Case Report 278
Eleetroeonvulsive Therapy in a Geriatrie Patient with Multiple Bone Fraetures and Generalized Plasmoeytoma M. Weller; 1. Kornhuber Departrnent of Psychiatry (Head: Prof. H. Beckmann, MD), University of Würzburg, Germany
--I
Electroconvulsive therapy (ECT) is a highly etfective treatment for patients with severe major depressive disorder. ECT can safely be administered even to medically ill, high-risk patients; we report on the complete remission of depressive psychopathology following five unilateral ECT treatments in a suicidal geriatric patient with concurrent prior venous thrombosis, coronary heart disease, multiple myeloma, glaucoma, bilateral petrous bone fractures, and a femoral neck fracture. Most medical complications during ECT can be managed with interdisciplinary cooperation.
Die Elektrokonvulsionstherapie (EKT) bringt oft den entscheidenden therapeutischen Erfolg bei Patienten mit schwerer endogener Depression, deren Erkrankung sich als resistent gegenüber pharmakologischer antidepressiver Therapie erwiesen hat. Auch körperliche Begleiterkrankungen stellen keine absolute Kontraindikation für die Durchführung einer EKT dar. Wir berichten über die Vollremission einer schweren endogenen Depression im Senium nach fünf unilateralen Stimulationen bei einer Patientin mit koronarer Herzkrankheit, Plasmozytom, Glaukom, beidseitigen Felsenbeinfrakturen und einer medialen Oberschenkelhalsfraktur. Die aktuelle Literatur belegt, daß somatische Komplikationen bei der EKT vermieden oder beherrscht werden können, sofern eine ausreichende Zusammenarbeit mit anderen medizinischen Disziplinen gewährleistet ist.
ease Report
Introduction
Electroconvulsive therapy (ECT) is the single most etfective treatment for major depressive disorders (Janicak et al., 1985; APA. 1990). However, owing to multiple objections and fears on the part of the public, patients, and their relatives, ECT is withheld from many patients who do not respond to pharmacological antidepressant therapy but who might benefit from ECT. Notably, the risk of medical complications, including severe morbidity and mortality, which would further reduce the acceptance of ECT by the public and by the medical profession, means that ECT is withheld from severely depressed patients with somatic multimorbidity. This report presents the clinical history of an elderly woman with severe major depressive disorder and multiple concurrent medical diagnoses necessitating hospital care for four months who eventually recovered fully after a short course of ECT.
A 78-year-old woman was transferred to our Department in April 1991 because of suicidal ideation. In a prior general hospital she had tried to cut open her wrist arteries. She had been admitted a fortnight earlier for examination of weight loss, chronic obstipation, gastric pain, and breathlessness. On admission to our unit, the patient was severely depressed, had given up all routine activities of daily life, complained of insomnia, breathlessness, fatigue, obstipation, and dysphagia. She suspected conspiracies among the other patients, feit she had been guilty all her life, and thought she had been admitted to receive a deserved punishment. The DSMIII-R diagnosis was major depressive disorder with mood-congruent psychotic features (296.24a). Her psychiatric history was unrevealing except for an examination, at a local psychiatric hospital in early 1991, for hypochondriac depressive complaints. There was no family history ofpsychiatric or neurologic disease. Her medical history included long-Iasting gastritis with suspected ulcer disease, recurrent pneumonia, and coronary
Pharmacopsychiat. 25 (1992) 278 -280 © Georg Thieme Verlag Stuttgart . New York
Received: Revised version: Accepted:
26. 11. 1991 11. 6. 1992 11. 6. 1992
Downloaded by: Universite Laval. Copyrighted material.
Elektrokonvulsionstherapie bei einer geriatrischen Patientin mit multiplen knöchernen Frakturen und generalisiertem Plasmozytom
Summary
Eleetroeonvulsive Therapy in a Geriatrie Patient wilh Multiple Bone Fraetures heart disease. In 1987, a diagnosis of multiple myeloma of IgO kappa type was made, which was treatcd with five courses of chemotherapy in 1988 and 1989. She had also been treated for bilateral glaucoma: medically until early 1991, and by bilateral laser iridotomy in 1990.
20
,. .. ...
10
. - . BPRS
60 50
...
