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
UK Psychiatric Hospital Mortality Rates in Depression Patients Aged 56 and Older 40 30 31% 46/149 1930-1939 1940-1948 26.5% 31/117 20 10 0 Treatment As Usual ECT Not Available ECT 3% 1/35 Kerner et al. Neuropsychiatry (2014) 4(1), 33 54
Predictors of ECT Response van Diermen, L., et al. (2018). Br J Psychiatry 212(2): 71-80
Lower Rehospitalisation Rates for Older Adults 15.1% Rehosp. Mean 232 days Median 81 days Range 1-1572 days Rosen, B. H., et al. (2016). J ECT 32(2): 93-98
Speed of Remission Elderly Patients with Depression: ECT v. Medication Spaans, H. P., et al. (2015). Br J Psychiatry 206(1): 67-71
Neuroimaging Findings & ECT MRI Medical temporal lobe atrophy (MTA) White matter hyper intensities (WMH) Global cortical atrophy (GCA)
Medial Temporal Lobe Atrophy (MTA) Oudega, M. L., et al. (2011). J Clin Psychiatry 72(1): 104-112
White Matter Hyperintensities (WMH) Oudega, M. L., et al. (2014). Am J Geriatr Psychiatry 22(2): 157-166
Memory & ECT Treatment 1 2 3 4 5 6 Retrograde Amnesia Anterograde Amnesia
Assessment of Memory Treatment 1 2 3 4 5 6 Autobiographical/Episodic Memory vs Semantic Memory Working Memory Visual Memory Verbal Memory Retrograde Amnesia Anterograde Amnesia
AMI-SF 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
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.
Efficacy & Cognitive Side Effects Hausner, L., et al. (2011). The Journal of Clinical Psychiatry 72(01): 91-97
Bifrontal ECT vs BT or RUL ECT MMSE Dunne, R. A. and D. M. McLoughlin (2012). World J Biol Psychiatry 13(4): 248-258
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
Right Unilateral Ultrabrief Pulse ECT in Geriatric Depression: Phase 1 of the PRIDE Study Kellner, C. H., et al. (2016). Am J Psychiatry 173(11): 1101-1109
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
PRESCRIPTION Options Best for OA Placement Pulse Width Dose RUL, BF, BT Ultra Brief 0.3 ms Brief 0.5 & 1 ms 0-1008 mc RUL Depends 0.3 ms Depends Just Above Seizure Threshold Frequency 2-3 x week Depends
PROCEDURE Options Best for OA Anaesthetic and Dose Timing of Anaesthetic Concurrent Medications Augmentation Strategies Propofol, Thiopentone Measure. Examine. Individualise. Antidepressants, Benzos, LiCO3 Remifentanil, Hyperventilation?Thiopentone About 2-4 min after start Antidepressant
MONITORING DURING A COURSE OF ECT 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
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