Efficacious retrial of electroconvulsive therapy (ECT) after a prolonged seizure in an older adult with a history of post ECT confusion

Abstract

<h3>Introduction</h3> This is a case of a 77-year-old woman with treatment resistant geriatric major depression who was admitted psychiatrically for the 5th time in 1.5 years. She had a history of intensive psychotherapy and psychotropic medication trials with poor efficacy. She had a history of adverse complication to electroconvulsive therapy (ECT) with prolonged seizure and postictal confusion during her 3rd hospitalization. At her 5th hospitalization, due to poor response to routine psychiatric treatment, ECT was pursued. We discuss challenges in pursuing ECT and outcome of retrial of an acute ECT series, in the context of paucity of similar literature in geriatric depression <h3>Methods</h3> Patient was involuntarily admitted to the Older Adult inpatient Unit due to worsening anxiety and depression with suicidal ideation that began 1 month prior to admission. Patient reported having suicidal thoughts on a daily basis. Patient had been experiencing worsening depression since her husband died 3 years ago, had attempted multiple outpatient treatments including psychotherapy and medications. Patient was psychiatrically hospitalized 4 times prior to the current hospitalization. The patient met criteria for major depressive disorder, recurrent, severe, without psychotic features, generalized anxiety disorder with panic attacks. Patient displayed cognitive deficits with executive dysfunction, impairment with problem solving and planning. For diagnostic clarification, patient received neuropsychiatric testing which revealed a mild neurocognitive disorder with potential contribution of her depression. During her 3rd psychiatric admission, she had received an acute series of electroconvulsive therapy. During her 4^th ECT session,the patient had a prolonged central seizure requiring total 2 mg of midazolam to abort the seizure which eventually lasted 489 seconds. This was followed by prolonged post ECT confusion that lasted for 7 days. Medical workup of any other etiology for her prolonged confusion was negative including EEG, CT head. Eventually confusion resolved and interestingly the patient's depression and anxiety also appeared to be in remission. <h3>Results</h3> With the above history influencing her current admission, we were initially hesitant to start an acute series of ECT, however, with continued treatment refractory depression, ECT was recommended to the patient and the family. Since prolonged seizures are not a contraindication for ECT and due to the patient's good response to ECT, we felt this was an appropriate treatment. Long discussion about risks, benefits and side effects occurred with patient, who signed informed consent for acute ECT. Patient received 6 right unilateral treatments three times a week. Patient also received serial Montreal cognitive assessment (MOCA) testing during her acute series. Patients first moca was 15/30 which increased to a 28/30 over 12 days indicating improvement in cognition with improvement in anxious depression. After 6th ECT, patient was deemed to be in remission and was transitioned to maintenance ECT. Per chart review, patient remains in remission after her 5th ECT treatment. After reviewing the literature we could not find evidence of an efficacious retrial of electroconvulsive therapy after a prolonged seizure in an older adult with a history of post ECT confusion. <h3>Conclusions</h3> ECT is an important treatment modality in the geriatric population indicated for severe major depression (1) While the APA quotes no absolute contraindications to ECT and further research has demonstrated that prolonged seizures or acute cognitive impairment are not relative contraindications either, the patient's history and past experiences with treatment are an important part of developing a treatment plan. (2) We present this case to demonstrate efficacy of retrial of ECT in older adults who experience both a prolonged seizure and negative cognitive effects can be an appropriate treatment plan. <h3>References</h3> 1. Electroconvulsive Therapy in Geriatric Psychiatry A Selective Review. 2. https://www.openanesthesia.org/ect_contraindications/. <h3>Funding</h3> none