40
Q)
Pharmaeopsyehiat. 25 (I992)
\
Physical examination showed loss of visual acuity to 20/1 00 on the right eye and 20/50 on the left eye, a left miotic pupil almost nonreactive to light, a right mydriatic pupil with normal pupillomotor function, bilateral hearing loss, and a protopathic sensory loss in the right L5 dermatoma. The electroencephalogram (EEO) was normal for her age. There was no firm radiologie evidence of plasmacytoma infiltration in the vertebral column, although several suspect areas were identified in radionuclide bone scans.
8In
Pathologie laboratory parameters included an erythrocyte sedimentation rate of 94 mm/h, moderate anemia, thrombocythemia of 429,000/mm 3, elevated total serum protein of 90 g/L with lowered serum albumin (36 g/L), massive serum IgO elevation of 39.3 g/L, suggesting paraproteinemia (normal range: 8-17 g/L), hypercholesterolemia of 289 mg/dl, hypertriglyceridemia of 175 mg/dl, proteinuria of 1.77 g/24 h, but no Bence Jones protein.
Fig. 1 Psychopathologie rating over the course of ECT using the Hamilton Depression Scale (HAM-D) (Hamilton, 1960) and the Brief Psychiatrie Rating Sc ale (BPRS) (Overall and Gorham, 1962). Triangles represent ECT treatments.
The patient was readmitted to our Department and subsequently treated with mianserin (50 mg daily), lorazepam (3.5 mg daily), and haloperidol (4 mg daily) for two weeks without obvious benefit. In an attempt to hang herself in the bathroom using the girdle of her bathing gown, she fell and suffered cerebral concussion and bilateral fractures of the petrous bones. Physical examination revealed no new findings except for multiple conjunctival and cutaneous petechiae above the strangulation zone and bilateral inner-ear hemorrhages (hematotympanoma). While cranial computed tomography (CCT) did not show any intracranial traumatic lesions, it did reveal a prior left-frontal border-zone ischemie lesion. The patient was transferred to the intensive care unit at our Department, where lorazepam monotherapy provided no relief of her psychiatrie symptoms. Despite a growing list of medical diagnoses including prior venous thrombosis, multiple myeloma, bilateral glaueoma, bilateral petrous fractures, and trieyclic depressant-related left bundle-braneh block, we decided to treat the patient with ECT. Consent was obtained from the patient and her relatives. She was seen by an ear, nose, and throat (ENT) surgeon, a neurosurgeon, an ophthalmologist, and at the Medical Department again, and no objections were made to a course of ECT. A bone-marrow biopsy revealed 30 % neoplastie plasma eell infiltration, but eon-
o
+-+
...
HAM-D
...... 5
15
25
35
45
time course (d)
sultants agreed that ehemotherapy was not indieated until the severe psychiatrie disorder had been adequately treated. We reinstituted piloearpin therapy for glaueoma but did not put the patient on aeetazolamide beeause of the patient's impaired renal funetion with reeurrent potassium imbalances. Repeat CCT two weeks after the trauma was unchanged, and repeat EEO was again normal. No benzodiazepines were given for one week prior to the first ECT treatment. The eonventional anesthesia protoeol used at our institute was not ehanged and included methohexital, alcuronium chloride, and suxamethonium chloride. In July 1991, following a first unilateral ECT with electrode placement aeeording to D 'Elia et al. (1983), applied by means of a Siemens Konvulsator, we observed a first (although short-lasting) improvement of mood lasting several hours. The next day, however, the patient slipped and suffered a right femoral neck fraeture whieh was treated by total endoprothesis. Ten days after the operation, the patient was readmitted to the Psychiatry Unit because of renewed suicidal ideation. Surgery to cover a severe saeral eubital ulcer that had developed during the immobilization following the petrous bone fractures and the reeent surgieal intervention was postponed. The patient was treated with unilateral ECT on two furt her occasions. While she improved on both occasions, the amelioration of symptoms lasted only a few days (Fig. I). She was transferred back to the Surgical Department for treatment of the eubital ulcer. After a second surgical intervention, we performed aseries of five unilateral ECT treatments in August 1991 which led to a full remission of depressive psychopathology. She received no eoncurrent psyehotropie medication and no other medieation except for the peripheral muscarinie receptor blocking agent, pirenzepine, to prevent duodenal ulcer formation. After eompletion of the course of ECT, the patient was given the new selective monoaminoxidase-A inhibitor, moc1obemide, 300 mg daily. As hemoglobin levels remained eon-
Downloaded by: Universite Laval. Copyrighted material.
