The Efficacy and Safety of Electroconvulsive Therapy in the Management of BPSD

Abstract

According to the Alzheimer Society of Canada (2016), there will be 937,000 Canadians living with dementia in 15 years, and 90% of those seniors will have behavioural and psychological symptoms of dementia (BPSD). The most common behaviours are physical and verbal aggression, which leads to poor health outcomes, caregiver burnout, and premature institutionalization. There are non-pharmacologic and pharmacologic interventions implemented to manage BPSD, but they are often ineffective when the BPSD causes imminent harm to self and others. Pharmacologic interventions are used to address behaviours that are causing imminent harm to self or others. However, these medications have many side effects and increase a patient's risk of death. Many case studies and retrospective chart reviews support the efficacy and safety of electroconvulsive therapy (ECT) in the management of BPSD. Many limitations are brought forward due to the lack of a randomized control. This paper aims to establish strong evidence for the safety and efficacy of ECT in the management of BPSD; during the course of the systematic literature review, it is determined that nursing has a primary role in providing patient-centred nonpharmacological interventions as the first-line treatment and ongoing management of BPSD in combination with ECT.

Keywords: Electroconvulsive therapy (ECT), behaviour and psychological symptoms of dementia (BPSD), dementia, agitation, aggression, nursing

The Efficacy and Safety of Electroconvulsive Therapy in the Management of Behaviors and Psychological Symptoms of Dementia

Behavioural and Psychological Symptoms of Dementia (BPSD) refer to the non-cognitive symptoms of dementia such as "agitation and restlessness; wandering and non-specific behaviour disturbances (i.e., hoarding); verbal or physical aggression; anxiety; depression; psychosis; delusion; hallucinations; repetitive vocalizations (i.e., cursing, screaming, and swearing); sleep disturbances; shadowing; and sundowning" (Fazzari, Marangoni, & Benzoni, 2015, p. 159). It is essential to know that BPSD is observed in 90% of patients with dementia (in all stages) and agitation and aggression are present in 60-80% of patients with Alzheimer's disease (Fazzari et al., 2015; Ellison, 2008). BPSD is also known as the neuropsychiatric symptoms (NPS) of dementia and is the core feature of dementia (Bessey & Walaszek, 2019). BPSD cannot be ignored as symptoms progress with time, and this leads to poor quality of life, increased mortality, increased total health care costs, and premature institutionalization; as the family or caregivers can no longer cope and manage at home (Salvedurai et al., 2018; Ujkaj et al., 2012). Nonpharmacological approaches are frequently attempted first, but medications (antipsychotics, antidepressants, and mood stabilizers) are often needed immediately. The aggression is often too severe and cannot be safely managed when the patient harms oneself and others (Gauthier et al., 2010). Medications, however, are limited by modest efficacy due to age-related pharmacokinetic (body's reaction and metabolism of the drug) changes. Patients with dementia are more likely to have adverse events and increased mortality rates with pharmacological therapy (Zhang et al., 2016). Many studies have shown that electroconvulsive therapy (ECT) is not only effective in reducing verbal and physical aggression in patients with BPSD, ECT also has fewer adverse outcomes as compared to psychopharmacological treatment. During the course of the systematic literature review, the role of nursing in the provision of patient-centred care planning and nonpharmacological interventions have been highlighted as the primary treatment for BPSD and ECT and pharmacological interventions as a last resort.

Behavioural and Psychological Symptoms of Dementia

The Alzheimer Society of Canada (2016) defines dementia as a broad term for a set of symptoms caused by disorders affecting the brain. Dementia is progressive, and many diseases that cause dementia (such as Alzheimer's, vascular dementia, Lewy body, Parkinson's, Huntington's, Creutzfeldt-Jakob disease, and many more) lead to irreversible brain cell death. Accurate diagnosis is essential to prevent overdiagnosis of dementia, as many treatable conditions (such as thyroid disease, vitamin deficiency, and sleep disorders) mimic dementia and cognitive deficits are reversible (Alzheimer Society of Canada, 2016). Dementia also needs to be differentiated from delirium, an acute episode of confusion and changes in behaviour, often precipitated by medication, surgery, and an acute illness. The cognitive and behavioural changes caused by delirium are reversed when the precipitating factor is addressed. The patient often returns to the baseline mental status (Registered Nurses' Association of Ontario, 2016). The Alzheimer Society of Canada (2016) emphasizes the need for dementia research as only 5% of the Canadian Institutes of Health Research budget is allocated for dementia. If more funding is allocated towards research, we will get closer to life-altering treatments, better care, and even a cure for dementia. There are 564,000 Canadians currently living with dementia, which will be 937,000 in 15 years. There are 25,000 new cases of dementia diagnosed each year. The annual cost of caring for Canadians with dementia is $10.4 billion in 2016. 56,000 Canadians with dementia occupy an acute care bed as facilities cannot handle the behaviours (Alzheimer Society of Canada, 2016). It is important to note that aggression and agitation (physical, verbal, and wandering) are the most common symptoms in 60% of patients with dementia (Glass et al., 2017).

