Is ECT Appropriate for Dementia-Associated Agitation?

ORLANDO—Electroconvulsive therapy (ECT) is a safe and effective treatment for refractory agitation in patients with dementia, including those with several medical comorbidities, according to data presented at the 2014 Annual Meeting of the American Association for Geriatric Psychiatry.

The study provides evidence for the short-term safety and efficacy of ECT, but no long-term data are available, said Yilang Tang, MD, PhD, an instructor at Emory University in Atlanta. He and his colleagues conducted a retrospective chart review of 38 patients with dementia who received ECT for agitation at Emory University’s Wesley Woods Geriatric Hospital in 2012.

On admission, patients were taking an average of six psychotropic medications. For half of the patients, the six medications included two or more antipsychotic agents. The participants had an average of 6.2 Axis III diagnoses. Patients received a mean of 10.2 and median of six ECT treatments. The ECT was performed initially with right unilateral electrode placement in 35 of 38 patients. Six patients were switched to bifrontal placement after four to six sessions because of poor response.

Agitation Scores Decreased by Eight Points
Participants’ mean baseline total Pittsburgh Agitation Scale score was 9.2. At discharge, after an average length of stay of 26 days, all patients demonstrated a significant reduction in their agitation scores. The median change from baseline was an 8-point decrease. Two patients had transient increases in their agitation score (one patient’s score increased from 7 to 11, and another’s increased from 3 to 7), but they improved with maintenance ECT after their acute course of therapy.

In addition, patients’ average number of psychotropic medications decreased from six at admission to five at discharge, according to Dr. Tang. Most patients were discharged after four to six ECT sessions, although seven patients received more than 12 treatments, which mostly were administered as outpatient maintenance therapy.

One patient experienced transient ECT-related delirium. No major treatment-related medical complications occurred, however. Seven patients had coronary artery disease, 24 patients had hypertension, three patients had a history of stroke, and three patients had heart failure.

Two of 38 patients were readmitted within one year after discharge, one of whom received another course of ECT. Although other patients may have been readmitted to other facilities, it seems unlikely that this outcome occurred often because patients’ surrogates were pleased with the post-ECT clinical improvement, said Dr. Tang.

ECT Is Not Indicated for Agitation
After Dr. Tang’s presentation, two geriatric psychiatrists discussed whether ECT has a legitimate role in treating agitation and other behavioral disturbances associated with dementia. “It’s an unconventional use of the therapy. I would say it would be a fairly rare occurrence. It should not be something that is done commonly,” said W. Vaughn McCall, MD, Professor and Case Distinguished Chairman of the Department of Psychiatry and Health Behavior at Georgia Regents University in Augusta.

“Remember, the FDA indication for ECT does not include that particular use, although like with medications, you have the right to use a device off label if you can justify it,” he added. “The key in justifying it is to make sure you’re treating the patient’s distress and [you’re not using it] for the benefit of the nursing home staff. If you’re going to use ECT for a patient with dementia-associated agitation, it needs to be crystal clear that this is being done for the benefit of the patient, that the patient is in distress, and if you can also make the case that there is a concurrent depression along with the major neurocognitive disorder, then possibly you could justify using ECT if all other options have been exhausted.”

“We do recommend ECT for patients with major neurocognitive disorders, either in instances where they have severe or treatment-resistant depression in the context of Alzheimer’s disease—where they tend to respond very well—or on rare occasions in treatment-resistant agitation,” said George T. Grossberg, MD, Professor of Neurology and Psychiatry at Saint Louis University School of Medicine. “After we’ve tried everything else possible and they’re just really difficult to manage, a trial of ECT may be warranted. It has a calming, dampening effect on agitation and irritability.

“One thing it’s important to keep in mind is that if you have depression in the context of Alzheimer’s disease and you decide to go with ECT because the depression is so severe or refractory, cognition will actually improve. When the depression starts to lift with the ECT, confusion and cognitive impairment will also improve. So, I would keep ECT on the agenda,” concluded Dr. Grossberg.

