The Use of Electroconvulsive Therapy In The Elderly Depressed Population
Current and Historical Sources of Controversy
For reasons including, but not limited to, chronic health conditions, increased lack of independence, social isolation, and existential angst, the elderly population (in most studies a time frame beginning at about age fifty-five) is particularly prone to depressive symptomology including Major Depressive Episodes, Dysthymia, and Adjustment Disorders. This is increasingly true with advances in modern medical technology that often extend the length of life without necessarily increasing the quality of life amongst the elder population. It is for these reasons that efficacious and safe treatment of depression within the Gerontology field is of particular concern to mental health clinicians, elderly mental health patients, and the public at large.
Across nearly all developed countries the risk of suicide increases as people reach late adulthood, particularly beginning at age 65. The demographic most likely to commit suicide is males over the age of 75. The demographic next most likely to commit suicide is males ages 65-74 (Suicide.org., 2005). While female completion of suicide occurs at a much lower rate than in men, women do attempt suicide at a rate about double that of their male counterparts (Shah, A., Bhat, R., McKenzie, S., & Koen, C. 2009). These statistics make the implementation of effective interventions for the remediation of depression a concern of tremendous importance. This concern is only further amplified when one considers the ever expanding demographic shift in age within the U.S. population. Nationalatles.gov reported that 35 million people in the U.S. were over 65 years of age according to the U.S. census in 2000. This trend has continued as 40.3 million people over the age of 65 were reported in the 2010 U.S. census. The “baby-boomer,” generation, born in the prosperity following WWII, is beginning to transition to retirement status and face the phase of life conditions and obstacles associated with increased age. As this happens the prominence of this issue concerning safe and effective treatment for depression for older clients has only become a more pressing matter.
As to the psychopharmacological approaches to treating depression in the elderly population some issues have been raised concerning potentially dangerous side-effects, including stroke, renal complications, gastrointestinal bleeding, and delirium for certain classes of anti-depressants (Weise, 2011). In one study SSRI’s were found to be potentially more capable of causing these types of side-effects than were older Tricyclic Antidepressants (Coupland CA, Dhiman P, Barton G, et al., 2011). Unfortunately Tricylics carry their own set of potential complications for the elderly population. These can include postural hypotension, cardiac problems, and anticholinergic effects (Weise, 2011). Postural hypotension leads directly to an increased number of falls. This is one of the leading causes of injury and potentially expensive and invasive surgeries, such as hip replacements, in the elderly population.
The other main, non-pharmaceutic intervention, Electroconvulsive Therapy (ECT) seems on face value to be a risky treatment strategy with older, possibly already cognitively impaired seniors. This concern has a two-fold etiology; firstly, memories of ECT in its earliest administrations still leave a legacy of public and professional perception of the practice as dangerous, experimental, and somewhat rebarbative. Secondly, the already frail condition of senior populations, including cognitive frailty, seems to argue against invasive electrical disruptions to the brain. Furthermore, the precise mechanism of action in depression alleviation via ECT is still unknown (Hausner, L. L., Damian, M. M., & Sartorius, A. A., 2011).
Despite these concerns, ECT is consistently found to be a somewhat more efficacious treatment for depressive symptomology than is Pharmacology (Salzman, C., Wong, E., & Wright, B., 2002). And so the questions regarding ECT’s therapeutic advantages in depression amelioration must be weighed in consideration of possible adverse cognitive side-effects in a population that is frail and often already coping with a plethora of medical issues. These medical issues may include cognitive impairments that, in some cases, may render an individual not fully capable of giving informed consent to such a seemingly invasive therapeutic intervention. This raises yet another issue, one pertaining to Ethics, in the already complex controversy concerning the use of ECT for the treatment of depression in the geriatric population.
Argument for ECT Use in the Elderly
Modern ECT little resembles the images and dangers associated with ECT in its earliest inception. Application of modern, well regulated electronic current (usually bilaterally) to the brain is now accompanied by the administration of muscle relaxants and anesthesia. This allows for a much safer and also less visually disturbing procedure than the images left in our minds by films of early ECT treatment. And while the exact effective mechanism remains only theoretical, the statistically consistent and often dramatic relief that modern ECT provides depressed patients cannot reasonably be disputed. Most elderly depressed patients report a greater relief of symptoms than do those receiving no treatment, placebo, or only pharmacological treatment (Brown University Geriatric Psychopharmacology Update, 15(2), 7-8., 2011).
