Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 121
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 143-145

Comorbid bipolar depression and dementia managed with electroconvulsive therapy: A case report and review of the evidence

Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_10_17

Rights and Permissions

Patients with bipolar disorder (BD) can have a range of comorbid psychiatric disorders, and clinical studies have reported BD to be a putative risk factor for the development of dementia. In this case report, we present a case of a 62-year-old female, who had been suffering from BD since early adulthood, developed symptoms of dementia at the age of 60 years, which led to diagnostic issues at the time of relapse of BD. At the time of presentation, she had a depressive relapse with catatonic symptoms and was managed with electroconvulsive therapy during the acute phase, and lithium was used for maintenance treatment.

Keywords: Bipolar disorder, dementia, electroconvulsive therapy

How to cite this article:
Grover S, Sahoo S. Comorbid bipolar depression and dementia managed with electroconvulsive therapy: A case report and review of the evidence. J Geriatr Ment Health 2017;4:143-5

How to cite this URL:
Grover S, Sahoo S. Comorbid bipolar depression and dementia managed with electroconvulsive therapy: A case report and review of the evidence. J Geriatr Ment Health [serial online] 2017 [cited 2023 Feb 5];4:143-5. Available from:

  Introduction Top

The prevalence of dementia in the general population is on the rise worldwide.[1] Studies that have tried to evaluate bipolar disorder (BD) as a putative risk for the development of dementia had found that individuals with a history of BD have a significantly higher risk of developing dementia.[2],[3],[4],[5] A recent meta-analysis revealed that BD leads to cognitive impairment and dementia.[6] Dementia in BD can lead to further impairment in functioning, greater disability, and poorer quality of life.[7] Development of dementia in an individual with BD can not only worsen the course of BD, but it can also pose a challenge to treatment. Self-recognition of cognitive deficits in patients with BD at an early stage of cognitive decline can precipitate depression.[8],[9] Major depressive episode in an elderly individual with BD often becomes severe and usually takes a longer time to respond to conventional treatment. Further, development of bipolar depression among patients with comorbid dementia can lead to a difficulty in recognizing symptoms of depression and further impairment in cognitive functions which in turn may cause delay in treatment and increase in severity of depression.

Hence, relapse of mood episode among patients of BD with comorbid dementia poses several treatment challenges, as most of the psychotropics have to be used judiciously due to both age factor and dementia. In cases of extreme severe depression or mania in an elderly individual with dementia, electroconvulsive therapy (ECT) has been found to be a relatively safe and beneficial option.[10],[11] ECT has also found to be useful to benefit severe agitation in cases of elderly individuals with advanced dementia.[12],[13],[14] Similarly, there is evidence of improvement of catatonia in dementia patients with ECT.[15],[16],[17]

In this report, we present the case of a 62-year-old female, who had been suffering from BD since early adulthood, developed symptoms of dementia at the age of 60 years, and presented to us with depressive catatonia. She was managed with ECT during the acute phase, and lithium was used for maintenance treatment.

  Case Report Top

Mrs. R, 62 years old, primary passed, homemaker, from lower socioeconomic status, rural background, with a family history of recurrent depressive disorder, presented with an episodic illness of 43 years' duration fulfilling the criteria of bipolar affective disorder with current episode severe depression with psychotic symptoms for the last 8 months. Detailed exploration of history revealed that she was poorly treated for her bipolar illness during the initial years. However, for the past 5 years, she was maintaining well on psychotropic medications, details of which could not be ascertained. About 2 years prior to presentation to our center (i.e., age 60 years), she was noticed to be forgetful, especially would have difficulty in recollecting recent events. She would forget as to who visited her 1 or 2 days back or what she had cooked the previous day. When corrected or reminded, she would not show much reaction. Over the next 3–4 months, the symptoms of forgetfulness increased, and she was noticed to forget days of the week and could not remember the appropriate day for the fasting/religious festivals, which she was doing over the years. In addition, she was also noticed to have difficulty in recalling names of relatives, had difficulty in wearing clothes and slippers, and would forget recent events. However, her remote memory was relatively preserved. On few occasions, she lost her way back to her home and went to her neighbor's home. Over the period, these symptoms kept on progressing. She would occasionally express distress about her failing cognition.