Amitryptilin-N-oxide antidepressant therapy, already initiated at the local general hospital, was continued up to a dose of 150 mg daily until the patient suddenly developed a left bundle-branch block and, concurrently (although presumably unrelated), a deep thrombosis of the right calf veins. Amitryptilin-N-oxide was discontinued and the patient's continuing suicidal ideation was treated with lorazepam instead. The patient was put on heparin, transferred to the Medical Department, and a vena cava umbrella was inserted to prevent pulmonary embolism. Short-term and long-term coagulation were contraindicated because of systemic plasmacytoma. The patient's e1ectrocardiogram had returned to normal.
30
279
M. Weller, J Kornhuber
Pharrnacopsychiat. 25 (1992)
stantly above 10 g/dL, the Medical Department recommended not to initiate chemotherapy at this stage. This decision was fully discussed with the patient and her relatives. The patient was discharged two weeks after the final ECT and has remained stable in the eight months since. Monitoring of the psychopathologie changes over the course of ECT was performed using the Hamilton Depression Scale (HAM-D) (Harn i/ton, 1960) and the Brief Psychiatrie Rating Scale (BPRS) (Overall and Gorharn, 1962). Changes over the course of ECT are presented in Fig. 1. Seizure duration was measured using the "cuff' method (Fink and Johnson. 1982). Comment
ECT is a safe and effective psychiatrie treatment for major depressive disorder (Janicak et al. , 1985; Abrarns. 1988; APA, 1990). Old age per se is by no means a contraindication for ECT, especially as the most common alternative approach, pharmacological antidepressant therapy using tricyclic antidepressant drugs, bears a high risk of side-effects in elderly patients. These include confusion, anticholinergic delirium, orthostatic hypotension, arrhythmia, precipitation of glaucoma, and urinary retention in predisposed patients. There are a number of medical conditions that may exacerbate and lead to increased morbidity and even mortality in ECT-treated patients (Regestein and Reich, 1985; Abrams, 1988; APA, 1990). However, with the abovementioned precautions and exhaustive interdisciplinary cooperation and counseling, ECT may be a life-saving treatment for medical high-risk patients with florid suicidal ideation and severe major depressive disorder: "We now understand that no contraindication to ECT is absolute, and indeed, even relative contraindications are few. Instead, it is more pertinent now to talk in terms of the level of risk rather than in terms of contraindications" (APA, 1990).
References Abrams, R.: Electroconvulsive Therapy. Oxford University Press, Oxford (1988) 53 - 78 American Psychiatrie Association (APA): The practice of electroconvulsive therapy. Recommendations for treatment, training, and privileging. A task force report ofthe American Psychiatric Association. Washington OC: American Psychiatric Press 1990 D 'E/ia, 0., J. 0. Ottosson, L. S. Stromgren: Present practicc of c1ectroconvulsive therapy in scandinavia. Arch. Gen. Psychiatry 40 (1983) 577 - 581 Fink, M, L. Johnson: Monitoring the duration of electroconvulsive therapy seizures. 'Cuff' and EEG methods compared. Arch. Gen. Psychiatry 39 (1982) 1189-1191 Hamilton. M: A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23 (1960) 56-62 Janicak, P. G.. J. M Davis, R. D. Gibbons, S. Ericksen. S. Chang, P. Gallagher: Efficacy of ECT: a meta-analysis. Amer. J. Psychiatry 142 (1985) 297-302 Overall, J. E., D. R. Gorham: The brief psychiatric rating scale. Psychol. Rep. 10 (1962) 799-812 Regestein, Q. R., P. Reich: Electroconvulsive therapy in patients at high risk for physical complications. Convulsive Therapy 1 (1985) 101-114
Dr. J Kornhuber Universitäts- Nervenklinik Füchsleinstraße 15 0-8700 Würzburg Germany
Downloaded by: Universite Laval. Copyrighted material.
