The Role of Baseline Cognitive Function in the Neurocognitive Effects of Electroconvulsive Therapy in Depressed Elderly Patients

Towards an understanding of the pathological basis of senile depression and incident dementia: Implications for treatment

Senile depression (SD) is a heterogeneous syndrome. Several clinical profiles are more likely to appear in SD than in early-life depression, but it remains unclear whether the pathophysiology is different. The prevalence of dementia increases with aging, and the underlying pathophysiological processes in the preclinical phase begin even before cognitive deficits or neurological signs appear. SD may be either a risk factor for developing dementia or a prodromal stage of dementia. The inconsistent findings regarding the association between SD and incident dementia may be attributable to the neuropathological heterogeneity underlying SD. Most studies have focused on patients with the clinical diagnosis of Alzheimer disease (AD) as an outcome, but several clinicopathological studies suggest that primary age-related tauopathy and argyrophilic grain disease may account for a proportion of cases clinically misdiagnosed as AD in the elderly population. Furthermore, most AD cases have additional neuropathologic changes such as cerebrovascular disease and Lewy body disease. Here, we review the neuropathological findings linking SD to incident dementia, focusing on common age-related neuropathologies. In particular, the roles of disturbance of neural circuity, imbalance of monoaminergic systems, dysregulation of the hypothalamic-pituitary-adrenal axis, and elevated neuroinflammatory status are discussed. Finally, we review the current treatment of SD in the context of age-related neuropathological changes.

The Effects of Baseline Impaired Global Cognitive Function on the Efficacy and Cognitive Effects of Electroconvulsive Therapy in Geriatric Patients: A Retrospective Cohort Study

OBJECTIVES

This study explores the association between baseline impaired global cognitive function and changes in global cognitive function and depression among geriatric patients undergoing acute course electroconvulsive therapy (ECT).

DESIGN

Retrospective cohort study.

SETTING

Single freestanding psychiatric hospital.

PARTICIPANTS

Patients aged 50 and older receiving ECT.

INTERVENTIONS

10 ECT treatments.

MEASUREMENTS

Cognitive assessments with the Montreal Cognitive Assessment (MoCA). Depression assessment with the Quick Inventory of Depressive Symptomatology Self Report 16 item scale (QIDS).

RESULTS

Baseline and follow-up data were available for 684 patients. On average, patients with baseline normal cognition (MoCA ≥26; N = 371) had a decrease in MoCA of -1.44±0.26 points over the course of treatment, while those with baseline impaired global cognitive function (MoCA <26; N = 313) had an increase in MoCA of 1.72±0.25 points. Baseline cognitive status was not associated with a differential response on the QIDS.

CONCLUSIONS

Patients with baseline impaired global cognitive function did not demonstrate a worsening in cognition following ECT, and baseline global cognitive function was not associated with a differential change in depression with ECT. These results suggest that impaired global cognitive function should not be viewed as a contraindication to ECT in geriatric patients.

First Acute-Course Electroconvulsive Therapy for Moderate-to-Severe Depression Benefits Patients With or Without Accompanying Baseline Cognitive Impairment

BACKGROUND

Researchers are increasingly investigating therapeutic response associated with new patient subgroups as a way to improve electroconvulsive therapy (ECT) treatment outcomes and reduce adverse events. This study is the first to examine baseline cognitive impairment status as a predictor of clinical outcome in first acute-course ECT patients.

METHODS

Baseline cognitive function at various thresholds and serial depressive symptom severity data from first-time ECT patients were examined using generalized linear mixed-effects models.

RESULTS

Of 1345 patients who met the inclusion criteria, 617 had available data at their third assessment visit (~15th treatment visit). There was a robust improvement in depression symptoms over time (P < 0.0001), and cognitive function was not associated with baseline levels of depressive symptoms or serially measured change in self-reported symptom severity during acute-phase ECT.

CONCLUSIONS

These results indicate that an acute course of ECT for the treatment of moderate-to-severe depression benefits patients with or without accompanying baseline cognitive impairment. These findings may be useful in informing shared decision-making discussions about ECT risks and expected benefits.

Long-Term Risk of Developing Dementia After Electroconvulsive Therapy for Affective Disorders

OBJECTIVES

Severe depression is associated with an increased risk of developing dementia, however, whether treatment with electroconvulsive therapy (ECT) modify this risk remains unknown.

METHODS

In this matched cohort study, 1089 consecutive in-patients with affective disorders, receiving ECT during the period 1982 to 2000, were matched with 3011 in-patients with affective disorders not treated with ECT (non-ECT), and 108,867 individuals randomly selected from the background population. The comparison cohorts were matched on sex, age, and the non-ECT cohort was further matched according to diagnoses and admission period and hospital. Dementia diagnoses were retrieved from the national patient health registry. Analyses were adjusted for disease severity, somatic, and psychiatric comorbidities.