About 8 months prior to presentation to our center, in addition to forgetfulness, she gradually developed depressive features in the form of low mood, anhedonia, lethargy, low self-esteem, ideas of hopelessness, nihilism, poverty, poor interaction, decreased sleep, decreased appetite, and more often started making mistakes in household work. Later on, about 3 months prior to presentation, additionally, she developed urinary and fecal incontinence, staring, and refusal to feed. She also lost a significant amount of weight due to poor intake. She was brought to our center due to complete refusal to feed for 5 days.

At the time of presentation, she was found to be thin built, emaciated, and dehydrated. Further physical examination revealed pallor, presence of bilateral pedal edema. No abnormality was detected in the cardiovascular and respiratory system and abdominal examination. A detailed neurological examination also did not reveal any abnormality. Mental status examination was characterized by the presence of marked psychomotor retardation, staring, marked decreased speech output, perseveration, increased reaction time, sadness of mood, ideas of hopelessness, poverty, nihilism, impaired recent memory, and partial insight. Based on the available history, a diagnosis of bipolar affective disorder, current episode severe depressive episode with psychotic symptoms (catatonia), dementia (Alzheimer's/nutritional deficiencies), and malnutrition was considered. Her Bush Francis Catatonia Rating scale score was 14, and on Hamilton Depression Rating Scale, she scored 32. All routine hematological and biochemical investigations (renal function test, liver function test, ultrasound abdomen, thyroid function test, fasting blood sugar, lipid profile) did not reveal any abnormalities except for the evidence of anemia and hypokalemia. Her serum Vitamin D levels were found to be low (<3 units). Her magnetic resonance imaging study revealed mild cerebral atrophy with small vessel ischemic changes. Initially, she was given appropriate nutritional supplements in the form of ferrous sulfate, Vitamin D, calcium, Vitamin B12, folic acid, and high protein diet to correct the nutritional deficiencies. Appropriate measures were also taken to correct hypokalemia. Given the severe depression and catatonia, she was started on ECT. She received 14 sessions of bilateral ECT, with which her depressive symptoms improved significantly. Later, she was started on lithium 600 mg/day after all the prerequisite investigations along with tablet olanzapine 7.5 mg/day and memantine 10 mg/day. Her Mini–Mental State Examination score increased from 10 at presentation to 18 after resolution of depression. Detailed cognitive function assessment 2 weeks after resolution of depression revealed significant impairment in memory and perceptuomotor functions. She has been maintaining well in terms of affective symptoms for the past 2.5 years on lithium 600 mg/day with regular monitoring of serum lithium along with olanzapine 5 mg/day and memantine 10 mg/day. There was no major further deterioration of dementia with Mini–Mental State Examination scores varying from 15 to 19, over the period of follow-up.

  Discussion Top

The recent meta-analysis [6] which had evaluated the risk of dementia in individuals with BD had revealed that the estimated risk of dementia in BD is larger than reported in meta-analyses of unipolar major depression (risk estimates ranging from 1.65 to 2.0).[18],[19] Unlike unipolar depression, individuals with BD have been found to have high pro-inflammatory activity, reduced neurotropic support, and high oxidative stress burden which elevate their risk of developing dementia in later life.[20],[21] Various other clinical factors such as strong genetic susceptibility, more number of affective episodes, earlier age of onset, and greater medical and psychiatric comorbidities also add on to the cognitive impairment in individuals with BD.[22] In the index case, there were several of these clinical factors such as positive family history of affective illness and age of onset of BD in the early 20s, with poorly treated episodes leading to frequent relapses in the initial years. All these could have been the possible risk factors for development of dementia in the index case.

Several studies have reported that depression in late life is not only a potential risk factor for dementia but also a prodrome/forerunner of dementia.[23] In this regard, though it has been well studied whether a depressive relapse in elderly individuals with BD poses an additional threat to development of dementia, it can be postulated that every mood episode, more particularly depression, leads to further cognitive decline as evident from the studies which have tried to evaluate the association of number of affective episodes and dementia among patients with BD.[22] The index case with BD was unique as she developed dementia first and subsequently had a depressive relapse which possibly could have led to worsening of cognitive symptoms.

