Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 132
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 74-82

Electroconvulsive therapy in the elderly

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: 10.4103/2348-9995.221903

Rights and Permissions

Electroconvulsive therapy (ECT) is one of the treatment modalities in psychiatry that has stood the test of time for years. ECT has been used in various psychiatric conditions in the elderly. Comorbid medical conditions and cognitive deficits have been the prime concerns in this population. The indications and contraindications of use of ECT in the elderly population are same as that in an adult. ECT has also been found to be effective in patients with Parkinson's disease and dementia. Pre-ECT evaluation and cognitive evaluation prior and during ECT are inevitable. The determination of right technique, dose, frequency, and assessment of side effects are prerequisites to the usage of ECT in elderly. Owing to risk of cognitive side effects, right unilateral ECT is preferred. In carefully selected indications, ECT may be a superior management modality than pharmacotherapy.

Keywords: Cognitive deficits, elderly, electroconvulsive therapy

How to cite this article:
Grover S, Somaiya M. Electroconvulsive therapy in the elderly. J Geriatr Ment Health 2017;4:74-82

How to cite this URL:
Grover S, Somaiya M. Electroconvulsive therapy in the elderly. J Geriatr Ment Health [serial online] 2017 [cited 2023 Feb 5];4:74-82. Available from:

  Introduction Top

Over the years, life expectancy has increased across the world. According to a report of the United Nations, in the year 2015, there were 901 million people across the world aged ≥60 years, with one in every eighth person being aged ≥60 years.[1] This figure is projected to increase to 1.4 billion by 2030 and 2.1 billion by 2050. It is projected that by 2030, every sixth person on this earth would be aged ≥60 years and by 2050, every fifth person on the earth would be aged ≥60 years.[1] Another reality is that two-third of the world's elderly population resides in developing countries, and these countries are experiencing faster growth in the elderly population than the developed countries. According to 2015 data of the United Nations, 508 million persons aged ≥60 years, accounting for 56% of the world elderly population were living in Asia.[1]

It is also now well known that the prevalence of noncommunicable diseases (NCDs) among elderly is quite high. A recent study reported that about three-fourth of elderly have at least one NCD and 47.5% have more than one NCD. Among the various NCDs, high blood pressure, arthritis, and diabetes mellitus are the most common medical morbidities reported in elderly.[2] These findings suggest that a significant proportion of elderly patients requires medications for various medical morbidities.

According to the World Health Organization, about 15% of the population aged ≥60 years suffer from a mental disorder with dementia and depression accounting for the most common morbidities.[3] According to the WHO, unipolar depression is encountered in 7% of the elderly, and it accounts for 5.7% of years lived with disability among the patients aged ≥60 years.[3] A recent study from European countries, which evaluated the prevalence of mental disorders among elderly reported that every second person reported having experienced a mental disorder in their lifetime, every third person reported having experienced a mental disorder in past 1 year, and one in every four elderly had current mental disorder. In terms of morbidity, anxiety disorders accounted for most of the burden, followed by affective and substance-related disorders.[4]

It is well known that compared to adult population, elderly patients are more vulnerable to the side effects of various psychotropic medications.[5],[6],[7],[8] It is suggested that risk of side effects with the use of psychotropic medications increases with increasing age due to physiological changes occurring with aging, resulting in alteration in the pharmacokinetics and pharmacodynamics of various psychotropic medications.[9],[10] The risk increases further with the use of a high number of medications.[11] Some of the data suggest that the risk of side effects among those aged >70 years is 3.5 times higher than the adult patients.[11] Hence, there is a need for safer treatments.

The significant rise in elderly population has resulted in a remarkable increase in medical comorbidities and psychiatric morbidities. This warrants psychiatric treatments which are safe, effective, with least or no interaction with medications used for the management of physical illnesses, which do not worsen the underlying physical illness and do not cause or unmask a physical illness.

Electroconvulsive therapy (ECT) is one of the oldest treatments still in use in all age groups. Over the years, the technique of use of ECT has shifted from use of unmodified ECT to use of modified ECT. Further, there is a refinement in technique from sin wave to pulse wave and brief pulse, use of muscle relaxant, bilateral to unilateral electrodes, bitemporal to bifrontal ECT, monitoring of seizure using cuff method to electroencephalogram seizures, etc. In terms of use of modified ECT, the understanding about the anesthetic agents to be used during the ECT has also improved, which has further improved the safety of use of ECT among people with various comorbid medical illnesses.

ECT has also been used safely among elderly patients with various psychiatric disorders since the beginning. In this article, we would like to review the use of ECT among elderly.

