Subcortical Structural Changes in ECT-Induced Delirium

Figiel, Gary S.; Ranga, K.; Krishnan, Ranga; Doraiswamy, P. Murali

doi:10.1177/089198879000300309

Cited by 69 publications

(19 citation statements)

References 17 publications

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“…This hypothesis is supported by the conclusion from recent coronary artery bypass grafting studies that the executive dysfunction and delirium relationship may be mediated by severity of atherosclerosis 7. Furthermore, abnormalities in the frontal-striatal circuitry have been previously shown to predict delirium among depressed individuals following electro-convulsive therapy 48 and are associated with executive deficits in a variety of patient populations 49,50. Again, the relationship between these factors and their independent and joint effects on delirium warrant further study.…”

Section: Discussionmentioning

confidence: 71%

Executive Function and Depression as Independent Risk Factors for Postoperative Delirium

Smith¹,

Attix²,

Weldon

et al. 2009

Anesthesiology

109

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Background Postoperative delirium has been associated with greater complications, medical cost, and increased mortality during hospitalization. Recent evidence suggests that preoperative executive dysfunction and depression may predict postoperative delirium; however, the combined effect of these risk factors remains unknown. We therefore examined the association between preoperative executive function, depressive symptoms, and established clinical predictors of postoperative delirium among 998 consecutive patients undergoing major non-cardiac surgery. Methods Nine hundred ninety eight patients were screened for postoperative delirium (n = 998) using the Confusion Assessment Method as well as through retrospective chart review. Patients underwent cognitive, psychosocial, and medical assessments preoperatively. Executive function was assessed using the Concept Shifting Task, Letter-Digit Coding, and a modified Stroop Color Word Interference Test. Depression was assessed by the Beck Depression Inventory. Results Preoperative executive dysfunction (P = .007) and greater levels of depressive symptoms (P = .049) were associated with a greater incidence of postoperative delirium, independent of other risk factors. Secondary analyses of cognitive performance demonstrated that the Stroop Color Word Interference Test, the executive task with the greatest complexity in this battery, was more strongly associated with postoperative delirium than simpler tests of executive function. Furthermore, patients exhibiting both executive dysfunction and clinically significant levels of depression were at greatest risk for developing delirium postoperatively. Conclusions Preoperative executive dysfunction and depressive symptoms were predictive of postoperative delirium among non-cardiac surgical patients. Executive tasks with greater complexity are more strongly associated with postoperative delirium relative to tests of basic sequencing.

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Section: Discussionmentioning

confidence: 71%

Executive Function and Depression as Independent Risk Factors for Postoperative Delirium

Smith¹,

Attix²,

Weldon

et al. 2009

Anesthesiology

109

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“…Elderly patients with underlying neuropsychiatric conditions, such as cognitive impairment [229], Parkinson’s disease/parkinsonism [228,230], dementia [231,232] and stroke [233,234] are at a higher risk of developing delirium and confusion immediately after ECT. A study compared the incidence of ECT-induced delirium in 14 depressed elderly patients who had a history of stroke with 14 depressed elderly controls (without a history of cerebrovascular accident) and found no difference in the overall incidence rates of delirium between the two groups (28.5%) [235].…”

Section: Ect Adverse Effects and Managementmentioning

confidence: 99%

“…A study compared the incidence of ECT-induced delirium in 14 depressed elderly patients who had a history of stroke with 14 depressed elderly controls (without a history of cerebrovascular accident) and found no difference in the overall incidence rates of delirium between the two groups (28.5%) [235]. Some patients who had a recent cerebrovascular accident involving the caudate nucleus appeared more likely to develop delirium in one study [234]. …”

Section: Ect Adverse Effects and Managementmentioning

confidence: 99%

Current electroconvulsive therapy practice and research in the geriatric population

2014

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SUMMARY Electroconvulsive therapy (ECT) is utilized worldwide for various severe and treatment-resistant psychiatric disorders. Research studies have shown that ECT is the most effective and rapid treatment available for elderly patients with depression, bipolar disorder and psychosis. For patients who suffer from intractable catatonia and neuroleptic malignant syndrome, ECT can be life saving. For elderly patients who cannot tolerate or respond poorly to medications and who are at a high risk for drug-induced toxicity or toxic drug interactions, ECT is the safest treatment option. Organic causes are frequently associated with late-life onset of neuropsychiatric conditions, such as parkinsonism, dementia and stroke. ECT has proven to be efficacious even when these conditions are present. During the next decade, research studies should focus on the use of ECT as a synergistic therapy, to enhance other biological and psychological treatments, and prevent symptom relapse and recurrence.

