The above title is a somewhat “colorized” summary of an email I got from Kim McRae. She has been aware of a growing use of ECT (electroconvulsive therapy) in people with dementia. I was surprised that I knew nothing about this, so I did a quick check with “Dr. Google”. But first, I’ll give you some background on ECT:
ECT has been around for decades as a treatment for severe, life-threatening cases of depression. While it sounds horrible, the use of modern anesthetic techniques has helped minimize some of the side effects. People treated with ECT receive a general anestheitc and a muscle relaxant, so that the seizure induced by the electric shock occurs only in the brain, not in the limbs (or mouth, etc.).
I have seen it used a few times in my long career, always in people with severe depression (and little or no memory impairment), who were failing rapidly and whose medications had so far been ineffective. It can definitely lead to improved mood in these cases, and some people have reported dramatic improvements; though in my experience with a population of older people, I would have to say that while it helped them to better maintain, it didn’t bring about any dramatic reversal of their depression.
The downside has been cognitive side effects, including persistent memory impairment. Others have reported worsening of other symptoms (like Parkinson’s). Alternate placements of the electrode leads has ameliorated, but not removed, these side effects.
So why use it in people with cognitive impairment (Alzheimer’s and/or dementia with Lewy bodies)? Well, what I found on Google is mostly anecdotal reports of the use of ECT in a few people with either persistent verbal agitation or physical combativeness. These reports were in online journals, not the big peer-reviewed print journals.
One case described a person receiving 11 treatments ( I never saw it used more than 4-6 times on any of my own patients with depression); in another report, two people with aggression had a half dozen treatments each, followed by monthly “maintenance” treatments. There is not a lot of detail in the online reports I’ve read, so I don’t know all the specifics.
But am I bothered by this? You bet I am!
Based on the experiential model I have been putting forth for viewing dementia, I would have to be very concerned about this approach. While some authors suggested it be used only for refractory cases, others are espousing expanded use (one author suggested it “be considered earlier rather than later”).
In researching my book, I was able to root out serious flaws in the use of antipsychotics and other such medications in dementia: (1) that the published studies are flawed, biased and use inadequate endpoints, (2) that most distress can be tied to unmet needs and environmental triggers, and (3) that there are many examples of similar people’s distress being relieved by transforming the approach to care and using no medication.
As I asked in my book, if you don’t like the way a person bathes you, or if you have no choice, control or meaningful engagement in your daily life, how would lowering your dopamine levels make for a better experience?
So now we have another way to manipulate the electro-chemical environment of the brain that is supposed to bring well-being when the care environment is inadequate to the person’s needs. And once again, the researchers are only looking for improvements in negative symptoms, not improved well-being or engagement. The subjects are certainly more docile (more “compliant”, one might say). Is that a good outcome? For whom?
Dr. Peter Whitehouse (neurologist and co-author with Dr. Danny George of The Myth of Alzheimer’s) was headed to Brazil when I contacted him for a comment, but his brief response indicated this was also largely unknown to him, and that it made little sense to him in light of the known negative effects of ECT on cognition.
Sorry folks, but I have to say it: This looks to me like a 21st century lobotomy.