BPSD is associated with poor quality of life and impairs a patient's ability to engage in their daily activities. BPSD also damages their relationships with their caregivers and families. The behaviours can be distressing and often trigger a need for a higher level of care, such as a nursing home (Bessey & Walaszek, 2019).

Review of Literature

CINAHL, Cochrane, Medline (Ovid), ProQuest Nursing & Allied Health, PubMed, and PsycARTICLES databases were used to search for literature. The following keywords were utilized: "ECT, BPSD, agitation, aggression, dementia, and nursing." No time frame restriction was placed, and the results requested were peer-reviewed. Literature was limited to patients/subjects above sixty-five years old. The inclusion criteria included either physical or verbal aggression or other symptoms of BPSD. Literature that discussed only ECT and depression was immediately removed.

There were a total of thirteen papers found: four case reports with a total of eight patients in the studies; two retrospective chart reviews with a total of thirty-nine patients in these studies; four literature reviews; and three case studies. Eight studies have concluded that ECT is a safe and effective treatment for BPSD, particularly aggression, where pharmacological approaches have yielded poor results. Two studies emphasized the need for maintenance of ECT to prevent recurrence of behaviours. Two studies still recommended a nonpharmacological approach, followed by medication use with least harm, and ECT as a last resort. Both Lavretsky (2004) and Glass et al. (2017) have pointed out that one common side effect of ECT is hypoactive delirium, which can be misinterpreted as reduced agitation. Despite this caution, most studies agreed that ECT is safer than pharmacological agents and that ECT is more effective in older patients.

Management of BPSD

Gauthier et al. (2010) mention that no single treatment works for all patients in all situations. It is crucial to identify that there is a complex interaction between biological factors (progression in brain pathology), psychosocial/psychological factors (unmet psychological needs such as thirst, hunger, pain, fear, abandonment, etc.), and environmental factors (excessive stimulation such as noise, chaotic/busy environment, etc.). The first step of managing BPSD is to complete a thorough assessment starting with a medical and psychiatric history (including substance use), medication review, and review of precipitants of behaviour to rule out delirium and other reversible conditions that are causing the behaviour. Some of these medical causes are metabolic (electrolyte imbalances, hypo/hyperthyroidism), infectious (urinary tract infection, meningitis), central nervous system insults (stroke, traumatic brain injury), and other medical conditions such as constipation or urinary retention, to name a few (Bessey & Walaszek, 2019).

Nonpharmacological Management

Nonpharmacological interventions are always the first attempt to manage BPSD and are used for all severities of BPSD. However, there is limited evidence in support of the efficacy of nonpharmacological management. In practice, all care settings rely heavily on pharmacological agents in treating agitation (Ujkaj et al., 2012). The routine evaluation of a patient with BPSD is to complete a thorough medical assessment to check for the presence of an acute infection, electrolyte imbalance, or other diseases that would "tip the behavioural balance towards distress and disinhibition" (Ellison, 2008, p. 57). The International Psychogeriatric Association (IPA, 2012) encourages nurses and other frontline staff to understand that BPSD is an attempt by a patient living with dementia to communicate. All behaviours have meaning, and a nurse needs to understand the perspective of a person with dementia. These are the conceptual models or theories that nurses use to help them know BPSD and help guide research and practice (IPA, 2012):

The Person-Centered Approach (PCA)

This approach encourages a nurse to take a step into the shoes of the patient. It promotes the questions to be asked: "How is a person interpreting things?" and "What are they trying to say?". The need for a PCA has led to Cohen-Mansfield's (2001) A-B-C Approach: Antecedents to the behaviour, details of the behaviour (duration, time, description), and Consequences identified to deduce environmental triggers influence behaviour and subsequently be used to create a patient-centred care plan.