280
Eleetroeonvulsive Therapy in a Geriatrie Patient with Multiple Bone Fraetures and Generalized Plasmoeytoma M. Weller; 1. Kornhuber Departrnent of Psychiatry (Head: Prof. H. Beckmann, MD), University of Würzburg, Germany
--I
Electroconvulsive therapy (ECT) is a highly etfective treatment for patients with severe major depressive disorder. ECT can safely be administered even to medically ill, high-risk patients; we report on the complete remission of depressive psychopathology following five unilateral ECT treatments in a suicidal geriatric patient with concurrent prior venous thrombosis, coronary heart disease, multiple myeloma, glaucoma, bilateral petrous bone fractures, and a femoral neck fracture. Most medical complications during ECT can be managed with interdisciplinary cooperation.
Die Elektrokonvulsionstherapie (EKT) bringt oft den entscheidenden therapeutischen Erfolg bei Patienten mit schwerer endogener Depression, deren Erkrankung sich als resistent gegenüber pharmakologischer antidepressiver Therapie erwiesen hat. Auch körperliche Begleiterkrankungen stellen keine absolute Kontraindikation für die Durchführung einer EKT dar. Wir berichten über die Vollremission einer schweren endogenen Depression im Senium nach fünf unilateralen Stimulationen bei einer Patientin mit koronarer Herzkrankheit, Plasmozytom, Glaukom, beidseitigen Felsenbeinfrakturen und einer medialen Oberschenkelhalsfraktur. Die aktuelle Literatur belegt, daß somatische Komplikationen bei der EKT vermieden oder beherrscht werden können, sofern eine ausreichende Zusammenarbeit mit anderen medizinischen Disziplinen gewährleistet ist.
ease Report
Introduction
Electroconvulsive therapy (ECT) is the single most etfective treatment for major depressive disorders (Janicak et al., 1985; APA. 1990). However, owing to multiple objections and fears on the part of the public, patients, and their relatives, ECT is withheld from many patients who do not respond to pharmacological antidepressant therapy but who might benefit from ECT. Notably, the risk of medical complications, including severe morbidity and mortality, which would further reduce the acceptance of ECT by the public and by the medical profession, means that ECT is withheld from severely depressed patients with somatic multimorbidity. This report presents the clinical history of an elderly woman with severe major depressive disorder and multiple concurrent medical diagnoses necessitating hospital care for four months who eventually recovered fully after a short course of ECT.
A 78-year-old woman was transferred to our Department in April 1991 because of suicidal ideation. In a prior general hospital she had tried to cut open her wrist arteries. She had been admitted a fortnight earlier for examination of weight loss, chronic obstipation, gastric pain, and breathlessness. On admission to our unit, the patient was severely depressed, had given up all routine activities of daily life, complained of insomnia, breathlessness, fatigue, obstipation, and dysphagia. She suspected conspiracies among the other patients, feit she had been guilty all her life, and thought she had been admitted to receive a deserved punishment. The DSMIII-R diagnosis was major depressive disorder with mood-congruent psychotic features (296.24a). Her psychiatric history was unrevealing except for an examination, at a local psychiatric hospital in early 1991, for hypochondriac depressive complaints. There was no family history ofpsychiatric or neurologic disease. Her medical history included long-Iasting gastritis with suspected ulcer disease, recurrent pneumonia, and coronary
Pharmacopsychiat. 25 (1992) 278 -280 © Georg Thieme Verlag Stuttgart . New York
Received: Revised version: Accepted:
26. 11. 1991 11. 6. 1992 11. 6. 1992
Downloaded by: Universite Laval. Copyrighted material.
Elektrokonvulsionstherapie bei einer geriatrischen Patientin mit multiplen knöchernen Frakturen und generalisiertem Plasmozytom
Summary
Eleetroeonvulsive Therapy in a Geriatrie Patient wilh Multiple Bone Fraetures heart disease. In 1987, a diagnosis of multiple myeloma of IgO kappa type was made, which was treatcd with five courses of chemotherapy in 1988 and 1989. She had also been treated for bilateral glaucoma: medically until early 1991, and by bilateral laser iridotomy in 1990.
20
,. .. ...
10
. - . BPRS
60 50
...