  Frequency of Use of Electroconvulsive Therapy in Elderly Top

Data from various surveys from most countries suggest that ECT is more frequently used among elderly compared to young adult population. In one of the earliest surveys from the United States, authors reported that about 1.12 persons per 10,000 population received ECT during the years of 1977–1983, with minimal variation over the years. This survey showed that the use of ECT was higher among elderly (3.86/10,000 vs. 1.12/10,000).[12] In a second survey covering the years of 1984–1994, the same group of authors reported a decline in the use of ECT over the years, despite increase in the facilities providing ECT. This survey also showed that compared to other age groups, use of ECT was higher among elderly.[13] A nationally representative survey from the United States showed that elderly forms the largest group to receive ECT.[14] In a follow-up survey by the same authors, it was noted that over the years 1980–1986, use of ECT increased and all increase could be attributed to its use in elderly.[15] About one-third (34.2%) of the recipients of ECT in the year 1986 were elderly, and ECT was selectively more frequently used among elderly.[15] A study from Sweden which evaluated the ECT data of National Quality Register showed that 41 inhabitants per 100,000 were treated with ECT.[16] Data also suggested that the chance of receiving ECT was higher among inhabitants in the age group of 55 or more, with highest in the age group of 75–84 years (77 per 1,00,000).[16] A review of data from various countries suggests that in Australia and New Zealand, one-third of the patients who receive ECT are above 65 years, whereas 48%–59% of the patients who receive ECT in the United States are aged 60 or more.[17]

A study from the UK, which evaluated the trends of use of ECT in South London during the period of 1949–2006, showed that there was a significant variation in the proportion of patients aged ≥65 years who were referred for ECT. During the year 1987, 40% of patients who received ECT were aged ≥65 years; this percentage was 39% during 1991, which increased to 50% in the year 1996 and remain constant for the year 2001; however, there was some decline in the year 2006.[18] Studies from other countries which have evaluated the trends of use of ECT over the years suggest that over the years, there is more decline in the use of ECT among adults compared to elderly patients.[19]

In contrast to the developing countries, data from developing countries suggest that elderly form a smaller proportion of patients who receive ECT. A survey which evaluated the ECT practices across 16 Asian countries showed that elderly form 4.4% of patients who receive ECT.[20] A survey of teaching institutions and various hospitals from India which evaluated the data of 19,632 patients who received in the previous year showed that among patients who receive ECT, 14.7% of patients were aged ≥65 years.[21] This data were replicated in another study from India.[22] Data from China suggest that about one-fourth (28.1%) of the elderly (>60 years) receive ECT.[23]

It is suggested that various factors contribute to the higher rate of use of ECT in the elderly which include sensitivity to psychotropics/tolerability issues, medical and neurologic conditions that may complicate or preclude the use of drugs, risk of complications of severe depression, hence faster improvement is desired; positive association between the ECT response and increasing age, higher rate of psychotic depression in late life, and consideration of ECT as the first-line treatment in late-life depression with psychotic features.[24]

  Indications of Electroconvulsive Therapy in Elderly Top

In terms of indication for ECT, most of the studies from developed countries suggest that ECT is used primarily for the management of depression in elderly. However, studies from developing countries suggest that ECT is also used for conditions other than depression among elderly. A study from China which evaluated the use of ECT in elderly showed that 37.9% of older patients who received treatment in those with bipolar disorders, 43.6% in major depression, 21.2% in schizophrenia, and 10.7% in other diagnoses.[23]

The indications of ECT among elderly are same as that in other age groups. According to treatment guidelines of various professional organizations, ECT is primarily indicated for management of depression (unipolar/bipolar disorder). Other indications for ECT include schizoaffective disorder, schizophrenia, bipolar mania, agitation in dementia, catatonia (functional/organic), and Neuroleptic malignant syndrome.[25],[26],[27] In general, ECT should be considered for patients with depression, who have not responded to psychotherapeutic and/or pharmacologic interventions, have psychotic features, catatonia, are at risk for suicide, refuse food leading to nutritional problems, past response to ECT, and whenever patient prefers to receive ECT. ECT also must be considered when there is a need for rapid treatment response.[27]

  Efficacy/effectiveness of Electroconvulsive Therapy in Depression in Elderly Top

Many studies have evaluated the efficacy/effectiveness of ECT in elderly. The studies on use of ECT among elderly have been published as early as 1944.[28] Most of the data is in the form of nonrandomized studies although randomized trials have been performed. A review of data, which included data from randomized trials and nonrandomized studies, reported that out of the 121 studies/reports included in the study, only 4 were randomized trials. Evidence from randomized trials suggests that real ECT is significantly more effective than simulated/sham ECT.[29] All the available data suggest that ECT is very effective in management of depression among elderly during the acute phase. Naturalistic prospective studies report rates of complete recovery that range from 55% to 84.6% at the end of ECT course and the complete recovery rates at 6 months to 4 years follow-up periods have varied between 46% and 79.3%.[29] These studies also suggest high recovery rates with increasing age. Studies which have evaluated the relapse and rehospitalization rates with ECT suggest that the relapse rates vary from 25% to 67%. Retrospective studies also support the superior effectiveness of ECT among elderly patients with depression. In most of the effectiveness/efficacy studies, most of the patients had not responded to antidepressants in the past. Studies also suggest that ECT is associated with faster remission rates.[24]