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“…Trzepacz et al (1989) used somatosensory evoked potentials to propose subcortical lesions. ECT and antidepressant-induced delirium were both investigated by Figiel et al (1989Figiel et al ( , 1990 using MRI. Lesions were found in the basal ganglia and subcortical white matter.…”

Section: Discussionmentioning

confidence: 99%

“…Their aetiology was linked to infarctions caused by atherosclerotic involvement of penetrating arterioles. The pathophysiological explanation for delirium was described by Figiel et al (1990). They implicated disruption of afferent projections from association cortices that were thought to be important for the maintenance of attention.…”

Section: Discussionmentioning

confidence: 99%

Is ect safe in patients with cerebrovascular disease?

Blackburn¹,

Decalmer²

1994

Int J Geriat Psychiatry

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SUMMARYA 70-year-old man with a history of peripheral vascular disease was treated initially with antidepressants, then bilateral electroconvulsive therapy (ECT) for a depressive illness. Apart from an episode of delirium following ECT he recovered fully. Four years later he relapsed. Low-dose antidepressants caused disorientation and oversedation, as did ECT. Shortly afterwards he developed a multi-infarct state with Parkinsonian symptoms, transient ischaemic attacks (TIAs) and cerebrovascular attacks (CVAs). His cognitive deficits implicated pathology in the frontal and subcortical areas of the brain. Postmortem examination confirmed widespread atherosclerotic disease, also cerebrovascular disease. The haemodynamic and cerebral effects of ECT are considered in the context of vascular disease. It is postulated that ECT given to such patients might cause permanent impairment of cognitive function through ischaemia of an already compromised cerebral circulation. Suggestions are outlined regarding a policy for a more comprehensive assessment of patients with atherosclerotic disease. Deficiencies of ECT procedures are highlighted.KEY woms-Electroconvulsive therapy, ECT, elderly, multi-infarct dementia, delirium.Mr G initially presented with depressive illness at the age of 70. His medical history included intermittent claudication. His mother had suffered from long-standing cardiac disease and died at the age of 66. He was a non-drinker and non-smoker. As his depression failed to improve on standard doses of mianserin and prothiaden, he was admitted for electroconvulsive therapy (ECT). Cardiovascular evaluation was normal. Following the fourth ECT he became disorientated with perseveration, disinhibition and aggression. This resolved over the next 2 days with phenothiazines. He was given one further bilateral ECT before being discharged on parstelin (compound tranylcypromine/trifuoperazine). Two months later he was readmitted with a relapse of depressive illness. Cognitive function tests were performed in detail but no impairment was demonstrated. Physical examination, routine blood tests, electrocardiograph (ECG) and chest X-ray (CXR) were all normal. ECT again resulted in delirium, this time after the ninth application. Mental state gradually improved as before. A computerized tomography (CT) scan was reported as normal. Six further ECTs were given without incident, and the patient was discharged improved in mood on lithium 1 g daily.Four years later (aged 74) Mr G again became depressed. Physically he complained of painful legs. An arteriogram showed calcification of the abdominal aorta and iliac arteries. Over the next 2 years his mood worsened, despite his receiving a range of antidepressants which included lithium, tricyclics and 5HT antagonists. Very low doses of all drugs resulted in oversedation and disorientation. Right unilateral ECT was given. Each one of the 12 treatments was followed by prolonged anaesthetic recovery, daytime drowsiness and confusion. Two months later a number of investigations were pe...

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Subcortical Structural Changes in ECT-Induced Delirium

Cited by 69 publications

References 17 publications

Executive Function and Depression as Independent Risk Factors for Postoperative Delirium

Executive Function and Depression as Independent Risk Factors for Postoperative Delirium

Current electroconvulsive therapy practice and research in the geriatric population

Is ect safe in patients with cerebrovascular disease?

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