Mohammed T. Abou-Saleh

488 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYbeen found 93 . The risk of confusion and memory loss tends to beassociated with high stimulus intensity, bilateral electrodeplacement, increased number and/or frequency of treatments,older age and pre-existing cognitive deficiencies. Adjustment ofthe stimulus waveform, decreasing the stimulus intensity, usingunilateral electrode placement or increasing the interval betweentreatment may decrease the cognitive side effects.Other somatic side effects include headaches, nausea, andmuscle soreness. Prophylactic treatment with analgesics or usingan increased dose of the muscle relaxants during ECT mayminimize these symptoms. ECT patients are also at a higher riskfor falls.Treatment ConsiderationsPrior to initiating ECT treatment, a focused medical history andphysical examination is necessary to assess and minimize anypotential risk factor. Laboratory tests should include a hematocritor hemoglobin, serum electrolytes and an electrocardiogram(ECG) 90 . Most practitioners also obtain either an EEG, CT ofthe head, or brain MRI prior to ECT. If a patient has a history ofmusculoskeletal disease or osteoporosis, spinal X-rays may beobtained to evaluate the presence of underlying compressionfractures, so that anesthetic/muscle relaxant medication may beproperly adjusted. Dental evaluation is of particular importancein aged patients and attention should be given to patients whohave loose teeth or none or only partial dentures.An informed consent should be obtained prior to initiatingECT. In geriatric patients whose judgement and insight arecompromised by their illness, the family should be involved intreatment decision making and consent. In the case of patients notcompetent to give consent, the legal guardian must be identifiedand approve consent.The use of psychiatric medications during ECT should beminimized. Lithium should be discontinued prior to ECT, since itmay increase the risk of status epilepticus and prolonged muscularblockade with succinylcholine. The anticonvulsants (valproate,carbamazepine) should also be discontinued, since they inhibit theECT seizure. It should also be remembered that all benzodiazepinesincrease seizure threshold. They can be tapered prior to ECTor a benzodiazepine antagonist can be used just prior to theprocedure.Early reports suggested that mania was more resistant to ECTor required more frequent treatments than depression. Recentresearch has found this not to be true. The patient’s clinicalimprovement is the best guide in deciding the optimal number oftreatments. An average of 6–12 treatments is usually required foroptimal response. Recommendations for treatment parametersmay be found in several other texts 90,91,94 .REFERENCES1. Young RC, Klerman GL. Mania in late-life: focus on age at onset. AmJ Psychiat 1992; 149: 867–76.2. 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