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Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder) – a promising option

Published online by Cambridge University Press:  18 January 2017

Oliver M. Glass*
Affiliation:
East Carolina University and Vidant Medical Center, Greenville, NC, 27834, USA
Brent P. Forester
Affiliation:
Division of Geriatric Psychiatry McLean Hospital, Behavioral Health Integration, Center for Population Health, Partners HealthCare, Harvard Medical School, Boston, MA, USA
Adriana P. Hermida
Affiliation:
Department of Psychiatry and Behavioral Science, Geriatric Psychiatry Fellowship, Emory University, Atlanta, Georgia, USA
*
Correspondence should be addressed to: Oliver M. Glass, MD, East Carolina University, 905 Johns Hopkins Drive, Greenville, NC 27834, USA. Phone: 252-744-1406; Fax: 252-744-2419. Email: oliver.glass@gmail.com.

Abstract

Background:

Agitation in patients with dementia increases caretaker burden, increases healthcare costs, and worsens the patient's quality of life. Antipsychotic medications, commonly used for the treatment of agitation in patients with dementia have a box warning from the FDA for elevated mortality risk. Electroconvulsive therapy (ECT) has made significant advances over the past several years, and is efficacious in treating a wide range of psychiatric conditions. We provide a systematic review of published literature regarding the efficacy of ECT for the treatment of agitation in patients with dementia (major neurocognitive disorder).

Methods:

We searched PubMed, Medline, Google Scholar, UptoDate, Embase, and Cochrane for literature concerning ECT for treating agitation in dementia using the title search terms “ECT agitation dementia;” “ECT aggression dementia;” “ECT Behavior and Psychological Symptoms of Dementia;” and “ECT BPSD.” The term “dementia” was also interchanged with “Major Neurocognitive Disorder.” No time frame restriction was placed. We attempted to include all publications that were found to ensure a comprehensive review. We found 11 papers, with a total (N) of 216 patients.

Results:

Limited to case reports, case series, retrospective chart review, retrospective case-control, and an open label prospective study, ECT has demonstrated promising results in decreasing agitation in patients with dementia. Patients who relapsed were found to benefit from maintenance ECT.

Conclusions:

Available studies are often limited by concomitant psychotropic medications, inconsistent use of objective rating scales, short follow-up, lack of a control group, small sample sizes, and publication bias. A future randomized controlled trial will pose ethical and methodological challenges. A randomized controlled trial must carefully consider the definition of usual care as a comparison group. Well-documented prospective studies and/or additional case series with explicit selection criteria, a wide range of outcome measures, and less selection bias of the study sample that may favor treatment response, is warranted. ECT may be a promising option for the treatment of aggression and agitation in patients with severe dementia who are refractory to other treatment options, but the limitations of available studies suggest that a cautious approach to future randomized controlled trials is warranted.

Type
Review Article
Copyright
Copyright © International Psychogeriatric Association 2017 

