THE PRACTICE OF ECT. Kiran Rabheru

Transcription

1 THE PRACTICE OF ECT Kiran Rabheru MD, CCFP, FRCP Geriatric Psychiatrist Professor University of Ottawa February 11, 2015 U of Ottawa Review Course in Psychiatry: Dr. K. Rabheru 1

2 Disclosures n NONE 2

3 Learning objectives: 1. To identify the indications and contraindications for ECT 2. Describe the effectiveness, side-effects and limitations of ECT 3. Explain the role of the anesthetist and the psychiatrist, and the collaboration of the team in optimizing quality of care. 4. To discuss issues around obtaining consent and cognitive impairment and ECT 3

4 References n APA Task Force Report, The Practice of ECT, 2 nd ed., 2001 n Royal College (UK) of Psychiatrists Handbook of ECT, 2005 n Canadian Psychiatric Association ECT Position Paper: Drs. Enns, Reiss, Chan

5 Websites n Royal College (UK) of Psychiatrists 2005 ECT Handbook n Australian web site: n BC Guidelines for ECT (2002) pages.pdf) n Canadian Psychiatric Association Position Paper click publications then professional guidelines. Available online fall

6 ECT Consultation n Indication? Primary vs. Secondary n Contraindications or Risks? Medical vs. Psychiatric Lab Investigations n Concurrent Medications? Discontinue, Hold, Taper n Consent? Involuntary or Voluntary Capable or Incapable 6

7 Primary Indications n Mood Disorders Major Depressive Episode Mania Mixed States n Schizophrenia n Schizoaffective Disorder 7

8 Primary Indication: Major Depressive Episode Medication: Refractory / Resistant / Intolerant When rapid response is needed for depression Psychotic Depression Severely suicidal Refusal of nourishment & fluids Depression with motor symptoms: n Catatonic / Retarded / Agitated Pregnancy Elderly 8

9 Primary Indication: Mania n Acute Mania with extreme agitation n Manic Delirium : acute onset of the excitement, grandiosity, emotional lability, delusions, and insomnia (characteristic of mania) plus disorientation and altered consciousness characteristic of delirium. course. The rapidity of response is the same as that of patients with catatonia. 9

10 Primary Indication: Schizophrenia & Related Disorders n Positive symptoms with abrupt or recent onset n Catatonia n History of good response to ECT n Refractory psychosis 10

11 Secondary Indications n Parkinson s Disease n Neuroleptic Malignant Syndrome (NMS) n Mood Disorder Secondary to Physical Conditions n Delirium n Intractable Status Epilepticus 11

12 ECT Response Rates in MDE n Generally: 75-85% n Elderly: 80-90% n Med-resistant: 60-70% n Clinical Practice in Elderly: >90% 12

13 ECT: The CORE Experience Multi-site, prospective, C-ECT vs. C-Meds N=253 MDD, 1.5T BL ECT Index Series 86% completers, 80% response overall TRD was not a predictor of response Nonpsychotic (n = 176) vs. psychotic (n = 77) n Psychotic depression remitted faster Age vs. HRSD remission rates (overall 75%): n 45 and under: 70% n yrs.: 89.8% n 65 and over: 90% Husain MM et al. J Clin Psychiatry O Connor K. et al., Am. J. Geri. Psych Petrides G et al. J ECT Rasmussen KG et al. J. ECT

14 ECT & the Elderly n Late onset geriatric depression is a predictor for developing dementia later 30-40% pseudo-demented develop dementia within 2-3 years (Alexopoulos) Double the risk for dementia in general (Jorm) n Incorporate in consent procedure. 14

15 ECT & Parkinson s Disease n Can treat both motor and mood symptoms n Watch for post-ect delirium n Consider dose of L-Dopa during ECT course n Maintenance schedule averages q3-4 weeks 15

16 Contraindications n No absolute contraindications n Relative Contraindications: Unstable & severe cardiovascular disease Space Occupying Lesion (SOL) with raised Intracranial Pressure (ICP). Recent cerebral hemorrhage or stroke Bleeding / Unstable vascular aneurysm Severe / unstable pulmonary condition ASA Class 4 or 5 16

17 Medically Fit for ECT? n ACC-AHA 2007: Low risk procedure Equal to non cardiac surgery n Short duration, no fluid shifts, low complication rate n If no active heart disease & patient is stable: Fit for ECT. Clinical effectiveness is not necessarily dependent on duration of motor or EEG but mainly Quality of Seizure. 17

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20 Clinical Application: Does where we place electrodes impact cognition and degree of benefit?

