when & how to use ect in older adults€¦ · when & how to use ect in older adults frans...
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When to Use
Most effective and rapid treatment for elderly with
severe MDD, bipolar mania, bipolar depression
Augmentation strategy in treatment refractory
schizophrenia
Kerner et al. Neuropsychiatry (2014) 4(1), 33–54
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0
10
20
30
40
Treatment As Usual ECT
1930-1939 1940-1948
26.5%
31/117
3%
1/35
Kerner et al. Neuropsychiatry (2014) 4(1), 33–54
UK Psychiatric Hospital Mortality Rates in Depression Patients Aged 56 and Older
31%
46/149
ECT Not
Available
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Predictors of ECT Response
van Diermen, L., et al. (2018). Br J Psychiatry 212(2): 71-80
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Rosen, B. H., et al. (2016). J ECT 32(2): 93-98
Lower Rehospitalisation Rates for Older Adults
15.1% Rehosp.
Mean 232 days
Median 81 days
Range 1-1572 days
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Spaans, H. P., et al. (2015). Br J Psychiatry 206(1): 67-71
Speed of Remission Elderly Patients with Depression:
ECT v. Medication
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Neuroimaging Findings &
ECT
MRI
Medical temporal
lobe atrophy (MTA)
White matter hyper
intensities (WMH)
Global cortical
atrophy (GCA)
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Oudega, M. L., et al. (2011). J Clin Psychiatry 72(1): 104-112
Medial Temporal Lobe Atrophy (MTA)
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Oudega, M. L., et al. (2014). Am J Geriatr Psychiatry 22(2): 157-166
White Matter Hyperintensities (WMH)
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Memory & ECT
Treatment
1 2 3 4 5 6
Anterograde Amnesia Retrograde Amnesia
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Assessment of Memory
Treatment
1 2 3 4 5 6
Anterograde Amnesia Retrograde Amnesia
Autobiographical/Episodic
Memory vs Semantic
Memory
Working Memory
Visual Memory
Verbal Memory
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McElhiney, M.C., Moody, B.J., Sackeim, H.A., 2001. The Autobiographical Memory Interview —
Short Form. Department of Biological Psychiatry, New York State Psychiatric Institute, NY
AMI-SF
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ECT at 7 New York Facilities
Sackeim HA et al. Neuropsychopharmacology (2007) 32, 244 – 254
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Vulnerability to Cognitive
Side Effects of ECT
54 elderly patients with unipolar or bipolar depression
Neurocognitive testing at baseline, 1 week, and 3
months post ECT with RUL or BF
MCI and No MCI groups
Both groups transient short-term cognitive effects
Neither group long-term cognitive deficits
Dybedal, G. S., et al. (2015). Clin Neuropsychol 29(4): 487-508.
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Hausner, L., et al. (2011). The Journal of Clinical Psychiatry 72(01): 91-97
Efficacy & Cognitive Side Effects
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Dunne, R. A. and D. M. McLoughlin (2012). World J Biol Psychiatry 13(4): 248-258
Bifrontal ECT vs BT or RUL ECT
MMSE
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RUL ECT Better than BT
ECT for Cognition
Kolshus, E., et al. (2016). "Psychological Medicine 47(03): 518-530.
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Predictors of Loss of Personal Memories
Martin, D. M., et al. (2015). Int J Neuropsychopharmacol 18(12)
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ECT Workshop. Prof C Loo and Dr B Simpson, Wesley Hospital, Kogarah, 26-27 October 2018
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Maintenance ECT
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Kellner, C. H., et al. (2016). Am J Psychiatry 173(11): 1101-1109
Right Unilateral Ultrabrief Pulse ECT in
Geriatric Depression: Phase 1 of the PRIDE Study
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Continuation ECT in Geriatric Depression
Kellner, C. H., et al. (2016). Am J Psychiatry 173(11): 1110-1118
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How to use
Dose Memory
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ECT Workshop. Prof C Loo and Dr B Simpson, Wesley Hospital, Kogarah, 26-27 October 2018
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How To Use
Prescription
Procedure
Monitoring
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Options Best for OA
Placement RUL, BF, BT RUL
Depends
Pulse Width Ultra Brief 0.3 ms
Brief 0.5 & 1 ms
0.3 ms
Depends
Dose 0-1008 mC Just Above Seizure
Threshold
Frequency 2-3 x week Depends
PRESCRIPTION
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Options Best for OA
Anaesthetic and
Dose
Propofol,
Thiopentone ?Thiopentone
Timing of
Anaesthetic
Measure. Examine.
Individualise.
About 2-4 min after
start
Concurrent
Medications
Antidepressants,
Benzos, LiCO3 Antidepressant
Augmentation
Strategies
Remifentanil,
Hyperventilation
PROCEDURE
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1. EEG
Quality
1. Recruitment time, 2. Morphology, 3. Amplitude,
4. Concordance, 5. Suppression
2. Cognition 1. Re-orientation time
2. Early after 3-4 treatments (MMSE, MOCA)
3. Response Hamilton DRS, MADRS, GDS, PHQ-9, CGI
Response vs Remission
MONITORING DURING A COURSE OF ECT
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Lee, W. H., et al. (2012). Neuroimage 59(3): 2110-2123
Stewart, P. T., et al. (2011). Int J Neuropsychopharmacol 14(5): 585-594
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Take Home Message
Consider using ECT more often
Prescription
RUL UBP
Monitor
Response
Cognition
EEG quality