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References

Acharya, D. et al. (2015). Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. International Journal of geriatric psychiatry, 30, 265273.CrossRefGoogle ScholarPubMed
Akcaboy, Z. N. et al. (2005). Effects of remifentanil and alfentanil on seizure duration, stimulus amplitudes and recovery parameters during ECT. Acta Anaesthesiologica Scandinavica, 49, 10681071.CrossRefGoogle ScholarPubMed
Aksay, S. S., Bumb, J. M., Janke, C., Hoyer, C., Kranaster, L. and Sartorius, A. (2014a). New evidence for seizure quality improvement by hyperoxia and mild hypocapnia. The Journal of ECT, 30, 287291.Google Scholar
Aksay, S. S., Hausner, L., Frolich, L. and Sartorius, A. (2014b). Severe agitation in severe early-onset alzheimer's disease resolves with ECT. Neuropsychiatric Disease and Treatment, 10, 21472151.Google Scholar
Bang, J., Price, D., Prentice, G. and Campbell, J. (2008). ECT treatment for two cases of dementia-related pathological yelling. The Journal of Neuropsychiatry and Clinical Neurosciences, 20, 379380.Google Scholar
Burgut, F. T., Popeo, D. and Kellner, C. H. (2010). ECT for agitation in dementia: is it appropriate? Medical Hypotheses, 75, 56.CrossRefGoogle ScholarPubMed
Carlyle, W., Killick, L. and Ancill, R. (1991). ECT: an effective treatment in the screaming demented patient. Journal of the American Geriatrics Society, 39, 637.CrossRefGoogle ScholarPubMed
Devanand, D. P., Verma, A. K., Tirumalasetti, F. and Sackeim, H. A. (1991). Absence of cognitive impairment after more than 100 lifetime ECT treatments. American Journal of Psychiatry, 148, 929932.Google ScholarPubMed
Dinwiddie, S. H., Glick, D. B. and Goldman, M. B. (2012). The effect of propofol-remifentanil anesthesia on selected seizure quality indices in electroconvulsive therapy. Brain Stimulation, 5, 402407.CrossRefGoogle ScholarPubMed
Grant, J. E. and Mohan, S. N. (2001). Treatment of agitation and aggression in four demented patients using ECT. The journal of ECT, 17, 205209.CrossRefGoogle ScholarPubMed
Holmberg, S. K., Tariot, P.N. and Challapalli, R. (1996). Efficacy of ECT for agitation in dementia: a case report. American Journal of Geriatric Psychiatry, 4, 330334.Google Scholar
Janke, C., Bumb, J. M., Aksay, S. S., Thiel, M., Kranaster, L. and Sartorius, A. (2015). Ketamine as anesthetic agent in electroconvulsion therapy. Der Anaesthesist, 64, 357364.CrossRefGoogle ScholarPubMed
Joshi, S. H. et al. (2016). Structural plasticity of the hippocampus and amygdala induced by electroconvulsive therapy in major depression. Biological Psychiatry, 79, 282292.CrossRefGoogle ScholarPubMed
Krystal, A. D., Watts, B. V., Weiner, R. D., Moore, S., Steffens, D. C. and Lindahl, V. (1998). The use of flumazenil in the anxious and benzodiazepine-dependent ECT patient. The Journal of ECT, 14, 514.Google Scholar
McClintock, S., Staub, B. and Husain, M. (2011). The effects of electroconvulsive therapy on neurocognitive function in elderly adults. Annals of Long-Term Care: Clinical Care and Aging, 19, 3238.Google Scholar
Peters, M. E. et al. (2015). Neuropsychiatric symptoms as predictors of progression to severe Alzheimer's dementia and death: the cache county dementia progression study. The American Journal of Psychiatry, 172, 460465.CrossRefGoogle ScholarPubMed
Reti, I. M. et al. (2014). Predictors of electroconvulsive therapy postictal delirium. Psychosomatics, 55, 272279.Google Scholar
Singh, P. M., Arora, S., Borle, A., Varma, P., Trikha, A. and Goudra, B. G. (2015). Evaluation of etomidate for seizure duration in electroconvulsive therapy: a systematic review and meta-analysis. The Journal of ECT, 31, 213225.Google Scholar
Sutor, B. and Rasmussen, K. G. (2008). Electroconvulsive therapy for agitation in Alzheimer disease: a case series. The Journal of ECT, 24, 239241.CrossRefGoogle ScholarPubMed
Tang, Y., Hermida, A., Khanh, H., Laddha, S. and McDonald, M. (2014). Efficacy and safety of ect for behavioral and psychological symptoms in dementia (BPSD): a retrospective chart review. American Journal of Geriatric Psychiatry, 22, S114S115.CrossRefGoogle Scholar
Ujkaj, M., Davidoff, D. A., Seiner, S. J., Ellison, J. M., Harper, D. G. and Forester, B. P. (2012). Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia. The American Journal of Geriatric Psychiatry : Official Journal of the American Association for Geriatric Psychiatry, 20, 6172.CrossRefGoogle ScholarPubMed
Wu, Q., Prentice, G. and Campbell, J. J. (2010). ECT treatment for two cases of dementia-related aggressive behavior. The Journal of Neuropsychiatry and Clinical Neurosciences, 22, E10–E11.Google Scholar
Zhang, Q. E. et al. (2016). Demographic and clinical profile of patients with dementia receiving electroconvulsive therapy: a case-control study. The Journal of ECT. 32, 183186.Google Scholar