Previous studies have reported that lithium has some neuroprotective effect against the development of dementia in patients with BD.[5],[24],[25] It has been hypothesized that lithium by inhibiting the transcription of the glycogen synthasekinase-3 gene may inhibit crucial processes in the overproduction of amyloid-b and tau hyper-phosphorylation [26] which are the main pathogenic mechanisms of dementia. In this line, few studies have suggested that long-term lithium treatment may have disease-modifying properties on the core pathophysiologic features in the development of dementia, particularly Alzheimer's dementia, and deliver a marginal clinical benefit, mostly if started at the earlier stages of the disease process.[5],[27] In the index case, we could not find any past history of treatment with lithium. However, addition of lithium possibly prevented further worsening of cognitive symptoms during follow-up period of 2.5 years, suggesting that lithium could have played some role in preventing further progression of dementia.

There has been substantial evidence on the beneficial effect of ECT in elderly individuals with both unipolar and bipolar depression.[28],[29] Role of ECT in comorbid dementia and depression though not extensively studied, few studies have reported ECT to be quite effective and safe with rapid resolution of depressive symptoms with no significant change in the existing cognitive impairment.[10],[30],[31] Treatment with ECT has been reported to be well tolerated, though post-ECT delirium and confusion are the two most common adverse side effects in depressed, demented individuals.[10] Existing literature in this regard is limited to few case series,[11] and only five prospective studies (sample size ranging from 19 to 105) on the use of ECT in individuals with depression superimposed on dementia are available in which the mean number of ECT sessions had been around nine and there was no reported worsening of cognitive impairment too.[32] In the index case, 14 sessions of bilateral ECT were used for the management of catatonia and depression with a substantial degree of improvement.

