Risk factors for falling in a psychogeriatric unit

OBJECTIVE: To identify risk factors associated with falls in a psychogeriatric inpatient population. DESIGN: Retrospective cohort study. SETTING: A psychogeriatric inpatient unit in a Brown University affiliated psychiatric hospital. PARTICIPANTS: A total of 1834 men and women who represented all admissions to the psychogeriatric inpatient unit between January 1992 and December 1995. RESULTS: Over the study period a total of 175 falls were recorded, giving a fall rate of 9.5%. Using a logistic regression model, six variables were found to be independently associated with an increased risk of falling: female gender, electroconvulsive therapy (ECT), mood stabilizers, cardiac arrhythmias, Parkinson's syndrome and dementias. Falls and ECT were associated with longer hospital stay, when adjusted for confounders including ECT. CONCLUSIONS: These findings support previous results and identify ECT as a possible risk factor for falling in a hospital setting.     

Orthostatic hemodynamic changes after electroconvulsive therapy treatments

Falls are common in patients receiving electroconvulsive therapy (ECT) treatments. One cause of falls is orthostatic hypotension. In an effort to deduce whether modifiable anesthetic factors are associated with posttreatment hemodynamic changes, we assessed supine and standing blood pressure and pulse in 62 patients given 295 treatments approximately 2 hours after ECT treatments. Mean changes were -5.25 mm Hg for systolic pressure, 1.5 mm Hg for diastolic pressure, and -17.0 beats per minute for pulse. Neither use of perianesthetic medications such as labetalol, glycopyrrolate, or remifentanil, or ECT technical variables such as seizure duration or electrode placement were associated with orthostatic blood pressure drop in the multivariate model. We conclude that none of the commonly used perianesthetic medications or variations in ECT electrode placement are associated with orthostatic hypotension after ECT treatments.     

Falls associated with electroconvulsive therapy among the geriatric population: a case report

Electroconvulsive therapy (ECT) is the treatment of choice in many older individuals with depression and a few other conditions. Like all medical treatments, this intervention has certain possible risks, which include undesirable reactions associated with general anesthesia and those attributed specifically to ECT itself, such as short-term memory loss. The potential association of falls with ECT has not been well studied. Our recent literature search revealed that information on this topic consists mainly of chart reviews and case reports. We present a case of an older woman with a history of recurrent major depressive disorder that required intervention with ECT. She suffered 2 falls during her course of ECT. This case adds to the growing body of anecdotal evidence supporting an association of falls with ECT and highlights the need for more scientifically rigorous data to clarify whether this apparent association is real and/or causally related.     

Effective use of electroconvulsive therapy in late-life depression.

OBJECTIVE: To review literature pertaining to the efficacy, safety, and tolerability of electroconvulsive therapy (ECT) in treating late-life depression. METHOD: We undertook a literature review with an emphasis on research studies published in the last 10 years. RESULTS: There is a positive association between advancing age and ECT efficacy. Age per se does not necessarily increase the risk of cognitive side effects from ECT, but this risk is increased by age-associated neurological conditions such as Alzheimer's dementia and cerebrovascular disease. With appropriate evaluation and monitoring, ECT can be used safely in patients of very advanced age and in those with serious medical conditions. Several technical factors, including dose of electricity relative to a patient's seizure threshold, position of electrodes, frequency of administration, and total number of treatments, have an impact on the efficacy and cognitive side effects of ECT and need to be taken into account when administering ECT. Naturalistic studies have found that 50% of more of patients have a relapse of depression within 6 to 12 months of discontinuing acute ECT. CONCLUSIONS: In recent years, there has been substantial progress in our understanding of the effect of technical factors on the efficacy and cognitive side effects of ECT. When administered in an optimal manner, ECT is a safe, well-tolerated, and effective treatment in older patients. Relapse of depression after response to ECT remains a significant problem, and there is a need for further research into the prediction and prevention of post-ECT relapse.     

