ECT E-Lecture 6

ECT in Special Patient Populations: 

ECT in Special Patient Populations E-Lecture 6

Outline: 

Outline ECT in Child & Adolescents ECT in the Elderly ECT during Pregnancy ECT in Learning Disability ECT and Neurological conditions ECT and Cardiovascular problems Consent to Treatment

ECT for Children & Adolescents: 

ECT for Children & Adolescents ECT is used infrequently in C&A Possible adverse effects on maturing CNS so only few studies available Adolescents and young adults ECT considered beneficial and relatively safe for debilitating & life threatening conditions (e.g. psychotic depression and catatonic states) Younger children Fewer data on ECT’s effects - most reports are anecdotal and outdated Reports include descriptions that are inadequate or obsolete in terms of diagnostic categories - difficult to generalize Yet young children do not always respond well to alternative Rx, ( eg antidepressants) and experience more side effects

ECT for Children & Adolescents : 

ECT for Children & Adolescents Response rate in adolescents with mood disorders: about 65% Problems: ethical and moral dilemma of treating children with ECT getting informed consent Psychiatrists caring for children with life-threatening and disabling depression face a difficult choice: ineffective therapy or no treatment or ECT A Rx many still oppose Clinical certainty in children has not been well established.

ECT in the Elderly: 

ECT in the Elderly ECT most frequently used in elderly to treat depression Approximately 50% of medication-resistant pts subsequently respond to ECT ECT should be considered first-line therapy for: severely ill pts refusing to eat or drink psychotic pts pts at high risk for suicide pts whose hepatic / renal / cardiac function prevent use of pharmacotherapy ECT has better speed of action and safety profile.

ECT in the Elderly : 

ECT in the Elderly Short-term outcome of ECT better compared with younger adults Often receive ECT earlier in the course of illness than do younger adults: due to medication intolerance, medical complications, or psychotic depression May not respond as well to unilateral ECT as younger patients more often require bilateral ECT more often require longer treatment course to achieve remission

ECT in the Elderly: 

ECT in the Elderly Seizure threshold rises with increasing age ( esp with bilateral ECT) difficult when exceeds maximum outputs of ECT machines reduce / withhold dosage of sedatives, hypnotics, benzodiazepines, or anticonvulsants prior to ECT use lower dosages of barbiturate anaesthesia and adequate ventilation during ECT Greater risk of ECT-related confusion and greater memory deficits more persistent amnesia for autobiographic information anterograde and retrograde amnesia. Baseline pre- ECT cognitive scores and postictal disorientation may predict degree of long-term retrograde amnesia in pts who are not neurologically impaired

ECT in the Elderly : 

ECT in the Elderly Cognitive impairment associated with depression may improve with ECT, even when associated with underlying cerebral vascular disease ECT causes hypo-profusion in frontal areas may contribute to dementia process in pts with compromised CV circulation risk of not treating must be weighed against potential risk of  cognitive impairment Elderly patients experience stress to their cardiovascular system during ECT evaluate carefully for ability to tolerate changes such as bradycardia , tachycardia, hypertension, or arrhythmia

ECT in the Elderly : 

ECT in the Elderly Patients residing in nursing homes have: higher rates of depression (upward of 40%) high rates of medical comorbidity & disability over long periods of time high risk for mortality Esp pts cognitively impaired / less functional / in poorer health Treating depression in institutionalized, ill, elderly pts may or may not improve survival likely to improve quality of life and outcomes of other comorbid medical conditions ECT is a very reasonable choice for: medically compromised pts pts not tolerating or not responding to medications

ECT Use During Pregnancy: 

ECT Use During Pregnancy Risks of Rx vs Risks of severe untreated mental illness Physiological changes of pregnancy = mother vulnerable to  Rx SE: plasma volume / GFR / GI absorption / protein binding Rx may harm foetus : Teratogenicity / toxicity / withdrawal But consequences of not treating can be fatal for mother and baby: varieties of malnutrition refusal of prenatal care inability to follow medical recommendations attempts at premature self-delivery substance abuse Suicide violence or neonaticide

ECT Use During Pregnancy: 

ECT Use During Pregnancy ECT = high efficacy & low risk during all 3 trimesters and post partum APA practice guidelines = ECT as primary Rx for major depression & bipolar disorder during pregnancy due to: morbidity from continued illness incompletely understood adverse effects of psychotropic drugs Some pregnant pts with severe depression have associated high- risk conditions

ECT Use During Pregnancy: 

ECT Use During Pregnancy Medications with some teratogenic risk during first trimester: Benzodiazepines / antipsychotics / lithium and other mood stabilizers Not TCAs or SSRIs Later in pregnancy: antipsychotics → neonatal motor abnormalities benzodiazepines → neonatal hypotonia , apnea, and temperature dysregulation TCAs → anticholinergic effects & withdrawal symptoms in neonates Lithium → premature labour , polyhydramnios , neonatal hypothyroidism, or lithium toxicity

ECT Use During Pregnancy : 

ECT Use During Pregnancy ECT relatively safe re teratogenic risk Succinylcholine not transferred to any extent across placenta little effect on foetus Barbiturates used for brief anaesthesia not fully studied short exposure unlikely to cause teratogenicity ECT complications during pregnancy no RCTs case report review 300 case reports from 1942 to 1991 28 (9.3%) out of 300 cases reported complications many lacked detailed information on use of psychotropic medication, diagnosis, number of treatments, trimester of pregnancy, and anaesthetic procedures.

