Case-control study by chart analysis – level of evidence 2
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Zhang et al.1919 Zhang QE, Sha S, Ungvari GS, Chiu HFK, Ng CH, He HB, et al, Demographic and clinical profile of patients with dementia receiving electroconvulsive therapy: a case-control study. J ECT. 2016;32(3):183-6. https://doi.org/10.1097/YCT.0000000000000314 https://doi.org/10.1097/YCT.000000000000...
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ECT: n=23 (age: 60y and older; M: 30.4%); Comparison group n=71 (age: 60y and older; M: 31%) |
Mild to severe dementia (AD, VD, mixed/AD+VD, other types) with agitation, aggression and suicide risk |
Bitemporal; mean sessions: 6.1 (±3.0); seizures greater than 25 seconds; pulse width: 0.25 and 1.0 ms |
CGI |
91.3% fully or partially responded to ECT behavioral disorders and risk of suicide |
47.8% experienced mild-moderate transient headache, myalgia, nausea, dyspnea, hypertension; no postictal confusion reported |
Transient memory impairment; no persistent memory changes |
Open-label and naturalistic study – level of evidence 3
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Acharya et al.2020 Acharya D, Harper DG, Achtyes ED, Seiner SJ, Mahdasian JA, Nykamp LJ, et al. Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. Int J Geriatr Psychiatry. 2015;30(3):265-73. https://doi.org/10.1002/gps.4137 https://doi.org/10.1002/gps.4137...
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n=23 age: 73.8 y F: 14 M: 9 |
Moderate to severe AD, VD, mixed/AD+VD, FTD, unspecified dementia |
Right unilateral (n=17), bilateral (n=4) transitioned to bitemporal (n=2) due to no response; 12 sessions; seizures duration not mentioned; pulse width: 0.5–1.0 ms |
CMAI-short form, NPI, CSDD, CGI |
Significant improvement in behavioral dyscontrol and agitation; no changes in mood and psychosis domains of the NPI |
Well tolerated by most participants; 3 patients presented delirium; 1 patient developed atrial fibrillation; 1 patient presented visual hallucinations |
From before to after ECT, the MMSE increased by approximately 2 points on average |
Retrospective and systematic analysis of chart review of case series – level of evidence 4)
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Sutor and Rasmussen2121 Sutor B, Rasmussen KG. Electroconvulsive therapy for agitation in Alzheimer disease: a case series. J ECT. 2008;24(3):239-41. https://doi.org/10.1097/YCT.0b013e3181587416 https://doi.org/10.1097/YCT.0b013e318158...
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n=11 Age: 81.4y (59-98y) F: 10 M: 1 |
Severe AD with psychosis, physical and verbal aggression; 8 patients had history of primary psychiatric disorders (depression, generalized anxiety, BP) |
Bitemporal (n=8), bifrontal (n=1), right unilateral (n=2); 4–8 sessions, duration of seizures unspecified dementia |
Objective behavior assessment not reported |
Improvement for 9 patients; no benefits in 2 patients |
Most patients tolerated the ECT well; one patient developed atrial fibrillation |
Decreased cognition in 2 patients, no information for the other 9 patients |
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Ujkaj et al.2222 Ujkaj M, Davidoff DA, Seiner SJ, Ellison JM, Harper DG, Forester BP. Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia. Am J Geriatr Psychiatry. 2012;20(1):61-72. https://doi.org/10.1097/JGP.0b013e3182051bbc https://doi.org/10.1097/JGP.0b013e318205...
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n=16 age: 66.6y F: 15 M: 1 (retrospective systematic chart review) |
Mild to severe AD (n=8); FTD (n=3), VD (n=2); unspecified dementia (n=3) with aggression and agitation |
9 sessions (from 2 to 15); bilateral (n=12), right unilateral (n=4), transitioned to bilateral when insufficient response (n=4); 9 patients received ETC maintenance; seizure duration not reported. |
PAS, CGI |
Significant improvement in aberrant vocalizations, motor agitation, aggressiveness, and care resistance |
In general, well tolerated; 10 patients developed postictal transient confusion. |
Cognition not reported after ECT course |
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Hermida et al.1414 Hermida AP, Tang YL, Glass O, Janjua AU, McDonald WM. Efficacy and safety of ECT for symptoms of dementia (BPSD): a retrospective chart review. Am J Geriatr Psychiatry. 2020;28(2):157-63. https://doi.org/10.1016/j.jagp.2019.09.008 https://doi.org/10.1016/j.jagp.2019.09.0...
