AMGP61489S1064-7481(12)61489-410.1097/00019442-200008000-00009American Association for Geriatric PsychiatryTABLE 1Subject demographicsElectroconvulsive TherapyPharmacotherapySignificance (P)n3939NSAge, years83.69 ±3–8383.43 ±3–26NSGender (female/male)36/334/5NSRace (white/black)38/137/2NSMedications4.64 ±2.034.18±2.57NSMedical diagnoses2.89 ± 1.63.08 ± 1.2NSCardiac diagnoses1424NSLength of stay42.51 ±20.9223–36± 11.490.001ASA score2.28±0.502.10±0.51NSNote: ASA = American Society of Anesthesia “medical acuity” score.TABLE 2ComplicationsCategoryElectroconvulsive TherapyPharmacotherapySignificance (P)Falls24NSCardiovascular060.013Confusion/Neurologic105NSGastrointestinal040.027Pulmonary10NSMetabolic00NSTotal complications1319NSPatients with complications, n1016NSNote: Several patients in each group had more than one complication.TABLE 3Cardiac historyElectroconvulsive TherapyPharmacotherapySignificance (P)Hypertension1918NSArteriosclerotic cardiovascular disease67NSMyocardial infarction22NSCongestive heart failure36NSTotal cardiac diagnoses3033NSPatients with cardiac history, n2424NSNote: Several patients in each group had more than one cardiac diagnosis.TABLE 4Outcome, n (percent)Electroconvulsive TherapyPharmacotherapySignificance (P)Good30 (76.9)13 (33.3)0.001Moderate9 (23.1)22 (56.4)0.003Poor04 (10.3)0.06Overall0.003Regular ArticlesElectroconvulsive Therapy in Old-Old PatientsDavid T.ManlyM.D.*Stanley P.OakleyJr.M.D.Richard M.BlochPh.D.Department of Psychiatric Medicine, East Carolina University School of Medicine, Greenville, North Carolina*Address correspondence to Dr. Manly, Park Ridge Hospital, P.O. Box 1569, Fletcher, NC 28732The authors compared falls, cardiovascular factors, confusion, gastrointestinal, pulmonary, and metabolic side effects for “old-old” (>75 years) patient groups treated with either electroconvulsive therapy (ECT) or pharmacotherapy. A subset of a pharmacotherapy patient group was selected to match for age, sex, and diagnosis in a case-control design. Side effects were recorded from each selected patient's medical record and compared between groups. Patients receiving ECT showed fewer cardiovascular and gastrointestinal side effects. Patients receiving ECT had longer lengths of stay and more favorable outcomes. Overall, there was a tendency for ECT to result in fewer side effects and better treatment outcomes. ECT appears to be relatively safe and more effective than pharmacotherapy for major depressive disorders in old-old patients.Major depression is a common and treatable cause of morbidity and mortality in elderly patients that is often underdiagnosed and undertreated in primary care settings and nursing homes. Studies in the past have shown that the use of electroconvulsive therapy (ECT) in major depression increases with age and that patients over 65 receive a disproportionately high share of ECT compared with younger patients.1 There are controversies over the safety of ECT in elderly and medically ill patients, and questions have been raised as to whether it is more effective than pharmacotherapy. As the population in the United States continues to age, the use and safety of ECT in elderly patients will be an increasingly important clinical issue. The most rapidly growing subgroup of our population is the “old-old”, generally defined as 75 years of age and older. Population projections for the period between 1980 and 2040 estimate the general population will grow 41%, whereas those over 65 will grow 160%, and those 75 and older will grow 268%.2Most studies of the treatment of depression have included patients of all ages and have often actually excluded the elderly patient with medical complications. Therefore, few studies have specifically addressed the treatment of depression in elderly patients.3,4 This is particularly true for the “old-old”, frail elderly patients, and those with concomitant medical or neurological disorders. A recent study addressing the use of ECT in old-old patients retrospectively compared 39 patients age 80 and older with 42 younger patients age 65 through 80. The study found ECT to be relatively well tolerated, even in the older age-group. Confusion was the most common complication in both age-groups. The older age-group had more cardiovascular problems and falls, reflecting higher medical acuity, as measured by American Society of Anesthesia (ASA) scores, number of medical problems, and number of cardiac medications. Outcome was better in the younger group, but the older patients did well, with at least moderate improvement noted in 85%.5The current study extends these findings by directly comparing two groups of old-old patients suffering from major depression. One of these age- and sex-matched