Electroconvulsive Therapy (ECT) to Treat Aggression in Dementia

An Evaluation of the Safety and Effectiveness of "Shock Therapy"

Brainwaves in Electroconvulsive Therapy
Mehau Kulyk Science Photo Library/ Getty Images

Electroconvulsive therapy (ECT) has long been used to treat people struggling with major depression disorder when they haven't improved with antidepressant medications. This is often referred to as treatment-resistant depression. While ECT remains somewhat controversial, in part because it is poorly understood, its use is expanding to other conditions. This includes severe agitation in Alzheimer's disease and other kinds of dementia.

Let's take a look at whether or not this treatment is effective and safe in dementia.

What Is ECT? How Is It Administered?

Electroconvulsive therapy involves the administration of electrical stimulation to the brain which causes a brief seizure.

Before undergoing ECT, a patient is given general anesthesia and a medication to relax muscles. The seizure caused by ECT will typically last about 30 seconds to a minute. After the seizure, the person wakens within a few minutes, and within an hour is usually able to resume normal activities, although some psychiatrists prohibit driving for 24 hours.

The number of ECT treatments will vary with your diagnosis, your overall condition, and your response to the treatments.

The History of ECT

ECT has a bad reputation for many who associate it with old ECT treatments that produced violent body jerking and appeared to cause people to become emotionally flat and almost vegetative in nature.

You can be reassured that much has changed in ECT.

When it was initially developed, there were far fewer safeguards in place. Now, however, if you were to watch an ECT treatment, you would barely notice any movement of the person while they're receiving the electric shock. You might see their hands or toes wiggle while receiving the treatment, but there will not be the convulsions you might picture from old movies such as, "One Flew Over the Cuckcoo's Nest." There is not pain during ECT because the person is given the anesthesia.

Additionally, ECT is administered with multiple medical staff present to ensure the safety and monitoring of the patient before, during and after the procedure.

What Side Effects May Develop?

Side effects include headaches, nausea, muscle soreness, memory loss, and confusion. Most research has concluded that the memory loss is limited, often to a short period before the ECT was administered and less commonly to a few weeks or months before treatment, and rarely to events or information from years before.

Other Uses for ECT

In addition to depression that's not responding to antidepressant medicine, ECT is also used at times to treat bipolar disorder and schizophrenia. Sometimes, it's also used if a person is catatonic (not responding at all to the world around her), manic, or unable to take antidepressants for some reason. ECT may be used for someone who's suicidal where it's felt that waiting for a medicine to help would take too long and the risk of that wait is greater than the risk of trying ECT.

Why Try ECT for Agitation and Aggression in Dementia?

ECT has been explored as a treatment for agitation in dementia because of the significant dysfunction and distress that some people with Alzheimer's and other dementias display.

This extreme agitation can make it very difficult to care for the person since he may be at the point of harming himself or those around him. In these cases, if other interventions are ineffective, some physicians may recommend ECT treatments.

What Should Be Attempted Prior to ECT?

While each person and his medical condition is unique, in general, there is an order of treatment approaches when it comes to helping the person with dementia who is aggressive and agitated:

  1. Non-pharmacological interventions
  2. Non-pharmacological interventions plus a medication
  3. Non-pharmacological interventions plus multiple combinations of medications

    ECT should typically not be attempted until the other approaches have been utilized. There are, however, exceptions to this rule, such as situations where medications can't be utilized or the situation is so dire that the medical staff feels the potential benefit outweighs the risk of trying ECT.

    Informed Consent

    Deciding if ECT is right for you or your loved one should be guided by focusing on the person receiving it. While caregivers struggle significantly to respond to challenging behaviors in dementia, the decision to try ECT should be made based on the attempt to decrease the distress of the person for whom it is proposed and the potential benefit to him, not the potential benefit to the caregiver.

    If several non-drug approaches and multiple medications have been attempted and the person still remains very distressed emotionally and physically out of control, it may be time to try ECT for dementia.