Risk factors for falls during treatment of late-life depression

BACKGROUND: Prior studies have found that antidepressant medications are associated with an increased risk of falling in elderly persons. However, little is known about the prevention of falls during treatment for depression in elderly persons. This study evaluated the time course and potential risk factors for falls in a treatment protocol for late-life depression to identify specific at-risk periods and risk factors for falls in this population. METHOD: One hundred four subjects aged 69 years and over were treated in a protocolized manner using paroxetine and interpersonal psychotherapy. Those who did not respond received augmentation therapy with bupropion, nortriptyline, or lithium. Subjects were assessed at baseline and weekly during treatment; demographic and clinical characteristics of those who experienced a fall during treatment were compared with those who did not fall. Cox proportional hazards models were used to define risk factors for falls in univariate and multivariate models. RESULTS: During a mean of 21 weeks of treatment, 40 subjects (38%) fell. About half (53%) of the subjects fell during the first 6 weeks of treatment. In the multivariate model, memory impairment and orthostatic changes in blood pressure during treatment were risk factors for falling. Additionally, augmentation with bupropion appeared to be a risk factor for falls in univariate analysis, but this result is preliminary due to the small number of subjects who took bupropion. CONCLUSION: Increased monitoring for falls is warranted during the acute treatment of late-life depression. When treating such patients, clinicians should be especially watchful of those with memory impairments or those who develop orthostatic blood pressure changes; orthostatic blood pressure should be measured throughout acute treatment. Additionally, augmenting paroxetine with bupropion may also increase the risk of falls, and this medication combination should be used with caution in elderly patients.     

Optimal use of electroconvulsive therapy: choosing a treatment schedule.

Choice of treatment schedule is an important component of the ongoing efforts to optimize electroconvulsive therapy (ECT) administration and thereby maximize therapeutic benefit while reducing cognitive adverse effects. Frequency of ECT administration (that is, the spacing between treatments) and the total number of treatments in a series are the two factors that define the ECT schedule. Available evidence supports the view that a schedule of twice weekly ECT with a total of six to eight treatments is an effective therapeutic regiment that potentially reduces cognitive morbidity associated with more frequent administration and a larger number of treatments. More frequent administration, however, may accelerate antidepressant response and may be indicated in cases in which rapidity of therapeutic effect is a significant clinical consideration. This consideration may be at the cost of greater cognitive impairment, which could be reduced by limiting the number of treatments administered. Aside from their clinical relevance, these issues have important implications for understanding the mechanisms of action of ECT.     

Electroconvulsive therapy in old-old patients.

The authors compared falls, cardiovascular factors, confusion, gastrointestinal, pulmonary, and metabolic side effects for "old-old" (>75 years) patient groups treated with either electroconvulsive therapy (ECT) or pharmacotherapy. A subset of a pharmacotherapy patient group was selected to match for age, sex, and diagnosis in a case-control design. Side effects were recorded from each selected patient's medical record and compared between groups. Patients receiving ECT showed fewer cardiovascular and gastrointestinal side effects. Patients receiving ECT had longer lengths of stay and more favorable outcomes. Overall, there was a tendency for ECT to result in fewer side effects and better treatment outcomes. ECT appears to be relatively safe and more effective than pharmacotherapy for major depressive disorders in old-old patients.     

Electroconvulsive Therapy in Geriatric Patients Undergoing Anticoagulation Therapy

Antidepressant treatment of the depressed geriatric patient can be complicated by concomitant medical illness. We report the successful administration of electroconvulsive therapy (ECT) in three depressed geriatric patients who received the oral anticoagulant warfarin (Coumadin) for cardiovascular disease. The physiologic changes associated with modified ECT and risk factors for intracerebral hemorrhage in patients receiving anticoagulants are discussed.     

