ECT for Treating Aggression and Agitation in Dementia

Electroconvulsive therapy (ECT) has long been used to treat people struggling with major depressive disorder when they haven't improved with antidepressant medications. This is often referred to as treatment-resistant depression.

While ECT remains somewhat controversial, in part because it is poorly understood, its use is expanding to other conditions. This includes severe agitation in Alzheimer's disease and other kinds of dementia.

Background

ECT has a bad reputation for many who associate it with old ECT treatments that produced violent body jerking and appeared to cause people to become emotionally flat and almost vegetative in nature. You can be reassured that much has changed in ECT.

When it was initially developed, there were far fewer safeguards in place. Today, if you were to watch an ECT treatment, you would barely notice any movement of the person while they're receiving the electric shock.

There is no pain during ECT because the person is given anesthesia. Additionally, ECT is administered with multiple medical staff present to ensure the safety and monitoring of the patient before, during, and after the procedure.

Indications

The indications for ECT vary based on a person's unique situation, but there are some guidelines for its appropriate use:

While each person and his medical condition is unique, in general, there is an order of treatment approaches when it comes to helping the person with dementia who is aggressive and agitated:

1. Non-pharmacological interventions
2. Non-pharmacological interventions plus a medication
3. Non-pharmacological interventions plus multiple combinations of medications

ECT should typically not be attempted until the other approaches have been utilized. There are exceptions to this rule, such as situations where medications can't be utilized or the situation is so dire that the medical staff feels the potential benefit outweighs the risks.

ECT for Agitation and Aggression in Dementia

ECT has been explored as a treatment for agitation in dementia because of the significant dysfunction and distress that some people with Alzheimer's and other dementias display.

This extreme agitation can make it very difficult to care for the person since they may be at the point of harming themself or those around them. In these cases, if other interventions are ineffective, some physicians may recommend ECT treatments.

Other Uses

In addition to depression that's not responding to antidepressant medicine, ECT is also used at times to treat bipolar disorder and schizophrenia. Sometimes, it's also used if a person is catatonic, manic, or unable to take antidepressants for some reason.

ECT may be used for someone who's suicidal where it's felt that waiting for a medicine to help would take too long and the risk of waiting is greater than the risk of trying ECT.

How Is ECT Administered?

Electroconvulsive therapy involves the administration of electrical stimulation to the brain which causes a brief seizure. Before undergoing ECT, a patient is given general anesthesia and medication to relax their muscles. The seizure caused by ECT will typically last about 30 seconds to a minute.

After the seizure, the person wakens within a few minutes, and within an hour is usually able to resume normal activities, although some psychiatrists prohibit driving for 24 hours.

The number of ECT treatments will vary depending on someone's diagnosis, overall condition, and response to the treatments.

Side Effects

Side effects include headaches, nausea, muscle soreness, memory loss, and confusion.

Most research has concluded that memory loss is limited, often to a short period before the ECT was administered and less commonly to a few weeks or months before treatment, and rarely to events or information from years before.

When used for the treatment of aggression and agitation with dementia, a study from Harvard Medical School has shown that ECT is relatively safe. With that said, some participants discontinued treatment when confusion was significant (often lasting more than 30 minutes).

However, the majority of people who received ECT for agitation in dementia did not appear to suffer serious side effects.

Complications

There is conflicting research about the effects of ECT on cognition. Some research has found that ECT in older adults vs. younger adults has a higher risk of confusion and memory loss, specifically for those who have vascular dementia or are in later stages of dementia.

However, it can be difficult to determine whether that risk is related to the ECT, the individual's depression (which can blunt cognition), or impair cognition that occurs with older age.

Other research concluded that cognition remained the same after multiple ECT sessions, while some studies determined it actually improved.

Because there are multiple factors in play, such as the underlying diagnosis that triggers the need for ECT, as well as age and overall health, it's often difficult to isolate any cognitive change specific to ECT.

Effectiveness

Using ECT to treat agitation and aggression in dementia is a less-researched approach. Nonetheless, there have been a few studies, including one published in the International Journal of Geriatric Psychiatric, that have concluded that ECT was effective in reducing agitation without producing major side effects.

Most people who received ECT in research studies for agitation in dementia demonstrated a decreased level of agitation following treatment. With that said, agitation and aggression may return in some people after ECT, so maintenance treatments may be needed to sustain control of these symptoms.

It's important to note that the studies involving ECT in the treatment of dementia generally involve small numbers of participants. The above-listed study, for example, only had 23 participants.

Considerations

Deciding if ECT is right for you or your loved one should be guided by focusing on the person receiving it.

While caregivers struggle significantly to respond to challenging behaviors in dementia, the decision to try ECT should be made based on the attempt to decrease the distress of the person for whom it is proposed and the potential benefit to them, not others.

If several non-drug approaches and multiple medications have been attempted and the person still remains very distressed emotionally and physically out of control, it may be time to try ECT for dementia.

A doctor must take other diagnoses and medical history into account.

A Word From Verywell

ECT may be a helpful option for treating agitation and aggression in dementia. However, there is a lack of research definitively qualifying its benefits in this respect.

If ECT is proposed for a loved one who is living with dementia, do not hesitate to express any concerns you have or to seek a second opinion from a psychiatrist experienced in ECT. The medical staff may have much knowledge about ECT, but your knowledge of your loved one's medical history makes you an important part of the treatment team.