Clinical Geriatrics

CASE PRESENTATION
Mrs. K is a 77-year-old woman with multiple medical problems, including insulin-dependent diabetes mellitus, peripheral vascular disease, peptic ulcer disease, and hypertension. Her cardiac history is significant for idiopathic dilated cardiomyopathy that developed at the age of 55 years, leading to severe congestive heart failure (CHF). After a deteriorating course, Mrs. K underwent a heart transplant in 1991. She has a long but poorly described history of mental illness. She was hospitalized in the 1950s for a “nervous breakdown,” although no records were available, and her family was unsure of the specific diagnosis or treatment. She had one other known psychiatric hospitalization in 1993 for major depressive disorder with psychotic features, which responded to medication and psychosocial support.

Mrs. K was admitted to a university hospital inpatient psychiatric unit in September 2001 after being transferred from a nearby community hospital. The patient had been hospitalized for approximately one month due to a severe episode of major depressive disorder with psychotic features, and was responding poorly to treatment. Her recent history showed a complex pattern of decline in both her medical and psychiatric conditions.

In May 2001, she developed progressively worsening symptoms of depression after an episode of CHF. Attempts at outpatient management included changing her medication regimen from bupropion and risperidone to citalopram and quetiapine, with no improvement. She became paranoid and disorganized, developed delusions about food, and began refusing her immunosuppressive medications, which led to her initial hospitalization. Mrs. K was treated with a regimen of venlafaxine 75 mg and risperidone 1 mg daily, with no improvement. At the time of transfer to the university hospital, she displayed ideas of reference, believed she was receiving messages from the television, and displayed paranoid ideation that her family intended to harm her. Her mood was significantly depressed, and she displayed mood-congruent delusions of guilt that she was responsible for ruining the entire heart transplant program at the hospital.

Shortly after admission, it was decided to evaluate Mrs. K for electroconvulsive therapy (ECT), as it was believed to be the fastest and most effective method of treatment. Due to concern regarding her heart transplant, consultations were requested from cardiology and geriatric medicine. Specific concerns regarding ECT included the patient’s labile electrolytes and her echocardiogram, which revealed left ventricular hypertrophy and severe tricuspid regurgitation. The impression of the treatment team was that Mrs. K could safely undergo ECT with close monitoring of her fluid and electrolyte status. She was treated with furosemide 80-160 mg daily for CHF, with potassium chloride 80 mEq daily, and magnesium oxide 250 mg daily to correct her electrolytes.

Mrs. K gave informed consent for ECT and underwent her first treatment in September 2001. She was anesthetized with methohexital 60 mg and succinylcholine 70 mg. The treatment stimulus utilized was 288 millicoulombs (mC). Her motor and electroencephalogram (EEG) seizures both lasted 36 seconds. Three treatments per week were given. Her seizure threshold increased rapidly. During ECT #6 she required 576 mC—the maximum dose allowable with the device used by the hospital. For ECT #7 she required pretreatment with caffeine 500 mg to lower her seizure threshold enough to allow for therapeutic treatment. Mrs. K’s symptoms of depression improved. She became less paranoid, more active on the unit, and she started eating some of her meals. Two additional treatments were given.

Unfortunately, after ECT #9 she became disoriented and confused. Her Mini-Mental State Examination score was 9/30, compared to 29/30 on admission, indicating a significant decline in cognition.