A recent large sample multicentric randomized study from the United States evaluated the efficacy, functional outcome, and tolerability of a novel strategy to enhance the long-term outcome of depression in the elderly.[30],[31] The study was conducted in two phases: The first acute ECT phase and a 6-month randomized maintenance phase. In the acute phase, patients received thrice a week ECT along with venlafaxine.[30] In Phase 2, patients who achieved remission in the Phase 1 were randomly assigned to receive either venlafaxine plus lithium or combined treatment with pharmacotherapy and continuation ECT (C-ECT) enhanced with individualized ECT schedule.[31] At the baseline, 240 patients were recruited for the Phase 1 of the study, of which 172 completed the study. Overall, 148 out 240 patients (61.7%) achieved remission (Hamilton depression rating scale [HDRS] score ≤10 on two consecutive ratings, and the HDRS score did not increase by >3 points on the second consecutive rating, or it remained ≤6), 10% did not achieve remission, and 28.3% dropped out. More than two-third (70%) of the patients met response criteria which were defined as a reduction in HDRS score by at least 50% from baseline to exist from Phase 1.[30] At the end of Phase 2 of the study, ECT plus medication group had had significantly higher reduction in HDRS scores compared to medication alone group. Significantly higher proportion of combined treatment group patients was rated as “not ill at all” on the clinical global impression severity scale when compared with medication only group.[31] Data also suggests that response to ECT is faster than response to pharmacotherapy [32].

  Predictors of Response to Electroconvulsive Therapy in Geriatric Depression Top

In terms of predictors of response, data in general suggest that ECT is more effective in elderly when compared to younger patients.[33] The best response with ECT in elderly is in the age group of 60–74 years (73%), followed by 75+ years (67%) and least in younger patients (54%).[34] Other factors which have been associated with better response rates include the presence of psychotic symptoms and presence of neurovegetative symptoms such as disturbance in sleep and appetite.[35] The factors associated with nonresponse to ECT include presence of physical illness during the index episode, fewer life events before onset of the index episode, and higher number of longer lifetime depressive episodes.[29]

  Electroconvulsive Therapy Technique and Response to Electroconvulsive Therapy in Geriatric Depression Top

Data from randomized trials also suggest that ECT is more effective when it is used thrice a week ECT (compared to once a week ECT) and use of unilateral ECT was more effective than bilateral ECT in the short term (after five treatments), but not in the longer run (after 3 weeks of treatment). Further data suggest that the use of fixed, high-dose right unilateral ECT is associated with faster response to treatment, when compared with a titrated, moderate-dose right unilateral ECT.[29] Studies have reported that the intensity of the stimulus is associated with efficacy of ECT and speed of response regardless of electrode placement is determined by the degree to which the stimulus intensity exceeds the individual patient's seizure threshold.[35] Some of the data suggest that there is no difference in response rate between unilateral and bilateral ECT in elderly.[36] Similarly, data also suggest that there is no difference in efficacy and remission rates in elderly depression between formulas-based bifrontal and right unilateral ECT.[37] Another study reported, patients who fail to respond to 5–8 moderate-charge right unilateral treatments may respond to high-charge right unilateral ECT and bilateral ECT. However, bilateral ECT was associated with more cognitive deficits.[38] Another recent study showed that right unilateral ultra-brief ECT is less effective and may not be appropriate as first-line technique for management of depression in elderly.[39] In terms of the number of treatment, some of the studies suggest that elderly may require longer courses of treatment to achieve the same level of remission as younger patients.[40],[41]

  Continuation and Maintenance Electroconvulsive Therapy in Elderly Top

Some of the studies have evaluated the role of C-ECT in prevention of relapse in depression. In one of the prospective studies on unipolar depressed patients on maintenance ECT (M-ECT) with no medication, a lower risk of relapse (8%) in M-ECT completers was observed.[42] A retrospective study also replicated the findings and reported significantly lower relapse rate with C-ECT in elderly (7%), when compared to pharmacotherapy (52%).[43] Two randomized single-blind studies compared the 2-year outcome of C-/M-ECT in elderly patients with psychotic depression after remission. Patients were treated with either maintenance nortriptyline (n = 13 and 17) or combined M-ECT plus nortriptyline (n = 6 and 16). During the 2-year maintenance treatment, relapse/recurrence rates significantly higher in the nortriptyline group than in the combined ECT plus nortriptyline subgroup. Both the treatment groups did not differ in terms of tolerability of treatments.[44],[45] A retrospective study evaluated the outcome of M-ECT in patients with severe mental disorders. The study included data of 22 patients with affective disorders and 20 patients with schizophrenia. Patients received 92.8 (85.9) M-ECT treatments. Average duration of the M-ECT course was 34 (29.8) months. Use of M-ECT led to reduction in the number of hospitalization and reduction in mean duration of hospital stay.[46]

  Comparison of Electroconvulsive Therapy With Pharmacotherapy in Elderly Depression Top

Open-label/naturalistic prospective studies which have compared the efficacy/effectiveness of ECT and pharmacotherapy although not specifically among elderly (but included elderly patients) suggest that ECT has better efficacy/effectiveness when compared with monoamine oxidase inhibitors,[47] imipramine and amitriptyline,[48],[49],[50] and serotonin reuptake inhibitors such as paroxetine.[51]