The Validation Approach

This approach emphasizes the need to respond and validate hidden feelings and meanings behind a patient's speech and behaviour. Magierski et al. (2020) note the need for caregivers to intervene appropriately based on the mechanisms behind the behaviour. Feil (2014) provides an excellent example:

Mrs. F shouts, "There's mother; she has the laundry; I need to help her!". Staff would attempt to reorient her, stating that her mother is dead. However, Mrs. F responds, "I know that, and you know that, but my mother does not know that, and I need to help her." Using the validation technique, the social worker acknowledged how Mrs. F loves her mother and how she wants to help her mother. Mrs. F expressed her guilt and grief and became more trusting and communicate more with the caregivers.

Need-Driven Dementia-Compromised Behavioral (NDB) Model

The unmet needs that a patient is trying to convey are either physical, emotional, intellectual, psychological, or social. As patients with dementia have lost effective use of language, behaviours such as wandering, vocalization, and aggression can convey needs and frustrations. Effectively ruling out unmet needs by understanding behaviour patterns and speaking with family who knows the patient best is the key point to this model. Pain and boredom have been identified as essential determinants of agitation, and interventions directed towards these positively affect decreasing agitation (Magierski et al., 2020).

Progressively Lowered Stress Threshold Model (PLST)

According to this model, behaviours can be used as barometers for internal (i.e., hunger, pain) and external (i.e., noise, large crowds) stress. Removing the source of anxiety and behaviours will not surface. Examples of indirect interventions to modify the environment or external stressors would be to adjust the temperature, light, and noise levels that the patient can tolerate (Magierski et al., 2020).

There are many nonpharmacological interventions that nursing, occupational therapy (OT), or recreational therapy (RT) can provide. The examples of nonpharmacological interventions will be provided below. Aromatherapy and physical exercise are also interventions studied to decrease BPSD. However, studies are based on small samples. Some patients with dementia have anosmia (smell blindness), leading to analytical bias (Oliveira et al., 2015).

Occupational Activities. Tailored Activity Program (TAP) is an OT intervention that focuses on reducing the incidence of BPSD by providing activities tailored to the current level of patient abilities, roles, and interests (Oliveira et al., 2015). In addition, providing patients with meaningful activities allowed both the patient and their families a positive experience. Patients enjoy the activities as they were engaged and focused. Their families are provided with an opportunity to learn more skills on approaching their loved ones. Finally, the activities provide a chance for patients to bond with their families (O'Connor et al., 2019).

Music Therapy. Audio recording of conversations about positive experiences in the past stimulates family presence, and playing favourite songs can both effectively reduce agitation (Oliveira et al., 2015). The environment can also be manipulated to minimize agitation by using playing audio loops of "white noise" or nature sounds (waterfall, rain, or ocean waves) (Herrmann, 2001).

Bright Light Therapy. Exposing patients to an hour of 10,000 lux bright light every morning has shown increased nocturnal sleep and reduction in agitation. Patients are seated three feet away in front of a full spectrum lamp, and a nurse reminds patients to keep their eyes open during an hour of treatment. (Herrmann, 2001; Oliveira et al., 2015).

Psychopharmacological Management

Gauthier et al. (2010) and Lavretsky (2004) state that there are effective pharmacologic options that exist to treat targeted symptoms of BPSD:

1. Antipsychotics treat psychosis, hostility, aggression, agitation, and sleep-wake cycle disturbances.

2. Antidepressants treat sleep-wake cycle disturbances, agitation, depressive syndromes, anxiety, and pathological crying.

3. Benzodiazepines treat anxiety, agitation, tension, and sleep disturbances.

4. Anticonvulsants treat agitation, aggression, hostility, sleep-wake cycle disturbance, and manic-type behaviour.

There are debates on the efficacy of the above medications. Glass et al. (2017) argue that benzodiazepines disinhibit patients, mood stabilizers take several days to reach therapeutic levels, and these medications increase the risk of falls and have serious side effects. These side effects are not limited to extrapyramidal symptoms (or Parkinsonian-like movements) and sedation; adverse events include increased risk for cardiovascular and metabolic side effects (Ujkaj et al., 2012). Anticholinergic effects of antipsychotics and antidepressants are also concerning. Patients become more confused/delirious and become constipated and retain urine, leading to behavioural agitation (Herrmann, 2001). Age-associated changes also affect the pharmacokinetics and pharmacodynamics of antipsychotics due to a longer half-life and elimination time (Herrmann, 2001).

