when & how to use ect in older adults€¦ · when & how to use ect in older adults frans...
TRANSCRIPT
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