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n=60 age: 77.5y F: 45 M: 15 (case series from a chart review) |
Moderate to severe AD n=28), VD (n=2), FTD (n=2), mixed (n=6), unspecified dementia (n=22) with aggression and agitation. |
Right unilateral; 8 patients transitioned to bifrontal due to poor response; 4−12 sessions (average: 9.6); seizure duration not mentioned; width pulse: 0.37 ms |
PAS, GAF, psychiatric consult notes |
Improvement in global functioning with decrease of psychotropic polypharmacy |
Postictal agitationand mild postictal confusion in 6 patients; delirium in 1 patient |
Cognition not reported after ECT course |
Case reports – level of evidence 5
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Carlyle et al.1515 Carlyle W, Killick L, Angill R. ECT: an effective treatment in the screaming demented patient. J Am Geritr Society. 1991;39(6):637. https://doi.org/10.1111/j.1532-5415.1991.tb03610.x https://doi.org/10.1111/j.1532-5415.1991...
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n=3 Age and gender not reported |
Unspecified dementia characterized by substantial cognitive decline and agitation |
Bilateral; number of sessions and seizure duration not mentioned |
Objective behavior assessment not reported |
Rapid resolution of screaming |
Tolerability or side effects not reported |
Cognition not reported after ECT course |
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Holmberg et al.1616 Holmberg SK, Tariot PN, Challapalli R. Efficacy of ECT for agitation in dementia: a case report. Am J Geriatr Psychiatry. 1996;4(4):330-4. https://doi.org/10.1097/00019442-199622440-00007 https://doi.org/10.1097/00019442-1996224...
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n=1 age: 78y, F |
Severe VD |
Bilateral; seizure duration from 45 to 60 seconds; 54 sessions; maintenance for 2 years; brief-pulse width |
Behavioral rating scale |
Dramatic improvement in agitation and aggression at the beginning of treatment; maintenance of ECT for 2 years with response oscillation |
Well tolerated |
Cognition not reported after ECT course |
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Roccaforte et al.3232 Roccaforte WH, Wengel SP, Burke WJ. ECT for screaming in dementia. Am J Geriatr Psychiatry. 2000;8(2):177. PMID: 10804080
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n=1 age: 77y, F |
Language advanced dementia; disruptive vocalizations, verbal aggression, warbling, loudly, obscenely |
6 sessions; lead placement not reported; seizure duration not reported |
Objective behavior assessment not reported |
Substantial improvement |
Tolerability or side effects not reported |
Before ECT the MMSE was 0, but not assessed after the procedure course |
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Grant et al.2323 Grant JE, Mohan SN. Treatment of agitation and aggression in four demented patients using ECT. J ECT. 2001;17(3):205-9. https://doi.org/10.1097/00124509-200109000-00012 https://doi.org/10.1097/00124509-2001090...
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n=4 Case 1: age: 56y, F |
Severe pre-senile AD with agitation and suspected visual hallucinations |
Bilateral, 4 sessions; seizures lasting 37–43 seconds; brief-pulse width |
Objective behavior assessment not reported |
Improvement in agitation and aggression |
Postictal confusion lasting several hours after treatment |
In the 4 cases, since dementia was severe, the risk of cognitive worsening was considered moot |
Case 2: age: 78y, M |
Severe AD with agitation and aggression |
Bilateral; 7 sessions; seizures lasting 26–39 seconds; brief-pulse width |
Objective behavior assessment not reported |
Dramatically reduction of agitation and aggression |
Tolerability or side effects not reported |
Case 3: age: 77y, F |
Severe AD with agitation, sleep disorder |
Bilateral; 2 sessions; seizures with 46 seconds and 52 seconds; brief-pulse width |
Objective behavior assessment not reported |
Improvement in agitation, verbal aggression, and sleeping |
Tolerability or side effects not reported |
Case 4: age: 78y, F |
Severe AD with agitation and verbal aggression |
Bilateral; 4 sessions in the first period and 4 additional sessions after three months (8 sessions); seizures lasting 30–54 seconds; brief-pulse width |
Objective behavior assessment not reported |
Improvement in verbal aggression and repetitive speaking after first course; no additional information |
Tolerability or side effects not reported |
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McDonald and Thompson1111 McDonald WM, Thompson TR. Treatment of mania in dementia with electroconvulsive therapy. Psychopharmacol Bull. 2001;35(2):72-82. PMID: 12397888.
