Ect and the Elderly: Shocked for the Aged

By Deborah Y. Liggan

Deborah Y. Liggan suffered her first bipolar depressive episode fourteen years ago.

It came without warning, and the medication she was prescribed was useless. Only after attempting suicide did she receive electroconvulsive therapy, sometimes called shock therapy.

Shed suffer several more bipolar episodes over the next ten years, but each time she was prepared. She knew what worked for her, and so she wasted no time in getting ECT treatments. Between psychotic episodes, she earned a medical degree.

In ECT for the Elderly, she explores how ECT has changed over the years so elderly patients considering it will know what to expect. The textbook is also a resource for students, medical practitioners, and mental health workers who want to identify and prepare elderly patients for treatment.

Before even thinking about using ECT, she urges all professionals to ask questions such as the following:

Does the patient have an ECT-responsiveness illness?
Does the patient have any medical problems that might require modifications of technique or increase the risks of the procedure?
Has appropriate informed consent been obtained?

Find out how ECT is being used to help the elderly with this textbook written by a doctor who has been treated with the therapy herself.

• Language: English
• Publisher: iUniverse
• Release date: May 12, 2017
• ISBN: 9781532017155

Deborah Y. Liggan

Deborah Y. Liggan, MD is a physician whose research and medical writing focuses on exploring the quality of daily life in elderly patients receiving mental health care. Dr. Liggan currently lives in Houston, Texas.

Book preview

ECT AND THE ELDERLY:

SHOCKED FOR THE AGED

DEBORAH Y. LIGGAN, MD

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ECT AND THE ELDERLY: SHOCKED FOR THE AGED

Copyright © 2017 Deborah Y. Liggan, MD.

All rights reserved. No part of this book may be used or reproduced by any means, graphic, electronic, or mechanical, including photocopying, recording, taping or by any information storage retrieval system without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews.

The information, ideas, and suggestions in this book are not intended as a substitute for professional medical advice. Before following any suggestions contained in this book, you should consult your personal physician. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising as a consequence of your use or application of any information or suggestions in this book.

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ISBN: 978-1-5320-1714-8 (sc)

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iUniverse rev. date: 05/12/2017

