NUR 7643 Module 3 ECT for Late-Life Depression Case: PRIDE Remission, Continuation Treatment and Consent Example

She Stopped Eating: Choosing Electroconvulsive Therapy and Planning Continuation Care for an 82-Year-Old With Psychotic Depression

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7643: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Populations Part B

Mentor Name

Month Day, Year

She Stopped Eating: Choosing Electroconvulsive Therapy and Planning Continuation Care for an 82-Year-Old With Psychotic Depression

A Rapid Decline

Margaret, an invented patient, is 82 and worked as a hospital nurse for forty-five years before retiring. She has had two episodes of depression in her life, both treated with medicine. Over the past six weeks she has grown silent, stopped reading and stayed in bed. In the past ten days she has eaten almost nothing and drunk little, saying her insides have "rotted away" and food would only poison her. She has lost twelve pounds. She believes she has done something terrible that has ruined her family, though she cannot say what.

Her daughter brought her to the hospital when she became dizzy and fell. She is dehydrated, with a raised creatinine and a sodium of 148. She had been taking sertraline at 100 mg for three months without benefit. She has atrial fibrillation treated with apixaban and a beta blocker, and osteoporosis. Her cognitive screen a year ago was normal.

Her daughter, Anne, is a social worker and is frightened by the word electroconvulsive. She remembers a film scene and asks whether her mother will be strapped down awake. The paper records how this is answered: the treatment is given under brief general anesthesia with a muscle relaxant, the seizure is induced in a controlled way and monitored on a screen, and her mother will wake within minutes in a recovery area, often with a headache and some confusion that clears within an hour or so. Anne is invited to visit the treatment suite before the first session.

Recognizing Psychotic Depression

Margaret has major depression with psychotic features: severe low mood, loss of interest, weight loss, psychomotor slowing, guilt and nihilistic delusions that her body has rotted. Her refusal of food and fluids makes the illness life threatening. Delirium from dehydration is checked; her attention is reduced but her symptoms began weeks before the dehydration, and she remains oriented. Her depression has not responded to an adequate trial of sertraline. Suicide risk is high in psychotic depression in later life, and she has said she deserves to die, though she has no plan.

Why ECT

A British meta-analysis pooled the randomized trials of electroconvulsive therapy for depression (UK ECT Review Group, 2003). Real ECT was more effective than simulated ECT across six trials with 256 patients, and ECT was more effective than medicine across 18 trials with 1,144 participants. Bilateral electrode placement was moderately more effective than unilateral placement, and higher doses more effective than lower ones, while cognitive side effects were a recognized cost. The authors concluded that ECT is an effective short-term treatment for depression and probably more effective than drug therapy.

Kellner et al. (2016a) reported the first phase of the PRIDE study, in which 240 depressed patients past their sixtieth birthday received right unilateral ultrabrief pulse ECT three times a week together with venlafaxine. Overall, 61.7 percent met criteria for remission, 70 percent responded and 28.3 percent dropped out. Among those who remitted, depression scores fell by about 79 percent on average, and remission took an average of 7.3 treatments. The authors described the approach as rapid, highly effective and well tolerated in older adults.

For Margaret, ECT is recommended because her depression is psychotic, life threatening through food and fluid refusal, and has not responded to medicine. A combination of an antidepressant and an antipsychotic is a recognized alternative, but it would take weeks she may not have, and antipsychotics carry fall and heart risks at her age.

Capacity and Consent

Margaret's ability to decide is assessed carefully. She understands what ECT is, having assisted with it as a young nurse, and she can explain the risks and benefits. Her delusions, however, lead her to say she deserves no treatment. The team judges that she has capacity, since she can reason about the choice, and after two conversations with her and her daughter, she agrees, saying she trusts the nurses. Had she refused, the paper notes, New Jersey law would require a court process before treatment could proceed over her objection, and that process would be followed.

The consent explains the procedure under brief general anesthesia with a muscle relaxant, the plan for right unilateral ultrabrief treatment to limit memory effects, the likelihood of short-term confusion after each session and some memory loss for events around the treatment period, and the small risks of anesthesia. Her apixaban and heart rhythm are reviewed with her cardiologist and anesthesiologist before the first session.

The Acute Course

Treatment is given three times a week. Her fluids and nutrition are supported through the first week, with a dietitian involved. Sertraline is switched to venlafaxine, as in the PRIDE protocol. Her depression is rated before each session, and her orientation and memory are checked weekly. By the sixth session she is eating, and by the eighth her delusions have faded and she is reading the newspaper again.

Keeping the Gains

Depression often returns after ECT, especially in the first months. Kellner et al. (2016b) reported the second phase of PRIDE, in which 120 older adults who remitted were randomly assigned to venlafaxine plus lithium alone or to the same medicines plus four continuation ECT sessions over a month, followed by more sessions only as symptoms required. After 24 weeks, the group receiving continuation ECT had lower depression scores and more were rated not ill at all, with no difference in global cognitive scores between the groups.

Margaret's plan follows this approach with one change: because of her kidney function and age, a low dose of lithium is considered carefully and her nephrologist is consulted. Four weekly continuation sessions are scheduled, then sessions only if her ratings rise. Her daughter will drive her to each one.

Her follow-up between sessions is practical. Anne keeps a short daily record of her mother's appetite, sleep, mood and memory for recent events, which she brings to each session. Her mother's apixaban is held on treatment mornings only if the anesthesiologist advises it. Falls are a particular worry after her dizzy spell, so she is helped to stand slowly for the first hours after each session and does not walk alone that day.

Conclusion

Margaret has severe psychotic depression in late life with food and fluid refusal, unresponsive to sertraline. A meta-analysis showing ECT outperforms medicine and the PRIDE study's high remission rate in older adults support ECT, chosen as the fastest effective treatment. Capacity and consent are documented with care. Right unilateral ultrabrief ECT with venlafaxine leads to remission, and continuation ECT from PRIDE's second phase, with medicine and monthly cognitive checks, protects her recovery.

References

Kellner, C. H., Husain, M. M., Knapp, R. G., McCall, W. V., Petrides, G., Rudorfer, M. V., Young, R. C., Sampson, S., McClintock, S. M., Mueller, M., Prudic, J., Greenberg, R. M., Weiner, R. D., Bailine, S. H., Rosenquist, P. B., Raza, A., Kaliora, S., Latoussakis, V., Tobias, K. G., & Briggs, M. C. (2016a). Right unilateral ultrabrief pulse ECT in geriatric depression: Phase 1 of the PRIDE study. American Journal of Psychiatry, 173(11), 1101-1109. https://doi.org/10.1176/appi.ajp.2016.15081101

Kellner, C. H., Husain, M. M., Knapp, R. G., McCall, W. V., Petrides, G., Rudorfer, M. V., Young, R. C., Sampson, S., McClintock, S. M., Mueller, M., Prudic, J., Greenberg, R. M., Weiner, R. D., Bailine, S. H., Rosenquist, P. B., Raza, A., Kaliora, S., Latoussakis, V., Tobias, K. G., & Briggs, M. C. (2016b). A novel strategy for continuation ECT in geriatric depression: Phase 2 of the PRIDE study. American Journal of Psychiatry, 173(11), 1110-1118. https://doi.org/10.1176/appi.ajp.2016.16010118

UK ECT Review Group. (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. The Lancet, 361(9360), 799-808. https://doi.org/10.1016/S0140-6736(03)12705-5