groups was treated pharmacologically, and the other was treated with ECT. We compared therapeutic outcomes and complications.METHODSWe conducted a retrospective chart review of inpatients at a university medical center with both private and academic psychiatric services. Charts were selected from the years 1987 to 1993 for patients 75 years of age and older whose discharge diagnoses included a major affective disorder (unipolar or bipolar depression) and who had received ECT. From these, data were obtained regarding age, gender, medical diagnoses, number and type of medications, number and laterality of ECT (if available), complications, and outcome. On the basis of matching age, gender, and discharge diagnosis of major affective disorder, a comparison group of records was sequentially identified for patients who had been treated psychopharmacologically without ECT. The same data elements were gathered from these charts. Diagnoses for all patients had been determined by an attending psychiatrist with DSM-III-R criteria as recorded in the discharge notes.6 Because all charts meeting ECT and age criteria were selected for the experimental group, and “computer-applied matching criteria” selected the comparison group, group selection bias was minimized.ECT was administered 2 or 3 times per week by use of a brief pulse device (Mecta SR1). Lead placements were bilateral in 19 patients, right-unilateral in 9, both bi- and unilateral in 9, and not noted in 2 patients.Medical status was assessed independently by one of the investigators (DM or SO) using the American Society of Anesthesiology (ASA) 5-point rating scale.7 Each selected chart was reviewed for notations of complications, which were defined as any unexpected event requiring intervention or a change in treatment plan. All complications were classified into one of six categories: cardiovascular, pulmonary, neurologic (including confusion), falls, gastrointestinal, and metabolic. Complications did not include the expected physiological responses to ECT, such as transient hypertension, tachycardia, or postictal confusion immediately after the stimulus. The results of treatment were evaluated by use of a global rating scale used by previous investigators.5,8,9 A good outcome was defined as a complete resolution of symptoms with a return to premorbid baseline and with no or only minor residual sequelae that do not interfere with social functioning. A moderate outcome was defined as some improvement, but with residual symptoms. A poor outcome was defined as no improvement or worsening of condition and level of functioning.The frequencies of various treatment complications and cardiac histories for each group were compared by use of the Fisher's exact test statistic. Other comparisons between groups, such as ASA scores or length of hospital stay, utilized standard t-tests for independent groups.10RESULTSTable 1 shows subject group characteristics. The ECT and pharmacological control populations are well matched for age, gender, and race. The two groups were also medically comparable. ASA scores did not differ between groups (t[76] = 1.56; P = 0.12). The majority of patients in both groups had scores of 2 or 3. No patients in either group had a score greater than 3. The average number of medications (4.6 vs. 4.2) and average number of medical diagnoses (3.1 vs. 2.9) were also similar between groups. However, the groups did differ in terms of the overall length of hospital stay, with the ECT group requiring an average of 19 more days of hospitalization than the medication-only control group (t[76] = 4.84; P = <0.001).The complications in both groups are noted in Table 2. The only neurological complication in the ECT group was confusion, which turned out to be common in the control group as well. Ten patients with ECT experienced confusion, whereas six experienced confusion in the control group (Fisher's P = 0.2 [NS]).Gastrointestinal side effects were noted only in the psychopharmacologically treated group (Fisher's P = 0.027). These included nausea/vomiting, constipation, and dry mouth. All except dry mouth were associated with the use of tricyclic antidepressants.The most common complication in the control group was cardiovascular in nature. Six pharmacologically treated patients experienced cardiovascular complications. Interestingly, no patients in the ECT group were noted to have cardiac complications (Fisher's P = 0.013), although, as shown in Table 3, there was no difference in the frequency of cardiac diagnoses. Overall, there were more complications in the control group, with 16 patients out of 39 having complications as compared with only 10 out of 39 in the ECT group, although this difference did