Ect-ad trial: rationale for ect lead placement and dosing in the treatment of refractory agitation and aggression in dementia

Introduction Electroconvulsive Therapy (ECT) is a safe and effective treatment for severe mental disorders in later life. It has been reported to be effective for the treatment of agitation in dementia; however, its use has been limited due to concerns regarding cognitive side effects and absence of clinical trial data. ECT requires the delivery of an electrical stimulus via 2 electrodes on the scalp. The position of the electrodes is a major determinant of the spatial distribution of the induced electric field which affects the efficacy and adverse cognitive effect profile. Commonly used electrode placements are: bitemporal or bilateral (BL), right unilateral (RUL), and bifrontal. In the ongoing ECT-Dementia (ECT-AD) trial, patients with severe treatment-refractory dementia-related agitation are randomized to ECT plus usual care or simulated ECT (S-ECT) plus usual care with up to 9 ECT or S-ECT sessions of RUL ultra-brief (UB) pulse width (PW). If there is no clinical response after 6 sessions, lead placement is switched to BL with brief PW. The rationale for starting with RUL-UB ECT is to minimize risk of adverse cognitive effects. In this literature review, we will present a table with published studies supporting the electrode placement rational for the ECT-AD study. Methods A literature search for BL and RUL lead placements in ECT on older patients with dementia with behavioral disturbances was conducted. Keywords included ECT, bilateral, right unilateral, dementia, and agitation. Studies were included if they involved participants with dementia and behavioral disturbance, a specified ECT treatment, and evidence that the use of Bilateral or Unilateral ECT is feasible in patients with agitation in dementia. Results We identified a total of 15 papers that were included in our analysis. Ten studies showed evidence for the use of BL ECT in patients with treatment-refractory agitation and aggression in dementia. One paper recommended the initiation of treatment with RUL placement. Another large study established the utility of RUL ultra-brief pulse-width as an efficacious treatment for the geriatric population (> 60 years old). Three other studies provided evidence that the use of BL ECT may be safe and effective when there is an inadequate response to unilateral ECT. Conclusions The existing literature of retrospective and prospective studies supports the safety and efficacy of ECT in elderly patients with dementia and severe agitation. The literature supports the design of the ECT-AD study with initial use of RUL placement and subsequent transition to BL ECT if there is inadequate response to RUL ECT. This research was funded by National Institute of Aging R01 AG061100-01. Electroconvulsive Therapy (ECT) is a safe and effective treatment for severe mental disorders in later life. It has been reported to be effective for the treatment of agitation in dementia; however, its use has been limited due to concerns regarding cognitive side effects and absence of clinical trial data. ECT requires the delivery of an electrical stimulus via 2 electrodes on the scalp. The position of the electrodes is a major determinant of the spatial distribution of the induced electric field which affects the efficacy and adverse cognitive effect profile. Commonly used electrode placements are: bitemporal or bilateral (BL), right unilateral (RUL), and bifrontal. In the ongoing ECT-Dementia (ECT-AD) trial, patients with severe treatment-refractory dementia-related agitation are randomized to ECT plus usual care or simulated ECT (S-ECT) plus usual care with up to 9 ECT or S-ECT sessions of RUL ultra-brief (UB) pulse width (PW). If there is no clinical response after 6 sessions, lead placement is switched to BL with brief PW. The rationale for starting with RUL-UB ECT is to minimize risk of adverse cognitive effects. In this literature review, we will present a table with published studies supporting the electrode placement rational for the ECT-AD study. A literature search for BL and RUL lead placements in ECT on older patients with dementia with behavioral disturbances was conducted. Keywords included ECT, bilateral, right unilateral, dementia, and agitation. Studies were included if they involved participants with dementia and behavioral disturbance, a specified ECT treatment, and evidence that the use of Bilateral or Unilateral ECT is feasible in patients with agitation in dementia. We identified a total of 15 papers that were included in our analysis. Ten studies showed evidence for the use of BL ECT in patients with treatment-refractory agitation and aggression in dementia. One paper recommended the initiation of treatment with RUL placement. Another large study established the utility of RUL ultra-brief pulse-width as an efficacious treatment for the geriatric population (> 60 years old). Three other studies provided evidence that the use of BL ECT may be safe and effective when there is an inadequate response to unilateral ECT. The existing literature of retrospective and prospective studies supports the safety and efficacy of ECT in elderly patients with dementia and severe agitation. The literature supports the design of the ECT-AD study with initial use of RUL placement and subsequent transition to BL ECT if there is inadequate response to RUL ECT.