This leaves the specter of possible cognitive side-effects, particularly concerning when treating already cognitively compromised patients. While in the immediate aftermath of an ECT treatment there is a noted decrease in memory functioning, particularly impersonal memory (Tielkes, C. M., Comijs, H. C., Verwijk, E., & Stek, M. L., 2008), these deficits are consistently described as, “transient,” (Russ, M. J., Ackerman, S. H., Burton, L., Shindledecker, R. D., & Goldberg, E.,1990), “reversible,” (Hausner, L. L., Damian, M. M., & Sartorius, A. A., 2011), and “manageable,” (Russ, M. J., Ackerman, S. H., Burton, L., Shindledecker, R. D., & Goldberg, E.,1990).
Studies on cognitive functioning post-ECT (typically around 2-weeks after treatment) show no lasting cognitive impairment as measured by such tools as the Mini-Mental Status Exam (MMSE) and the Mattis Dementia Rating Scale (MDRS). What’s more some studies, examined in a meta-analysis, found consistent improvement in such areas as global cognitive functioning, visual memory, visuo-construction, speed of information processing, orientation, and concentration as soon as one week after ECT treatment (Tielkes, C. M., Comijs, H. C., Verwijk, E., & Stek, M. L., 2008) (Hausner, L. L., Damian, M. M., & Sartorius, A. A.,2011).
Even elderly patients ages 75 and above seemed to gain some cognitive benefit when tested post-ECT treatment. The mean age in 72 studies examining the comparative efficacy of medication and ECT and subsequent cognitive performance was 72.8 and eight of these studies had of mean age of 80 or greater. Fourteen other studies focused on those between the ages of 75 and 80.
These, “older,” elders did not experience any increased negative side-effects from ECT than did their younger counterparts and showed the same post-ECT modest cognitive improvement (Salzman, C., Wong, E., & Wright, B., 2002). These findings held for those patients classified as suffering from dementia or significant cognitive impairment (Brown University Geriatric Psychopharmacology Update, 15(2), 7-8., 2011).
According to the meta-analyses examined (Coupland CA, Dhiman P, Barton G, et al, 2011) (Salzman, C., Wong, E., & Wright, B., 2002) (Tielkes, C. M., Comijs, H. C., Verwijk, E., & Stek, M. L., 2008) ECT is not only one of the most efficacious treatments of depression in the elderly, there is considerable evidence that it may marginally boost cognitive functioning amongst even the eldest and most cognitively ravaged patients. While these findings may be antithetical to what common sense might suggest it would hardly be the first instance in which common sense was shown to lack veracity. Careful study and statistical analysis has shown that the elderly population, in whatever condition of cognitive function, can safely benefit from the therapeutic benefits of ECT with no risk to long-term cognitive functioning.
Do you know someone who received ECT treatment? What was the result?
Argument against ECT Use in the Elderly Population
Electroconvulsive Therapy or “Shock treatment,” has a long and nefarious history characterized by harm from induced seizures, lack of patient consent, and the over-application of unreliable and varying amounts of electrical current to the brain resulting in lasting cognitive deficits. Though this treatment is now administered in a much more humane and safe manner this does not elevate all concerns surrounding the practice. It remains a controversial topic in Psychiatry (Brown University Geriatric Psychopharmacology Update, 15(2), 7-8., 2011). In countries other than the United States ECT remains a therapeutic intervention of last resort (Stek, M. L., Van Der Wurff, F. B., Uitdehaag, B. J., Beekman, A. F., & Hoogendijk, W. G., 2007). In countries like the Netherlands and the UK, professional and public opinion regarding ECT makes even conducting a study on the efficacy and safety of ECT very difficult for lack of patients willing to participate.
In addition, the exact mechanism by which ECT efficaciously treats depression is not fully understood which should cause us to be particularly leery of its use in one of the most vulnerable of populations, the elderly. Overall the literature seems to support that medication (particularly Paroxatine, Fluoxatine, and Sertraline), an arguably less invasive therapeutic intervention for depression, is safe and sufficiently efficacious considering the potential and, as yet, unknown risks that might result from ECT (Salzman, C., Wong, E., & Wright, B., 2002). Dr. Peter Breggin speaks very eloquently on the potential dangers of applying current to something like the brain which we still understand so little about.
The immediate, and nearly universal, side-effects of ECT, include amnesia and anterograde memory loss. It cannot reasonably be denied that these side-effects may be significantly distressing. This may be particularly true in the cases of cognitively impaired elderly patients that may already be suffering from varying degrees of dementia. Memories of the week prior to an ECT treatment are often not fully recovered by patients (Squire LR, Slater PC, Miller PL., 1981). Such cognitive frustrations could potentially increase depression in some patients dealing with diseases such as Alzheimer’s thus defeating the original purpose of the treatment.