21 Question n During ECT, % current is resisted by the skull and shunted through the scalp and % of the charge delivered by the ECT device enters the brain: n 40-50; n 50-60; n 60-70; n 70-80; n 80-90; 10-20

22 Modern ECT Devices Brief Pulse Device + - Duration ( Pulse Train )

23 Modern ECT Devices Brief Pulse Device Pulse Width Current Frequency

24 Seizure A rhythmic and repeated discharge (depolarization) of brain cells in unison. Initiated when a pacemaker area of the brain is activated, begins firing and seizure activity is propagated throughout the brain via neuronal projections.

25 Seizure Threshold Sufficient neurons must be depolarized in order to create the excitatory process in the brainstem Therefore, via the ECT device, we deliver tiny doses of current to the scalp, repeatedly, pulse by pulse, until that critical point has been reached and a seizure ensues - Abrams

26 Potential Complications: Anesthesia & ECT Known to cause or associated with: n myocardial ischemia / infarction n ventricular tachycardia n cardiac rupture n transient LV systolic & diastolic function decrease n TIAs n cortical blindness n fractures n dislocations n muscle aches n nausea, headache n emergent agitation n sudden death 26

27 Special Precautions Increased Autonomic Sensitivity Anesthesia Sensitivity n Hyperthyroidism n CHF/ MI/ Stroke / Valve dysfunction/ arrhythmias n Increased ICP n Fragile aneurysm n Glaucoma n Retinal detachment n Genetic / Acquired pseudocholinesterase deficiency n Myasthenia gravis n Neuroleptic malignant syndrome n Pregnancy n Dementia n Pheochromocytoma 27

28 Response to ECT: Physiologic n Acute increase Cerebral Blood Flow (CBF) by 133% & Intracranial Pressure (ICP). n Parasympathetic: secs, Sympathetic: 5 mins: 20% HR increase and 30-40% BP increase, 2-5 x increase RPP, Bilateral>Unilateral, older age >younger n Low level CO 2 correlates with Sz duration 28

29 Response to ECT: Cardiovascular n Initial Tonic Phase: Parasympathetic response n Subconvulsive seizures: = HIGHER RISK! Bradycardia: + / - hypotension Asystole Atrial arrythmias PACs & PVCs AV Blocks 29

30 Response to ECT: Cardiovascular n Sympathetic Phase with seizure n Dramatic increase HR (52%) & BP (25%) n Sympathetic tone à Tachycardia & hypertension. n Increase in Rate Pressure Product (RPP) = heart rate x BP n Transient decrease in ejection fraction n In most patients minor & transient: n Resolves in 20 min but needs attention 30

31 Medical Problems to watch for: n n n Cardiovascular: Age: >80: 36% vs >65: 12% Pre-existing disease: IHD, CHF, Arrythmias, valvular disease Falls: Age: >65: 14% vs >85: 36% Increased with # ECTs & Parkinson s Disease Pulmonary: COPD, Asthma, Pneumonia n n n Neurologic: Raised intracranial pressure (ICP) Delirium Memory loss: age, electrode placement, frequency Nuisance effects: Headache, nausea, fatigue, etc. Myalgias: succinylcholine: Enzyme deficiency n Airway, anticipate intubation problems 31

32 CNS Issues n Intracranial mass or SOL: n If CNS exam = Normal, No edema & mass effect, à OK for ECT. n If vascular intracranial mass: high risk if RPP! n Neurology, neurosurgery, anesthesia: consults recommended n Lesions < 10 mm are generally OK. n IV β-blockers & nitroprusside used to reduce 32 RPP.

33 Stroke n Cerebrovascular disease: little data n ECT: No lasting effect; transient delirium in ¼ n If fresh stroke, worry about ischemia with BP & hemorrhage with BP; tight control during ECT. n 5/14 were done within a month of stroke n Recommendation: Delay 1 mth post stroke n Anticipate 25mm rise in systolic & diastolic BP n No clear guidelines for Rx >140/90 33

34 Question n On the morning of ECT, the following medications must be held: n Aspirin n Statins n Antihypertensives n Antianginal agents n Antiepileptic medications 34