Contents

Maintenance ECT

Preface

Acknowledgements

List of Tables and Figure

Chapter One: The History of ECT

1.1 Convulsive Therapy

1.2 Fink’s Introduction of ECT

1.3 The Golden Era of ECT

1.4 Outpatient ECT

1.5 Self-Assessment Questions

Chapter Two: Madness Cured with Electricity

2.1 Shock Therapy

2.2 Insulin Coma Therapy

2.3 Metrazol Convulsion Therapy

2.4 The Neurotransmitter Theory

2.5 Sources of Seizures

2.6 Cerletti’s Electrical Activity

2.7 Self-Assessment Questions

Chapter Three: Patient Preparation

3.1 Assessment of the Older Patient

3.2 The Mental Status Examination

3.3 Pre-ECT Evaluation

3.4 Informed Consent

3.5 Caffeine Pre-treatment

3.6 Pre-Treatment with Atropine

3.7 Medical Factors

3.8 Self–Assessment Questions

Chapter Four: Treatment Procedure

4.1 ECT Equipment

4.2 Electrode Placement

4.3 Anesthetic Agents

4.4 Treatment Stimulus

4.5 Observe the Seizure

4.6 Self-Assessment Questions

Chapter Five: Postictal Care

5.2 Cognitive Effect

5.3 Reaction After the Treatment

5.4 ECT Affect on Memory

5.5 Brain Location

5.6 Self-Assessment Questions

Chapter Six: The Self-Vignette

6.1 The Clinical Problem

6.2 ECT Response

6.3 Maintenance ECT

6.4 Coping with ECT After-Effects

6.5 Follow-Up Care

6.6 Suicidal Safety Plan

6.7 Self-Assessment Questions

Chapter Seven: ECT Discussion

7.1 Neurobiological Features

7.2 Suicidal Patients

7.3 When does ECT Work?

7.4 ECT Complications

7.5 ECT Risk Factors

7.6 Self-Assessment Questions

Chapter Eight: Geriatric Psychiatry

8.1 The Elderly Patient

8.2 Common Psychiatric Disorders in Old Age

8.3 Mood Disorders

8.4 Schizophrenia and Other Late-life Psychoses

8.5 Paranoia

8.6 Delusional Disorders

8.7 Clinical Problems in Old Age

8.8 Self-Assessment Questions

Chapter Nine: Psychiatry Treatments in the Elderly

9.1 Drug Use in the Elderly

9.2 Anti-psychotic Medications

9.3 Anti-depressant Medications

9.4 Anti-anxiety Medications

9.5. Treating Insomnia

9.6 Psychotherapies

9.7 Self-Assessment Questions

Chapter Ten: ECT in the Medically Ill Elderly

10.1 Central Nervous System Diseases

10.2 Cardiovascular Diseases

10.3 Pulmonary Diseases

10.4 Endocrine Diseases

10.5 Self-Assessment Questions

Subject Index

Bibliography

About the Author

Maintenance ECT

Bipolar disorder is expressed in emotional

            reactivity associated with loss in

            three-week cyclic suicide ideations.

As voices command me to contemplate

            my overdosing medications, or slitting my wrists,

            or hanging from a shower faucet.

Suicide is such a reality that I ask forgiveness

            for what I am about to do.

Voices reaffirm that I will only gain God’s favor if I kill myself.

I acknowledge treatment for severe endogenous

            depression with each treatment I am destitute,

            And a fatal lease on life leaves me,

            Hoping that I am overwhelmed with the end of life.

I am aware at 9:00 am when I am transported

            to the Operating Room prep area,

            where I am pre-medicated with a muscle relaxant.

Then anesthetized by IV injection of a short acting barbiturate.

An electrode is placed over each temple

            and an alternating current of about

            400mA and 70 to 120V is passed

            between them for 0.1 to 0.5 seconds.

What is wrong with me?

            I contemplate victory as a life

            drains from my body and hope

            that death becomes a reality with each procedure.

When I awaken it is as if I am a new person of life.

            I will continue taking my medications

            to maintain steady moods during intervals

            between three-week maintenance treatments.

Deborah Y. Liggan, M.D.

Preface

There was a perceived need for a comprehensive study of geriatric ECT. Three questions must be answered when treating a patient with ECT:

1. Does the patient have an ECT-responsiveness illness?

2. Does the patient have any medical problems that might require modifications of technique or increase the risks of the procedure?

3. Has appropriate informed consent been obtained?

I agreed to use shock in the title because that is the name by which most people recognize the treatment. Modern ECT has come a long way since the 1930’s origins (chapter one). In chapter four oxygenation, anesthesia, muscle relaxation, modifications in the form and doses of the energies, and variations in electrode placements have reduced the immediate cognitive effects, making the treatments more tolerable. Patients are fully anesthetized and relaxed during each induction. In addition, the consent process recognizes the importance of giving ECT to competent patients who consent voluntarily.

This book is written for those faced with decisions about the use of ECT and is meant to educate elderly patients about what they can expect. It is also meant to help students, medical practitioners, and mental health workers to intelligently identify and prepare elderly patients for treatment. My personal narrative in chapter six shares my experience with ECT. Four-teen years ago, I went through the first of five terrifying acute bipolar depressive episodes the changed my life forever. My first acute depression was the worse one in that I had no warning. And to make matters worse, all the medication trials that were prescribed to me were useless.

On two occasions I attempted suicide, resulting in ECT treatment. Over the next ten years, I relapsed into acute bipolar episodes four more times. But I was prepared. I knew what worked for me, so I wasted no time in getting ECT treatments. Between psychotic depressive episodes, I went back to school to get a medical degree. This qualified me to author multiple medical articles and a medical textbook targeting African American elderly. My second book, The Veteran’s Guide to Psychiatry, played a central role in the provision of mental health services that impact on the veteran’s life. Readers who are interested in learning more about the research conducted on ECT can consult the publications listed in the Bibliography.

Acknowledgements

This book is the product of more than 15 years of interest in electroshock. A number of geriatric patients gave generously of their time in interviews, especially working as monitor of my condition. In the interests of accuracy, I tried to interview as many people involved with my life, my illness and my treatments as possible.