ECT and intracranial vascular masses

In 1990, the APA Task Force on ECT cited no "absolute" contraindications to ECT but "Substantial Risk" to be associated with ECT for patients with space occupying or other cerebral lesions with increased intracranial pressure and with bleeding or otherwise unstable vascular aneurysm or malformation. These findings indicate that patients with intracranial vascular masses are at increased risk for serious morbidity and mortality. Several authors have reported performing ECT in patients with intracranial vascular masses without adverse events by monitoring blood pressure both with and without pharmacologic intervention. Given the relatively recent change in practice of considering ECT for patients with intracranial vascular masses and the few number of cases thus far reported, we present a review of the existing literature and two additional cases of ECT performed with good result and no adverse events. With the cases we have presented, the literature now contains eight cases of ECT performed in patients with intracranial vascular masses, none of which had adverse outcomes. While such numbers do not establish unequivocal safety in this population, and the individual ECT practitioner must continue to make a risk/benefit analysis on a case-by-case basis, this report adds to the growing literature on the safety and efficacy of ECT for such patients.     

Risk factors for falls among residents with dementia living in group dwellings

BACKGROUND: Falls are a major cause of morbidity and mortality among elderly people, and people with dementia run an increased risk of falling. The aim of this study is to identify risk factors for falls in people with dementia. METHOD: The study was performed over a six-month period in northern Sweden using a sample of 160 residents living in 20 group dwellings for people with dementia. RESULTS: Sixty-four residents (40%) sustained at least one fall during the period. The total number of falls during the study period was 191, and the fall incidence was 2.6 per person year (169 falls/130 residents). Using logistic regression analysis, the independent risk factors strongly associated with falling were: requiring help with hygiene, displaying verbally disruptive/attention-seeking behavior, able to rise from a chair, walking with assistive devices, and participating in outdoor walks. These factors explained 36.1% of the variance in falls with a concordance of 79.6%. Thirty-five percent of the falls occurred between 9 pm and 6 am, with a peak between 5 pm and 6 pm. Symptoms preceding the falls were anxiety (31.1%) and confusion (13.3%). CONCLUSION: Among residents with dementia it is important to identify those who run an increased risk of falling and need more careful supervision, especially in the evening and during the night. In addition, the causes of anxiety and confusion have to be prevented and treated.     

Pulmonary embolism after ECT

Electroconvulsive therapy (ECT) is a safe procedure, infrequently associated with life-threatening complications. Pulmonary embolism (PE) as a complication of ECT has been rarely reported. We describe a nonfatal case of PE that developed during ECT in a 50-year-old man with depression, hypertension, and diabetes. He developed symptoms of PE immediately upon awakening from the eighth right unilateral ECT, which was later confirmed by spiral chest computed tomography. We review the literature, discussing risk factors relevant to the pathophysiology of PE and making suggestions about the management of patients with suspicious symptoms.     

Long-term Outcome Following Electroconvulsive Therapy for Late-Life Depression: Five-Year Follow-up Data From the MODECT Study

ObjectiveElectroconvulsive therapy (ECT) is the most effective treatment for late-life depression (LLD). Research addressing long-term outcome following an acute course of ECT for LLD is limited. We aimed to describe relapse, cognitive impairment and survival 5 years after a treatment with ECT for severe LLD, and assess the association of clinical characteristics with all three outcome measures.MethodsThis cohort study was part of the Mood Disorders in Elderly treated with ECT (MODECT) study, which included patients aged 55 years and older with major depressive disorder. Data regarding clinical course, cognitive impairment and mortality were collected 5 years after the index ECT course. We used multivariable Cox proportional hazards models and logistic regression models to assess the association of clinical characteristics with relapse and survival, and cognitive impairment, respectively.ResultsWe studied 110 patients with a mean age of 72.9 years. 67.1% of patients who showed response at the end of the index ECT course relapsed, and the included clinical characteristics were not significantly associated with the risk of relapse. 38.8% of patients with available data showed cognitive impairment at five-year follow-up. 27.5% were deceased; higher age and a higher number of previous psychiatric admissions were significantly associated with increased risk of mortality.ConclusionsFive-year outcome after a course of ECT for severe LLD seems to be in line with long-term outcome following other acute treatments for severe LLD in terms of relapse, cognitive impairment and survival. Additional studies aimed at improving long-term outcome in severe LLD are warranted.     