An open-label study compared the effectiveness of ECT (n = 17) with combined use of nortriptyline and perphenazine (n = 8) in elderly patients with psychotic depression. In contrast to the response rate of 25% with combination of nortriptyline and perphenazine, significantly higher proportion of patients (88.2%; n = 15) in the ECT group responded, which was defined as reduction in HDRS score to ≤10 and absence of delusions and hallucinations. Patients who did not respond to combined antidepressant-antipsychotic medication underwent augmentation treatment with lithium for 2 weeks. Still there was trend for lower response rate with combined treatment. Further, it was evident that use of ECT was associated with faster response.[24] A retrospective study which involved the comparison of patients who received ECT and who did not for their geriatric unipolar depression showed that patients who received ECT had higher chance of being alive at follow-up and to demonstrate greater clinical improvement than those treated only with pharmacotherapy although both the treatment groups did not differ in terms of overall rate or severity of medical comorbidity.[52] Another retrospective case-controlled study, which compared the outcome of elderly patients receiving ECT with those treated with pharmacotherapy, showed that the use of ECT was associated with a more favorable outcome (76.9% vs. 33.3% rated as having good outcome) but longer duration of hospital stay. Gastrointestinal and cardiovascular side effects were lower for patients in the ECT group.[25]

  Efficacy of Electroconvulsive Therapy Compared to Other Somatic Treatments in Elderly Depression Top

In recent times, repetitive transcranial magnetic stimulation (rTMS) has been evaluated as an alternative to ECT in management of depression in elderly. An open-label study compared the usefulness of ECT and rTMS in the management of major depressive disorder. Forty patients, of whom significant proportions of patients were aged 60 or more, were randomly assigned to receive either ECT or rTMS. rTMS was performed for 20 days at 90% power of the motor threshold with stimulation frequency of 10 Hz for either 2 s ( first eight patients) or 6 s (final 12 patients) for 20 trains. This study showed that response to ECT was better than rTMS. It was further noted that response to ECT was better in patients with psychotic depression, whereas the response rate was comparable for patients without psychotic symptoms.[53] In a randomized controlled trial, same group of researcher compared ECT and rTMS in forty patients, majority of whom were aged 60 years or more. The authors reported a response rate of 60% with ECT and 55% with rTMS, with no significant difference between the two treatments.[54] The response was defined as at least 50% reduction in HDRS score. Another randomized controlled trial compared the efficacy of ECT and rTMS in patients with severe depression. Forty-six patients were randomly assigned to standard course of ECT (n = 22) or 15 day course of rTMS of the left dorsolateral prefrontal cortex (n = 24). This study also showed that ECT was more effective than rTMS. At the end of the treatment, 13 patients (59.1%) in the ECT group and 4 (16.7%) in the rTMS group achieved remission (defined as HDRS score of ≤8). However, at 6 months follow-up, there was no significant difference between the two groups.[55]

Based on this data, it can be said that ECT is more efficacious than rTMS in management of depression in elderly.

  Electroconvulsive Therapy in Other Psychiatric Disorders Top

There is limited data on use of ECT in elderly with other psychiatric disorders. Data on use of ECT have been used for the management of catatonia, mania, psychosis, and Parkinson's disease (PD) among elderly. Elderly patients with catatonia saw a transient improvement in catatonic symptoms; however, relapse rates were high after the stoppage of ECT. Maintenance ECT was found to be useful in few cases. In four patients, ECT was continued during the maintenance phase and was found to be effective. In terms of use of ECT in patients with psychotic disorders, data in the form of case reports and case series involving 24 patients showed that ECT is effective in psychosis. Except for one report (which reported response in 1 out of 6 cases), most of the reports of use of ECT in elderly for psychotic illness suggest that it is useful.[56]

  Electroconvulsive Therapy for Parkinson's Disease Top

PD is one of the nonpsychiatric conditions, in which ECT has been used successfully for management of symptoms of PD. ECT has also been used for the management of psychiatric disorders in the background of PD. A double-blind study involving 11 patients with PD showed that compared to sham ECT, use of real ECT was associated with a reduction in severity of symptoms of PD, with a significantly prolonged duration of “on” periods after treatment. Use of ECT was associated with significantly lower time and number of steps required to walk 10 meters. However, the improvement seen with ECT was generally short lasting.[57] The data of use of ECT in patients with movement disorders published during 1990–2000 was reported in a review. This review showed that 58 of the 75 (77%) patients with PD but without psychiatric illness improved with ECT.[58] In some of the reports, patients (n = 41) also had psychiatric symptoms in the form of affective and psychotic symptoms. Improvement in motor symptoms was seen in 88% with psychiatric manifestations. In terms of motor symptoms although there was variability in reporting, improvement has been reported in tremors, reduction in on/off time, rigidity, and reduced cogwheeling. There is no consensus in terms of predictors of response. Occasional reports suggest that less preexisting impairment is associated with better response, whereas others suggest that more severe symptoms and older age are associated with better response in motor symptoms.[58] In the same review, Kennedy et al.[58] and others reported that 59 out of 144 (44%) patients reported in literature developed delirium during the course of ECT. Therefore, it is important to note that patients with PD have higher risk of development of delirium while receiving ECT. A prospective study reported incidence of delirium with ECT in patients with PD to be 85%; however, the authors did not specify the duration.[59] Data also suggest that in few cases, the delirium may last for as long as 3 months.[58] Recent reports of use of ECT in patients with PD with comorbid psychiatric disorders also suggest that ECT is useful in management of both psychiatric symptoms including refractory psychosis and motor symptoms of PD.[60] ECT has also been used in recent studies for management of drug included parkinsonian symptoms,[61] refractory anxiety in patients with PD,[62] severe obsessive–compulsive disorder with PD,[63] drug-induced psychosis,[64],[65] and residual axial symptoms partially unresponsive to L-dopa.[66] In a recent report, ECT was used successfully without any complication in a patient with PD who had implanted deep brain stimulation instrument.[67]