  Conclusion Top

The present case reflects that patients with BD can develop dementia. Further, the case shows that lithium can have some neuroprotective effect in the presence of dementia and may prevent further progression of dementia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Prince M, Ali GC, Guerchet M, Prina AM, Albanese E, Wu YT, et al. Recent global trends in the prevalence and incidence of dementia, and survival with dementia. Alzheimers Res Ther 2016;8:23.  Back to cited text no. 1
Kessing LV, Olsen EW, Mortensen PB, Andersen PK. Dementia in affective disorder: A case-register study. Acta Psychiatr Scand 1999;100:176-85.  Back to cited text no. 2
Kessing LV, Nilsson FM. Increased risk of developing dementia in patients with major affective disorders compared to patients with other medical illnesses. J Affect Disord 2003;73:261-9.  Back to cited text no. 3
da Silva J, Gonçalves-Pereira M, Xavier M, Mukaetova-Ladinska EB. Affective disorders and risk of developing dementia: Systematic review. Br J Psychiatry 2013;202:177-86.  Back to cited text no. 4
Nunes PV, Forlenza OV, Gattaz WF. Lithium and risk for Alzheimer's disease in elderly patients with bipolar disorder. Br J Psychiatry 2007;190:359-60.  Back to cited text no. 5
Diniz BS, Teixeira AL, Cao F, Gildengers A, Soares JC, Butters MA, et al. History of bipolar disorder and the risk of dementia: A systematic review and meta-analysis. Am J Geriatr Psychiatry 2017;25:357-62.  Back to cited text no. 6
Cardoso T, Bauer IE, Meyer TD, Kapczinski F, Soares JC. Neuroprogression and cognitive functioning in bipolar disorder: A systematic review. Curr Psychiatry Rep 2015;17:75.  Back to cited text no. 7
Devanand DP, Sano M, Tang MX, Taylor S, Gurland BJ, Wilder D, et al. Depressed mood and the incidence of Alzheimer's disease in the elderly living in the community. Arch Gen Psychiatry 1996;53:175-82.  Back to cited text no. 8
Modrego PJ, Ferrández J. Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: A prospective cohort study. Arch Neurol 2004;61:1290-3.  Back to cited text no. 9
Rao V, Lyketsos CG. The benefits and risks of ECT for patients with primary dementia who also suffer from depression. Int J Geriatr Psychiatry 2000;15:729-35.  Back to cited text no. 10
Weintraub D, Lippmann SB. ECT for major depression and mania with advanced dementia. J ECT 2001;17:65-7.  Back to cited text no. 11
Aksay SS, Hausner L, Frölich L, Sartorius A. Severe agitation in severe early-onset Alzheimer's disease resolves with ECT. Neuropsychiatr Dis Treat 2014;10:2147-51.  Back to cited text no. 12
Ujkaj M, Davidoff DA, Seiner SJ, Ellison JM, Harper DG, Forester BP. Safety and efficacy of electroconvulsive therapy for the treatment of agitation and aggression in patients with dementia. Am J Geriatr Psychiatry 2012;20:61-72.  Back to cited text no. 13
Acharya D, Harper DG, Achtyes ED, Seiner SJ, Mahdasian JA, Nykamp LJ, et al. Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. Int J Geriatr Psychiatry 2015;30:265-73.  Back to cited text no. 14
Suzuki K, Takano T, Matsuoka H. A case of catatonia resembling frontotemporal dementia and resolved with electroconvulsive therapy. World J Biol Psychiatry 2009;10:245-7.  Back to cited text no. 15
Kendurkar A. Catatonia in an Alzheimer's dementia patient. Psychogeriatrics 2008;8:42-4.  Back to cited text no. 16
Paul S, Goetz J, Bennett J, Korah T. Efficacy of electroconvulsive therapy for comorbid frontotemporal dementia with bipolar disorder. Case Rep Psychiatry 2013;2013:124719.  Back to cited text no. 17
Ownby RL, Crocco E, Acevedo A, John V, Loewenstein D. Depression and risk for Alzheimer disease: Systematic review, meta-analysis, and metaregression analysis. Arch Gen Psychiatry 2006;63:530-8.  Back to cited text no. 18
Diniz BS, Butters MA, Albert SM, Dew MA, Reynolds CF 3rd. Late-life depression and risk of vascular dementia and Alzheimer's disease: Systematic review and meta-analysis of community-based cohort studies. Br J Psychiatry 2013;202:329-35.  Back to cited text no. 19
Berk M, Kapczinski F, Andreazza AC, Dean OM, Giorlando F, Maes M, et al. Pathways underlying neuroprogression in bipolar disorder: Focus on inflammation, oxidative stress and neurotropic factors. Neurosci Biobehav Rev 2011;35:804-17.  Back to cited text no. 20
Naismith SL, Norrie LM, Mowszowski L, Hickie IB. The neurobiology of depression in later-life: Clinical, neuropsychological, neuroimaging and pathophysiological features. Prog Neurobiol 2012;98:99-143.  Back to cited text no. 21
Kessing LV, Andersen PK. Does the risk of developing dementia increase with the number of episodes in patients with depressive disorder and in patients with bipolar disorder? J Neurol Neurosurg Psychiatry 2004;75:1662-6.  Back to cited text no. 22
Muliyala KP, Varghese M. The complex relationship between depression and dementia. Ann Indian Acad Neurol 2010;13 Suppl 2:S69-73.  Back to cited text no. 23
Kessing LV, Søndergård L, Forman JL, Andersen PK. Lithium treatment and risk of dementia. Arch Gen Psychiatry 2008;65:1331-5.  Back to cited text no. 24
Forlenza OV, De-Paula VJ, Diniz BS. Neuroprotective effects of lithium: Implications for the treatment of Alzheimer's disease and related neurodegenerative disorders. ACS Chem Neurosci 2014;5:443-50.  Back to cited text no. 25
Klein PS, Melton DA. A molecular mechanism for the effect of lithium on development. Proc Natl Acad Sci U S A 1996;93:8455-9.  Back to cited text no. 26
Forlenza OV, Diniz BS, Radanovic M, Santos FS, Talib LL, Gattaz WF. Disease-modifying properties of long-term lithium treatment for amnestic mild cognitive impairment: Randomised controlled trial. Br J Psychiatry 2011;198:351-6.  Back to cited text no. 27
van der Wurff FB, Stek ML, Hoogendijk WJ, Beekman AT. The efficacy and safety of ECT in depressed older adults: A literature review. Int J Geriatr Psychiatry 2003;18:894-904.  Back to cited text no. 28
Aziz R, Lorberg B, Tampi RR. Treatments for late-life bipolar disorder. Am J Geriatr Pharmacother 2006;4:347-64.  Back to cited text no. 29
Price TR, McAllister TW. Safety and efficacy of ECT in depressed patients with dementia: A review of clinical experience. Convuls Ther 1989;5:61-74.  Back to cited text no. 30
Tielkes CE, Comijs HC, Verwijk E, Stek ML. The effects of ECT on cognitive functioning in the elderly: A review. Int J Geriatr Psychiatry 2008;23:789-95.  Back to cited text no. 31
Oudman E. Is electroconvulsive therapy (ECT) effective and safe for treatment of depression in dementia? A short review. J ECT 2012;28:34-8.  Back to cited text no. 32


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report

 Article Access Statistics
    PDF Downloaded252    
    Comments [Add]    

Recommend this journal