When & How to Use ECT in Older Adults€¦ · When & How to Use ECT in Older Adults Frans...

When & How to Use ECT

in Older Adults Frans Hugo SJOG Midland Hospital, PERTH Frans.Hugo@sjog.org.au

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

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

Predictors of ECT Response

van Diermen, L., et al. (2018). Br J Psychiatry 212(2): 71-80

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

Spaans, H. P., et al. (2015). Br J Psychiatry 206(1): 67-71

Speed of Remission Elderly Patients with Depression:

ECT v. Medication

Neuroimaging Findings &

ECT

MRI

Medical temporal

lobe atrophy (MTA)

White matter hyper

intensities (WMH)

Global cortical

atrophy (GCA)

Oudega, M. L., et al. (2011). J Clin Psychiatry 72(1): 104-112

Medial Temporal Lobe Atrophy (MTA)

Oudega, M. L., et al. (2014). Am J Geriatr Psychiatry 22(2): 157-166

White Matter Hyperintensities (WMH)

Memory & ECT

Treatment

1 2 3 4 5 6

Anterograde Amnesia Retrograde Amnesia

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

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

ECT at 7 New York Facilities

Sackeim HA et al. Neuropsychopharmacology (2007) 32, 244 – 254

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.

Hausner, L., et al. (2011). The Journal of Clinical Psychiatry 72(01): 91-97

Efficacy & Cognitive Side Effects

Dunne, R. A. and D. M. McLoughlin (2012). World J Biol Psychiatry 13(4): 248-258

Bifrontal ECT vs BT or RUL ECT

MMSE

RUL ECT Better than BT

ECT for Cognition

Kolshus, E., et al. (2016). "Psychological Medicine 47(03): 518-530.

Predictors of Loss of Personal Memories

Martin, D. M., et al. (2015). Int J Neuropsychopharmacol 18(12)

ECT Workshop. Prof C Loo and Dr B Simpson, Wesley Hospital, Kogarah, 26-27 October 2018

Maintenance ECT

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

Continuation ECT in Geriatric Depression

Kellner, C. H., et al. (2016). Am J Psychiatry 173(11): 1110-1118

How to use

Dose Memory

ECT Workshop. Prof C Loo and Dr B Simpson, Wesley Hospital, Kogarah, 26-27 October 2018

How To Use

Prescription

Procedure

Monitoring

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

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

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

Lee, W. H., et al. (2012). Neuroimage 59(3): 2110-2123

Stewart, P. T., et al. (2011). Int J Neuropsychopharmacol 14(5): 585-594

Take Home Message

Consider using ECT more often

Prescription

RUL UBP

Monitor

Response

Cognition

EEG quality

When & How to Use ECT

in Older Adults Frans Hugo SJOG Midland Hospital, PERTH Frans.Hugo@sjog.org.au