It is alarming to note that the above treatments come with a black-box warning from the Food and Drug Authority in 2005: There is an overall increase in mortality associated with the use of antipsychotics to treat agitation in the elderly with dementia (Ellison, 2008; Glass et al., 2017; Kales et al., 2012). However, despite the black box warning, it is surprising that antipsychotics are still used when most studies using antipsychotics and other mediations have shown minimal to moderate effects in managing behaviours compared to trials with other drugs or placebo (Sathe et al., 2017).

Magierski et al. (2020) state that nonpharmacological interventions have low-quality and limited evidence for their use with BPSD. Only a minority of the interventions with antipsychotic drugs are appropriate (Magierski et al., 2020). Pharmacological interventions should only be prioritized in severe agitation cases that endanger the patient and others (Magierski et al. 2020). A hallmark study called CATIE-AD (Comparative Atypical Trial for Intervention Effectiveness in Alzheimer's Disease) demonstrates that physicians change antipsychotics rapidly after initiation and do not titrate doses, which leads to worsening behaviours (Schneider et al., 2006). There has been an overuse of antipsychotics in nursing homes, which lead to implementing the Appropriate Use of Antipsychotics (AUA) methodology in both Canada and the United States to focus on collaborative teamwork and patient-centred care and has successfully reduced antipsychotic use from 22% to 14.9% in over two years. (Bakaev et al., 2021).

There are limited controlled trials of nonpharmacological therapies, and these interventions are highly individualized and depend on the knowledge and skills of the health care provider; however, these should always be attempted before pharmacological treatments as pharmacological treatments have many adverse effects and have insufficient evidence (Bessey & Walaszek, 2019; Herrmann, 2001; Magierski et al., 2020; Oliveira et al., 2015).

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is primarily used first (and medication trial is skipped) in situations where there is a need for "rapid and definitive response to a severe medical or psychiatric condition" where the patient has a history of inadequate medication response and previous good response with ECT (Das & Chiu, 2002). ECT is well documented to be effective in treating medication-resistant depression, mania, and schizophrenia (Gauthier et al., 2010; Lavretsky, 2004). As stated earlier in the literature review, many systemic reviews and case reviews have indicated that ECT is a safe and effective therapy for BPSD compared to pharmacologic treatment. However, despite decades of research, the exact mechanism of action that makes ECT effective in treating depression and now BPSD is not entirely understood (Ujkaj et al., 2012). ECT remains the definitive treatment when there is no improvement with both nonpharmacological and pharmacological interventions and when psychiatric/behavioural symptoms require rapid response (McMurray & Deren, 2019).

Procedure

ECT has received bad publicity through the media because ECT, most commonly known in layman terms as "shock therapy," was historically performed without anesthesia or muscle relaxants (Glass et al., 2017). However, ECT procedures are now well researched, and safety has improved over the decades. A psychiatrist and anesthesiologist routinely perform ECT as a day-procedure (minor procedure not requiring an overnight stay) in an operating theatre, where electrical stimulation to the brain is provided by an ECT machine called Mecta Spectrum 500Q after the patient is placed under general anesthesia and sedated (Ujkaj et al., 2012). Electric currents are delivered to the patient's brain using one electrode (unilateral) on one of the temples or two electrodes (bilateral) on each side of the temple. Electric stimulation is intended to induce seizures, and the amount of stimulus provided is measured by an electroencephalogram (EEG). Dosing of electric stimulus is determined by seizure threshold. Four or five pulses of ECT are supplied in one treatment (Das et al., p. 245). The patient is monitored closely as the effects of the anesthesia wear off and the patient wakes up.

Risks and Benefits

The most common side effect is a headache and transient memory impairment, which resolves independently after forty-eight hours (Ujkaj et al., 2012; Zhang et al., 2016). Other known adverse events are increased pulse and blood pressure, increasing myocardial oxygen demand (Gauthier et al., 2010). ECT is considered a low-risk procedure even for the elderly with known cardiac risk factors (Das et al., 2002).

The risk of potential adverse cognitive effects with ECT needs to be outweighed by the potential benefits of reducing agitation and aggression, as continued use of pharmacological interventions (with insufficient evidence and efficacy) will also lead to adverse events such as toxicity (Ujkaj et al., 2012). Das et al. (2002) provide objective data on the safety of ECT when they conducted serial Magnetic Resonance Imaging (MRI) of the brain pre and post ECT and found no structural changes. There is slow-wave activity and decreased brain metabolism, as shown on an EEG and positron emission tomography (PET). However, these normalized in a few weeks.