ECT Use During Pregnancy : 

ECT Use During Pregnancy ECT use in the first trimester (review) 15 cases → 14 published before 1964 - 5 (33.3%) had complications: premature birth / Miscarriages / vaginal bleeding. authors recommend caution with ECT in 1 st trimester of pregnancy risk of possible spontaneous abortion should be clarified in formed consent. ECT in 3rd trimester described in case reports of 2 pts who were treated effectively

ECT Use During Pregnancy Potential Risks of ECT During Pregnancy: 

ECT Use During Pregnancy Potential Risks of ECT During Pregnancy potential risks related to physiology of pregnancy may be  by ECT spontaneous abortion / preterm labour uteroplacental insufficiency / placental abruption Obstetric consultation prior to ECT to clarify risks Preparation for ECT during pregnancy should include: pelvic examination discontinuation of nonessential anticholinergic Rx intravenous hydration ECT may be administered with relative safety and effectiveness during pregnancy with following precautions: elevate pregnant woman’s right hip external foetal cardiac monitoring possible intubation avoid excessive hyperventilation

ECT Use During Pregnancy Postpartum Risks: 

ECT Use During Pregnancy Postpartum Risks Breast feeding does not need to be interrupted during a course of ECT Anaesthetic agents administered with ECT pose little risk to the nursing infant  exposure to medication administered during ECT by: Delaying breast feeding by a few hours post ECT Collection & storage of breast milk on day prior to ECT

ECT in people with Learning Disability: 

ECT in people with Learning Disability Studies in LD usually involve pts with ill-defined, heterogeneous aetiologies grouped on the basis of degree of LD rather than proximate causes Use of ECT for pts with both LD & psychiatric disorder remains uncommon Most studies are single case reports or small case series A study on LD consultant psychiatrists: Small majority felt that ECT was underused in this group Mainly due to consent issues and diagnostic difficulties.

ECT in people with Learning Disability: 

ECT in p eople with Learning Disability Various case studies & case series showed ECT useful in: Depression esp when biological features and psychotic features predominated Persistent screaming + depressive features Self-injurious behaviour + depressive features Severe agitated behaviour + depressive features Depression with nihilistic delusions Down’s syndrome & depression (& dementia) Bipolar mood disorder Catatonic states

ECT in People with LD : 

ECT in People with LD Some pt’s with Down’s syndrome have atlanto -axial neck joint instability rarely limits an active life some undetected cases where manipulation / restraint led to severe injury or death anaesthetist should be aware of these risks, especially relating to intubation and muscle relaxation.

ECT in People with LD Observations on reported usage: 

ECT in People with LD Observations on reported usage Use of ECT seems much less frequent in adults with LD vs rest of population Presence of LD of any degree, however, has not been a contraindication to use of ECT. Like general population, its use has not been restricted to Rx of depressive disorders. Most descriptions are of pts who failed to respond to meds or who exhibit life-threatening behaviours . Many reports note its efficacy where psychotic features are present, like findings in general population. Maintenance ECT is reported in a surprisingly large proportion of cases. Where the laterality is stated, bilateral ECT is by far the most frequently used. In majority of reports there are no indications of how improvement after ECT was measured, and this lack of outcome data is especially relevant when the frequency of maintenance use is considered.

Medical Conditions & ECT CNS – Space Occupying Lesions: 

Medical Conditions & ECT CNS – Space Occupying Lesions Pts with brain SOL &  ICP historically considered high-risk during ECT based primarily on older literature describing neurological deterioration occurring in such pts following ECT most tumours discovered only after clinical decompensation occurred APA’s task force on ECT no absolute contraindication to ECT but pts with cerebral SOLs pose a substantially increased risk ECT risk with SOLs attributed to  ICP resulting from ECT’s cerebral hemodynamic effects. Studies of electrically induced seizures show that during seizure: cortical blood flow  by 300% cerebral metabolic rate of glucose & oxygen  by ~ 200%

Medical Conditions & ECT CNS – Space Occupying Lesions: 

