Among the concerns about ECT that have impeded efforts to "move it up on the treatment algorithm" are those having to do with cognitive effects. Cognitive effects should be considered a tolerability issue rather than a safety issue when it comes to ECT, but regardless, in this study, almost no differences were found with respect to cognitive effects between the three placements studied, he said.
One exception was with reorientation.
"Patients wake up much more easily from right unilateral ECT," he said, noting that this also appears true in the PRIDE study, which is an ongoing evaluation of right unilateral ultrabrief pulse ECT.
Right unilateral ultrabrief pulse ECT
Preliminary data from the PRIDE trial also suggest that right unilateral ultrabrief pulse ECT is extremely effective in elderly patients: Of the first 152 patients from that study, 62% experienced remission, 11% did not, and 27% dropped out of the study.
The patients in that multicenter study have a mean age of 70 years and severe depression.
An interesting finding is that a small percentage of patients "get completely well with a short course of ECT," Dr. Kellner said.
Although most require the usual treatment course and some might require a longer treatment course, some remit very quickly. Thus, it is inappropriate to prescribe a fixed number of treatments in advance.
Also, as has been well documented in other ECT studies, outcomes with right unilateral ultrabrief pulse ECT improve with age.
"The older you get, the better ECT works," he said.
Remission rates were 62%-67% for those aged 70-79 years and 80 years or older, compared with 59% for those aged 60-69 years.
An emerging ECT indication: agitation
Among newer indications for ECT in older patients is agitation in dementia, according to Dr. Robert M. Greenberg.
Dementia is generally not a contraindication to ECT, and although most data on ECT in dementia involve patients with comorbid depression and/or psychosis, many case reports and two small case series suggest that it is effective for agitation alone in patients with dementia, said Dr. Greenberg, director of geriatric services and chief of geriatric psychiatry and ECT services at Lutheran Medical Center, Brooklyn, N.Y.
Behavioral and psychological symptoms, including agitation, occurs at some point in up to 90% of patients with dementia, and agitation and aggression occur in 60%-80% of patients with Alzheimer’s disease. These symptoms account for much of the functional impairment, caregiver burden, hospitalization, and health care costs in dementia patients, and treatment options are limited, he said.
Case reports over the past 2 decades suggest that anywhere from two to eight courses of ECT result in up to 12 months of improvement in symptoms, in some cases with monthly maintenance ECT or repeat courses.
In the largest retrospective case series published to date, 15 of 16 patients who underwent a mean of nine treatments – mostly administered bilaterally – experienced improvement in symptoms, Dr. Greenberg said.
Patients in that study included eight patients with Alzheimer’s disease. Three had mild dementia, eight had moderate-to-severe dementia, and five had severe dementia. Only two patients experienced severe postictal confusion (Am. J. Geriatr. Psychiatry 2012;20:61-72).
Although the evidence base for ECT for agitation in dementia remains fairly weak, the existing data do provide some support for its use. In the cases reported, ECT was usually a last resort after failure of multiple pharmacologic and nonpharmacologic approaches, the impact of behavioral disturbance was severe, and reported benefits were usually of major clinical significance, Dr. Greenberg said, noting also that when addressed, global cognitive function was usually improved following ECT.
Thus, ECT is a reasonable option for dementia with severe agitation in cases after a careful diagnostic evaluation, including assessment for inciting/exacerbating causes, and after failure of behavioral and pharmacologic management.
In patients for whom ECT is deemed appropriate – and for whom proper consent is obtained – Dr. Greenberg recommended starting with titrated unilateral ultrabrief pulse stimulus (in nonemergent cases), and widening the treatment interval if the patients experience significant cognitive worsening.
ECT should be stopped when improvement plateaus, he said.
Also, consider an ECT taper to ensure stability of response and to allow for optimization of continuation pharmacotherapy, he said.
Continuation ECT can be considered if symptoms recur.
Environmental triggers of agitation also should be addressed, he said.
Dr. Petrides and Dr. Greenberg reported having no disclosures relevant to their presentations. Dr. Kellner reported receiving research support from the National Institute of Mental Health. He also reported serving as a paid contributor to UpToDate, a clinical decision support service and as a paid ECT course teacher at Northshore-LIJ Health System.