Electroconvulsive therapy parameters for behavioral and psychological symptoms of dementia

Abstract

AbstractIntroductionBehavioral and Psychological Symptoms of Dementia (BPSD) are a heterogenous group of non‐cognitive symptoms impacting up to 90% of patients with dementia, and include emotional disturbance, psychosis, agitation, aberrant motor behavior, and circadian rhythm disturbance. Multiple reviews have found ECT to be efficacious in treating BPSD that have not responded to other interventions. However, no published guidelines exist to inform clinicians about how protocols for ECT should be implemented in the treatment of BPSD. This study aims to identify ECT parameters commonly utilized for BPSD in the literature.MethodsMEDLINE and APA PsychInfo were searched from database inception until September 2022. Two reviewers independently screened and full text reviewed the retrieved articles. Articles included in the full text review stage discussed how ECT is implemented for patients experiencing BPSD.ResultsAfter duplicate removal, 800 unique citations were identified for screening. Of these, 160 were included in full text review. 32 studies were ultimately included (Figure 1). Characteristics of included studies are highlighted in Figures 2 and 3.Most studies utilized thrice weekly ECT, however, twice weekly was suggested to carry a lower risk of ECT‐related cognitive side effects. The number of sessions needed for response ranged between 2‐15, with improvement typically observed within 3‐6 treatments. The choice between unilateral and bilateral placement rests on weighing the risk of confusion with improved clinical response. Multiple authors recommend starting with unilateral treatment to reduce cognitive side effects and switching to bilateral if response is inadequate after 3‐5 sessions. Typical pulse width was 0.30‐0.37ms for ultrabrief and 1‐2s for brief treatment. Minimum recommendations for adequate seizure duration varied from 25 to 30 seconds on EEG and 15 to 20 seconds by observed motor movements. Stimulus dosage ranged between 1.5‐2.5x seizure threshold for bilateral placement, and 4‐6x seizure threshold for unilateral placement. Maintenance ECT was commonly used to reduce the risk of relapse.DiscussionECT is both safe and efficacious for patients with BPSD, and the present review focuses on commonly implemented ECT parameters in the literature. Notably, studies are limited by inconsistent reporting of ECT parameters and short follow‐up durations.