—Bruce Jancin

ORLANDO—Electroconvulsive therapy (ECT) is a safe and effective treatment for refractory agitation in patients with dementia, including those with several medical comorbidities, according to data presented at the 2014 Annual Meeting of the American Association for Geriatric Psychiatry.

The study provides evidence for the short-term safety and efficacy of ECT, but no long-term data are available, said Yilang Tang, MD, PhD, an instructor at Emory University in Atlanta. He and his colleagues conducted a retrospective chart review of 38 patients with dementia who received ECT for agitation at Emory University’s Wesley Woods Geriatric Hospital in 2012.

On admission, patients were taking an average of six psychotropic medications. For half of the patients, the six medications included two or more antipsychotic agents. The participants had an average of 6.2 Axis III diagnoses. Patients received a mean of 10.2 and median of six ECT treatments. The ECT was performed initially with right unilateral electrode placement in 35 of 38 patients. Six patients were switched to bifrontal placement after four to six sessions because of poor response.

Agitation Scores Decreased by Eight Points
Participants’ mean baseline total Pittsburgh Agitation Scale score was 9.2. At discharge, after an average length of stay of 26 days, all patients demonstrated a significant reduction in their agitation scores. The median change from baseline was an 8-point decrease. Two patients had transient increases in their agitation score (one patient’s score increased from 7 to 11, and another’s increased from 3 to 7), but they improved with maintenance ECT after their acute course of therapy.

In addition, patients’ average number of psychotropic medications decreased from six at admission to five at discharge, according to Dr. Tang. Most patients were discharged after four to six ECT sessions, although seven patients received more than 12 treatments, which mostly were administered as outpatient maintenance therapy.

One patient experienced transient ECT-related delirium. No major treatment-related medical complications occurred, however. Seven patients had coronary artery disease, 24 patients had hypertension, three patients had a history of stroke, and three patients had heart failure.

Two of 38 patients were readmitted within one year after discharge, one of whom received another course of ECT. Although other patients may have been readmitted to other facilities, it seems unlikely that this outcome occurred often because patients’ surrogates were pleased with the post-ECT clinical improvement, said Dr. Tang.

ECT Is Not Indicated for Agitation
After Dr. Tang’s presentation, two geriatric psychiatrists discussed whether ECT has a legitimate role in treating agitation and other behavioral disturbances associated with dementia. “It’s an unconventional use of the therapy. I would say it would be a fairly rare occurrence. It should not be something that is done commonly,” said W. Vaughn McCall, MD, Professor and Case Distinguished Chairman of the Department of Psychiatry and Health Behavior at Georgia Regents University in Augusta.

“Remember, the FDA indication for ECT does not include that particular use, although like with medications, you have the right to use a device off label if you can justify it,” he added. “The key in justifying it is to make sure you’re treating the patient’s distress and [you’re not using it] for the benefit of the nursing home staff. If you’re going to use ECT for a patient with dementia-associated agitation, it needs to be crystal clear that this is being done for the benefit of the patient, that the patient is in distress, and if you can also make the case that there is a concurrent depression along with the major neurocognitive disorder, then possibly you could justify using ECT if all other options have been exhausted.”

“We do recommend ECT for patients with major neurocognitive disorders, either in instances where they have severe or treatment-resistant depression in the context of Alzheimer’s disease—where they tend to respond very well—or on rare occasions in treatment-resistant agitation,” said George T. Grossberg, MD, Professor of Neurology and Psychiatry at Saint Louis University School of Medicine. “After we’ve tried everything else possible and they’re just really difficult to manage, a trial of ECT may be warranted. It has a calming, dampening effect on agitation and irritability.

“One thing it’s important to keep in mind is that if you have depression in the context of Alzheimer’s disease and you decide to go with ECT because the depression is so severe or refractory, cognition will actually improve. When the depression starts to lift with the ECT, confusion and cognitive impairment will also improve. So, I would keep ECT on the agenda,” concluded Dr. Grossberg.

