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6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person ELECTROCONVULSIVE THERAPY AND OLDER ADULTS Christopher B. Wiegand, MD Aleph Center Learning Objectives: Explain three indications for ECT. Identify potential ECT patients. DISCLOSURE OF COMMERCIAL SUPPORT Christopher B. Wiegand, MD does not have a significant financial interest or other relationship with manufacturer(s) of commercial product(s) and /or provider(s) of commercial services discussed in this presentation. The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 1 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person ___________________________________ ___________________________________ Mood Disorders, Dementia, and Electroconvulsive Therapy ___________________________________ ___________________________________ ___________________________________ Christopher B. Wiegand, MD Psychiatrist, The ALEPH Center, PLLC Volunteer Faculty, University of Arizona ___________________________________ ___________________________________ My practice setting: ___________________________________ Long-term care facilities (50%) Aggression Impulsivity (wandering, frequent yelling out) Sexually disinhibited behavior (usually not "inappropriate") Depression/suicidal statements Hallucinations/Delusions (esp. of abuse from peers/caregivers) Sleep-wake cycle disturbances ___________________________________ ___________________________________ ___________________________________ Outpatient office (30%) Depression, Mood Disorders Anxiety Disorders Memory problems ___________________________________ ___________________________________ ECT (20%) Treatment-resistant mood and behavioral disturbances ___________________________________ Learning Objectives ___________________________________ • Examine the relationship between dementia and mental illnesses, especially mood disorders • Discuss current treatments for dementia and comorbid mood disorders • Understand how ECT fits into current available treatments. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 2 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person Diagnostic Criteria for Dementia ___________________________________ 1. Memory impairment PLUS one or more of the following: ___________________________________ • • • • ___________________________________ Aphasia Apraxia Agnosia Impairment of executive functioning ___________________________________ ___________________________________ ___________________________________ 2. Functional impairment 3. Progressive decline ___________________________________ Adapted from American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Mood Disorder and Dementia ___________________________________ • Mood Disorder secondary to dementia • Mood disorder as presenting sign of dementia‐to‐come • Mood disorder as cause of dementia • Mood disorder and dementia are both the results of common neurological processes ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Dementia and Depression ___________________________________ • 30‐40% of Dementia patients experience depression at some point in the course of illness. • Higher incidence in Vascular Dementia (30‐ 40%) vs Alzheimer’s (20‐30%) • Depression could be a prodromal symptom of Alzheimer’s (50% of patients with late‐onset depression go on to develop AD) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 3 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person Major Depression: The Not-So-Great Imitator ___________________________________ Can look like: ___________________________________ Dementia That's why I don't diagnose it until depression is adequately treated. ___________________________________ ___________________________________ Delirium Psychotic depression can mimic it! ___________________________________ "Failure to Thrive" Internal medicine's synonym for severe depression. ___________________________________ ___________________________________ Treatment-Resistant Depression ___________________________________ Various definitions exist. ___________________________________ Person has been on at least two different antidepressant medications from different classes at maximum dose for at least four weeks. ___________________________________ Has not responded to antidepressant augmentation, ie Lithium, thyroid supplement, second-generation antipsychotic. ___________________________________ ___________________________________ ___________________________________ Has not responded to an MAOI. ___________________________________ Kindling & Treatment Resistance ___________________________________ ___________________________________ There is evidence that the longer an episode of any psych illness lasts, the more difficult it is to treat. Also, the more episodes a person has, the longer, more severe, and more difficult-to-treat the episodes get. ___________________________________ Exposing patients to multiple unsuccessful medication trials may simply add to treatment-resistance and prolong suffering. Fava & Davidson, 1996. Flint & Rifat, 1996. ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 4 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person SSRI's in geriatric/hospice settings ___________________________________ ___________________________________ Most antidepressant treatments take 4-6 weeks to have full benefit. ___________________________________ In geriatric/hospice settings, SSRI's FAIL 70% of the time. ___________________________________ In my experience, that number can be extrapolated to all antidepressant classes. ___________________________________ One "quick-fix" = stimulants, ie Ritalin. ___________________________________ ___________________________________ Late‐onset Bipolar = Bipolar Type VI? ___________________________________ ___________________________________ • Ng et al (Aksiskal), 2007 • Case series of manic/mixed symptoms emerging in late‐life, usually in the setting of dementia or cognitive deficits • Mood lability plus cognitive decline • Dementia may “release latent bipolarity” ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Antipsychotics in the Elderly ___________________________________ ___________________________________ • Black box warning: Atypicals increase risk of stroke and MI in dementia patients. • Typicals vs atypicals? Atypicals seem to confer more risk than typicals (there’s conflicting evidence about this) • Dementia is part of the risk. • Sometimes benefits outweigh the risks, ie for treatment of psychotic symptoms or severe aggressive behaviors ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 5 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person ECT: A brief history ___________________________________ ___________________________________ • 1785: Therapeutic use of seizures reported in London Medical Journal • 1934: Meduna in Hungary induced seizures with camphor and cardiazol • 1937: Cerletti and Bini in Italy use electricity to induce seizure • 1951: widespread use of anesthesia in ECT with introduction of succinylcholine ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Indications ___________________________________ • Need for fast, definitive response because of severity of a psychiatric/medical condition • Risk of alternative treatments outweighs risks of ECT • History of poor response to medications • History of intolerable side effects to medications • History of good response to ECT • Patient preference of ECT over alternatives • Psychiatric disorder during pregnancy (NOT a contraindication) ___________________________________ Treatable Diagnoses ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ • Depressive Episode (Bipolar or Unipolar) • Manic Episode • Schizophrenia or Schizoaffective Disorder (esp. abrupt onset of psychosis) • Catatonia (regardless of etiology) • Dementia with Behavioral Disturbance and/or comorbid/secondary psychiatric conditions • Neuroleptic Malignant Syndrome • Parkinson’s Disease • Epilepsy or intractable seizures (esp. if accompanied by mood and/or psychotic symptoms) ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 6 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person Mechanism? ___________________________________ • With a seizure, cerebral blood flow increases 300%, cerebral metabolism increases 200% • Outpouring of catecholamine neurotransmitters: norepinephrine, epinephrine, dopamine • “Resetting” brain pathways: CTRL-ALT-DELETE [analogous to shocking a heart that’s in a bad rhythm?] ___________________________________ Contraindications ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ • NO ABSOLUTE CONTRAINDICATIONS • Cardiovascular: recent MI, unstable angina, poorly compensated CHF, severe valvular disease • Arterial aneurysm or AVM (esp. cardiac or intracranial) • Increased intracranial pressure • Recent or severe CVA • Severe pulmonary disease • Medical conditions that complicate anesthesia (obstructive sleep apnea, obesity, multisystemic disease, hematologic diseases, hyperthyroidism, pheochromocytoma, etc.) Side Effects • • • • • • • ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Short-term memory loss Confusion/delirium Headache Nausea/vomiting Muscle pain Fractures Cardiac events ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 7 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person Efficacy ___________________________________ ___________________________________ • Rate of response 80-90% in mood disorders & catatonia: compared to 6070% for any given medication regimen • Speed of response: weeks/months with meds vs. days/weeks with ECT ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Acute Efficacy ___________________________________ In a meta-analysis of RCTs, ECT superior to sham, placebo, TCAs, MAOIs, antidepressants in general for depression. “Response” defined as “recovered” or “marked improvement” on HAM-D. Pagnin et al., 2008. ___________________________________ ___________________________________ ___________________________________ Case reports (ie Weintraub & Lippman, 2001) support ECT as beneficial and well-tolerated in elderly patients with comorbid affective disorder and advanced dementia. ___________________________________ ___________________________________ Unipolar, Bipolar I and Bipolar II all show significant improvement with ECT; unipolar respond best, Bipolar I worst results (residual sx). Medda et al., 2009. ___________________________________ Acute Efficacy ___________________________________ ___________________________________ Elderly with medication-resistant depression have positive response to ECT in 80-90% of cases. Retrospective, n=373. Jain et al, 2008. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 8 6th Annual Spring Geriatric Mental Health & Aging Conference Arizona Geriatrics Society GERIATRIC BEHAVIORAL HEALTH: Treating The Whole Person Maintenance Treatment ___________________________________ For elderly patients with psychotic depression, maintenance ECT plus nortriptyline is superior to nortriptyline alone. Navarro et al., 2008. ___________________________________ For chronic depression that responds well to ECT, maintenance ECT plus antidepressant meds has better outcome (less chance of relapse/recurrence) than meds alone. 5 years: 73% vs. 18% remission. Gagne et al., 2000. ___________________________________ After a successful index series, if it is decided that the patient will have medication maintenance alone, it is better to switch antidepressant class vs. staying with the medication the patient was on at the start of ECT. Nakajima et al., 2009. Maintenance Treatment ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ After index ECT for medication-resistant depression, imipramine was superior to placebo in preventing relapse in first 6 months: 18% vs 80%. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ECT Take-home points ___________________________________ • ECT is the most effective treatment for depression, mania, and catatonia • ECT is safe, humane, and available for appropriately identified and consented patients • ECT is surrounded by controversy fueled by its history, media portrayal, and antipsychiatry propaganda ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ The information in this document may not be reproduced or disclosed to unauthorized parties without the prior consent of the Arizona Geriatrics Society. 2013 Arizona Geriatrics Society All Rights Reserved 9