  Use of Electroconvulsive Therapy in Presence of Cognitive Deficits and Other Brain Conditions Top

Data also suggest that the presence of cognitive impairments has no impact on treatment outcome with ECT. There is some evidence to suggest that preexisting cognitive impairment is associated with higher rate of confusion. However, some of the studies do not support the same. The data from all the retrospective and prospective studies were reviewed and it was suggested that only five prospective studies have evaluated the effect of ECT on depression in dementia.[68] In the first study, 21 patients with dementia with depression were compared with 84 patients without dementia with depression. The rate of improvement with ECT for management of depression in elderly was comparable among patients with and without dementia.[69] Post-ECT confusion correlated with severity of dementia.[69] Second study also involved 40 patients with late-life depression, 19 of whom had dementia. However, it was unclear from this study whether patients with dementia were more vulnerable to confusion.[70] Rao and Lyketsos [71] used standard measures for the assessment of depression and confusion. The study included 31 patients. Use of ECT was associated with significant decline in Montgomery–Asberg Depression Rating Scale and increase in mini–mental state examination (MMSE) rating by 1.62 points. However, 15 out of 31 patients developed delirium during the course of ECT.[71] Fourth study involved 30 elderly patients, of which 19 had depression with dementia.[72] Use of ECT was associated with improvement in cognitive functions in the group experiencing cognitive impairment before ECT.[72] A recent study evaluated the cognitive functioning of depressed elderly with or without preexisting cognitive impairment in patients receiving their first course of ECT. Forty-four patients were divided into three groups, i.e., no cognitive impairment (NCI), mild cognitive impairment (MCI), and dementia group and they were evaluated for cognitive performance with the MMSE before first ECT, after sixth ECT, and 6 weeks and 6 months after completion of ECT. Depressive symptoms were rated using 21-item HDRS. Depressive symptoms remitted in all the three groups. During the initial course of treatment, there was a nonsignificant deterioration in cognitive functioning in all the three groups. NCI group showed a significant improvement in cognitive functions at 6 weeks and 6 months. MCI group showed a significant improvement in cognition at 6 months. In the dementia group, there was an improvement in the MMSE scores over the course of ECT; however, this was statistically nonsignificant. Patients with dementia who were on treatment for dementia improved in cognition to a clinically relevant extent after the sixth ECT, whereas those not on antidementia treatments deteriorated. After the 6th ECT, more than two-third of dementia patients (70%) and patients with MCI (68.8%) presented a cognitive decline at 6 weeks after ECT. Six months after completion of ECT, one-third of the dementia patients still had a cognitive decline. Pre-ECT cognitive deficits were the best predictor of MMSE decline.[73]

In terms of medical illnesses, ECT has been found to be effective in patients with poststroke depression with response rates varying from 57% to 95%.[74],[75]

  Efficacy of Electroconvulsive Therapy in Elderly With Concurrent Medical Illness Top

Initially, various medical conditions were considered as absolute or relative contraindications for use of ECT.

Neurologic disorders

Small/chronic space-occupying lesions are not so much of a concern; however, if associated with increased intracranial pressure, a risk of neurological decompensation remains despite measures to reduce intracranial pressure.[76] Patients with subcortical hyperintensities on magnetic resonance imaging reportedly do not have an increased risk with ECT.[77],[78] ECT has proved it to be efficacious in patients with pseudodementia.[79] The only absolute contraindication to using ECT is a central nervous system lesion with an increase in intracranial pressure.[80] Physiological considerations during and immediately after anesthesia are of concern in the elderly.

Cardiovascular conditions

Recent myocardial infarction, unstable angina, uncompensated congestive heart failure, severe valvular heart disease, cardiac arrhythmias, and vascular aneurysms are considered as risk factors for starting ECT.[27] However, these are not absolute contraindications for ECT.