RESULTS

The cumulative incidence of dementia was 13.45% (10.75-16.46%) in the ECT cohort after 34 years of follow-up, 10.53% (8.5-12.81%) in the non-ECT cohort, and 8.43% (8.17-8.7%) in the background cohort. Using the ECT cohort as reference and age as the underlying time scale, the adjusted hazard ratio of developing dementia was 0.73 (0.52-1.04) in the non-ECT cohort and 0.61 (0.49-0.76) in the background cohort. The stratified analysis based on age at index (<65 years; 65-80 years; >80 years) found no age-related difference in the risk of developing dementia between the ECT cohort and non-ECT cohort.

CONCLUSIONS

The ECT treatment of affective disorders was not associated with an increased long-term risk of developing dementia compared with in-patients with affective disorders not treated with ECT.

Low-Frequency Transcranial Magnetic Stimulation (LF-TMS) in Treating Depression in Patients With Impaired Cognitive Functioning

OBJECTIVE

Common methodologies for treating depressive symptoms have demonstrated decreased efficacy among individuals with impaired cognitive functioning. While transcranial magnetic stimulation (TMS) has been approved to treat major depressive disorder, few studies have analyzed the ability of TMS to treat depressive symptoms among individuals with cognitive impairments. The present study had two objectives: to determine whether low-frequency TMS (LF-TMS) might demonstrate efficacy in treating depressive symptoms among individuals with impaired cognitive functioning; and to determine whether LF-TMS might improve neurocognitive functioning above and beyond depressive symptom improvements.

METHODS

Data were derived from a pre-existing database at Eastern Virginia Medical School. Fifty-three (N=53) participants completed LF-TMS treatment. The Beck Depression Inventory II (BDI-II) and CNS Vital Signs (CNS-VS) neurocognitive assessment were administered at multiple time points throughout treatment. Participants were classified as impaired cognitive functioning or average cognitive functioning based on baseline CNS-VS scores. Data were analyzed using restricted maximum likelihood (REML) measures-within-persons longitudinal hierarchical linear modeling (HLM) with time-varying covariates.

RESULTS

LF-TMS produced significant reductions in depressive symptoms for individuals in both cognitive functioning groups; however, a significant group-by-time interaction indicates differential effects between these two groups. Low-frequency TMS produced significant improvements in three neurocognitive domains above and beyond improvements in depressive symptoms; however, the reliability of these changes may be questionable.

CONCLUSIONS

This study adds to the growing body of empirical findings for LF-TMS treatment in improving neurocognitive functioning above and beyond other treatment-related effects.

Electroconvulsive Therapy and Age: Effectiveness, Safety and Tolerability in the Treatment of Major Depression among Patients under and over 65 Years of Age

Electroconvulsive therapy (ECT) remains the most effective therapy in treatment-resistant depression. However, the safety of ECT has been consistently questioned, particularly among elderly patients. We assessed the efficacy and safety of ECT in patients before and after 65 years old. The study was conducted between 2015 and 2018 and included 91 patients (61 under and 29 over 65 years old) with major depression undergoing ECT. The Hamilton Depression Rating Scale was used to evaluate efficacy. Cognitive functions were assessed using: MMSE, RAVLT, Trail Making Test, Stroop Test and Autobiographical Memory Interview-Short Form. ECT was more effective in older patients as compared to younger (p < 0.001). No serious adverse events were observed in either group. Increased blood pressure and arrhythmias were more common in the older compared to the younger group (p = 0.044 and p = 0.047, respectively), while disturbances of consciousness did not differ between groups (p = 0.820). Most of the cognitive functions remained unchanged compared to baseline, whereas the outcomes of MMSE, RAVLT and Stroop tests showed greater improvements in the older compared to the younger group (all p < 0.05). The decline in the retrieval consistency of autobiographical memory was more pronounced in the younger group (p = 0.024). ECT is a highly effective, safe and well-tolerated method of treating depression regardless of age.

Right unilateral versus bilateral formula-based electroconvulsive therapy in the treatment of major depression in elderly patients: a randomised, open label, pilot controlled trial

BACKGROUND

Electroconvulsive therapy (ECT) remains the most effective treatment of depression in the elderly population; however, it is still unclear which type of ECT is most beneficial in this population. The aims of this study were: (i) to assess the feasibility of a randomised controlled trial in elderly depressed patients treated with right unilateral (RUL) or fronto-temporal bilateral (BT) formula-based ECT; (ii) to compare formula-based RUL and BT ECT in terms of efficacy, safety and tolerability in this population.

