Case 1 Answer 6 ( Question 6—If she responds to ECT, what would you choose as a maintenance strategy?)
6.2.2 Case 2 Case 2 History
Mr. X. is a 90-year-old man from a long-term care home. He is followed by a geriatric psychiatrist in the community due to a history of recurrent, treatment-resistant depressive disorder with psychotic features and mild-to-moderate major neuro- cognitive disorder due to vascular disease. His psychiatrist, long-term care staff, and the patient’s family noted an increase in depressive mood symptoms over a period of 2 months with prominent irritability, affective lability, poor frustration tol- erance, verbal aggression, and social isolation. He was also refusing medications, food, and personal care. He was mildly suspicious about the motives of long-term care staff, but there were no overt psychotic symptoms. This presentation was in keeping with previous episodes of major depression.
Due to functional decline and symptom severity, Mr. X.
was hospitalized at an acute care hospital in the community.
During a one-and-a-half-month admission, the depressive symptoms failed to respond to the addition of duloxetine 60 mg daily and aripiprazole 3 mg daily. A brief course of ECT was attempted, and he responded well, but ECT was discontinued due to the patient’s perceived “frailty.” He was then transferred to a tertiary care hospital for consideration of the viability of a return to ECT and consideration of alter- natives.
His past psychiatric history is significant for several epi- sodes of major depressive disorder with psychotic features requiring hospitalization due to failed outpatient manage- ment and significant functional impairment. Acute and maintenance ECT had been used with success several times over the past 15 years. Although his depressive symptoms have been severe, Mr. X. has no history of suicide attempts.
There is no history of hypomania, mania, or psychosis in the absence of depressive symptoms. A diagnosis of mild- moderate, major neurocognitive disorder, vascular type, was
made 4 years ago. He now requires assistance with activities of daily living. He has consistently refused cognitive testing over the last several years.
Mr. X.’s medical history is quite extensive; he has had sev- eral falls secondary to intermittent hypotension and suffers from atrial fibrillation, hypertension, and congestive heart failure. He also has chronic renal failure and poor vision sec- ondary to glaucoma and cataracts. Recent intermittent food refusal has led to a decrease in weight from 110 lbs. (50 kg) to 84 lbs. (38 kg). He now uses a wheelchair as he is too deconditioned to ambulate independently. Recent laboratory investigations that accompanied Mr. X. show that a complete blood count with differential, electrolytes, extended electro- lytes, blood urea nitrogen, and creatinine are all within nor- mal limits.
Prior to ECT, he intermittently refused prescribed medi- cations due to irritability and suspiciousness. Following ECT, however, his adherence has improved, and his weight loss has stabilized. He is currently prescribed duloxetine 60 mg daily, aripiprazole 3 mg daily, furosemide 20 mg daily, metopro- lol 100 mg twice daily, apixaban 2.5 mg twice daily, digoxin 0.0625 mg daily, and vitamin B12 1000 mcg intramuscular injection every 4 weeks. Previous psychiatric medication tri- als have included paroxetine, citalopram, escitalopram, flu- voxamine, venlafaxine XR, amitriptyline, and clomipramine.
On mental status exam, Mr. X. is a very thin, small- statured man seen sitting in a wheelchair quietly. Eye contact is appropriate, and his speech is slow and quiet. His attitude is dismissive. He reports his mood as “so-so” and has several vague complaints about physical discomfort and the hospital staff. He is mildly irritable. His thought content is vague, and he is unable to accurately discuss recent events but alludes to some accurate details regarding his personal history. There is no evidence of psychosis, and he adamantly denies suicidal ideation. Cognition, although not formally tested, appears to be impaired. Insight and judgment are poor.
Case 2 Questions and Answers Case 2 Questions
?Question 1. What are the indications for ECT in Mr. X.’s case?
?Question 2. You are considering a return to ECT to com- plete the treatment of Mr. X.’s major depressive episode.
Which elements of the history would you pursue further?
What would your pre-ECT work-up include?
?Question 3. Do aging and increased frailty affect the viability of ECT?
?Question 4. It can be difficult to differentiate premorbid mood or anxiety disorder symptoms from behavioral and psychological symptoms (or neuropsychiatric symp- toms) associated with a neurocognitive disorder. Can behavioral and psychological symptoms be successfully treated using ECT? What are the effects on cognition in this population?
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Case 2 Answers
Case 2 Answer 1 (Question 1—What are the indications for ECT in Mr. X.’s case?)
ECT is an important treatment for severe and treatment- resistant depression when multiple pharmacological trials have failed and when a rapid response is necessary [75].
Rapid ECT initiation should be considered in cases of active suicidal ideation and behavior, severe weight loss, malnutri- tion or dehydration, overall worsening medical status, and psychosis.
