ABSTRACT

Background: Electroconvulsive therapy (ECT) is safe and efficacious in the elderly population. However,
clinicians are still weary to use it among the old-old population, citing safety concerns. Our case report
highlights the use of ECT in a 91 year old lady with late onset Bipolar Mania. 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 A 91-year-old woman, a known case of late onset Bipolar Disorder
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 comorbidities,
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 cognitive testing on the MoCA done the day after revealed a score of 26/30. 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 developed 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). 3.
Discussion 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 symptoms 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