Therapeutic and prophylactic utility of the memory-enhancing drug donepezil hydrochloride on cognition of patients undergoing electroconvulsive therapy: a randomized controlled trial

Bipolar Disorder and Manic-Like Symptoms in Alzheimer's, Vascular and Frontotemporal Dementia: A Systematic Review

BACKGROUND

An increased risk of manic episodes has been reported in patients with neurodegenerative disorders, but the clinical features of bipolar disorder (BD) in different subtypes of dementia have not been thoroughly investigated.

OBJECTIVES

The main aim of this study is to systematically review clinical and therapeutic evidence about manic syndromes in patients with Alzheimer's disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). Since manic-mixed episodes have been associated to negative outcomes in patients with dementia and often require medical intervention, we also critically summarized selected studies with relevance for the treatment of mania in patients with cognitive decline.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines. PubMed, Scopus, and Web of Science databases were searched up to February 2022. Sixty-one articles on patients with AD, VaD, or FTD and BD or (hypo) mania have been included.

RESULTS

Manic symptoms seem to be associated to disease progression in AD, have a greatly variable temporal relationship with cognitive decline in VaD, and frequently coincide with or precede cognitive impairment in FTD. Overall, mood stabilizers, and electroconvulsive therapy may be the most effective treatments, while the benefits of short-term treatment with antipsychotic agents must be balanced with the associated risks. Importantly, low-dose lithium salts may exert neuroprotective activity in patients with AD.

CONCLUSION

Prevalence, course, and characteristics of manic syndromes in patients with dementia may be differentially affected by the nature of the underlying neurodegenerative conditions.

The Role of Acetylcholinesterase Inhibitors in the Treatment of Prolonged Postelectroconvulsive Therapy Delirium

Electroconvulsive therapy (ECT) is an extremely effective treatment modality for severe depression but is often associated with transient or persistent cognitive impairment. ECT-induced cognitive impairment, however, can serve as a deterrent to completion of treatment. We present a case of a prolonged post-ECT delirium lasting approximately 3 weeks in which donepezil, an acetylcholinesterase inhibitor, was used and was successful in shortening the duration of post-ECT delirium.

Pharmacological interventions to diminish cognitive side effects of electroconvulsive therapy: A systematic review and meta-analysis

OBJECTIVE

The authors conducted a systematic review and meta-analysis of pharmacological interventions to diminish cognitive side effects of ECT.

METHODS

Electronic databases of Pubmed, PsycInfo, Embase and Scopus were searched from inception through 1 April, 2021, using terms for ECT (e.g. electroconvulsive therapy), cognitive outcome (e.g. cogni*) and pharmacological intervention (e.g. calcium channel blocker and general terms, like protein). Original studies with humans receiving ECT were included, which applied pharmacological interventions in comparison with placebo or no additive intervention to diminish cognitive side effects. Data quality was assessed using Risk of Bias and GRADE. Random-effects models were used. PROSPERO registration number was CRD42021212773.

RESULTS

Qualitative synthesis (systematic review) showed 52 studies reporting sixteen pharmacological intervention-types. Quantitative synthesis (meta-analysis) included 26 studies (1387 patients) describing twelve pharmacological intervention-types. Low-quality evidence of efficacy was established for memantine (large effect size) and liothyronine (medium effect size). Very low-quality evidence shows effect of acetylcholine inhibitors, piracetam and melatonin in some cognitive domains. Evidence of no efficacy was revealed for ketamine (very low-quality), herbal preparations with anti-inflammatory properties (very low to low-quality) and opioid receptor agonists (low-quality).

CONCLUSION

Memantine and liothyronine are promising for further research and future application. Quality of evidence was low because of differences in ECT techniques, study populations and cognitive measurements. These findings provide a guide for rational choices of potential pharmacological intervention research targets to decrease the burden of cognitive side effects of ECT. Future research should be more uniform in design and attempt to clarify pathophysiological mechanisms of cognitive side effects of ECT.