Medical Conditions & ECT CNS – Space Occupying Lesions MRI studies: ECT induces temporary functional breakdown of blood–brain barrier with increased vascular permeability This marked cerebral hyper-perfusion increases cerebral blood volume risk of brain herniation and possible death Small / chronic SOLs = minimal risk, unless associated with  ICP / other mass effects Most successful treated SOL cases involved asymptomatic meningiomas unlikely to cause obstruction of CSF Unlikely to cause sudden  ICP / peri-tumour oedema . Possible strategies to  risk: Hyperventilation Medication – antihypertensives / diuretics / steroids No controlled trials have been done

Medical Conditions & ECT CNS – Brain Tumours: 

Medical Conditions & ECT CNS – Brain Tumours Several case reports: ECT safe & successful in pts with brain tumours , particularly meningiomas Various investigators have successfully administered ECT to patients with brain tumours following pretreatment with Steroids (esp. dexamethasone ) → reduces edema short acting selective beta-blocker ( esmolol ) → blocks seizure induced increases in heart rate and blood pressure without significantly effecting seizure duration short-acting diuretic ( furosemide ) → antihypertensive effects hyperventilation with 100% oxygen → reduces ICP during ECT Poor outcome in pts with brain tumours & ECT: CT or MRI evidence of increased ICP focal neurological deficits / history of headaches

Medical Conditions & ECT CNS – Brain Tumours: 

Medical Conditions & ECT CNS – Brain Tumours Measures to optimize outcome and minimize post- ECT delirium: Unilateral placement of electrodes Lowering the stimulus dose Spacing the treatments Using little or no anticholinergic Rx ( esp meds that cross BBB) Obtaining pre- ECT consultations with specialists in neurosurgery Further studies needed to reevaluate safety of ECT in such pts Even though the risk remains high, it must be weighed carefully against severity & persistence of psychiatric manifestations in each case.

Medical Conditions & ECT CNS – Intracranial Vascular Masses: 

Medical Conditions & ECT CNS – Intracranial Vascular Masses Major concerns = possibility of rupture / mass effect Risk Factors = Cardiovascular side effects during ECT: arterial hypertension increased cerebral blood flow increased ICP Can be catastrophic and fatal However, cases of uncomplicated recovery have also been reported No reports of ECT- induced rupture of intracranial aneurysm despite estimated 4% prevalence in adult population A review of the literature and case reports: 8 cases of ECT performed in patients with IVMs, none of whom had adverse outcome But these numbers do not establish unequivocal safety in this population Risk–benefit analysis needed on a case-by-case basis.

Medical Conditions & ECT CNS – Intracranial Vascular Masses: 

Medical Conditions & ECT CNS – Intracranial Vascular Masses In patients with intracranial aneurysms primary anaesthetic aim is to try to control systemic blood pressure Abrupt changes in transmural pressure from either increases in systemic pressure or decreases in ICP may cause rupture. Contrary to mass lesions (i.e. brain tumours ) hyperventilation to  ICP is detrimental avoid hyperventilation Pay close attention to control of blood pressure and heart rate Such pts have been treated successfully with a combination of: Atenolol + IV sodium nitroprusside to prevent tachycardia and hypertension Atenolol associated with severe confusion in 1 case Pretreatment does not totally block hypertensive surges but seems to reduce morbidity

Medical Conditions & ECT CNS – Stroke: 

Medical Conditions & ECT CNS – Stroke 30 - 60% develop depression within 2 years after a stroke impedes recovery and rehabilitation ECT effective in antidepressant resistant pts with post stroke depression no generally accepted recommendation on how long to wait post stroke before administering ECT Risk of ECT with stable lesions thought to be small Risk of ECT with fresh lesions: haemorrhagic lesions more likely to rebleed & need careful pharmacologic blunting of hypertensive surge ischaemic strokes generally do not require aggressive control due to risk of hypotension morbidity ? ECT after a fresh stroke: may worsen the effects of the original stroke may be associated with  incidence of delirium or cardiac complications

Medical Conditions & ECT CNS – Stroke: 

Medical Conditions & ECT CNS – Stroke ECT very effective & generally well tolerated in post stroke pts but high risk of relapse despite robust ECT response & maintenance antidepressant Rx ECT in the acute post stroke period: use with caution & monitor treatment carefully only in settings where adequate medical, neurologic, and radiologic consultations are available

Medical Conditions & ECT CNS – Epilepsy: 

Medical Conditions & ECT CNS – Epilepsy ECT has excellent anticonvulsant properties For intractable medication-resistant epilepsy or status epilepticus May cause prolonged or spontaneous seizures May need regular epilepsy medication despite increase in seizure threshold Determine seizure threshold for ECT

Medical Conditions & ECT CNS – Dementia: 

Medical Conditions & ECT CNS – Dementia Higher risk (21%) of transient post-ECT confusion but remits spontaneously Affective benefits comparable to pts without dementia Extensive review found 73% positive response for depressive symptoms Subcortical dementias (e.g. Parkinson’s) respond better than cortical (e.g. Alzheimer’s) Cognitive improvement in 29% due to alleviation of depression