METHODS

The study lasted 3 years and managed to randomise 29 patients over 65 years old to receive either BT (n = 14) or RUL (n = 15) ECT. Brief pulse width (0.5 ms) and age-based dosing method were applied. The clinical efficacy was assessed using Hamilton Depression Rating Scale, somatic state was monitored throughout the ECT course. In neuropsychological examination general cognitive performance, executive functions, verbal fluency, memory, autobiographical memory were evaluated.

RESULTS

The recruitment was poor due to small number of patients able to give informed consent. ECT proved to be a highly effective and safe method of treatment among elders. Formula-based RUL ECT did not differ from BT in antidepressant efficacy and had cognitive advantages - the indices of general cognitive performance, verbal fluency and memory were significantly better than before the treatment in the RUL group. Decline in retrieval consistency of autobiographical memory was more pronounced in the BT group, although it was observed across both groups.

CONCLUSIONS

Formula-based RUL ECT might not differ from BT in antidepressant efficacy and has an advantage in terms of tolerability.

Management of Late-Life Depression in the Context of Cognitive Impairment: a Review of the Recent Literature

PURPOSE OF REVIEW

Evidence regarding the treatment of late-life depression is not necessarily generalizable to persons with a neurocognitive disorder and comorbid depression. Thus, this article reviews recent evidence that pertains to the treatment of depression in older adults with neurocognitive disorders, and synthesizes and critically analyzes this literature to identify methodological issues and gaps for the purpose of future research.

RECENT FINDINGS

Controlled trials and meta-analyses examining depression treatment in neurocognitive disorders, published between 2015 and 2019 (N = 16 reports), can be divided into those addressing pharmacotherapy, psychological and behavioral therapy, and somatic therapy. The evidence generally does not support benefit of antidepressant medication over placebo in treating depressive disorders in dementia. No pharmacological studies since 2015 have examined antidepressant medication in participants with mild cognitive impairment (MCI). Problem adaptation therapy demonstrates efficacy for depression in MCI and mild dementia. Other psychological and behavioral interventions for depressive symptoms in dementia demonstrate mixed findings. The only somatic treatment trials published since 2015 have assessed bright light therapy, with positive findings but methodological limitations. Psychological, behavioral, and somatic treatments represent promising treatment options for depression in neurocognitive disorders, but further studies are needed, particularly in participants with depressive disorders rather than subclinical depressive symptoms. Little is known about the treatment of depression in patients with MCI, and rigorous identification of MCI in late-life depression treatment trials will help to advance knowledge in this area. Addressing methodological issues, particularly the diagnosis and measurement of clinically significant depression in dementia, will help to move the field forward.

Low-Charge Electrotherapy in Geriatric Major Depressive Disorder Patients: A Case Series

To examine the feasibility of low-charge electrotherapy (LCE) in treating geriatric major depressive disorder (MDD) patients. Bi-temporal LCEs (approximately 25 mC) were performed with an electroconvulsive therapy (ECT) instrument three times per week. We used the Hamilton Depression Scale 17 (HAMD-17) and the Hamilton Anxiety Scale (HAMA) to assess the effects of LCE and the Mini-Mental State Examination (MMSE) to evaluate the cognitive function change before and after LCE. Six visits occurred at the baseline, after LCE sessions 3, 6, and 9, after the last session, and at the end of the one-month follow-up period. Four patients were enrolled in the study. Two patients completed all LCE sessions. Two patients withdrew during the trial, one due to the adverse event of uroschesis potentially caused by atropine and the other due to her own will. All four patients completed the follow-up sessions. The HAMD-17 and HAMA scores were reduced significantly at the last LCE session and the end of the follow-up period compared with the scores at the baseline. As measured by the MMSE, cognitive impairment showed no significant changes at the last LCE session and the end of the follow-up period compared with that at the baseline. In this case series, LCE showed potential as an alternative current-based treatment for treating geriatric MDD patients. Further research is needed to assess the efficiency and safety of LCE.

Network neurobiology of electroconvulsive therapy in patients with depression

Graph theory, a popular analytic tool for resting state fMRI (rsfMRI) has provided important insights in the neurobiology of depression. We aimed to analyze the changes in the network measures of segregation and integration associated with the administration of ECT in patients with depression and to correlate with both clinical response and cognitive deficits. Changes in normalised clustering coefficient (γ), path length (λ) and small-world (σ) index were explored in 17 patients with depressive episode before 1st and after 6th brief-pulse bifrontal ECT (BFECT) sessions. Significant brain regions were then correlated with differences in clinical and cognitive scales. There was significantly increased γ and σ despite significant increase in λ in several brain regions after ECT in patients with depression. The brain areas revealing significant differences in γ before and after ECT were medial left superior frontal gyrus, left paracentral lobule, right pallidum and left inferior frontal operculum; correlating with changes in verbal fluency, HAM-D scores and delayed verbal memory (last two regions) respectively. BFECT reorganized the brain network topology in patients with depression and made it more segregated and less integrated; these correlated with clinical improvement and associated cognitive deficits.