Efficacy of donepezil for the attenuation of memory deficits associated with electroconvulsive therapy

We sought to confirm and extend the findings of studies that reported that acetylcholinesterase inhibitor drugs protect against electroconvulsive therapy (ECT)-induced cognitive impairment. We randomized 30 patients with depression (n=24) or schizophrenia (n=6) to receive either donepezil (10 mg/day; n=15) or placebo (n=15) during a fixed course of 6 thrice-weekly, modified, bifrontotemporal sine wave ECT, and for 30 days subsequently. We assessed memory using the Postgraduate Institute Memory Scale (PGI-MS) at baseline, and again at days 2, 7, and 30 after the ECT course. At baseline, memory functioning was comparable in the 2 groups. At 2 days post-ECT, memory functioning was impaired on almost all 10 subtests and on the total scale. At 30 days post-ECT, memory functioning improved to (numerically) above baseline levels on almost all subtests and on the total scale, with the bulk of the improvement evident by day 7, itself. There was no significant difference between groups in the primary outcome, improvement in PGI-MS scores between Days 2 and 30 post-ECT. On almost all subtests, also, there was no significant difference between groups. In summary, we found that donepezil (10 mg/day) did not improve memory outcomes after ECT.

The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.

Therapeutic and prophylactic role of cognitive enhancers in electroconvulsive therapy-induced cognitive deficits

OBJECTIVES

The objective is to evaluate the pattern of cognitive deficits after electroconvulsive therapy (ECT); to ascertain the role of various psychosocial, illness and treatment-related parameters on cognitive functions after ECT; and to evaluate the effect of donepezil on various cognitive deficits.

MATERIALS AND METHODS

A triple-blind randomized controlled trial was undertaken. Ninety patients undergoing ECT were included into study after due consent and institutional ethical approval. They were randomized into two groups: one using donepezil with ECT and the other using placebo with ECT. Various cognitive parameters were studied before ECT, after a course of ECT and after 4 weeks of last ECT. Findings were assessed in the light of available socialdemographic and clinical parameters and existing literature.

RESULTS

ECT was found to be an effective therapeutic modality. Immediate memory worsened over the course of ECT till after 4 weeks of ECT. Augmentation of donepezil was found useful. It sped up the improvement of general memory and working memory during ECT.

CONCLUSION

Donepezil has therapeutic and prophylactic benefit on cognition of patients undergoing ECT over the course of treatment till 4 weeks after the ECT.

Acetylcholinesterase inhibitors for electroconvulsive therapy-induced cognitive side effects: a systematic review

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective treatment for severe late-life depression; however, ECT-induced cognitive side effects frequently occur. The cholinergic system is thought to play an important role in the pathogenesis. We systematically reviewed the evidence for acetylcholinesterase inhibitors (Ache-I) to prevent or reduce ECT-induced cognitive side effects.

METHODS

A systematic search was performed in Pubmed, EMBASE, PsychINFO, and the Cochrane database to identify clinical trials investigating the effect of Ache-I on ECT-induced cognitive side effects. Key search terms included all synonyms for ECT and Ache-I. Risk of bias assessment was conducted by using the Cochrane Collaboration's tool.

RESULTS

Five clinical trials were eligible for inclusion. All studies focused on cognitive functioning as primary endpoint, but assessment of cognitive functioning varied widely in time point of assessment and in cognitive tests that were used. There was also great variety in study medication, route and time of administration and dosages, duration of drug administration, and ECT techniques. Finally, only two out of five studies were considered at low risk of bias. Despite the aforementioned shortcomings, without exception, all studies demonstrated significantly better cognitive performance in individuals treated with Ache-I.

CONCLUSIONS

Despite large heterogeneity in studies, Ache-I appear to have beneficial effects on ECT-induced cognitive side effects, supporting an association with the cholinergic system in ECT-induced cognitive impairment. Methodological sound studies controlling for putative confounders are warranted. Copyright © 2017 John Wiley & Sons, Ltd.

Cognitive Impairment and Electroconvulsive Therapy in Geriatric Depression, What Could be the Role of Rivastigmine? A Case Series

Electroconvulsive therapy (ECT), albeit highly effective in treating depression, is frequently associated with cognitive impairment, either temporary or more persistent. Especially in older patients, who generally respond even better, serious cognitive impairment during the course of ECT may lead to premature termination of ECT. Treatment of this cognitive impairment is of utmost importance. In this case series report, we present the effect of rivastigmine, an acetylcholinesterase inhibitor, on cognitive impairment in three older, severely depressed patients during or after a course of ECT. An improvement of cognitive functioning, in particular a decline of confusional symptoms, was observed in two patients with structural brain alterations associated with aging. In the other patient, who suffered primarily from amnesia, no effect of rivastigmine was observed. These preliminary results emphasize the need for detailed profiling of cognitive impairment when developing a research design to study the potential benefits of rivastigmine in the prevention or treatment of cognitive impairment in severely depressed patients treated with ECT.