Medical Conditions & ECT CNS – Parkinson’s Disease : 

Medical Conditions & ECT CNS – Parkinson’s Disease Useful for medication-refractory, medication-intolerant patient with severe disability Useful in acute and continuation or maintenance phases Improves motor symptoms, especially the “on- off” phenomenon, independently of psychiatric symptoms Benefits persist for days to months and require less dopaminergic medication Post-ECT cognitive dysfunction and delirium minimized by: levodopa dose reduction starting with right unilateral ECT proceeding to bilateral if no response by third ECT

ECT Use in Patients with Cardiovascular Disorders : 

ECT Use in Patients with Cardiovascular Disorders General population estimated mortality with ECT is: about 1 in 10 000 patients or 3 to 4 in 100 000 treatments mostly due to cardiac complications anaesthesia effects, muscle relaxants, and hypoxia often contribute to the risk factors for mortality In healthy pts, post-ECT changes of blood pressure or heart rate and rhythm are transient and safely managed.

ECT Use in Patients with Cardiovascular Disorders : 

ECT Use in Patients with Cardiovascular Disorders A controlled study found that: preexisting disease predicted type of cardiac complication Pts with preexisting ischaemic disease and conduction disorders were at risk for ischaemia and arrhythmias respectively 8 major & 14 minor cardiac complications among 40 pts there were no deaths 38 of the 40 were able to complete ECT course Authors concluded that with close monitoring, ECT is relative safety in pts with severe cardiovascular disease A retrospective study of 80 patients divided according to degree of cardiac risk found: the cardiac group was more prone to developing minor but not major complications no deaths or permanent cardiac morbidity occurred during ECT These studies suggest: ECT in pts with cardiovascular disease = higher cardiac risk ECT should not be dismissed = most pts in both trials were able to complete ECT Rx

ECT Use in Patients with Cardiovascular Disorders : 

ECT Use in Patients with Cardiovascular Disorders Recent MI is a risk for re-infarction during ECT not studied objectively a 3-month interval be allowed to lapse post- MI, prior to ECT Clinical decision when to administer ECT post-MI is based on severity of MI time lapsed since MI other effective treatment options available for psychiatric condition Exclude other significant cardiovascular risk factors: uncompensated congestive heart failure severe valvular disease unstable angina uncontrolled hypertension fragile vascular aneurysms clinically significant cardiac arrhythmias

ECT Use in Patients with Cardiovascular Disorders : 

ECT Use in Patients with Cardiovascular Disorders Thorough medical evaluation critical prior to ECT for high-risk cardiac pts: careful history, physical examn , appropriate bloods, ECG and CXR Functional cardiac testing may be needed in selected cases Optimal medical therapy to minimize risk during and after treatment. Usual cardiac medication should be continued, unless specific C/I Particularly controlling blood pressure and heart rate by avoiding dehydration and hypotension. Medications to lower cardiovascular risk for anaesthesia may be needed: Antihypertensives / anticholinergics / short- acting nitrates Lidocaine should be avoided if possible, due to potent anticonvulsant effect Anticoagulation with heparin or warfarin may be safely administered during ECT for patients at risk for embolization

ECT Use in Patients with Cardiovascular Disorders : 

ECT Use in Patients with Cardiovascular Disorders Cardiac pacemakers generally have protective effect during ECT: Improve the heart’s rate and rhythm A fixed-rate or demand pace maker can protect against asystole during excessive vagal tone some physicians convert a demand pace maker to a fixed mode using a magnet, to prevent unnecessary triggering and tachycardia during ECT Implanted defibrillators are not problematic with ECT a cardiac electrophysiologist should be consulted prior to treatment Oxygen during ECT protects the myocardium from ischemia

Consent Issues for ECT in Special Patient Populations: 

Consent Issues for ECT in Special Patient Populations Obtaining informed consent from pts: Pt needs to understand the information Be able to retain it for long enough To weigh it in the balance And to communicate his decision without coercion Obtaining informed consent for ECT from special patient populations is often challenging due to their lack of capacity to provide it Need to enhance pt’s capabilities as much as possible eg visual aides / translator / sign language etc Difficult question in some cases is effect of depression on right to refuse life-saving medical treatment conflicts between medical and psychiatric treatment goals are challenging to resolve

Consent Issues for ECT in Special Patient Populations: 

Consent Issues for ECT in Special Patient Populations In pregnancy, capacity involves ability to consider needs of unborn baby, as well as mother herself Young children and adolescents also frequently lack ability to fully understand and appreciate the procedure and its potential consequences. If pt is incapable, appropriate substitute consent must be promptly obtained to prevent unnecessary suffering, physical morbidity, and possible fatality Legal requirements must be met in each case