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n=3 Case 1 Age: 73y M |
Severe Lewy-body dementia and BP, with mania symptoms, agitation, and aggressiveness |
Right-unilateral acute course; 8 sessions plus maintenance ECT every 2 weeks for the following 18 months; seizures duration not mentioned; 8 brief-pulse width |
Objective behavior assessment not reported |
Marked improvement in mood and behavior |
No postictal confusion or worsening in dementia |
Cognition improved – MMSE from unobtainable to 9 out of 30 |
Case 2 Age: 85y F |
Moderate dementia not otherwise specified with agitation and aggressiveness and mania symptoms; history of alcohol and benzodiazepines dependence |
Right-unilateral ECT acute course; 6 sessions with maintenance course for 6 months; seizures duration not mentioned; 6 brief-pulse width |
Objective behavior assessment not reported |
Significant improvement in mood and behavior |
No postictal confusion or worsening in dementia |
Cognition remained stable; MMSE 15–16 out of 30 |
Case 3 Age: 71y F |
Mild-moderate dementia not otherwise specified and BP with mania symptoms and agitation |
Right-unilateral ECT acute course; 7 sessions with maintenance course for the subsequent 18 months; seizures duration not mentioned; 7 brief-pulse width |
Objective behavior assessment not reported |
Complete resolution of mania and agitation |
No postictal confusion or worsening in dementia |
Cognition improved; MMSE from 24 to 28 out of 30. Later this patient was diagnosed with “pseudodementia” |
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Bang et al.2424 Bang J, Price D, Campbell J. ECT treatment for two cases of dementia-related pathological yelling. J Neuropsychiatry Clin Neurosci. 2008;20(3):379-80. https://doi.org/10.1176/jnp.2008.20.3.379 https://doi.org/10.1176/jnp.2008.20.3.37...
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n=2 Case 1: age: 88y, F |
Severe AD+PDD with verbal agitation, obscenities, hollering, palilalia, and screaming; |
Bilateral; 11 sessions; seizures up to 84 seconds |
Objective behavior assessment not reported |
Marked improvement in verbal agitation |
Well tolerated |
The patient improved in verbal language and in nodding in response to questions |
Case 2: age 80y, F |
Severe unspecified dementia, with agitation, screaming, spitting, striking |
Bilateral; 5 sessions; seizures up to 56 seconds |
Objective behavior assessment not reported |
Improvement in verbal agitation and aggression |
Well tolerated |
Cognition not reported after ECT course |
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Suzuki et al.2525 Suzuki K, Awata S, Matsuoka H. One-year outcome after response to ECT in middle-aged and elderly patients with intractable catatonic schizophrenia. J ECT. 2004;20(2):99-106. https://doi.org/10.1097/00124509-200406000-00005 https://doi.org/10.1097/00124509-2004060...
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n=1 age: 51y, M |
FTD overlapping severe BP with angering, joking, followed by apathy or agitation |
Bitemporal; 9 sessions; seizures lasting 39–70 seconds; brief-pulse width |
Objective behavior assessment not reported |
Improvement in behavioral disturbances |
High fever, liver dysfunction and ECT interruption for 1 week, being resumed afterward |
Improvement in attention and abstract thinking |
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Wu et al.2626 Wu Q, Prentice G, Campbell JJ. ECT treatment for two cases of dementia-related aggressive behavior. J Neuropsychiatry Clin Neurosci 2010;22(2):E10-11. https://doi.org/10.1176/jnp.2010.22.2.247.e10 https://doi.org/10.1176/jnp.2010.22.2.24...
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n=2 Case 1: age: 78y, M |
Severe AD with aggression |
Bitemporal; 7 sessions, seizures lasted up to 65 seconds |
Objective behavior assessment not reported |
Marked improvement |
Well tolerated |
Cognition not reported after ECT course |
Case 2: age: 71y, M |
Severe FTD with pushing, grabbing, choking |
Bitemporal; 6 sessions, seizures lasted up to 58 seconds; maintenance for every 28 days |
Objective behavior assessment not reported |
Improvements in aggression |
Well tolerated |
Cognition not reported after ECT course |
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Paul et al.3333 Paul S, Goetz J, Bennett J, Korah T. Efficacy of electroconvulsive therapy for comorbid frontotemporal dementia with bipolar disorder. Case Rep Psychiatry. 2013;124719. https://doi.org/10.1155/2013/124719 https://doi.org/10.1155/2013/124719...