Defense Automated Neurobehavioral Assessment Accurately Measures Cognition in Patients Undergoing Electroconvulsive Therapy for Major Depressive Disorder

OBJECTIVES

The Defense Automated Neurobehavioral Assessment (DANA) is an electronic cognitive test battery. The present study compares DANA to the standard Mini-Mental State Examination (MMSE) in subjects undergoing electroconvulsive therapy for the treatment of major depressive disorder.

METHODS

Seventeen inpatient subjects in the Johns Hopkins Hospital Department of Psychiatry were administered longitudinal paired DANA and MMSE tests (7.6 ± 4.1 per patient) from January 10, 2014 to September 26, 2014. Regression analyses were conducted (with or without MMSE scores of 30) to study the impact of the MMSE upper limit, and within-subject regression analyses were conducted to compare MMSE and DANA scores over time.

RESULTS

Statistically significant relationships were measured between DANA and MMSE scores. Relationships strengthened when MMSE scores of 30 were omitted from analyses, demonstrating a ceiling effect of the MMSE. Within-subject analyses revealed relationships between MMSE and DANA scores over the duration of the inpatient stay.

CONCLUSIONS

Defense Automated Neurobehavioral Assessment is an electronic, mobile, repeatable, sensitive, and valid method of measuring cognition over time in depressed patients undergoing electroconvulsive therapy treatment. Automation of the DANA allows for more frequent cognitive testing in a busy clinical setting and enhances cognitive assessment sensitivity with a timed component to each test.

Key updates in the clinical application of electroconvulsive therapy

ECT is the oldest and most effective therapy available for the treatment of severe major depression. It is highly effective in individuals with treatment resistance and when a rapid response is required. However, ECT is associated with memory impairment that is the most concerning side-effect of the treatment, substantially contributing to the controversy and stigmatization surrounding this highly effective treatment. There is overwhelming evidence for the efficacy and safety of an acute course of ECT for the treatment of a severe major depressive episode, as reflected by the recent FDA advisory panel recommendation to reclassify ECT devices from Class III to the lower risk category Class II. However, its application for other indications remains controversial, despite strong evidence to the contrary. This article reviews the indication of ECT for major depression, as well as for other conditions, including catatonia, mania, and acute episodes of schizophrenia. This study also reviews the growing evidence supporting the use of maintenance ECT to prevent relapse after an acute successful course of treatment. Although ECT is administered uncommonly to patients under the age of 18, the evidence supporting its use is also reviewed in this patient population. Finally, memory loss associated with ECT and efforts at more effectively monitoring and reducing it are reviewed.

Electroconvulsive Therapy in the Elderly: New Findings in Geriatric Depression

This paper reviews recent research on the use of electroconvulsive therapy (ECT) in elderly depressed patients. The PubMed database was searched for literature published within the past 4 years, using the search terms: "electroconvulsive elderly," "electroconvulsive geriatric," "ECT and elderly," and "ECT elderly cognition." The studies in this review indicate excellent efficacy for ECT in geriatric patients. Adverse cognitive effects of ECT in this population are usually transient and not typically severe. In addition, continuation/maintenance ECT (C/M-ECT) may be a favorable strategy for relapse prevention in the elderly after a successful acute course of ECT. ECT is an important treatment option for depressed geriatric patients with severe and/or treatment-resistant illness. New data add to the evidence demonstrating that ECT is a highly effective, safe, and well-tolerated antidepressant treatment option for geriatric patients.

Baseline cognitive function does not predict the treatment outcome of electroconvulsive therapy (ECT) in late-life depression

BACKGROUND

No prior study has investigated whether impairment of specific cognitive functions at baseline may predict the short-term treatment outcome of electroconvulsive therapy (ECT) in elderly non-demented patients with major depression (MD).

METHODS

This longitudinal cohort study included 65 elderly patients with unipolar or bipolar MD, aged 60-85 years, treated with formula-based ECT. Treatment outcome was assessed using the 17-item Hamilton Rating Scale for Depression (HRSD17). Cognitive function at baseline was assessed using nine neuropsychological tests or subtests measuring information processing speed, verbal learning and memory, and aspects of executive function.

RESULTS

A poorer performance on the word reading task of the Color Word Interference Test rendered higher odds of achieving remission during the ECT course (p=0.021). Remission was defined as an HRSD17 score of 7 or less. There were no other significant associations between the treatment outcome of ECT and cognitive performance parameters assessed at baseline.

LIMITATIONS

The limited number of subjects may have reduced the generalizability of the findings. Multiple statistical tests increase the risk for making a type I error.

CONCLUSIONS

How well patients perform on neuropsychological tests at baseline is most likely not a predictor of, or otherwise not significantly associated with the treatment outcome of formula-based ECT in elderly patients with MD.