40
Q)
Pharmaeopsyehiat. 25 (I992)
\
Physical examination showed loss of visual acuity to 20/1 00 on the right eye and 20/50 on the left eye, a left miotic pupil almost nonreactive to light, a right mydriatic pupil with normal pupillomotor function, bilateral hearing loss, and a protopathic sensory loss in the right L5 dermatoma. The electroencephalogram (EEO) was normal for her age. There was no firm radiologie evidence of plasmacytoma infiltration in the vertebral column, although several suspect areas were identified in radionuclide bone scans.
8In
Pathologie laboratory parameters included an erythrocyte sedimentation rate of 94 mm/h, moderate anemia, thrombocythemia of 429,000/mm 3, elevated total serum protein of 90 g/L with lowered serum albumin (36 g/L), massive serum IgO elevation of 39.3 g/L, suggesting paraproteinemia (normal range: 8-17 g/L), hypercholesterolemia of 289 mg/dl, hypertriglyceridemia of 175 mg/dl, proteinuria of 1.77 g/24 h, but no Bence Jones protein.
Fig. 1 Psychopathologie rating over the course of ECT using the Hamilton Depression Scale (HAM-D) (Hamilton, 1960) and the Brief Psychiatrie Rating Sc ale (BPRS) (Overall and Gorham, 1962). Triangles represent ECT treatments.
The patient was readmitted to our Department and subsequently treated with mianserin (50 mg daily), lorazepam (3.5 mg daily), and haloperidol (4 mg daily) for two weeks without obvious benefit. In an attempt to hang herself in the bathroom using the girdle of her bathing gown, she fell and suffered cerebral concussion and bilateral fractures of the petrous bones. Physical examination revealed no new findings except for multiple conjunctival and cutaneous petechiae above the strangulation zone and bilateral inner-ear hemorrhages (hematotympanoma). While cranial computed tomography (CCT) did not show any intracranial traumatic lesions, it did reveal a prior left-frontal border-zone ischemie lesion. The patient was transferred to the intensive care unit at our Department, where lorazepam monotherapy provided no relief of her psychiatrie symptoms. Despite a growing list of medical diagnoses including prior venous thrombosis, multiple myeloma, bilateral glaueoma, bilateral petrous fractures, and trieyclic depressant-related left bundle-braneh block, we decided to treat the patient with ECT. Consent was obtained from the patient and her relatives. She was seen by an ear, nose, and throat (ENT) surgeon, a neurosurgeon, an ophthalmologist, and at the Medical Department again, and no objections were made to a course of ECT. A bone-marrow biopsy revealed 30 % neoplastie plasma eell infiltration, but eon-
o
+-+
...
HAM-D
...... 5
15
25
35
45
time course (d)
sultants agreed that ehemotherapy was not indieated until the severe psychiatrie disorder had been adequately treated. We reinstituted piloearpin therapy for glaueoma but did not put the patient on aeetazolamide beeause of the patient's impaired renal funetion with reeurrent potassium imbalances. Repeat CCT two weeks after the trauma was unchanged, and repeat EEO was again normal. No benzodiazepines were given for one week prior to the first ECT treatment. The eonventional anesthesia protoeol used at our institute was not ehanged and included methohexital, alcuronium chloride, and suxamethonium chloride. In July 1991, following a first unilateral ECT with electrode placement aeeording to D 'Elia et al. (1983), applied by means of a Siemens Konvulsator, we observed a first (although short-lasting) improvement of mood lasting several hours. The next day, however, the patient slipped and suffered a right femoral neck fraeture whieh was treated by total endoprothesis. Ten days after the operation, the patient was readmitted to the Psychiatry Unit because of renewed suicidal ideation. Surgery to cover a severe saeral eubital ulcer that had developed during the immobilization following the petrous bone fractures and the reeent surgieal intervention was postponed. The patient was treated with unilateral ECT on two furt her occasions. While she improved on both occasions, the amelioration of symptoms lasted only a few days (Fig. I). She was transferred back to the Surgical Department for treatment of the eubital ulcer. After a second surgical intervention, we performed aseries of five unilateral ECT treatments in August 1991 which led to a full remission of depressive psychopathology. She received no eoncurrent psyehotropie medication and no other medieation except for the peripheral muscarinie receptor blocking agent, pirenzepine, to prevent duodenal ulcer formation. After eompletion of the course of ECT, the patient was given the new selective monoaminoxidase-A inhibitor, moc1obemide, 300 mg daily. As hemoglobin levels remained eon-
Downloaded by: Universite Laval. Copyrighted material.