In Mr. X.’s case, symptoms of major depressive disorder were initially causing mental suffering and are affecting his adherence to medications and preventing adequate nutri- tional intake. Physical deterioration in the form of a 26-lb.
weight loss and the new inability to ambulate were concern- ing signs of declining physical health. Mr. X. was at risk for further mental and physical deterioration if his depressive symptoms did not rapidly improve. The initial indication for ECT appears to have been good. His current state, however, is somewhat improved, with less distress and a stabilization of his nonadherence to treatment and his weight loss. There appears to be less urgency to return to ECT at this point.
Mr. X. does, however, have a history of many failed medi- cation trials for past depressive episodes and has required maintenance ECT in the past. Mr. X.’s history indicates that he has always had a robust response to ECT. A history of bet- ter response to ECT than to pharmacological management is another instance in which ECT is indicated. A return to maintenance ECT could be indicated based on past response, but the risks and benefits of this approach need to be care- fully considered.
Teaching Point
ECT is the treatment of choice when there is clinical urgency and a need for a rapid response. Past response to ECT is another important indication.
Case 2 Answer 2 (Question 2—You are considering a return to ECT to complete the treatment of Mr. X.’s major depressive episode. Which elements of the history would you pursue fur- ther? What would your pre-ECT work-up include?)
Prior to initiating ECT, an evaluation by an ECT psychia- trist should be conducted to ensure that ECT is the appropri- ate treatment option for the patient. The consultation serves three main functions: (i) to verify that the patient has an ECT-responsive diagnosis of adequate severity to warrant the treatment, (ii) to assess the patient’s general medical his- tory and current general medical status in order to maximize safety during the treatment, and (iii) to begin the consent process [75].
Mr. X.’s current major depressive episode has resulted in significant weight loss (though this is now stabilized), and he is potentially at risk for further physical deterioration. He has only intermittently been adherent to medications and has a history of inadequately responding to pharmacological
interventions. Acute and maintenance ECT have been suc- cessful at managing Mr. X.’s depressive symptoms in the past.
All of these factors are indications supporting the use of ECT to treat Mr. X.’s residual symptoms of major depressive disor- der and to consider a transition to maintenance ECT. Before ECT can be initiated, Mr. X.’s medical history and current medical status must be evaluated, and informed consent must be obtained.
Prior to prescribing and initiating a course of ECT, the operating psychiatrist, medical consultants, and anesthe- siologists should work collaboratively prior to and during a course of ECT. A thorough psychiatric history including previous response to ECT, a medical history, and physical examination with focus on the cardiovascular, respiratory, neurological, and musculoskeletal systems must be con- ducted. A history of dental problems and examination for loose or missing teeth is also indicated as well as eliciting a history of experience with anesthesia use both personally and within the family [14].
Mr. X. has an extensive medical history with several cardiac and cardiovascular risk factors. His medical history includes glaucoma, cataracts, and chronic renal failure, and his cardiac and cardiovascular risk factors include intermit- tent hypotension, atrial fibrillation, hypertension, and con- gestive heart failure. There is no available information about the recent course of ECT other than that it was discontinued due to “frailty.” In this case it would be important to contact Mr. X.’s last treating psychiatrist to inquire about the most recent course of ECT. Important questions to ask include:
What electrode placement and pulse width was used? Were there any adverse effects? How was it tolerated? Was there perceived benefit? How many treatments did he receive, and, finally, why were the treatments discontinued? This inquiry may result in valuable information about Mr. X.’s health and inform the decision as to whether he is a suitable candidate for ECT. It is also important to review the patient’s current medications as certain medications can negatively impact the efficacy of ECT, patient safety, and post-ECT recovery.
As part of the pre-ECT evaluation, a physical examina- tion was performed and revealed the following: Mr. X.’s blood pressure was 149/88 mm Hg, and his heart rate was 77 beats/minute and irregularly irregular. Respiratory rate was 16 breaths/minute, and his oxygen saturation was 98%
on room air. He did not appear to be in any distress. The car- diovascular examination revealed a 2/6 mid systolic ejection murmur in the aortic area. Capillary refill time was delayed and there was evidence of 2+ (moderate pitting) bilateral pedal edema. The lungs were bilaterally clear to auscultation.
Musculoskeletal examination was significant for kyphosis.
Other than diffuse, symmetrical weakness, the neurological examination was normal.
Although there are no routine laboratory tests recom- mended, generally performed tests include a complete blood count, serum chemistry with sodium and potassium, as well as an electrocardiogram. A chest x-ray can be considered in patients with cardiovascular or pulmonary disease or with a history of smoking [15]. Testing of cerebral functioning,
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including electroencephalography and/or neuropsychologi- cal assessment, can be ordered on an individualized basis if there are specific concerns. Spinal radiographs should also be considered in patients with known or suspected spinal disease. When the risks of ECT in the setting of the existing medical disease are unclear, further testing or consultation should be considered.
