Electroconvulsive therapy (ECT) has a special role in the treatment of late-life depression and other psychiatric conditions in the elderly. Using ECTs in the elderly could be difficult. In an Indian setting, ECT in the geriatric population is used as last resort of treatment which is in contrast to Western countries. There is dearth of data available for the use of ECT in the elderly in India. Methodology: Retrospective data review was carried out to identify patients 55 years or older who had received ECT from January 2014 to June 2016 in tertiary care teaching hospital in a metropolitan city in India. Results: A total of 304 ECTs were administered to 25 elderly aged >55 years with average of 12 ECTs per patient. Schizophrenia (56%) was the most common diagnosis among patients who were considered for ECT, and this was followed by major depression without psychotic features (24%) and major depression with psychotic features (8%). The most common indication to start ECT was nonresponsiveness to medications (92%). There was an increase in mean Mini-Mental State Examination (MMSE) scores from baseline (23.42) to the end of the sixth (24.60) and last ECT (24.60). Duration of current used during ECT had positive correlation with MMSE. Patients with comorbid medical illness (20%) received ECT without any complication. Conclusions: This study adds to scarce database on the use of ECT in old-age patients in India and adds to evidence that ECT is safe and effective treatment in old age with no negative impact on cognition.

Keywords: Cognition, elderly, electroconvulsive therapy

How to cite this article:
Dadarwala DD, Kedare JS, Pusalkar AG, Subramanyam AA, Kamath RM. Electroconvulsive therapy in the elderly: Retrospective analysis from an urban general hospital psychiatry unit. J Geriatr Ment Health 2017;4:123-6

How to cite this URL:
Dadarwala DD, Kedare JS, Pusalkar AG, Subramanyam AA, Kamath RM. Electroconvulsive therapy in the elderly: Retrospective analysis from an urban general hospital psychiatry unit. J Geriatr Ment Health [serial online] 2017 [cited 2023 Apr 1];4:123-6. Available from: https://www.jgmh.org/text.asp?2017/4/2/123/221909

Introduction

Globally with aging population, the number of elder patients with severe psychiatric illnesses other than depression is increasing.^[1],[2] Electroconvulsive therapy (ECT) has a special role in the treatment of late-life depression and other psychiatric conditions in the elderly.^{[3],[4],[5],[6]} Using ECTs in the elderly could be difficult because doses of anesthesia need to be modified, and geriatric population is vulnerable for cognitive side effects due to the presence of medical comorbidities. Despite difficulty to use, ECT is preferred in the elderly in the West. In contrast, there are only two studies from India available for the use of ECT in elderly patients.^[7],[8] With this background, we carried out a retrospective study aimed to (1) find clinical and demographic profile of elderly patients receiving ECT, (2) study cognitive status of elderly patients before and after having received ECT, and (3) find association between ECT-related parameters and cognition.

Methodology

Exemption from review of ethics committee, i.e., waiver of consent in view of retrospective analysis was obtained. Retrospective data review was carried out to identify patients 55 years and older who had received ECT from January 2014 to June 2016 in tertiary care teaching hospital in a metropolitan city in India. Confidentiality and complete anonymity for the identity of the patients were maintained.

In the above center, a standard procedure for administration of ECT is followed. Decision to start ECT course is taken in consultation with senior psychiatrist. Once anesthesia fitness is obtained, ECT course is started. A written informed consent after explaining procedure, benefits, risks, and complications is obtained from relative of the patient. Modified ECT is given using a brief-pulse, constant energy ECT machine. Before each ECT session, Mini-Mental State Examination (MMSE) score of the patient is noted on ECT card. Electrical charge is calibrated in joules (range, 36 J–135 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 and 90 Hz (settings of 20, 40, 50, 60, 70, and 90 Hz), and adjusting the pulse width from 0.1 to 1.5 s (0.1, 0.2, 0.5, 1, 1.2, and 1.5 s). Electrical charge is varied by changing the duration of current while keeping the frequency and pulse width constant. Electrical dose is calculated using empirical dose titration method, by which initial dosage that results in adequate seizures is selected. If the first stimulus dose does not result in adequate seizures, stimulus dose is increased in duration, and patient is restimulated till patient has adequate seizures. Most patients have adequate seizures by the second or third stimulation. Interval between restimulations should be approximately 20 s to account for the delayed seizures. Initial duration of current is kept at 1 s and duration of current is increased in increments of 0.1 s until the patient achieves a seizure of adequate duration (motor seizure of 15–20 s duration). Thrice weekly ECT sessions are administered to the patients. A normal ECT course involves 6–8 ECTs and may extend to 12–14 ECTs till the patient achieves remission. Electrodes are placed bilaterally in the temporal region in all the patients; in cases where confusion or memory loss occurs, right unilateral placement of electrodes is considered.