The right to be fully informed as to the nature of Psychiatric treatments before participating in them is paramount to the concepts of informed consent and individual autonomy. And these concepts have been central to medical ethics since Hippocrates. Although many studies have shown ECT to be safe there is a still a stigma attached to it by both patients and their families (Malekian A et al., 2009). In one study that proposed to study the effects of ECT versus nortriptyline in 50 elderly depressed patients 38 refused to participate at the very mention of ECT (Stek, M. L., Van Der Wurff, F. B., Uitdehaag, B. J., Beekman, A. F., & Hoogendijk, W. G., 2007). This would indicate that this issue of consent in a population in which some may be suffering from diminished cognitive capacities is more than just an academic concern. It would seem that many elderly patients if given the opportunity to refuse ECT treatment would do so. The fact that many seniors suffering from neuro-degenerative diseases have a health care proxy who makes such decisions for them means that such a choice is taken out of the hands of the actual elderly patients. In light of this fact, patient self-determination, even if misguided, must remain of chief importance. A major concern in the administration of ECT to an elderly population that might already be suffering from cognitive deficits is this issue of consent. Should a health care-proxy, unfamiliar with the facts associated with ECT be granted the right to authorize this treatment for a family member? This inescapably raises Ethical concerns as to an elderly patient’s right to have significant input into the particulars of their own medical care.
Involuntary ECT treatment, though rare, according to the Surgeon General, does occur in the United States. A fair number of these involuntary treatments are performed on the already disenfranchised and marginalized elderly population (The Reports of The Surgeon General, 1999). This should be upsetting to everyone and of particular concern to the helping and medical professions that emphasize the values of autonomy, beneficence, nonmaleficence, and justice (Gladding & Newsome, 2010)
ECT is often needed on a sustained basis to maintain abatement of depressive symptomology. In one study 43% of elderly patients receiving ECT were rehospitalized within a year in comparison to a slightly lower 38% who were on an antidepressant (Brown University Geriatric Psychopharmacology Update, 9(1), 1-6., 2005). An obvious question is begged by this fact: What is the effect of sustained and frequent neurological disruption by outside electrical current on the brain? Considering the complexity of the brain and how little we actually know about the inner workings of neuro-circuitry, particularly in respect to neurotransmitters, this may not be a question that Neuroscience or Psychiatry is currently equipped to answer.
Considering the public leeriness of ECT, the availability of SSRI’s, Tricyclics, and MAOI’s, and the somewhat mixed results of studies regarding the short and long-term effects of ECT on the mind, particularly aging and increasingly vulnerable minds that might not be able to give fully informed consent, an attitude of conservative caution might be the most responsible stance to adopt in regard to the use of ECT.
I began this research project rather uniformed about ECT, particularly as a Geriatric intervention for depression. As such I was completely open to following the evidence to a logical conclusion on this issue. Through the numerous articles and meta-analyses I read on the subject, I have reached one.
ECT, as it is currently practiced, seems to be a highly effective and consistently safe intervention for depression in the elderly. I was particularly surprised by the modest cognitive gains made in the elderly population post ECT treatment, as I had expected to discover the opposite, namely cognitive deficits, to be the result of such a treatment.
While I am still highly concerned about an elderly patient’s right to refuse this intervention, I think this problem could be best amended as most problems are; through education and open discourse surrounding the issue. If this education is to have any effect on the public perception of ECT then Psychiatry will have to honestly acknowledge some of the barbarous aspects of this treatment as it was originally practiced. If they cannot concede this then the public has no reason to trust Psychiatry, in general, or ECT, in particular, in its present form.
If, after such admissions, a client or their family remains recalcitrant to the idea of ECT in the face of Psycho-education then three classes of anti-depressants have shown efficacy, with manageable side-effects, in the treatment of geriatric depression thus providing patients with a reasonable alternative to ECT.
That being said ECT seems to have distinguished itself as slightly more effective than Pharmacological interventions. It also does not have the side-effects and risks associated with SSRI’s and Tricyclic Antidepressants and appears to have no lasting cognitive side-effects in either the geriatric population with neuro-degeneration or the geriatric population without neuro-degeneration. In addition it appears to result in mild cognitive performance increases, particularly in the elder population.
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Bonnie S. Wiese, MD, MA, FRCPC
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