Successful electroconvulsive therapy in an elderly man with severe thrombocytopenia: case report and literature review

Electroconvulsive therapy (ECT) is a safe and effective treatment for depression. Furthermore, modifications to ECT have made it a safe procedure for patients who were previously thought to be too ill or old to undergo the stress of convulsions. Little is known, however, of the safety of performing ECT on patients with severe thrombocytopenia. Such patients may be at increased risk for hemorrhagic complications due to the procedure. In this article, we describe the case of a 74-year-old man with major depression and myelodysplastic syndrome with associated severe thrombocytopenia, who underwent successful administration of a full course (nine treatments) of ECT. The physiologic changes caused by modified ECT and the potential risk of hemorrhage (including intracranial hemorrhage) in thrombocytopenic patients undergoing ECT are also discussed.     

Balancing speed of response to ECT in major depression and adverse cognitive effects: role of treatment schedule

Schedule of administration (number of ECT per week and total number of treatments in the course) is one of a number of factors that may significantly influence the degree of cognitive impairment induced by ECT. We examined the effect of twice (ECT x 2) versus three times weekly (ECT x 3) bilateral ECT on cognitive function, particularly memory, in patients with major depression. Two studies were conducted, both double blind and controlled by the administration of simulated ECT (anesthesia and muscle relaxant only with no electrical stimulation). The results of these studies showed that the antidepressant effect of the two schedules, when assessed at the end of the ECT course, was equal. Speed of response was significantly greater with ECT x 3 but this schedule induced more severe memory impairment, even when the number of ECT in the series was not significantly different between the two groups. These findings are in general accordance with other studies that were similar in design although not as rigorously controlled. They support the conclusion that ECT x 2 is the more appropriate schedule for regular clinical practice unless speed of response is an overriding concern. In an era when patients administered ECT tend to be older and are more likely to manifest cognitive impairment for other reasons, choice of schedule is of particular relevance along with other factors such as electrode placement and stimulus intensity that influence ECT-induced cognitive impairment.     

Causes and risk factors of falls in patients with Parkinson's disease

BACKGROUND AND PURPOSE: Falls are a common and serious problem among Parkinson's disease (PD) patients. However, knowledge about the causes and risk factors of falls is limited. There have been a few attempts to classify the causes of falls. The classification suggested by Olanow seems to be the most comprehensive one. The aim of this study was to analyze retrospectively the causes of falls and risk factors of falls in PD patients. MATERIAL AND METHODS: One hundred and four patients with moderately advanced PD were included in the study. The patients were asked to describe the circumstances and consequences of falls which occurred during 12 months preceding the examination. The falls were classified according to the Olanow classification of causes of falls. RESULTS: Fifty-two patients (50%) reported at least one fall during the previous year with a mean number of 1.5 falls per year. The most common causes of falls were environmental factors, sudden falls and postural instability. There were no falls caused by severe dyskinesia, drugs or cardiovascular disorders. The only independent risk factors of the recurrent falls identified in this study were UPDRS part II score (OR 1.17, 95% CI: 1.02-1.37) and Mini Mental State Examination score (OR 0.85, 95% CI: 0.72-0.99). CONCLUSIONS: Considering these results we may be able to prevent most falls by means of the education of patients about environmental factors and using adequate rehabilitation techniques concentrating on postural stability and gait.     