Further improving the cognitive effect profile of electroconvulsive therapy (ECT): the case for studying carbamylated erythropoietin

Electroconvulsive therapy (ECT) remains the most effective acute treatment for severe depression and several other psychiatric illnesses. However, its use has been limited by concerns about cognitive adverse effects. ECT may cause temporary cognitive impairment in some patients, typically anterograde amnesia for 1-2 weeks after a course of treatment, and circumscribed retrograde amnesia. These cognitive effects largely disappear within days to weeks after treatment. Efforts to find a pharmacological agent to reduce the cognitive effects of ECT have largely been unsuccessful, with the possible exception of thyroid hormone. We review the literature on pharmacological attempts to attenuate ECT's cognitive effects, and propose a novel neuroprotective and neurotrophic agent, carbamylated erythropoietin (CEPO), for this indication.

Electroconvulsive therapy use in adolescents: a systematic review

BACKGROUND

Considered as a moment of psychological vulnerability, adolescence is remarkably a risky period for the development of psychopathologies, when the choice of the correct therapeutic approach is crucial for achieving remission. One of the researched therapies in this case is electroconvulsive therapy (ECT). The present study reviews the recent and classical aspects regarding ECT use in adolescents.

METHODS

Systematic review, performed in November 2012, conformed to the PRISMA statement.

RESULTS

From the 212 retrieved articles, only 39 were included in the final sample. The reviewed studies bring indications of ECT use in adolescents, evaluate the efficiency of this therapy regarding remission, and explore the potential risks and complications of the procedure.

CONCLUSIONS

ECT use in adolescents is considered a highly efficient option for treating several psychiatric disorders, achieving high remission rates, and presenting few and relatively benign adverse effects. Risks can be mitigated by the correct use of the technique and are considered minimal when compared to the efficiency of ECT in treating psychopathologies.

Delayed onset and prolonged interictal delirium following electroconvulsive therapy

Electroconvulsive therapy is safe and effective in the treatment of depression in older individuals. Minor cognitive side effects of electroconvulsive therapy include acute postictal confusion and reversible short-term memory deficits. However, interictal delirium is uncommon in absence of risk factors. Herein, we report the case a depressed male patient without any known risk factors who developed interictal delirium 2 days after his sixth electroconvulsive therapy session. Interictal delirium improved with treatment within 1 week.

Electroconvulsive therapy-induced persistent retrograde amnesia: could it be minimised by ketamine or other pharmacological approaches?

BACKGROUND

Certain pharmacological agents administered during electroconvulsive therapy may have the potential to prevent persistent retrograde amnesia induced during electroconvulsive therapy. This review examines mechanisms for electroconvulsive therapy-induced retrograde amnesia, and evaluates the suitability of the anaesthetic ketamine for preventing this amnestic outcome.

METHODS

A review of human studies, animal models and theoretical models in light of memory dysfunction following electroconvulsive therapy was conducted. MEDLINE was searched from 1950 to April 2009 using the MeSH terms "electroconvulsive therapy", "memory", "memory short term", "memory disorders", "excitatory amino acid antagonists", and "ketamine". PREMEDLINE was searched using the terms "electroconvulsive therapy", "amnesia" and "ketamine". Additional keyword and reference list searches were performed. No language, date constraints or article type constraints were used.

RESULTS

Disruption of long term potentiation as a mechanism for electroconvulsive therapy-induced retrograde amnesia is well supported. Based on this putative mechanism, an N-methyl-D-aspartate receptor antagonist would appear suitable for preventing the retrograde amnesia. Available evidence in animals and humans supports the prediction that ketamine, an anaesthetic agent and N-methyl-D-aspartate receptor antagonist, could effectively prevent electroconvulsive therapy-induced persistent retrograde amnesia. Whilst there are concerns about the use of ketamine with electroconvulsive therapy, such as possible psychotomimetic effects, on balance this anaesthetic agent may improve or hasten clinical response to electroconvulsive therapy.