not reach statistical significance.Table 4 shows the outcome data for the two treatment groups. Significantly more ECT patients had a good outcome (76.9%) than the pharmacologically treated group (33.3%; Fisher's P<0.001). In contrast, more patients in the pharmacologically treated group achieved only a moderate outcome (56.4% vs. 23.1%; Fisher's P = 0.003) whereas four of the pharmacologically treated group had a poor outcome (10.3%; Fisher's P = 0.06). It should be noted that no ECT-treated patients had a poor outcome in this study.DISCUSSIONTreatment of depression in elderly patients is frequently complicated by comorbid medical conditions and polypharmacy. These issues are particularly prominent in “old-old” patients, a group that has been inadequately studied in the past. In fact, old-old patients have frequently been excluded from treatment studies because of their age and frequent comorbidity. Our study was undertaken to evaluate the safety and efficacy of ECT in this group. Our hypothesis was that ECT would be found to be more effective, with fewer side effects than pharmacologic treatment in hospitalized old-old patients with major affective disorders. This study confirms our hypothesis and extends the result of Cattan et al.5 Our study is particularly useful in that ECT-treated patients were compared with an age- and gender-matched, pharmacologically treated group of comparable medical status.Length of stay was considerably longer in the ECT-treated group, 41.5 days compared with 23.3 days in the medically-treated control subjects. This finding is consistent with several previous studies showing significantly longer length of stays in ECT-treated inpatients.11–14 In one study of 101 elderly (more than 65 years old) patients with depression, 46 patients who received ECT were hospitalized for 43.7 days as compared with 55 patients not treated with ECT, who were hospitalized for only 24.4 days.11 A recent retrospective naturalistic study12 of geriatric patients hospitalized for depression found that the length of stay for ECT patients was twice that of patients treated without ECT (48 days vs. 24 days). Furthermore, they found that when ECT was the treatment of choice initially, the length of stay was 40 days. However, when ECT was used secondarily, following a medication trial, the length of stay increased to 56 days. Yet another study13 found the mean length of time between admission and the first ECT was 21.4 days. This suggests that significant factors in the longer lengths of stay for ECT patients are medication trials prior to ECT, weaning off medications, and medical evaluation and stabilization of elderly patients before ECT. Furthermore, it has become common practice to initiate maintenance antidepressant medication after the completion of ECT, which can further extend the length of stay.The incidence of complications noted in Table 2 is in agreement with similar studies. Confusion was the most common complication, with 10 of 39 ECT patients (25.6%) experiencing confusion and 7.6% of patients experiencing other medical complications. Our overall complication rate was 33%. Mulsant et al.13 reviewed the literature, citing 14 studies with a total of over 1,000 geriatric patients (age 65 and older) treated with ECT and found the incidence of confusion to be about 10% and also found 6% of patients having some other medical complications during ECT. The same investigators performed a prospective naturalistic study of elderly inpatients and found a complication rate very similar to ours. They found that 31% of patients suffered confusion, and 7% had some other medical complication. Cattan et al. found confusion to be the most common complication, occurring in 45% of patients age 65–80 and in 59% of patients over the age of 80. It should be noted that one possible factor in the discrepancy in the rate of confusion between our study and Cattan et al.5 is that patients in Cattan's study were treated with a sine-wave ECT apparatus, which is known to cause significantly greater confusion.15,16 Individual studies show a wide range of incidence of complications, ranging from none to over 50%. The most common complications seem to be cardiovascular, confusion, and falls. Our study differs in that we had no cardiovascular complications noted within our ECT population. As shown in Table 3, both groups had the same frequency of cardiac diagnoses (24/39) and so were equally at risk of cardiac side effects. The lack of cardiac complications, although surprising, may be, in part, due to the fact that we did not include transient phenomena, which should be considered “normal” physiological concomitants of ECT, such as transient hypertension, sinus tachycardia, or