Recurrent falls are associated with increased length of stay in elderly psychiatric inpatients

OBJECTIVES: To identify factors which may contribute to prolonged length of stay in an elderly psychiatric inpatient setting. DESIGN: Retrospective case note study. METHODS: A list of all patients over the age of 65 discharged from a private psychiatric hospital over a three-year period excluding those with a length of stay of over 365 days was obtained (n = 1147). A random sample of 150 patients was selected from the study population. A case note study was then performed looking at a number of variables which have been postulated to affect length of stay. The resulting data was analysed using multivariate statistics. RESULTS: There was no statistically significant association found between baseline factors (including age, gender, cognitive impairment, marital status, order of admission and preadmission living arrangement) and length of stay. Having recurrent falls whilst an inpatient was associated with prolonged hospital stay (p = 0.0006). CONCLUSION: Experiencing recurrent falls whilst an inpatient is associated with prolonged length of stay. Recurrent falls in the elderly may be associated with both physical illness and the use of psychotropic medications. A prospective study examining factors contributing to falls would be important in decreasing fall risk and reducing length of stay.     

A case of prolonged seizure after ECT in a patient treated with clomipramine, lithium, L-tryptophan, quetiapine, and thyroxine for major depression

Electroconvulsive therapy (ECT) is indicated for the treatment of severe treatment refractory depression in many countries. It is associated with a low risk of morbidity and mortality. It is usual for high doses of psychotropic medications to be prescribed concomitantly with ECT, although published data on the interactions of these with ECT is lacking. Here, we present the case of a middle-aged woman on multiple psychotropic medications who went into status epilepticus for 45 minutes after ECT.     

Atrial Fibrillation, Cardioversion, and Electroconvulsive Therapy

An elderly female patient with major depression and incidental atrial fibrillation received electroconvulsive therapy (ECT). Minutes after two different treatments on two separate occasions, she converted to a normal sinus rhythm. Although atrial fibrillation itself is associated with an increased risk of thromboembolic stroke, cardioversion without anticoagulation in individuals with nonacute atrial fibrillation is associated with a 1-2% incidence of embolization. Cardioversion during ECT may be infrequent but its possibility should alert clinicians to the consideration of prophylactic anticoagulation for some patients undergoing ECT.     

What the electroconvulsive therapy practitioner needs to know about obstructive sleep apnea

Obstructive sleep apnea (OSA) is common and increasingly so in countries experiencing an epidemic of obesity. The rate of OSA is likely as high or higher in psychiatric patients and patients receiving electroconvulsive therapy (ECT) as compared with the general population. Obstructive sleep apnea can be detected by maintaining a high degree of suspicion in patients with risk factors, symptoms, and typical physical findings. Failure to detect OSA can lead to serious long-term problems with cardiovascular health, excessive sleepiness, and increased risk of motor vehicle accidents. It is unknown whether failure to treat OSA could promote failure to respond to ECT or greater cognitive problems with ECT, but failure to recognize and manage the risk for OSA in patients receiving ECT might expose them to anesthetic difficulties. Ideally, patients with suspected OSA should have a sleep laboratory evaluation and a definitive treatment plan in place before ECT, but, sometimes, psychiatric urgency and lack of access to resources in developing countries would make this unworkable. At a minimum, steps can be taken during the ECT procedure to manage airway obstruction in suspected or known patients with OSA.     

Sleep,insomnia and falls in elderly patients

Insomnia is common in older people and can be associated with significant daytime dysfunction. Sleep problems, and the medications used to treat them, may contribute to the risk of falls and fractures in this population; however, the independent effects of disturbed sleep or the risk of hypnotic use are not well understood. Data arising from the Study of Osteoporotic Fractures (SOF) cohort of elderly women have confirmed the link between sleep problems (measured subjectively or objectively) and an increased risk of falls after taking into account the use of insomnia medications (benzodiazepines) in a community-dwelling population of older women. The data also suggest that benzodiazepine use is associated with increased risk of falls, although this association is less clear-cut when insomnia/sleep problems are taken into consideration. The risk of falls should be considered when prescribing benzodiazepines in this population. So far no data exist concerning whether the effective treatment of insomnia in the elderly may help prevent falls. Furthermore, studies are warranted to evaluate the efficacy and safety of the non-benzodiazepine BZRAs (benzodiazepine receptor agonists) in relation to risk of falls. In addition, there is a need to include fall risk factors such as postural sway and reaction time as outcomes for trials of new insomnia treatments.