Amitryptilin-N-oxide antidepressant therapy, already initiated at the local general hospital, was continued up to a dose of 150 mg daily until the patient suddenly developed a left bundle-branch block and, concurrently (although presumably unrelated), a deep thrombosis of the right calf veins. Amitryptilin-N-oxide was discontinued and the patient's continuing suicidal ideation was treated with lorazepam instead. The patient was put on heparin, transferred to the Medical Department, and a vena cava umbrella was inserted to prevent pulmonary embolism. Short-term and long-term coagulation were contraindicated because of systemic plasmacytoma. The patient's e1ectrocardiogram had returned to normal.
30
279
M. Weller, J Kornhuber
Pharrnacopsychiat. 25 (1992)
stantly above 10 g/dL, the Medical Department recommended not to initiate chemotherapy at this stage. This decision was fully discussed with the patient and her relatives. The patient was discharged two weeks after the final ECT and has remained stable in the eight months since. Monitoring of the psychopathologie changes over the course of ECT was performed using the Hamilton Depression Scale (HAM-D) (Harn i/ton, 1960) and the Brief Psychiatrie Rating Scale (BPRS) (Overall and Gorharn, 1962). Changes over the course of ECT are presented in Fig. 1. Seizure duration was measured using the "cuff' method (Fink and Johnson. 1982). Comment
ECT is a safe and effective psychiatrie treatment for major depressive disorder (Janicak et al. , 1985; Abrarns. 1988; APA, 1990). Old age per se is by no means a contraindication for ECT, especially as the most common alternative approach, pharmacological antidepressant therapy using tricyclic antidepressant drugs, bears a high risk of side-effects in elderly patients. These include confusion, anticholinergic delirium, orthostatic hypotension, arrhythmia, precipitation of glaucoma, and urinary retention in predisposed patients. There are a number of medical conditions that may exacerbate and lead to increased morbidity and even mortality in ECT-treated patients (Regestein and Reich, 1985; Abrams, 1988; APA, 1990). However, with the abovementioned precautions and exhaustive interdisciplinary cooperation and counseling, ECT may be a life-saving treatment for medical high-risk patients with florid suicidal ideation and severe major depressive disorder: "We now understand that no contraindication to ECT is absolute, and indeed, even relative contraindications are few. Instead, it is more pertinent now to talk in terms of the level of risk rather than in terms of contraindications" (APA, 1990).
References Abrams, R.: Electroconvulsive Therapy. Oxford University Press, Oxford (1988) 53 - 78 American Psychiatrie Association (APA): The practice of electroconvulsive therapy. Recommendations for treatment, training, and privileging. A task force report ofthe American Psychiatric Association. Washington OC: American Psychiatric Press 1990 D 'E/ia, 0., J. 0. Ottosson, L. S. Stromgren: Present practicc of c1ectroconvulsive therapy in scandinavia. Arch. Gen. Psychiatry 40 (1983) 577 - 581 Fink, M, L. Johnson: Monitoring the duration of electroconvulsive therapy seizures. 'Cuff' and EEG methods compared. Arch. Gen. Psychiatry 39 (1982) 1189-1191 Hamilton. M: A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23 (1960) 56-62 Janicak, P. G.. J. M Davis, R. D. Gibbons, S. Ericksen. S. Chang, P. Gallagher: Efficacy of ECT: a meta-analysis. Amer. J. Psychiatry 142 (1985) 297-302 Overall, J. E., D. R. Gorham: The brief psychiatric rating scale. Psychol. Rep. 10 (1962) 799-812 Regestein, Q. R., P. Reich: Electroconvulsive therapy in patients at high risk for physical complications. Convulsive Therapy 1 (1985) 101-114
Dr. J Kornhuber Universitäts- Nervenklinik Füchsleinstraße 15 0-8700 Würzburg Germany
Downloaded by: Universite Laval. Copyrighted material.
280