CONCLUSIONS

A clinical trial is warranted to determine if ketamine anaesthesia during electroconvulsive therapy can lessen persistent retrograde amnesia and improve therapeutic response. Electroconvulsive therapy with ketamine anaesthesia may provide effective antidepressant action with minimal side effects.

Successful use of donepezil in treatment of cognitive impairment caused by maintenance electroconvulsive therapy: a case report

Cognitive deficits are commonly associated with maintenance electroconvulsive therapy (ECT). Treatment of these cognitive deficits is important but difficult. Cholinergic pathways are involved in these side effects, and donepezil, a cholinesterase inhibitor, may be useful for improvement of cognition. In this case report, we describe for the first time successful use of donepezil in treating cognitive deficits associated with maintenance ECT. The role of cholinesterase inhibitors in the treatment of cognitive deficits caused by ECT needs further studies.

Neuropsychological effects and attitudes in patients following electroconvulsive therapy

The current study examined the effects of electroconvulsive therapy (ECT) on neuropsychological test performance. Forty-six patients completed brief neuropsychological and psychological testing before and after receiving ECT for the treatment of recalcitrant and severe depression. Neuropsychological testing consisted of the Levin Selective Reminding Test (Levin) and Wechsler Memory Scale-Revised Edition (WMS-R). Self-report measures included the Beck Depression Inventory (BDI), the Short-Term Memory Questionnaire (STMQ), and several other measures of emotional functioning and patient attitudes toward ECT. The mean number of days between pre-ECT and post-ECT testing was 24. T-test revealed a significant decrease in subjective ratings of depression as rated by the BDI, t(45) = 9.82, P < 0.0001 (Pre-BDI = 27.9 +/- 20.2; post-BDI = 13.5 +/- 9.7). Objective ratings of memory appeared impaired following treatment, and patients' self-report measures of memory confirmed this decline. More specifically, repeated measures MANOVA [Wilks Lambda F(11,30) = 4.3, p < 0.001] indicated significant decreases for measures of immediate recognition memory (p < 0.005), long-term storage (p < 0.05), delayed prose passage recall (p < 0.0001), percent retained of prose passages (p < 0.0001), and percent retained of visual designs (p < 0.0001). In addition, the number of double mentions on the Levin increased (p < 0.02). This study suggests that there may be a greater need to discuss the intermittent cognitive risks associated with ECT when obtaining informed consent prior to treatment. Further that self-reports of cognitive difficulties may persist even when depression has remitted. However, patients may not acknowledge or be aware of changes in their memory functioning, and post-ECT self-reports may not be reliable.

Pharmacological attenuation of electroconvulsive therapy--induced cognitive deficits: theoretical background and clinical findings

Electroconvulsive therapy (ECT) is an effective treatment for depression and other psychiatric disorders. However, the practice of ECT is limited by memory and nonmemory cognitive adverse effects. Technical strategies such as a preference for unilateralover bilateral ECT and low-dose over high-dose stimulation reduce these cognitive adverse effects but may also be associated with lesser treatment efficacy or slower treatment response. This article therefore reviews the use of psychopharmacological agents in the attenuation of ECT-induced cognitive deficits with 2 objectives: the identification of implicated mechanisms and the identification of putative efficacy in both animal and human studies. Drugs examined include N-methyl-d-aspartate receptor antagonists, cyclooxygenase inhibitors, calcium channel blockers, cholinesterase inhibitors, glucocorticoid receptor antagonists, thyroid hormones, opioid antagonists, NO donors, nootropic agents, and other medications. Although the clinical data at present are sparse and inconsistent, many recently opened lines of research improve our understanding of the mechanisms involved as well as suggest possible avenues for the testing of new treatments with the potential to attenuate the cognitive adverse effects of ECT.

Treatment of post-electroconvulsive therapy delirium and agitation with donepezil

Delirium and agitation are commonly encountered after administration of electroconvulsive therapy (ECT). Management is generally fairly straightforward, although some patients may have a severe, prolonged, or refractory course. We recently cared for a 65-year-old man who consistently developed severe and very prolonged post-ECT delirium that did not respond to typical pharmacological agents; the duration of delirium was dramatically shortened by the addition of donepezil. Cholinesterase inhibitors may have a place in mitigating severe and prolonged post-ECT delirium.