ECT record for each patient is maintained. The ECT record has sociodemographic details of the patient as well as details of each ECT session. Several details about their demographic profile, psychiatric diagnosis, indication to give ECT, medical comorbid illnesses if present, and number of ECTs given are noted in the ECT card. ECT seizure duration (motor seizure) along with other details of ECT (duration of current given, frequency, pulse width, and MMSE score at baseline, sixth, and last ECT) is also noted. For this study, all these data were extracted.

Data thus obtained were analyzed using SPSS 17.0 software (Software is available with TATA Institute of Social Sciences) and represented by frequency and percentage tables. Chi-square test, post hoc Chi-square (standardized residual) test, and Fisher's exact test of statistical significance were used for analysis.

Results

Twenty-five elderly patients (aged >55 years) received ECTs, which is 5.34% of the total number of patients (n = 468) across all age groups who received ECTs from January 2014 to June 2016. Mean age was 58.40 years (standard deviation [SD] =3.055). Only four patients had age above 60 years; rest (n = 21) were between age group of 55 and 60 years. Males (n = 12) were almost equal in number to females (n = 13) to receive ECTs. Five patients (20%) had medical comorbidities; hypertension (n = 2), diabetes (n = 1), and both diabetes plus hypertension (n = 2).

A total of 304 ECTs were administered to 25 elderly (aged >55 years) from January 2014 to June 2016. Average of 12 (SD = 7.6, minimum 3 to maximum 29) ECTs were given per elderly. Mean effective seizure duration was 23.71 s (SD = 7.9 s). Mean duration of current delivered to produce effective seizures was 2.12 s (SD = 0.54 s, range 1.25–3.35). Mean electrical dose given was 44 J (range, 26 J–82 J). No untoward cardiac events, fractures, nor anesthesia-related complications were noted in any of the patients during any of the ECT treatments. Psychotic disorders (n = 16) were more than mood disorders (n = 9) among elderly who received ECTs. Most common diagnosis was schizophrenia (n = 14, 56%) followed by major depressive disorder without psychotic features (n = 6, 24%) and major depressive disorder with psychotic features (n = 2, 8%) and other indications. Other indications were catatonia (n = 1) and suicidal ideation (n = 1). Indication to start ECT course in almost all of these patients was nonresponse to medications (n = 23, 92%).

As shown in [Table 1], mean MMSE score at baseline was 23.42, at sixth ECT was 24.60, and at the end of ECT course was 24.60. Overall, there was an improvement in cognition (increase in mean MMSE scores) over ECT course. As seen in [Figure 1], 50% patients of psychotic disorders had increase and 44.44% patients of mood disorders had no change in MMSE scores whereas very few patients had decline in MMSE scores.

Table 1: Mini-Mental State Examination scores

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Figure 1: Diagnosis and Mini-Mental State Examination status cross tabulation

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As seen in [Graph 1] and [Graph 2], for the first six ECTs, as number of ECT treatment (Pearson's correlation coefficient − 0.096, P= 0.686) and duration of current (Pearson's correlation coefficient − 0.071, P= 0.767) increased, there was decline in MMSE. However, later with continued course of ECT, number of ECT treatment (Pearson's correlation coefficient 0.053, P= 0.852) and duration of current (Pearson's correlation coefficient 0.388, P= 0.152) had positive correlation with MMSE.