—Bruce Jancin

ORLANDO—Electroconvulsive therapy (ECT) is a safe and effective treatment for refractory agitation in patients with dementia, including those with several medical comorbidities, according to data presented at the 2014 Annual Meeting of the American Association for Geriatric Psychiatry.

The study provides evidence for the short-term safety and efficacy of ECT, but no long-term data are available, said Yilang Tang, MD, PhD, an instructor at Emory University in Atlanta. He and his colleagues conducted a retrospective chart review of 38 patients with dementia who received ECT for agitation at Emory University’s Wesley Woods Geriatric Hospital in 2012.

On admission, patients were taking an average of six psychotropic medications. For half of the patients, the six medications included two or more antipsychotic agents. The participants had an average of 6.2 Axis III diagnoses. Patients received a mean of 10.2 and median of six ECT treatments. The ECT was performed initially with right unilateral electrode placement in 35 of 38 patients. Six patients were switched to bifrontal placement after four to six sessions because of poor response.

Agitation Scores Decreased by Eight Points
Participants’ mean baseline total Pittsburgh Agitation Scale score was 9.2. At discharge, after an average length of stay of 26 days, all patients demonstrated a significant reduction in their agitation scores. The median change from baseline was an 8-point decrease. Two patients had transient increases in their agitation score (one patient’s score increased from 7 to 11, and another’s increased from 3 to 7), but they improved with maintenance ECT after their acute course of therapy.

In addition, patients’ average number of psychotropic medications decreased from six at admission to five at discharge, according to Dr. Tang. Most patients were discharged after four to six ECT sessions, although seven patients received more than 12 treatments, which mostly were administered as outpatient maintenance therapy.

One patient experienced transient ECT-related delirium. No major treatment-related medical complications occurred, however. Seven patients had coronary artery disease, 24 patients had hypertension, three patients had a history of stroke, and three patients had heart failure.

Two of 38 patients were readmitted within one year after discharge, one of whom received another course of ECT. Although other patients may have been readmitted to other facilities, it seems unlikely that this outcome occurred often because patients’ surrogates were pleased with the post-ECT clinical improvement, said Dr. Tang.

ECT Is Not Indicated for Agitation
After Dr. Tang’s presentation, two geriatric psychiatrists discussed whether ECT has a legitimate role in treating agitation and other behavioral disturbances associated with dementia. “It’s an unconventional use of the therapy. I would say it would be a fairly rare occurrence. It should not be something that is done commonly,” said W. Vaughn McCall, MD, Professor and Case Distinguished Chairman of the Department of Psychiatry and Health Behavior at Georgia Regents University in Augusta.

“Remember, the FDA indication for ECT does not include that particular use, although like with medications, you have the right to use a device off label if you can justify it,” he added. “The key in justifying it is to make sure you’re treating the patient’s distress and [you’re not using it] for the benefit of the nursing home staff. If you’re going to use ECT for a patient with dementia-associated agitation, it needs to be crystal clear that this is being done for the benefit of the patient, that the patient is in distress, and if you can also make the case that there is a concurrent depression along with the major neurocognitive disorder, then possibly you could justify using ECT if all other options have been exhausted.”

“We do recommend ECT for patients with major neurocognitive disorders, either in instances where they have severe or treatment-resistant depression in the context of Alzheimer’s disease—where they tend to respond very well—or on rare occasions in treatment-resistant agitation,” said George T. Grossberg, MD, Professor of Neurology and Psychiatry at Saint Louis University School of Medicine. “After we’ve tried everything else possible and they’re just really difficult to manage, a trial of ECT may be warranted. It has a calming, dampening effect on agitation and irritability.

“One thing it’s important to keep in mind is that if you have depression in the context of Alzheimer’s disease and you decide to go with ECT because the depression is so severe or refractory, cognition will actually improve. When the depression starts to lift with the ECT, confusion and cognitive impairment will also improve. So, I would keep ECT on the agenda,” concluded Dr. Grossberg.

—Bruce Jancin