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n=1 Age: 51y, M |
FTD with history of bipolar disorder; unreported severity |
9 sessions; localization not reported; seizures duration not reported |
Objective behavior assessment not reported |
Significant improvement in mood symptoms without benefits for erratic behavior and laughter |
Tolerability or side effects not reported |
The MMSE score went from 6/28 before ECT up to 20/28 after treatment (two items were excluded: the drawing and written portions of the exam) |
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Aksay et al.3030 Aksay SS, Hausner L, Frölich L, Sartorius A. Severe agitation in severe early-onset Alzheimer’s disease resolves with ECT. Neuropsychiatr Dis Treat. 2014;10:2147-51. https://doi.org/10.2147/NDT.S71008 https://doi.org/10.2147/NDT.S71008...
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n=1 Age: 57y, F, right-handed |
Severe pre-senile AD with agitation, aggressiveness, and repetitive outbursts |
Right unilateral, 8 sessions; seizures duration not mentioned; pulse width: 0.25 ms |
PAS |
Significant improvement |
Well tolerated despite headache; 3 spontaneous self-limiting generalized seizures. |
ECT without any recognizable worsening of cognition |
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Borisovskaya et al.3131 Borisovskaya A, Augsburger J, Pascualy M. Electroconvulsive therapy for frontotemporal dementia with comorbid major depressive disorder. J ECT. 2014;30(4):e45-6. https://doi.org/10.1097/YCT.0000000000000152 https://doi.org/10.1097/YCT.000000000000...
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n=1 age: 70y, M |
Moderate to severe FTD with perseverative behavior, psychosis, apathy, and depression |
Right unilateral, 6 sessions; seizures average of 60 seconds; several months with maintenance treatment; ultrabrief pulse of 0.3 ms |
FAB |
Initial improvement and subsequent worsening |
ST-segment depression at EKG. |
No worsening in cognition |
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Fazzari et al.2727 Fazzari G, Marangoni C, Benzoni O. Maintenance ECT for the treatment and resolution of agitation in Alzheimer’s dementia. J Psychopathology. 2015;21:159-60.
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n=1 age: 76y, F |
Severe AD with agitation, insomnia, mood lability, weeping, anger, repetitive vocalization, and swearing |
Bitemporal and bifrontal: 21 sessions including acute course and maintenance; seizure duration not mentioned. |
Objective behavior assessment not reported |
Resolution of confusional state, psychomotor agitation and behavioral disturbance |
Tolerability or side effects not reported |
Cognition not reported after ECT course |
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Selvadurai et al.2828 Selvadurai MI, Waxman R, Ghaffar O, Fischler I. Efficacy and safety of maintenance electroconvulsive for sustaining resolution of severe aggression in a major neurocognitive disorder. BMJ Case Rep. 2018;2018:bcr2017222100. https://doi.org/10.1136/bcr-2017-222100 https://doi.org/10.1136/bcr-2017-222100...
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n=1 age: 64y, M |
Severe unspecified dementia, with agitation and aggression |
Bitemporal with 15 sessions for an acute course followed by a weekly and until every 5 weeks for maintenance was continued by a 17 month-period; seizure duration not reported |
NPI-C |
Substantial and sustained improvement of agitation and aggression |
Discontinuation of the ECT acute phase due to pneumonia; later ECT was resumed |
Prior ECT cognition assessment was not achievable due to aggressiveness; however, ECT was beneficial for cognition |
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França et al.2929 França GC, Barreto HCB, Paranhos T, Nunes JC, Oliveira-Souza R. Case report: catatonic stupor in behavioral variant frontotemporal dementia. Front Neurol. 2022;12:798264. https://doi.org/10.3389/fneur.2021.798264 https://doi.org/10.3389/fneur.2021.79826...
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n=1 age: 95y, F |
Severe late-onset FTD with sexual disinhibition, aggressiveness, agitation, bizarre social behavior, followed by catatonic stupor |
Bitemporal; 6 sessions; seizures lasting 20–30 seconds; brief-pulse width |
Bush-Francis Catatonia Rating Scale; Northoff Catatonia Scale |
No benefits, and interruption of ECT course |
Tolerability or side effects not reported |
Cognition not reported after ECT course |