Electroconvulsive therapy (ECT), traditionally used for severe depression, is emerging as a potential treatment for managing the behavioral and psychological symptoms of dementia (BPSD). With over 6 million adults in the United States affected by dementia and its prevalence expected to rise, the need for effective interventions for BPSD is critical, as current FDA-approved treatments are lacking.
Evidence from Clinical Trials and Analyses
While randomized controlled trials are still underway, prospective non-randomized trials have shown promising results. One study (NCT01856010) on inpatients with dementia complicated by severe agitation and aggression found that 78.3% of patients exhibited significantly reduced agitation from baseline to discharge, as measured by the Cohen-Mansfield Agitation Inventory. Neuropsychiatric inventory scores also significantly decreased (P < .001), indicating memory improvement.
Another study (NCT02969499) demonstrated improvements in neuropsychiatric functioning one week post-ECT and reduced agitation eight weeks post-ECT, without worsening cognitive or dementia symptoms.
Retrospective analyses further support ECT's potential. A review of 31 patients with primary dementia and depression showed lower depression severity scores and an improvement on the Folstein Mini-Mental State Examination (1.6 points; P < .02) after ECT. A larger study using Medicare claims data (N = 145 ECT vs. N = 415 control) indicated that while all patients generally declined in functional status post-discharge, those receiving ECT had more favorable activities of daily living scores compared to the control group, with no differential worsening in cognitive function.
Clinical Considerations for ECT Use
Given the limited effective therapies for BPSD, ECT may be considered in select cases, provided a thorough analysis of benefits and risks is conducted. Key considerations include:
- Consent: Adhering to state-level laws governing consent for ECT, ensuring a thorough and legal consent process, potentially involving judicial authorities.
- Comorbid Medical Issues: Tailoring treatment schedules (e.g., twice-weekly acute series) for older individuals with multiple comorbidities to improve tolerability.
- Airway Management: Employing anticholinergic medications like glycopyrrolate to manage secretions and improve airway safety during procedures.
Reassuring Data on Cognitive Impact
Large database analyses have largely dispelled concerns that ECT causes dementia. Studies on patients with dementia or cognitive impairment suggest that ECT does not worsen baseline dementia or cognitive impairment; some data even indicate cognitive function improvement following ECT.
In conclusion, ECT can be considered in select cases to manage BPSD where resources, patient and family preferences, and clinical considerations align, and when potential benefits outweigh the risks.