Discussion

As per data from the National Institute of Mental Health Survey showed that one-third of recipients of ECTs were aged 65 years and older.^[9] However, we found that one in twenty recipients of ECTs (5.34%) was aged >55 years. Older adults are expected to have greater risk of mortality associated with ECT due to higher prevalence of medical comorbidity, but on the contrary, retrospective chart review in the West by Nuttall et al.^[10] found that complication rate was 0.92% with no deaths over 13-year period. A previous study from India on the use of ECT in the elderly revealed that 66% of cases had medical comorbidity, and there were no untoward events caused by ECT.^[7] Furthermore, another retrospective chart review by Phirke et al. from India ^[8] and Tomac et al.^[11] from the West reported a lack of major complications caused by ECT. Similarly, we also found a lack of major complications across all ECT treatments in old age despite the presence of medical comorbidity. It emphasizes that ECT has low complication rate in old age. Similar to another chart review from India, in our study, the most common indication was nonresponse to medications (92%).^[7] Elderly patients cannot tolerate or respond poorly to medications and are at a high risk for drug-induced toxicity or toxic drug interactions, and ECT is the safest treatment option.^[12] However, in India, ECT treatment is not easily considered in elderly patients with or without medical comorbidity.

A large body of Western literature supports the use of ECT as an effective treatment for elderly patients with major depression, even in very old age (>85 years), in fact it has been regarded as the treatment of choice for geriatric depression.^[13],[14] Late-onset depression has melancholic features, delusions, suicidal ideations, and is more likely to be medication resistant.^[15],[16]. Antidepressant effect of ECT is greater than any pharmacological agent.^{[17],[18],[19]} Follow-up study by Philibert et al. showed that older adults with major depression, who received ECT, lived longer, had a greater clinical improvement, and less relapse rate compared with patients who received pharmacotherapy only.^[20] Thus, efficacy of ECT in major depression in old age is well established, but on the contrary, we had more number of patients with schizophrenia who received ECT in old age.

Cognitive side effects of ECTs are the major concern of practicing ECTs in geriatric population. Old age and low baseline cognitive performance increase the degree of risk for adverse cognitive impairment with ECT as expected, and also the presence of depressive symptoms increases cognitive difficulties.^{[21],[22],[23]} Previous Indian study has reported cognitive side effects in 45% of the cases.^[8] In the West, Brodaty et al., followed up older patients with depression receiving ECTs over 7 years, found no impairment in memory functioning after ECTs. It suggests that improvement of depressive symptoms after ECTs leads to reduction of cognitive difficulties and overall improvement in cognition.^[24] Similarly, schizophrenia has a natural course with decline in cognition, but improvement in cognition post-ECT in schizophrenia could be as a function of symptomatic response. Our elderly patients with psychotic disorders had increase in MMSE scores, and patients with mood disorders had no decline in MMSE scores post-ECTs. Overall, we did not find cognitive side effects post-ECT; rather, there was an improvement in global cognitive status, which could be attributed to an improvement or stability in the cognitive domain of the illnesses.

Results of the study by Devanand et al.^[24] suggest that patients given more number of ECTs over several courses in lifetime do not manifest cognitive impairment at long-term follow-up, but it is frequency of ECTs, which predicts degree of cognitive impairment post-ECT.^[24] As a standard procedure, we give alternate day thrice a week ECTs for initial 4 ECTs, subsequently with continued course, we decrease the frequency to twice week. We found that initially with more frequent ECTs, elderly patients had decline in cognition but with continued course and reduction in frequency of ECTs with symptomatic improvement cognition improved. Traditionally, there is widely held belief that efficacy of ECT depends exclusively on whether or not a seizure was induced adequately, and stimulus dosing was responsible for cognitive side effects.^[25] In contrast, we found that increase in stimulus dose by increasing duration of current leads to an improvement in cognition rather than cognitive decline. This could be because by increasing duration of current, seizure threshold is exceeded which increases efficacy of ECT leading to symptomatic improvement.

Conclusions and Implications

Less use of ECT in the elderly is practiced in India due to fear/apprehension among psychiatrists. The use of ECT in an Indian old-age population seemed to be restricted to those who had nonresponse to medications. Very few elderly receive ECT, predominantly patients with schizophrenia received ECT. ECT is safe and effective treatment in old age. Patients with or without medical comorbidity received ECT without any complication including cognitive side effects. One of the worst fears we have is worsening of cognition in elderly patients who receive ECTs. This study obviously unfounds that premise.

Limitations

Being a retrospective chart review, no rating scale could be used to monitor effectiveness of ECT in terms of treatment response and clinical improvement.

Recommendations and future directions

There is a need of longitudinal study to compare clinical improvement using rating scales before and after ECT in the elderly. Comparative case–control studies are needed to compare clinical improvement in elderly patients who received ECT versus elderly patients who did not receive ECT and other adult population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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