sign in sign up
<<
Home , Psychomotor agitation, Sundowning

Case report

Maintenance ECT for the treatment and resolution of agitation in Alzheimer’s L’ECT di mantenimento nel trattamento e risoluzione dell’agitazione nella demenza di Alzheimer

G. Fàzzari1, C. Marangoni2, O. Benzoni1

1 UO Psichiatria 23, Azienda Ospedaliera Universitaria Spedali Civili di Brescia, Montichiari Hospital; 2 Dipartimento di Scienze Biomediche e Chirurgico Specialistiche, Università di Ferrara

Summary antipsychotis, anxiolytics and mood stabilizers. The patient was treated with acute and maintenance bilateral ECT. Background Behavioural and psychological symptoms of dementia (BPSD) Conclusions refer to the distressing, non-cognitive symptoms of dementia and This case represents a successful use of acute and maintenance include agitation or restlessness; and non-specific be- ECT in the treatment of BPSD, in particular psychomotor agi- haviour disturbance e.g. hoarding; verbal or physical aggression; tation, associated with Alzheimer’s dementia. According to our ; ; , , hallucinations; repeti- experience, it is important to manage this psychiatric manifesta- tions with ECT, especially in those cases in which the psychop- tive vocalisation, cursing, screaming and swearing; sleep distur- harmacological treatment alone does not give satisfactory results bance; shadowing; . in clinical improvement. Clinical case Key words We report the case of a patient with advanced stage Alzheimer’s dementia with severe BPSD not respondent to several trials of Electroconvulsive therapy • Dementia • Agitation

Behavioural and psychological symptoms of dementia Electroconvulsive therapy (ECT) has been shown to be ef- (BPSD) refer to the distressing, non-cognitive symptoms of fective in the treatment of BPSD 6. dementia. BPSD include symptoms of disturbed percep- Herein, we report a case of successful use of ECT as acute tions, thought content, and changes of mood or behaviour and maintenance treatment for BPSD in a patient compared to baseline 1. The spectrum of BPSD includes from advanced stage Alzheimer’s dementia. Mrs E.S. is a agitation or restlessness; wandering and non-specific 76-year-old white female, with negative psychiatric his- behaviour disturbance, e.g. hoarding; verbal or physical tory, but a clear hyperthymic temperament and a 3-year aggression; anxiety; depression; psychosis, delusions, history of severe Alzheimer’s dementia. Psychiatric family hallucinations; repetitive vocalisations such as cursing, history was positive: the older daughter had hyperthymic screaming and swearing; sleep disturbance; shadowing; temperament and the younger suffered from severe so- sundowning 1. cial and later developed an episode of psychotic BPSD are observed in up to 90% of patients with demen- , treated successfully with lithium and . tia: agitation and aggression are present in 60-80% of sub- Mrs E.S. was admitted to the unit for , jects with Alzheimer disease 2. severe and restlessness, , Primary intervention, after failure of non-pharmacological mood lability with weeping and , repetitive vocali- measures, is the use of antidepressants, mood stabilisers sation, cursing and swearing. Because of her behaviour, and 3 4. Unfortunately, there are few con- the management of the patient by relatives and a visiting trolled trials in patients with dementia, and atypical antip- nurse at home failed (Activities of Daily Living, ADL = 0). sychotics have been shown to increase overall mortality; Therapeutic trials of trazodone, promazine, zuclopenthix- moreover, patients often are unable to tolerate the side ol and valproic acid were ineffective. On admission, med- effects of these medications 5. ications included quetiapine 800 mg/day, lithium 900 mg/

Correspondence Ciro Marangoni, via Ponte Assa 80, 44123 Ferrara, Italy • Tel/Fax +39 0532 427722 • E-mail: [email protected]

Journal of 2015;21:159-160 159 G. Fàzzari et al.

day, valproate 1,000 mg/day, 200 mg/day and controlled trials with ECT are necessary to further assess niaprazine 30 mg/day. its efficacy for this indication. Cognitive screening with the Mini Mental State Examina- tion (MMSE) was not possible because of agitation. Labora- Conflict of interests tory exams were normal. A head computerized tomogra- None of the authors have anything to declare. phy (without contrast) showed diffuse cortico-subcortical atrophy with secondary ventricular enlargement. The pa- References tient was treated with a course of 3 applications of ECT 1 with bitemporal lead placement, with resolution of confu- Casacchia M, Pollice R, De Risio A. Demenze degenerati- sion, psychomotor agitation and behavioural disturbance. ve primarie: clinica e terapia. Journal of Psychopathology At home, the patient continued therapy with quetiapine 2000;6:247-63. and prometazine. In the next 7 months, the patient was ad- 2 Bartels SJ, Horn SD, Smout RJ, et al. Agitation and depres- mitted to the hospital three times because of behavioural sion in frail nursing home elderly patients with dementia: disturbances, and was treated with a total of 8 applications treatment characteristics and service use. Am J Geriatr Psy- of ECT (6 bitemporal, 2 bifrontal). Since the effect of ECT chiatry 2003;11:231-8. was rapid and effective, but short-acting, with the patient 3 Tariot PN. Treatment of agitation in dementia. J Clin Psy- relapsing approximately every 2 months, we started main- chiatry 1990;60(suppl. 8):11-18. tenance ECT (2 applications every 45 days) for the next 6 4 Moretti L, Perugi G. Gli antipsicotici atipici nelle sindromi months. During maintenance ECT, the patient showed re- psico-comportamentali secondarie a disturbi neurologici. lapses and remained in good behavioural control. Quetia- Accesibile online at www.gipsicopatol.it. Journal of Psycho- pine was tapered to 50 mg/day and continued for the fol- pathology 2001;7(4). lowing 2 years. No further ECT was indicated. The patient 5 Schneider LS, Dagerman KS, Insel MS, et al. Risk of death died at the age of 80 years for progressive kidney failure. with atypical drug treatment for dementia: Discerning the aetiology of behavioural and mood meta-analysis of randomized placebo-controlled trials. JA- changes in the setting of advanced dementia is difficult: MA 2005;294:1934-43. agitation and aggression may be the result of impairment 6 Ujkaj M, Davidoff DA, Seiner SJ, et al. Safety and efficacy of of cognitive functioning, psychosis, anxiety, mania, agi- electroconvulsive therapy for the treatment of agitation and tated depression, physical illness or discomfort, or a side aggression in patients with dementia. Am J Geriatr Psychia- effect of medical therapy. Although depressive disorders try 2012;20:61-72. remain the most common indication for ECT in the el- 7 Liu AY, Rajji TK, Blumberger DM, et al. Brain derly, a growing body of literatures has identified ECT as in the treatment of late-life severe mental illness other than an effective intervention for severe refractory agitation in unipolar nonpsychotic depression. Am J Geriatr Psychiatry patients with dementia 7. We believe that randomised, 2014;22:216-40.

160