    Before you proceed with ECT, be sure to have the physician clearly explain the risks and benefits of the proposed treatment for you or your loved one. You need to have adequate information in order to make this decision, and that information should take into account the other diagnoses and medical history of the person so that you can look at the individual situation and make an educated, informed consent decision about receiving ECT.

    Is ECT Effective for Agitation in Dementia?

    Using ECT to treat agitation and aggression in dementia is a less-researched approach. Nonetheless, there have been a few studies that have concluded that ECT was effective in reducing agitation without producing major side effects. Most people who received ECT in research studies for agitation in dementia demonstrated a decreased level of agitation following treatment; however, it's important to note that the studies that have been conducted have involved small numbers of participants.

    Additionally, some of the participants' agitation and aggression returned after time elapsed following the end of the ECT treatments, so some researchers are recommending maintenance treatments which involve less frequent but ongoing ECT treatments.

    Is ECT Safe?

    ECT was also found to be relatively safe for people with dementia. However, a small percentage of participants in one study did discontinue ECT because of side effects of significant confusion that didn't resolve in the 30 minutes following the treatment. Most people who received ECT for agitation in dementia did not appear to suffer serious side effects.

    Does ECT Increase Risk of Memory Loss and Dementia?

    There is conflicting research about the effects of ECT on cognition. Some research has found that ECT in older adults vs. younger adults has a higher risk of confusion and memory loss side effects, specifically for those who have vascular dementia or are in later stages of dementia. However, it can be difficult to determine whether that risk is related to the ECT, the individual's depression which can blunt cognition, or the older age of those participants. Other research determined that cognition remained the same after multiple ECT sessions, and some studies determined it actually improved after ECT.

    Because there are multiple factors in play, such as the underlying diagnosis that triggers the need for ECT, as well as age and overall health, it's difficult to isolate any cognitive change to ECT.

    A Word From Verywell

    ECT may be a helpful option for treating agitation and aggression in dementia; however, we lack enough research and results to definitely conclude so at this time. Additional research is needed to continue to assess whether ECT is effective and safe for use in people with agitation and aggression in dementia.

    If ECT is proposed for a loved one who is living with dementia, be reassured that it's appropriate to ask the medical staff questions about any concerns you have, as well as to consult with others about this treatment decision. The medical staff treating your loved one has much knowledge, but your knowledge of his medical and overall history makes you an important part of the treatment team and helps promote the best possible outcome.

    Sources:

    Acharya, D., Harper, D., Achtyes, E., et al. (2014). Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. International Journal of Geriatric Psychiatry, 30(3), pp.265-273.

    Glass, O., Forester, B. and Hermida, A. (2017). Electroconvulsive therapy (ECT) for treating agitation in dementia (major neurocognitive disorder) – a promising option. International Psychogeriatrics, 29(05), pp.717-726. doi: 10.1017/S1041610216002258

    Burton, M., Koeller, S., Brekke, F., Afonya, A., Sutor, B. and Lapid, M. (2017). Use of Electroconvulsive Therapy in Dementia-Related Agitation. The Journal of ECT, p.1. doi: 10.1097/YCT.0000000000000432.

    Sartorius, A., Aksay, S., Hausner, L. and Frölich, L. (2014). Severe agitation in severe early-onset Alzheimer's disease resolves with ECT. Neuropsychiatric Disease and Treatment, p.2147. doi: 10.2147/NDT.S71008

    Ujkaj, M., Davidoff, D., Seiner, S., et al. (2012). Safety and Efficacy of Electroconvulsive Therapy for the Treatment of Agitation and Aggression in Patients With Dementia. The American Journal of Geriatric Psychiatry, 20(1), pp.61-72. doi: 10.1097/JGP.0b013e3182051bbc.

    Van den Berg, J., Kruithof, H., Kok, R., et al. (2017). Electroconvulsive Therapy for Agitation and Aggression in Dementia – a Systematic Review. The American Journal of Geriatric Psychiatryhttps://doi.org/10.1016/j.jagp.2017.09.023

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