Asian Journal of Psychiatry 50 (2020) 101986

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Asian Journal of Psychiatry

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Letter to the Editor

T
Electroconvulsive therapy in a 91-year old Asian lady with late onset bipolar mania

ARTICLE INFO ABSTRACT

Keywords: Background: Electroconvulsive therapy (ECT) is safe and efficacious in the elderly population. However, clin-
ECT icians are still weary to use it among the old-old population, citing safety concerns. Our case report highlights the
Elderly use of ECT in a 91 year old lady with late onset Bipolar Mania.
Bipolar disorder Case report: A 91 year old lady presented with an acute manic relapse for the past 2 weeks. She was previously
on oral Sodium Valproate, and during this current admission was augmented with oral Quetiapine IR 100 mg bd.
She remained unwell and was planned for right unilateral ECT with age-based dosing stimuli. After only 4
sessions, she showed complete resolution of her manic symptoms.
Result: In our case study, the patient showed rapid response to right unilateral ECT. Even though the Post
Suppression Index (PSI) was not significant, there is some evidence that in elderly patients, burst suppression
(not measured in this case) may be more accurate measure of ECT efficacy. The transient treatment emergent
delirium was short lived and ECT was very tolerated in this patient.
Conclusion: Clinicians should not delay ECT in old-old patients who do not respond to pharmacologic treatment,
as early switch to ECT results in rapid response with good safety profile.

1. Introduction
Electroconvulsive Therapy (ECT) is a safe and efficient mode of
treatment in the elderly (Grover et al., 2018). Elderly patients may be
better suited for early ECT intervention, due to safety concerns of
neuroleptics and the complex pharmacokinetics in this age group. Our
case reports the rapid reduction in manic symptoms in a 91-year-old
lady Asian lady after only 4 unilateral ECTs at a suprathreshold level.
2. Case report
Her next ECT was done similarly, with the dosing increased to 2 times
seizure threshold (90 % = 453 mC) [CS: 17 s, EEG seizures: 23 s, PSI:
Not available (N/A)]. Post ECT MoCA done remained the same at 26/
30. Her 3rd ECT was done the day after with the same intensity of 90 %
(453 mC) [CS: 10 s, EEG seizures: 17 s, and PSI: N/A]. Post ECT MoCA
was 23/30. After her 4th ECT was done (100 % = 504mC), she de-
veloped an acute confusional state (MoCA: 4/30), which lasted a few
hours. However, she rapidly recovered from her confusion and had
complete resolution of her manic symptoms (pre-discharge MoCA: 20/
30).

A 91-year-old woman, a known case of late onset Bipolar Disorder 3. Discussion

on oral Sodium Valproate 200 mg bd, was admitted to our unit with a
relapse of her manic symptoms. She presented with elated mood and
increased energy, grandiose ideations, reduced need for sleep and had
pressured speech. During her admission to our ward, a decision was
made to augment treatment with oral Quetiapine IR 200 mg bd.
However, she remained unwell and a decision was made to proceed
with a course of ECT.
Upon a thorough medical review, she had no underlying medical co-
morbidities, except for well-controlled hypertension. She underwent a
full blood panel testing, a contrasted Computer Tomography (CT) scan,
and an echocardiogram. All her investigations turned out normal. A
pre-ECT cognitive assessment with the Montreal Cognitive Assessment
(MoCA) scale was done, whereby she scored 28/30.
She was planned for a course of Right Unilateral (RUL) ECT using a
half-age dosing stimuli as the initial energy (45 % = 226 mC). ECT was
conducted using the ThymatronR System IV machine with the following
specifications: square wave and brief pulse (1 ms). Her first ECT was
done [Clinical seizures (CS): 25 s, Electroencephalogram (EEG)
Seizures: 30 s, Post Suppression Index (PSI): 45 %] and post ECT cog-
nitive testing on the MoCA done the day after revealed a score of 26/30.
The stigma related to ECT continues to make acceptability towards
it scarce, particularly in the old-old population. Our patient’s family
initially received the idea of ECT sceptically, and only agreed after
much persuasion. Several studies have been published regarding use of
ECT in patients above the age of 90 years old, however these studies
comprised of Caucasians and were mostly targeting depressive symp-
toms and early onset bipolar disorders (Narang et al., 2018; Burke et al.,
2007). To the authors’ knowledge, this is the first case report on ECT
used for an Asian lady in her 9th decade of life with late onset bipolar
mania.
An interesting observation in our patient was that despite the PSI
being suboptimal for all of her ECTs, she still showed rapid response.
Earlier studies showed a relationship between postictal suppression and
therapeutic outcomes in ECT (Azuma et al., 2007). Elderly patients, in
contrast, have higher probability of burst suppression episodes. Thus,
burst suppression (BS) index, which was not done in this patient, may
be a more accurate measurement instead of PSI (Purdon et al., 2015).
The patient became confused after the 4th right unilateral ECT. Post
ECT delirium in the elderly is not uncommon, and can occur in the

https://doi.org/10.1016/j.ajp.2020.101986
Received 23 January 2020
1876-2018/ © 2020 Elsevier B.V. All rights reserved.
Letter to the Editor
context of prolonged seizure duration (Reti et al., 2014), and in patients
with hemispheric asymmetry (Sakauye et al., 2003). As 7.5 % of people
who are right handed have right brain dominance (Knecht et al., 2000),
it is possible that our patient, who was right handed, suffered from
transient memory impairment and delirium due to the right unilateral
lead placement. However, she rapidly improved as shown by her MoCA
scores.
An age based dosing method was used in our patient. Despite
emerging evidence that dose titration has superior outcomes than age-
based dosing strategies (O’Neill-Kerr et al., 2017); these studies were
not inclusive of patients in their 9th decade of life. Our one-patient
experience with a 91-year-old lady with late onset Bipolar Mania
showed that age-based dosing allows for rapid response with minimal
and transient cognitive impairment. Given that the seizure threshold is
somewhat predicted by age, the age-based method enables faster re-
sponse with minimal side effects.
4. Conclusion
In treating old-old patients with late onset bipolar mania, clinicians
should consider switching to ECT early if patients do not show response
with standard pharmacologic approaches.
Financial disclosure
None
Declaration of Competing Interest
None
Acknowledgement
None
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Benedict Francis*
Department of Psychological Medicine, University Malaya Medical Centre,
59100, Kuala Lumpur, Malaysia
E-mail address: ben.franciscan@gmail.com.
Chiara Francine Petrus
Department of Psychiatry, Hospital Raja Permaisuri Bainun, 30450, Ipoh,
Perak, Malaysia
E-mail address: chiarafrancinepetrus@gmail.com.
Haw Huo Wong
Department of Psychological Medicine, University Malaya Medical Centre,
59100, Kuala Lumpur, Malaysia
E-mail address: simmedic@yahoo.com.