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36 ECT, Anesthesia: Drug Interactions n Antidepressants and ECT combine safely and beneficially. n MAOIs: CAUTION! especially irreversible. n Anticonvulsants and mood stabilizers, lithium: risk of delirium and/or organic syndromes developing. Concerns with valproate, carbamazepine, lamotrigine, gabapentin and topiramate may inhibit seizure activity. Carbamazepine may prolong the action of succinylcholine. Naguib M, Koorn R : Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management. CNS Drugs. 2002;16(4):229-47

37 ECT, Anesthesia: Drug Interactions n Antipsychotics and ECT is well tolerated, and may in fact be beneficial. n Anxiolytics, benzodiazepines are anticonvulsants : may lower therapeutic efficacy of ECT. n CNS stimulants prolong seizures; arrythmias & elevate BP. n Calcium channel blockers: cautiously to avoid cardiac depression. Naguib M, Koorn R : Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management. CNS Drugs. 2002;16(4):229-47

38 Continuation & Maintenance ECT n MECT: Vital tool for psychiatrists n Effective for prophylaxis in medicationresistant, refractory, or intolerant patients. n Reduces relapse, recurrence, and rehospitalization in recurrent mood, thought, or motor-function disorders. Elderly depressed respond particularly well. n Efficacious, well-tolerated, relatively safe, & cost-effective when appropriately used for maintenance therapy.

39 Areas of Mental Competence Martin, B.A., J of ECT 1994;(4): n Evidencing a choice Awareness of requirement Ability to express preference and choice n Understanding Benefits vs. risks of treatment and alternatives n Reasoning Concern for own well-being and wish to recover Absence of delusions n Appreciation Awareness of illness and need for treatment Consequences of no treatment Awareness of role of the doctor in the treatment 39

40 Repeat or Renewed Consent For an index course: show significant response after 15 treatments, another medical opinion should be sought. For a maintenance course: obtained after six months or fifteen treatments 40

41 ECT & Memory Impairment n Autobiographical memory impairment occurs with ECT. n Objectively memory loss is relatively short term (6 months post treatment), n Subjectively amnesia is more persistent (96 months post-ect). n ECT predominantly affects memory of prior personal events that are near the treatment (within 6 months). n Autobiographical memory loss is reduced by: Brief pulse vs. sine wave Unilateral vs. bilateral; Titrating to the patient s own seizure threshold. 41

42 Factors affecting Cognition in ECT n n n n n n ECT Factors: Electrical stimulus Electrical waveform Electrode placement Stimulus dosing Frequency of treatments Number of treatments. Patient factors age premorbid intellect Both anterograde and retrograde memory impairments. Study of non-memory cognitive functions relatively neglected. Considerable recovery seen within weeks of treatment completion Data lacking in the longer term. 42

43 Memory & Bifrontal ECT n Use of BF ECT increasing rapidly, research to date is concerned with its clinical efficacy. n Limited studies : cognitive side-effect profile n Majority limited: tests memory and global cognitive functions. n BF ECT affects the frontal lobes. n Research on prefrontal cortex, specifically executive functions is needed. 43

44 Anesthesia & Cognition in ECT n Cognitive outcome after ECT may be improved by the use of an appropriate anesthetic agent. n Paradigm shift for anesthetists. n Anesthetic agents à effects on seizure parameters & emergence and reorientation after anesthesia and ECT treatment. n Studies now needed. e.g. use of short acting opioids and ketamine in ECT anesthesia. 44

45 Cognition in ECT: Over age 55 Review studies: : ECT and cognition in the elderly Minimum or mean age 55 years Valid measure of cognition before and after ECT. Results n 9/15 eligible studies were focused exclusively on the elderly. n 3 reported verbal learning and recall problems post ECT, n 3 found positive effects of ECT on memory, speed of processing and concentration. n Global cognitive functioning in patients with cognitive impairment improved in all studies. n At follow up, most studies reported improvement of cognitive functions. Learning verbal information and executive functioning were impaired in M-ECT patients whereas global cognition remained stable after M-ECT over a year. Conclusions Research is very limited. Urgently needed. 45

46 Cognition in ECT: Elderly n 27 studies examined: n Results: Interictal slowing of processing speed Mixed results with cognitive domains Factors : n unilateral, bilateral, or mixed e - placement; n Patients with dementia n Small sample sizes n Tests insensitive to subtle cognitive changes. n Conclusions: Effect of ECT in elderly = unclear n More critically selected methodology required. n Recommend: Clinicians regularly administer brief focused cognitive 46 tests before, during, and after treatment to monitor progress.

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