Laboratory investigations were repeated as a part of the pre-ECT assessment for Mr. X. The complete blood count and differential were within normal limits. Serum chem- istry was within normal limits except for a mildly elevated creatinine. An electrocardiogram revealed atrial fibrillation at a rate of 75 beats/minute. There was evidence of an old infarct, and the QTc interval was 445 milliseconds. As there was no suspected spinal disease, a spinal radiograph was not performed. A CT of the brain was available from his commu- nity hospital, where it had been performed after a fall 1 year prior to the current admission. It revealed diffuse, moder- ate cerebral microvascular disease and mild diffuse atrophy.
There was no evidence of stroke or space-occupying lesions.
In order to establish a cognitive baseline, cognitive testing was attempted, but Mr. X. was uncooperative.
A telephone conversation with Mr. X.’s last outpatient psychiatrist revealed the following information about his previous course of ECT: ECT was initiated to treat the major depressive episode as his symptoms failed to respond to med- ications, and he had previously been successfully treated with ECT. Due to concerns about weight loss and malnutrition, bitemporal lead placement and brief pulse width were used in an effort to elicit a rapid response. Mr. X. showed improve- ment after three treatments and continued to improve clini- cally over the course of eight treatments. He became less suspicious, and adherence to medications and food intake improved. He seemed less irritable and more consistently able to enjoy visits from his family, although some irritability and negativity persisted.
His last outpatient psychiatrist went on to explain that during his eighth ECT treatment, he developed a supraven- tricular tachycardia in the ECT suite and subsequently had respiratory arrest in the ECT recovery area; he was rapidly resuscitated with no sequelae. The incident was reviewed with his outpatient psychiatrist, ECT psychiatrist, and the anesthesiologist. Risks and benefits of ongoing treatment were reviewed, and Mr. X.’s surrogate decision maker was contacted. The treating team and Mr. X.’s surrogate decision maker felt that the risks outweighed the benefits of treatment and ECT was discontinued. It was at this point that he was referred to the tertiary care center for consideration of the viability of a return to ECT.
Patients with systemic medical conditions that predis- pose them to increased risk during ECT may benefit from a specialist consultation to comment further on their suitabil- ity. Due to his recent cardiac event during ECT, Mr. X. was referred to cardiology to assess the cardiac risks associated with a potential return to ECT. After an evaluation, the car- diologist stated that Mr. X. remained at high risk for future adverse events if ECT were continued. After consultation
with his surrogate decision maker, lithium 150 mg at night was initiated for relapse prevention, with an aim to maintain serum levels around 0.4 mmol/L (mEq/L).
Teaching Point
In general, ECT is safe and effective in even the frail geri- atric patients. There are circumstances, however, when the risks are deemed to outweigh the benefits and con- sideration of alternatives is necessary. These situations involve consultation, collaboration, and consideration of the values and priorities of the patient.
Teaching Point
An antidepressant in combination with lithium is a more effective strategy for relapse prevention than an antide- pressant alone. The tolerability of this approach must be considered on an individual basis.
Case 2 Answer 3 (Question 3—Do aging and increased frailty affect the viability of ECT?)
Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes including falls, incident disability, hospitalization, and mortality (See 7Chap. 1 for further details on frailty). It is defined as a clini- cally recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors. Frailty is associated with increasing age and has been estimated to affect up to 12% of older individuals in the USA [76].
There is no upper age limit for the use of ECT; older age is a positive predictor of response to ECT. In a study of ECT in the very old, 86.3% of patients had a favorable response to ECT, and the rate of complications was 22.7%, lower than the previously cited rates of 27–77% [77]. In geriatric patients with depression, ECT results in faster and higher remission rates compared to depression treatment with pharmacotherapy [78].
However, ECT in older adults does present some chal- lenges. While older age itself is not a risk factor for mortal- ity associated with ECT, older adults may be at greater risk because of a higher prevalence of medical comorbidity (See 7Chap. 1). There are no absolute contraindications to the use of ECT, but when considering the medical risks, the car- diovascular system, the respiratory system, and the central nervous system are of importance.
Conditions associated with increased risk during ECT include brain lesions with increased intracranial pressure, hematoma, cerebral aneurysm, and other cerebrovascular malformations. High anesthetic risk (American Society of Anesthesiologists level 4 or 5), pheochromocytoma, poorly compensated congestive heart failure, recent intracerebral stroke/hemorrhage, recent myocardial infarction, severe car- diac valvular disease, severe chronic obstructive pulmonary
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disease, asthma, or pneumonia may also predispose to increased risk with ECT.
