Systematic Review of Cognitive Effects of Electroconvulsive Therapy in Late-Life Depression

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Objective

Late-life depression (LLD) is known to negatively impact cognition even after remission of mood symptoms. Electroconvulsive therapy (ECT) and newer nonconvulsive electrical and magnetic brain stimulation interventions have been shown to have cognitive effects in patients with neuropsychiatric disorders.

Methods

This review systematically assessed the effects of ECT on cognition in LLD. EMBASE, Ovid Medline, and PsycINFO were systematically searched through June 2015. The search was limited to publications from peer-reviewed journals in the English language.

Results

A total of 5,154 publications was identified; 318 were reviewed in full text, of which 39 publications related to ECT were included. We focused this review only on ECT because evidence on newer interventions was deemed insufficient for a systematic review. This literature suggests increased rates of interictal and postictal cognitive decline with ECT but no long-term (i.e., 6 months or longer) deleterious effects on cognition. Instead, long-term cognitive outcomes with ECT have been reported as either not changed or improved. This literature favors nondominant unilateral ECT over bilateral ECT for cognition.

Conclusion

Published literature on brain stimulation interventions in LLD is mainly limited to ECT. This literature suggests that deleterious effects of ECT in LLD are limited and transient, with better cognitive outcomes with unilateral ECT. There is not enough evidence to fully characterize long-term deleterious effects of ECT or effects of newer brain stimulation techniques on cognition in LLD.

Introduction

Late-life depression (LLD) is a serious public health problem with an estimated prevalence of 1.8%–13.3% in the community and 20%–25% in long-term care settings.1, 2, 3 The relationship between LLD and cognition is complex. LLD is known to present as a prodrome of dementia and is also known to negatively impact cognition, thus considered as one of the main modifiable risk factors for dementia.4, 5, 6, 7 In one study 45% of patients with LLD were found to be cognitively impaired at a 1-year follow-up, even after remission of mood symptoms.5 Long-term antidepressant medications do not improve cognition, despite maintenance of recovery from depressive symptoms.8, 9 Thus, there is a need to understand interventions that impact cognition in patients with LLD.

Neurostimulation interventions have been associated with positive and negative impact on cognition. Electroconvulsive therapy (ECT) is a well-established treatment for LLD, with remission rates around 60% and response rates of up to 90%.10, 11, 12 However, ECT can impair cognition.13, 14, 15 Studies in adults with depression have shown that ECT causes both anterograde and retrograde memory deficits.10, 14, 16, 17 In contrast, studies using novel electrical and magnetic brain stimulation interventions have shown a pro-cognitive effect, for example, of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) among patients with neuropsychiatric disorders.18, 19, 20, 21, 22, 23, 24 However, little is known about the effects of these interventions on cognition in patients with LLD. Thus, the objective of this review is to systematically assess the effects of ECT on cognition in LLD. We also covered in our search other brain stimulation interventions.

Section snippets

Search Strategy

EMBASE, Ovid Medline, and PsycINFO were searched in June 2015 using the following terms: (electroconvulsive therapy or transcranial magnetic stimulation or transcranial direct current simulation or vagus nerve stimulation or deep brain stimulation or rTMS or magnetic seizure therapy) AND depress* AND cognit*. The search was limited to “age 65 and over,” “human,” “English,” and “peer-reviewed journal.” Publications reporting mean age above 65 years or analyzed greater than 65 years age group as

Publications Reporting Only Short-Term Effects of ECT

Six publications reported only short-term effects of ECT on cognition in LLD as a primary outcome.26, 27, 28, 29, 30, 31 The first publication (Table 1, serial 1) reported on62 patients (mean age: 74.7; standard deviation [SD]: 6.6; mean number of ECT sessions: 9.5; SD: 3.2). There was a decline in performance on letter fluency as measured by the FAS test (Controlled Oral Word Association Test using letters F, A and S) from the Delis-Kaplan Executive Function System battery. There was no

Discussion

To date, ECT remains the most effective brain stimulation for treating mood symptoms in patients with LLD, but it has been associated with cognitive deficits. These cognitive deficits have been better characterized in the general adult population than in geriatric groups.11, 17 The current literature is striking in that it does not provide convincing evidence that ECT is associated with clinically significant cognitive deficits in LLD except for a transient cognitive impairment during the acute

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