(PSYCHIATRIC TIMES) - As the population in the United States continues to age, the use and safety of electroconvulsive therapy (ECT) in elderly patients will become an increasingly important clinical issue. This is especially true in the "old-old," who are generally defined as 75 years of age and older. Although ECT is generally considered a low-risk procedure (Abrams, 1992), its use and safety in the very old and medically ill are still considered controversial by some clinicians and in the general population. Fortunately, recent studies have begun to address these important issues. A small number of retrospective studies (Casey and Davis, 1996; Cattan et al., 1990; Gormley et al., 1998) including our own (Manly et al., 2000) have shown that ECT is effective and reasonably safe in the old-old. In addition, a prospective study by Tew et al. (1999) came to the same conclusion. They found the old-old, even with greater physical illness and cognitive impairment, tolerated ECT as well as younger adults and responded as well or better.
The indications for ECT in the old-old are the same as in younger adults. The most common indication is severe major depression. ECT is often the treatment of choice in the elderly patient whose depression presents with life-threatening symptoms or behavior, such as suicidality or refusal to eat, or in patients with catatonia or psychosis. In these situations, waiting for one or more medication trials can be unwise. A history of favorable response to ECT in past episodes of severe depression should also suggest going directly to ECT.
Other important indications include severe bipolar depression, schizoaffective disorder and other psychotic disorders such as schizophrenia and bipolar mania. Neuropsychiatric disorders that respond to ECT include Parkinson's disease, neuroleptic malignant syndrome and dementing disorders with depression. Patients with less severe types of depression are often referred for ECT when they do not respond to medication trials.
Consideration of potential candidates for ECT requires assessment of potential benefits as well as potential risks. Most of the risks and complications of ECT are related to anesthesia and the physiological effects of the induced seizure. Therefore, knowledge of these effects and how they impact the cardiovascular and neurologic systems helps the clinician anticipate complications and minimize risks before the procedure.
Following the electrical stimulus, there is an initial brief parasympathetic/vagal discharge that can be accompanied by a brief period (several seconds) of asystole and a drop in blood pressure during the tonic phase, followed by an intense sympathetic surge during the clonic phase. During the clonic phase, pulse and blood pressure increase substantially, resulting in an increase in rate pressure product, which roughly correlates to myocardial oxygen demand (Abrams, 1992). Other significant physiological changes include increased cerebral blood flow and intracranial pressure and a transient increase in intragastric pressure and intraocular pressure.
Although there are no absolute contraindications, in 1990 the American Psychiatric Association Task Force on ECT identified conditions associated with increased risk of morbidity and mortality. These include recent (less than three months) myocardial infarction or stroke or a space-occupying intracranial lesion. In these situations, the risk of untreated depression must be weighed against the risk of the procedure.
There is a slowly increasing body of experience in the anesthetic management even in these risky situations (Knos and Sung, 1993). Conditions considered "relative contraindications" several years ago can now be managed without much difficulty with appropriate consultative help. These include angina, congestive heart failure, cardiac pacemaker, anticoagulation for thrombophlebitis, severe chronic obstructive pulmonary disease and severe osteoporosis. Age in itself is not a contraindication alone when concurrent medical risks are accounted for.
The safe and successful practice of ECT in old-old populations requires that a careful and thorough pre-ECT evaluation be completed to identify potential conditions that may increase risk. Many ECT practitioners request a consultation with an internist or cardiologist to assist in pre-ECT evaluation. A careful history focusing on medications, past anesthetic experience and past ECT response, as well as cardiac, pulmonary and neurologic histories should be taken. A history of myocardial infarction, angina, congestive heart failure, valvular heart disease, lung disease, smoking, stroke or seizure disorder should also be sought. Consideration of history of diabetes mellitus is also important, because of its potential implications for the vascular system.
In this age group, an electrocardiogram and chest X-ray should be routine. Laboratory studies should include a metabolic panel with electrolytes, a complete blood count and a urinalysis. A baseline cognitive evaluation such as the Folstein Mini-Mental State Examination (MMSE) should be performed prior to the first treatment. When indicated by findings in the history and physical examination, optional studies include a computed tomography scan or magnetic resonance imaging of the head, electroencephalogram, or spinal X-rays.
The focus of these studies is to identify conditions that need to be corrected, stabilized and monitored during the course of ECT. In 1997, Applegate reviewed the evaluation and management of ischemic heart disease in the ECT patient and found, with careful screening, ECT could be used safely. Similarly, Rayburn (1997) reviewed management of congestive heart failure and valvular heart disease in this setting, noting that with appropriate precautions, ECT can be performed safely in most patients.
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