Patients with cardiac disease have a significantly higher rate of cardiac complications during ECT compared to those without disease due to physiologic changes in heart rate and cardiac output during ECT. Vulnerable patients may experience transient cardiac arrhythmias or sinus arrest.
Controlling hypertension and optimizing congestive heart failure treatment prior to ECT may help prevent transient ischemic changes and rates of complications. Surgical treat- ment may be required to correct anatomic problems asso- ciated with large aneurysm or severe valvular heart disease before ECT. Although complication rates are higher than among younger patients, they must be interpreted in the context of the illness and potential complications of alternate treatments, as well as the potential consequences of no treat- ment at all [78].
Mr. X. is an example of a patient who has had a robust response to ECT but in whom increasing age and cardiac risk factors pose an increased risk. While it is likely that he will once again respond to treatment, the risk of a seri- ous adverse event is higher than when ECT was used in the past. Important factors to consider in such cases are (i) the urgency of the required treatment, (ii) the availability and viability of other treatment options, and (iii) the nature of the risk associated with ECT.
For Mr. X., this evaluation would include an examination of his current medical and psychiatric status. Is he at risk for acute physical deterioration due to refusal of oral intake or medication nonadherence? Does the level of mental suffering need to be urgently addressed? Is he at risk for acute harm to himself or others? Other treatment options and their relative risks and benefits in comparison to ECT must be considered.
In this case, all treatment trials should be reviewed. Have all possible medications been tried? Is there anything that has had modest benefit in the past than can be revisited? And finally, if Mr. X. were to be treated with ECT, what are the adverse outcomes that may result?
Mr. X. has had significant weight loss and decondition- ing because of the major depressive episode, now partially treated. Although he has deteriorated physically, his vital signs are stable, and the laboratory investigations are gener- ally within normal limits except for a mildly elevated serum creatinine indicating dehydration. Therefore, he is likely not at an acute risk for systemic medical decompensation.
Psychiatric evaluation reveals no suicidal or homicidal ide- ation. His affect remains irritable, and his thought content is somewhat negative, but he remains improved after the ECT course. His weight loss has stabilized, and his adher- ence to treatment is more consistent. Finally, the extent of the risk associated with ECT must be considered. History and physical examination reveals cardiac disease and a history of a serious cardiac incident and respiratory arrest during the last ECT treatment. These factors increase the likelihood of adverse events with ECT.
Clinically, one must assess whether Mr. X.’s symptoms warrant the use of a procedure with the risk of severe cardiac and respiratory complications and potentially even death. As Mr. X. is not acutely medically compromised and his psy- chiatric symptoms are not causing severe distress, the risks of ECT were judged to outweigh the risks of ongoing medi- cal management at the present time. However, if his clinical status deteriorated rapidly and emergent treatment with ECT was necessary, the risks and benefits of treatment with ECT might be analyzed differently. In the face of a life-threatening clinical situation, a return to ECT might make sense despite the associated risks. A return to ECT would need to be dis- cussed carefully with Mr. X.’s surrogate decision maker, and informed consent would need to be obtained prior to initiat- ing treatment.
Teaching Point
There are no absolute contraindications for ECT, but some conditions are associated with increased risk. ECT can be done in most patients, but the benefits must be weighed against the potential risks. Collaborative decision-making with patients and surrogate decision makers is essential.
Case 2 Answer 4 (Question 4—It can be difficult to differenti- ate premorbid depressive or anxiety disorder symptoms from behavioral and psychological symptoms (or neuropsychiatric symptoms) associated with a major neurocognitive disorder.
Can behavioral and psychological symptoms be successfully treated using ECT? What are the effects on cognition in this population?)
Major neurocognitive disorder is one of the major causes of disability in the geriatric population. Behavioral and psy- chological symptoms of major neurocognitive disorder refer to the distressing, non-cognitive symptoms of major neuro- cognitive disorder, which includes agitation or restlessness, wandering and hoarding, verbal or physical aggression, anxi- ety, depression, psychosis, and/or repetitive vocalizations. It can be observed in up to 90% of patients with major neuro- cognitive disorder.
A growing body of literature has identified ECT as an effective intervention for severe refractory agitation in patients with major neurocognitive disorder [53, 79, 80].
However, trials comparing the efficacy of ECT and antipsy- chotic drugs for treatment of patients with major neurocog- nitive disorder with severe behavioral disturbances have yet to be done [81].
There has been concern surrounding the cognitive ability of geriatric patients receiving ECT, but cognitive impairment per se should not necessarily exclude recommendations for ECT in geriatric patients. Certain geriatric patients with baseline cerebral impairment may be at greater risk of more prolonged disorientation and/or the development of
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