  Side Effects of Electroconvulsive Therapy in Elderly Top

Persistent confusion and memory deficits are a concern in the elderly while on ECT and even after it. Elderly and patients with medical complications predict the risk of prolonged confusion.[27] Relative to younger patients, elderly with depression have more severe anterograde and retrograde amnesia at the end of the ECT course.[81] However, a recent systematic review [82] of literature suggests that use of ECT is associated with increased rates of interictal and postictal cognitive decline, but there are no long-term (i.e., 6 months or longer) deleterious effects on cognition. The authors concluded that there is a lack of convincing evidence to suggest that ECT is associated with clinically significant cognitive deficits in patients with late life depression, except for transient cognitive impairment during the course of ECT, which is more so in patients with late-life depression in the background of dementia. In fact, data suggest that long-term cognitive outcomes improve or remain unchanged.[82] Data also suggest that compared to bilateral ECT use of nondominant unilateral ECT is associated with lower cognitive problems.[82]

The data are limited to suggest that compared to adult population, elderly experience higher rates of other side effects associated with ECT. There is some evidence to suggest that when compared to young patient, delirium is more often noted in elderly patients. In fact, the systematic review suggested that compared to those without dementia, those with dementia experience higher rates of delirium.[81]

  Discussion Top

ECT is one of the most effective psychiatric treatments which have been used since more than seven decades. Available data suggest that ECT is safe and effective treatment for management of depression in elderly. Data also suggest its usefulness in management of mania, psychosis, and symptoms of PD in elderly. Based on the available guidelines, recommendations have been made by various professional organizations with regard to use of ECT in elderly.[27],[83],[84] The important issues with regard to the use of ECT in elderly are given in [Table 1]. These recommendations in general suggest that the indications and contraindications for ECT in elderly are same as that in adults and being elderly do not confer any specific risk for ECT.[27],[83],[84] Accordingly, the clinicians must weigh the risk and the benefit of ECT. A thorough assessment of comorbid physical conditions must be done and these must be stabilized before ECT. As such there are no absolute contraindications for use of ECT. While using ECT, premedication and anesthesia should involve the use of lowest possible doses.[27] Modifications in the doses of anticholinergic, anesthetic, and relaxant agents must be done considering the physiologic changes associated with aging and physical comorbidities. It is advisable to reduce or withdraw sedative/hypnotic or other anticonvulsant agents (including benzodiazepines) while using ECT. Minimizing doses of barbiturate anesthesia and ensuring adequate ventilation can help to reduce dosages of medications used during ECT.[27]
Table 1: Considerations for electroconvulsive therapy among elderly

Click here to view

ECT stimulus intensity should be selected with an awareness that seizure threshold generally increases with age.[27],[83],[84] It must be remembered that in elderly, the seizure duration decreases and the seizure threshold increases and the number of treatments involve 6–12 ECTs on an average and if no response is observed after 12 ECTs than the patient must be considered nonresponsive to ECT.[85] In terms of frequency of ECT schedule, data suggest that there is no difference in the efficacy of using twice weekly or thrice weekly ECT although use of thrice weekly ECT is associated with more rapid improvement, but at the cost of more retrograde amnesia, both immediately and after a month.[85] Accordingly, twice weekly regimen is preferred than the thrice weekly regimen. In terms of electrode placement, data suggest that compared to bitemporal ECT, use of right unilateral ECT is associated with lesser cognitive side effects. However, bitemporal ECT is found to be more effective than unilateral ECT.[85] Hence, it is suggested that initially, patient must preferably be started with right unilateral ECT and if required may be shifted to bitemporal ECT. However, if the illness is severe that bitemporal ECT is preferred right from the beginning.

Older patients are more susceptible to confusion after ECT. This should guide decisions regarding the ECT technique employed. The decision about ECT technique should be guided by the possibility that ECT-induced cognitive dysfunction may be greater in elderly patients, particularly those with preexisting cognitive or neurologic impairment. The electrode placement, stimulus intensity, and treatment frequency (e.g., twice instead of 3 times weekly) should be modified as needed to minimize adverse cognitive effects.[27],[83],[84] Cognitive function should be assessed at least 24 h following ECT, to avoid contamination by acute postictal effects. If confusion proves to be a problem, consideration should be given to switching from bilateral to unilateral ECT.[83]