Supporting Patients and Families

Information Matters. Educational interventions regarding dementia (disease process and management) that target families and their paid caregivers have positively impacted them; they are more confident in providing care for patients with BPSD and have less caregiver distress or burnout (Bessey & Walaszek, 2019). Elias et al. (2019) discuss that despite ECT's superior efficacy and safety records, ECT is one of the most opposed treatments in medicine, presumably because of the stigma attached to it due to the poor portrayal of media as "shock therapy" (Glass et al., 2017). The agent of a patient or next of kin needs to be informed that ECT is a treatment of a biological illness, rather than behavioural control or "punishment" as it is historically perceived (Ujkaj et al., 2012). Elias et al.'s (2019) study invite families to either attend one session of ECT or watch an ECT DVD to help reduce stigma. The majority of the families in the study are reassured of the safety of ECT and had a positive experience.

ECT-Specific Support Group. Bessey and Walaszek (2019) state that support groups promoted coping strategies and resiliency. These groups assist with problem-solving, acceptance, and social-emotional support. A study by Mignone et al. (2008) states that families of patients receiving ECT often feel excluded and often ostracized due to the double stigma associated with mental health and ECT. As a result, an ECT-specific support group is recommended by the study.

Nursing Role in ECT. The nurse has a responsibility in addressing the psychological needs of a patient undergoing the course of an ECT; and allaying fears of both the patient and their family by providing scientific facts and evidence (Kavanagh & McLoughlin, 2009). Kavanagh & McLoughlin (2009) state that ECT may become a nurse-led service once appropriate training has been attained. Nurses already participate in ECT by ensuring proper electrode placement, operating the ECT machine, and providing post-op care after the ECT.

Recommendations

Double-Blinded Randomized Controlled Trial

Glass et al. (2017) have presented a complete list of study limitations: "Publication bias, small sample sizes, lack of control group, short follow-up, inconsistent use of objective rating measures, and concomitant use of psychotropic medications" (p. 724). All studies have strongly recommended a double-blinded randomized controlled trial to eliminate bias and establish the efficacy of ECT in managing BPSD.

Clear Criteria for Research Participants

There must be a strict and precise selection criterion for subjects. Participants need to be above 65 years old, be diagnosed with dementia as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth edition text revision (DSM-V-TR), have BDSM that is not caused by any medication, disease, or mental health diagnosis, and the BDSM (especially aggression and agitation) does not respond to either or both non-pharmacologic and pharmacologic interventions (Glass et al., 2017). Fazzari et al. (2015) also pointed out the importance of identifying the etiology of the agitation and aggression of the patient that is studied. The aggression/agitation displayed could be a side effect of a medication or caused by a medical condition. Behaviours could also be due to an unmet need. ECT has often been an adjunct to non-pharmacologic and pharmacologic interventions; it would be necessary to trial in future studies how BPSD is affected by ECT alone (Ujkaj et al., 2012).

Objective Rating of Aggression/Behaviors

Studies should use a consistent and objective rating tool (such as the Cohen-Mansfield Agitation Inventory, Pittsburgh Agitation Scale, or Neuropsychiatric Inventory) for measured agitation, pre and post ECT (Zhang et al., 2016). Selvaduraj et al. (2017) also recommend using bilateral ECT at maximum doses, as it had a better impact on reducing behaviours. Future studies should include the tapering off of maintenance ECT to add data on the long-term effects of ECT.

Rule-out Mood Disorders

Ujkaj et al. (2012) have also raised the question of BPSD being a manifestation of a mood disorder and is a subject that may need further research as the efficacy of ECT for BPSD is highly related to its antidepressant and antipsychotic properties. Glass et al. (2017) agreed and stated that aggression and anxiety could also be symptoms of depression or an existing psychotic disorder. The decrease in agitation could be due to the ECT treating the underlying mood disorder and psychotic disorder, misinterpreting the behaviours due to BPSD, and could lead to a false report.

Conclusion

There have been many systemic reviews, retrospective studies, and even case studies that have determined that ECT is safe and effective in managing BPSD; however, these studies have limitations regarding small sample size, lack of a randomized control, and a consistent rating tool to measure agitation pre- and post-ECT objectively. ECT is currently not indicated as the standard treatment of BPSD, and pharmacological therapies are still being utilized, despite insufficient evidence and adverse effects. Furthermore, nursing has a role in giving patients and their families support during the ECT process by alleviating fears and by providing scientific facts. Much evidence suggests that ECT is effective and safe in treating BPSD. However, nonpharmacological nursing interventions that are patient-centred remain the primary intervention for managing BPSD.

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