occasional PVCs. A recent retrospective study by Gormley et al.17 also found no cardiac complications in a review of 93 courses of ECT in 67 patients over the age of 75.In this study we used a retrospective naturalistic design. Several notable weaknesses are inherently possible in this design. The nonblinded nature of the data-gathering could have resulted in bias in the assessment of the outcome. Furthermore, the difference in length of stay could have led to an overestimation of the response rate to ECT due to the fact that patients were evaluated at different points in time. Also, when data are collected retrospectively, the evaluation of complications depends on the documentation of the attending physician at the time of occurrence. Subtle biases in the recognition or documentation of side effects of ECT could, therefore, account for some of the findings in the current study. Patient selection biases must also be considered. Patients viewed as likely to have side effects may be less likely to be given ECT in the first place. The fact that this study replicates and extends similar ECT side-effect advantages in elderly patients5 suggests that at least local biases in terms of selection, recognition, or documentation are less likely to have accounted for these findings. A final methodological consideration involves the possibility that multiple comparisons may have taken advantage of chance differences between groups. The low level of various types of side effects was a relatively consistent pattern for ECT and makes it highly unlikely that the findings reflect a consistent multiple-comparison effect.Our study supports a dramatic positive effect of ECT in the treatment of affective disorders, even in the old-old age-group. Our results are in agreement with the study by Rubin and colleagues11 that found a 98% response rate, with 45 of 46 patients showing a moderate-to-good response to ECT, as measured by the Beck Depression Inventory, Global Depression Scale, and nonblinded global assessment. Mulsant et al.'s study13 using the Ham-D scale in elderly patients demonstrated that 100% had at least a slight degree of improvement, with two-thirds of patients showing at least a 50% reduction in Ham-D scores.Our study confirms that ECT is both safe and extremely effective in geriatric patients with severe depression and extends earlier results to the old-old population over 75 years of age. If carefully monitored, even “old-old” patients can be safely treated with ECT. Further prospective studies using objective outcome measures such as the Ham-D18 and documentation of complications are indicated to elaborate upon these findings.References1JWThompsonRDWeinerCPMeyersUse of ECT in the United States in 1975, 1980, and 1986Am J Psychiatry1511994165716612DPRiceDemographic realities and projections of an aging populationSAndreopoulosJJognessHealth Care for Aging Society1989Church LivingstoneNew York15453SIFinkelEfficacy and tolerability of antidepressant therapy in the old-oldJ Clin Psychiatry57suppl5199623284CSalzmanLSchneiderBLebowitzAntidepressant treatment of very old patientsAm J Geriatr Psychiatry1199321295RACattanPPBarryGMeadElectroconvulsive therapy in octogenariansJ Am Geriatr Soc3819907537586American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders3rd Edition1987American Psychiatric AssociationWashington, DCRevised7American Society of AnesthesiologistsNew classification of physical statusAnesthesiology2419631118WJBurkeJLRuthefordCFZorumskiElectroconvulsive therapy and the elderlyCompr Psychiatry2619854804869WJBurkeEJRubinCFZorumskiThe Safety of ECT in geriatric psychiatryJ Am Geriatr Soc35198751652110StatMost 32 for Windows1996DataMost CorporationSalt Lake City, UT11EHRubinDAKinsherfSAWehrmanResponse to treatment of depression in the old and very oldJ Geriatr Psychiatry Neurol41991657012RAPhilibertLRichardsCFLynchEffect of ECT on mortality and clinical outcome in geriatric unipolar depressionJ Clin Psychiatry56199539039413BHMulsantJRosenJEThorntonA prospective naturalistic study of electroconvulsive therapy in late-life depressionJ Geriatr Psychiatry Neurol4199131314DKoesslerBSFogelElectroconvulsive therapy for major depression in the oldest oldAm J Geriatr Psychiatry11993303715RAbramsElectroconvulsive Therapy2nd Edition1992Oxford University PressNew York16HASackeimElectroconvulsive therapy in late-life depressionCSalzmanClinical Geriatric Psychopharmacology3rd Edition1998Williams & WilkinsBaltimore, MD26230917NGormleyCCullenLWaltersThe safety and efficacy of electroconvulsive therapy in patients over age 75Int J Geriatr Psychiatry13199887187418MHamiltonDevelopment of a rating scale for primary depressive illnessBr J Soc Clin Psychol61967278296