Mohammed T. Abou-Saleh

434 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYFogel 16 suggests that ECT might be more readily used in theelderly if we were more objective about its virtues as comparedwith the severe side effects often associated with neuroleptics,which are quite readily used in the agitated elderly patient. Extrapyramidaleffects were usually the limiting factor but are not sonoticeable with atypical neuroleptics. However, he postulates thatthe demented patient who is very agitated and screaming mightsuffer less indignity and fewer side effects if treated with ECT,rather than tranquillizers, as the patient may have an underlyingaffective disturbance manifest only by the agitation and negativismthat one often sees in this condition.CONTRAINDICATIONSThere are no absolute contraindications, only relative risks,relative that is to the morbidity and mortality of untreateddepression. The limiting factor is whether the patient is fit for thelight anaesthetic that ECT requires. The majority of risk factorsare therefore associated with the cardiovascular system. Manypeople are denied treatment due to irrational caution. Forexample, pacemakers are not barriers to treatment; the bodilytissues, being highly resistant, prevent the ECT stimulus fromreaching the pacemaker in any case. The patient should remaininsulated from the ground, however, to prevent the unlikely eventof the current leaking to earth and being conducted down thepacemaker wire to the heart. Equally, myocardial infarction is nota contraindication to treatment if the depression is so severe as tothreaten life; in less severe cases, an interval, governed bysentiment rather than science, of 4–6 weeks is usually left. Therisks are greatest during the first 10 days post-infarct, andprobably negligible after 3 months. I have treated a patient withtreated hypothyroidism who had two prosthetic heart valves, wastherefore on anticoagulants and had a pacemaker, with no specialprecautions or untoward effects. Patients with osteoporosis orwith recent femoral neck fractures can be treated, provided anadequate muscle relaxant is given. Stroke is certainly not acontraindication, and ECT given as soon as 1 month after doesnot present a major risk to patients. There is now a growing bodyof literature attesting to the usefulness of ECT in treating poststrokedepression 27 .The case of deep venous thrombosis (DVT) is less clear. I havegiven ECT to a patient who had a DVT in his calf during hisdepressive illness, once he was adequately anticoagulated. In fact,the risk of pulmonary embolism seems, in my practice, greater inthe dehydrated immobile depressive than in those receiving ECT.Arterial hypertension is often regarded as a contraindication, asblood pressure is well known to rise during ECT. This can sometimesbe controlled and the pressor response avoided by usingsublingual nifedipine or short-acting b-blockers shortly beforetreatment 28 . Chronic glaucoma is another condition in which ECTcauses fewer problems than tricyclic antidepressants; in fact,intraocular pressures are said to reduce ECT 29 . Insulin-dependentdiabetes is a condition, like Parkinson’s disease, which altersduring ECT. Insulin requirements may decrease quite substantiallyduring the course of ECT, so more careful monitoring ofblood glucose levels is needed. It is also necessary to avoidhyperglycaemia prior to treatment, which may significantly raisethe fit threshold, and the timing of ECT administration may needconsideration to prevent undue fluctuations in diabetic control.Transient asystole occasionally occurs, for some reason lessfrequently in the old-old, but it is not of any consequence andneed not prevent further treatments 30,31 .Epileptic patients on anticonvulsants should not stop theirmedication during ECT, as that might increase the risk of statusepilepticus. However, they may need higher than usual electricaldosages to produce an adequate response.It is interesting that the seizure during ECT is invested withgreat powers of harm compared with epileptic seizures per se,which can of course occur in patients with any disease or at anytime and seldom result in death. It seems understandable, then,that a seizure in the controlled conditions of the ECT room isprobably even less likely to result in fatality. There is, of course, amortality rate associated with ECT but, as noted by Fink 32 , thetreatment rate of 0.002% compares favourably with the rate foranaesthetic induction alone (0.003–0.04%).ADMINISTRATIONThe responses of senior psychiatrists to the process of ECT varyfrom those who simply prescribe six treatments and leave theadministration to the newest recruit, who has often had notraining at all, to those surgeons manque´s who may overstate therisks and precautions in order to increase the perceived risk oftheir jobs. Clearly, the ideal path lies somewhere between, butnearer the latter than the former! ECT is the only psychiatrictreatment in the elderly that involves significant medical interventionwith general anaesthesia, and as such, the psychiatristshould have a clear understanding of what he/she is prescribingand regular involvement in its administration. As much attentionshould be paid to the prescription of ECT as to any otherprescription.A clear decision as to whether bilateral or unilateral electrodeplacement is wanted should be made; the ECT record sheet shouldbe reviewed to ensure that an adequate convulsive response hasoccurred without excessive stimulus; treatments should not be inblocks of six, but, provided that the illness is one with a goodprognosis, treatment should be continued until the expecteddegree of improvement is obtained, whether that is after three or23 treatments.There is no evidence that the habit of giving one or two extraECTs after full recovery is effective in preventing relapse 33 . Thedecision to give unilateral or bilateral ECT in the elderly ismade easier by the fact that high dose unilateral ECT doesseem to produce less confusion, memory loss and headache andappears to be equally effective in many patients 34,52 . However,there is a great deal of discrepancy in the results of comparativestudies, possibly due to differences in diagnosis, age and gender,together with variance in the technique of administration ofunilateral ECT. The consensus seems to indicate that, for manypatients, both treatments are equally effective; some patientsrequire more right unilateral treatments than bilateral toachieve the same result and some patients who do not respondto right unilateral ECT will respond when switched to bilateraltreatment. Male gender and older age are also associated withbetter response to bilateral treatment.It is my practice to use bilateral treatment initially in very severepsychotic depressives but right unilateral treatment in most othercases, particularly if there is evidence of prior cognitive impairment,switching to bilateral treatment if there is no response aftersix to eight right unilateral treatments. Brief pulse ECT at amoderately supra-threshold stimulus (which is often only around275–350 millicoulombs) appears to offer efficacy, with theadvantage of much less memory loss and confusion than themodified sine wave stimulus, and should be used in all cases, witha record of dosage received by the patient to ensure adequatetechnique 53 .There is considerable debate about the necessity to use a dosetitrationtechnique to establish seizure threshold prior to treatment,with some viewing this as unnecessary and even detrimental inthose patients requiring several non-convulsive stimuli. Adequateseizure response can be measured using inter-ictal EEG monitoring.Some clinicians seem to have developed an over-weaning