I would like to acknowledge the many people in my life journey that I consider blessed by their presence. I also thank the nurses and aides who were responsible for the daily care of these patients; without their support and faith, the clinical studies drawn upon here would not have been possible. Each person was involved by giving the manuscript in a critical reading to tell the story from my own point of view.

I have been very fortunate in the course of writing this book to have had the help and support of many wonderful people along the way. First and foremost, my two amazing children, Desiree and Rachael-their understanding, encouragement, love and support story provided the courage I needed to forge ahead with this project. To my typist Desiree Fawn Liggan, I would like to give special thanks for the typing and word processing of many drafts and for her encouragement through our publication.

This book owes a special debt to my parents, Moses and Alberta Brooks, who encouraged me to tackle the subject, which I conceived as a study of geriatric electro-convulsive therapy. As it became apparent that telling the ECT story involved by giving the manuscript a critical reading to tell the story from my own pint of view.

Corliss Clayton, a soul sister, who believed in my ability way before I believed in myself. Her relentless spirit and passion fueled my own spirit and passion to finally finish this book.

And finally, my utmost gratitude to the many health care professionals at the Psychosocial Rehabilitation and Recovery Center (PRRC) whose care I depended on in my darkest moments.

Thank you

List of Tables and Figure

Chapter One

The History of ECT

The ancient Greeks were the first to dream of an electric cure. They believed there were special curative powers in the seizures of epileptics. This was followed by the early Romans who put those powers to the rest by treating head pain by generating an electric pulse potent enough to produce a convulsion.

The theory was: the more severe the convulsion, the better the results. According to the primitive technology two electrodes were strapped to the patient’s head, then, at a nod from the doctor, a nurse plugged the other end of the cord directly into the wall outlet. There was no shock machine to control the safety of the current or its duration. At a second sign from the doctor, the nurse unplugged the cord, the patient had a seizure, and all was presumed to be well. Those early patients often let out a shriek as the electricity was applied, but as they convulsed they blacked out.

1.1 Convulsive Therapy

Electroconvulsive therapy (ECT) was introduced in the 1930’s at a time when no effective treatment for the severe mentally ill was known. Convulsive therapy, in the form of chemically induced seizures, was first tested in the 1930’s in patients with dementia praecox, a disorder that is now widely labeled as schizophrenia (Meduna 1935, 1937; Fink 1979).

The induction of a seizure by Metrazol was a frightening procedure. Within a few minutes after the intravenous injection, the patient’s thoughts began to race, his heart beat more rapidly, he experienced feelings of terror and impending doom, and suddenly lost consciousness. When he awakened, his muscles and back ached, often his tongue and lips were bleeding, and he had a violent headache.

A successful method was designed in Rome by Ugo Cerletti and Lucio Bini, where a seizure was safely induced electrically. The original Cerletti method relied on alternating current from a wall socket the pulsed from positive to negative at forty-five cycles per second (45 hertz). This form of current is calling a sine wave.

Just how fast shock was catching on became clear in a U.S. Public Health Service Survey in October 1941, barely eighteen months after the treatment arrived in America. At this time physicians were already experimenting with drugs to relax the muscles and reduce fractures and dislocations.

1.2 Fink’s Introduction of ECT

Dr. Max Fink was first and foremost among clinicians introducing ECT. He watched his first ECT as a medical student in the 1940’s and started giving it regularly during his residency in 1952, ECT’s heyday. Electroconvulsive Therapy (ECT) has been used for nearly seventy years to treat mental illness. As ECT pioneer Max Fink puts it: except for penicillin for neuro-syphilis and niacin for pellagra, ECT for severe illness is the most effective treatment developed in the twentieth century. So clear are the benefits of ECT for patients who might otherwise commit suicide, or languish for years in the blackness of depression, that there should be little controversy over whether it is safe or effective. The assertion that ECT is associated with memory loss, but in the vast majority of patients, memory is restored within weeks after the last treatment, suggesting that no long-term damage to the brain’s memory capacities is sustained. In addition, it was used for the treatment of the deep sadness of melancholia, the delusion of psychotic depression, the unceasing restlessness of mania, or the hallucination of schizophrenia. ECT proved again and again that it was too valuable to be jettisoned with its sister therapies. It survived because it was needed and it worked.

By the mid 1950’s, patients were getting high doses of oxygen along with their anesthesia and muscle relaxant (Falk and Zangerl,