To conclude, it can be said that ECT is efficacious in the management of depression and other psychiatric conditions in elderly. Hence, ECT can be used in elderly regardless of age as the efficacy of ECT possibly increases with age. ECT is more efficacious than pharmacological agents and rTMS in the management of depression in elderly. Accordingly, age must not be criteria for not considering use of ECT. Medical and comorbid conditions are common and should be taken into account while giving ECT. Some of the researchers suggest that among the elderly, ECT may lead to lesser complications than some of the pharmacological agents. However, while using ECT, technique must be modified to minimize the adverse effects, especially cognitive side effects.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2015 – Highlights (ST/ESA/SER.A/368); 2015.  Back to cited text no. 1
Mitchell-Fearon K, Waldron N, Laws H, James K, Holder-Nevins D, Willie-Tyndale D, et al. Non-communicable diseases in an older, aging population: A developing country perspective (Jamaica). J Health Care Poor Underserved 2015;26:475-87.  Back to cited text no. 2
World Health Organization. Mental Health and Older Adults. Fact Sheet. Available from: [Last updated on 2016 Apr].  Back to cited text no. 3
Andreas S, Schulz H, Volkert J, Dehoust M, Sehner S, Suling A, et al. Prevalence of mental disorders in elderly people: The European MentDis_ICF65+ study. Br J Psychiatry 2016. pii: Bjp.bp. 115.180463.  Back to cited text no. 4
Bulat T, Castle SC, Rutledge M, Quigley P. Clinical practice algorithms: Medication management to reduce fall risk in the elderly – Part 3, benzodiazepines, cardiovascular agents, and antidepressants. J Am Acad Nurse Pract 2008;20:55-62.  Back to cited text no. 5
Carr M. Sedative and psychotropic medications. Nurs BC 2005;37:29-30.  Back to cited text no. 6
Grasso BC, Bates DW, Shore MF. Incidence Rates of Psychiatric Medication Errors in General Medical Settings; 2007. Available from: [Last retrieved on 2008 Jun 03].  Back to cited text no. 7
Mott S, Poole J, Kenrick M. Physical and chemical restraints in acute care: Their potential impact on the rehabilitation of older people. Int J Nurs Pract 2005;11:95-101.  Back to cited text no. 8
Ruscin MJ. Drug therapy in the elderly. In: Porter RS, Kaplan JL, editors. The Merck Manual. Whitehouse Station, NJ: Merck, Sharp & Dohme Corp.; 2011. p. 3090-8.  Back to cited text no. 9
Simon C, Everitt H, Van Dorp F. Oxford Handbook of General Practice. Oxford: Oxford University Press; 2010.  Back to cited text no. 10
Brooks JO, Hoblyn JC. Neurocognitive costs and benefits of psychotropic medications in older adults. J Geriatr Psychiatry Neurol 2007;20:199-214.  Back to cited text no. 11
Kramer BA. Use of ECT in California, 1977-1983. Am J Psychiatry 1985;142:1190-2.  Back to cited text no. 12
Kramer BA. Use of ECT in California, revisited: 1984-1994. J ECT 1999;15:245-51.  Back to cited text no. 13
Thompson JW, Blaine JD. Use of ECT in the United States in 1975 and 1980. Am J Psychiatry 1987;144:557-62.  Back to cited text no. 14
Thompson JW, Weiner RD, Myers CP. Use of ECT in the United States in 1975, 1980, and 1986. Am J Psychiatry 1994;151:1657-61.  Back to cited text no. 15
Nordanskog P, Hultén M, Landén M, Lundberg J, von Knorring L, Nordenskjöld A. Electroconvulsive therapy in Sweden 2013: Data from the national quality register for ECT. J ECT 2015;31:263-7.  Back to cited text no. 16
Lesage A, Lemasson M, Medina K, Tsopmo J, Sebti N, Potvin S, et al. The prevalence of electroconvulsive therapy use since 1973: A meta-analysis. J ECT 2016; May 25. [Epub ahead of print].  Back to cited text no. 17
Lambe S, Mogg A, Eranti S, Pluck G, Hastilow S, McLoughlin DM. Trends in use of electroconvulsive therapy in South London from 1949 to 2006. J ECT 2014;30:309-14.  Back to cited text no. 18
Munk-Olsen T, Laursen TM, Videbech P, Rosenberg R, Mortensen PB. Electroconvulsive therapy: Predictors and trends in utilization from 1976 to 2000. J ECT 2006;22:127-32.  Back to cited text no. 19
Chanpattana W, Kramer BA, Kunigiri G, Gangadhar BN, Kitphati R, Andrade C. A survey of the practice of electroconvulsive therapy in Asia. J ECT 2010;26:5-10.  Back to cited text no. 20
Chanpattana W, Kunigiri G, Kramer BA, Gangadhar BN. Survey of the practice of electroconvulsive therapy in teaching hospitals in India. J ECT 2005;21:100-4.  Back to cited text no. 21
Jain G, Kumar V, Chakrabarti S, Grover S. The use of electroconvulsive therapy in the elderly: A study from the psychiatric unit of a north Indian teaching hospital. J ECT 2008;24:122-7.  Back to cited text no. 22
Zhang XQ, Wang ZM, Pan YL, Chiu HF, Ng CH, Ungvari GS, et al. Use of electroconvulsive therapy in older Chinese psychiatric patients. Int J Geriatr Psychiatry 2015;30:851-6.  Back to cited text no. 23
Flint AJ, Rifat SL. The treatment of psychotic depression in later life: A comparison of pharmacotherapy and ECT. Int J Geriatr Psychiatry 1998;13:23-8.  Back to cited text no. 24
Manly DT, Oakley SP Jr., Bloch RM. Electroconvulsive therapy in old-old patients. Am J Geriatr Psychiatry 2000;8:232-6.  Back to cited text no. 25
Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry (London) 2014;4:33-54.  Back to cited text no. 26
American Psychiatric Association. Committee on Electroconvulsive Therapy. Use of Electroconvulsive Therapy in Special Population. The Practice of Electroconvulsive Therapy, Recommendation for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association. 2nd ed. Washington, DC: American Psychiatric Association; 2001. p. 46-51.  Back to cited text no. 27
Gold L, Chiarella CJ. The prognostic value of clinical findings in cases treated with electric shock. J Nerv Ment Dis 1944;100:577-83.  Back to cited text no. 28
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. 29
Kellner CH, Husain MM, Knapp RG, McCall WV, Petrides G, Rudorfer MV, et al. Right unilateral ultrabrief pulse ECT in geriatric depression: Phase 1 of the PRIDE study. Am J Psychiatry. 2016 Jul 15:appiajp201616010118. [Epub ahead of print.  Back to cited text no. 30
Kellner CH, Husain MM, Knapp RG, McCall WV, Petrides G, Rudorfer MV, et al. A Novel Strategy for Continuation ECT in Geriatric Depression: Phase 2 of the PRIDE Study. Am J Psychiatry 2016; Jul 15:appiajp201615081101. [Epub ahead of print].  Back to cited text no. 31
Spaans HP, Sienaert P, Bouckaert F, van den Berg JF, Verwijk E, Kho KH, et al. Speed of remission in elderly patients with depression: Electroconvulsive therapy v. medication. Br J Psychiatry 2015;206:67-71.  Back to cited text no. 32
O'Connor MK, Knapp R, Husain M, Rummans TA, Petrides G, Smith G, et al. The influence of age on the response of major depression to electroconvulsive therapy: A C.O.R.E. Report. Am J Geriatr Psychiatry 2001;9:382-90.  Back to cited text no. 33
Tew JD Jr., Mulsant BH, Haskett RF, Prudic J, Thase ME, Crowe RR, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry 1999;156:1865-70.  Back to cited text no. 34
Sackeim HA. Use of electroconvulsive therapy in late-life depression. In: Schneider LS, Reynolds CF 3rd, Liebowtiz BD, Friedhoff AJ, editors. Diagnosis and Treatment of Depression in Late Life. Washington, DC: American Psychiatric Press; 1994. p. 259-77.  Back to cited text no. 35
Frazer RM, Glass IB. Unilateral and bilateral ECT in elderly patients. A comparative study. Acta Psychiatr Scand 1980;62:13-31.  Back to cited text no. 36
Bjølseth TM, Engedal K, Benth JŠ, Dybedal GS, Gaarden TL, Tanum L. Clinical efficacy of formula-based bifrontal versus right unilateral electroconvulsive therapy (ECT) in the treatment of major depression among elderly patients: A pragmatic, randomized, assessor-blinded, controlled trial. J Affect Disord 2015;175:8-17.  Back to cited text no. 37
Tew JD Jr., Mulsant BH, Haskett RF, Dolata D, Hixson L, Mann JJ. A randomized comparison of high-charge right unilateral electroconvulsive therapy and bilateral electroconvulsive therapy in older depressed patients who failed to respond to 5 to 8 moderate-charge right unilateral treatments. J Clin Psychiatry 2002;63:1102-5.  Back to cited text no. 38
Ramalingam J, Elias A, George K, Thangapandian S, Bhat R. Retrospective comparison of effectiveness of right unilateral ultra-brief pulse with brief pulse ECT in older adults (over 65) with depression. Int Psychogeriatr 2016;28:469-75.  Back to cited text no. 39
Ottosson JO. Experimental studies of the mode of action of electroconvulsive therapy. Acta Psychiatr Scand 1960;35 (Suppl 145):1-141.  Back to cited text no. 40
Rich CL, Spiker DG, Jewell SW, Neil JF, Black NA. The efficiency of ECT: I. Response rate in depressive episodes. Psychiatry Res 1984;11:167-76.  Back to cited text no. 41
Clarke TB, Coffey CE, Hoffman GW Jr., Weiner RD. Continuation therapy for depression using outpatient electroconvulsive therapy. Convuls Ther 1989;5:330-7.  Back to cited text no. 42
Gagné GG Jr., Furman MJ, Carpenter LL, Price LH. Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients. Am J Psychiatry 2000;157:1960-5.  Back to cited text no. 43
Serra M, Gastro C, Navarro V, Torres X, Blanch J, Masana G. Maintenance electroconvulsive therapy in elderly psychotic unipolar depression. Med Clin (Barc) 2006;126:491-2.  Back to cited text no. 44
Navarro V, Gastó C, Torres X, Masana G, Penadés R, Guarch J, et al. Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late-life psychotic depression: A two-year randomized study. Am J Geriatr Psychiatry 2008;16:498-505.  Back to cited text no. 45
Shelef A, Mazeh D, Berger U, Baruch Y, Barak Y. Acute electroconvulsive therapy followed by maintenance electroconvulsive therapy decreases hospital re-admission rates of older patients with severe mental illness. J ECT 2015;31:125-8.  Back to cited text no. 46
Stanley WJ, Fleming H. A clinical comparison of phenelzine and electro-convulsive therapy in the treatment of depressive illness. J Ment Sci 1962;108:708-10.  Back to cited text no. 47
Gangadhar BN, Kapur RL, Kalyanasundaram S. Comparison of electroconvulsive therapy with imipramine in endogenous depression: A double blind study. Br J Psychiatry 1982;141:367-71.  Back to cited text no. 48
McDonald IM, Perkins M, Marjerrison G, Podilsky M. A controlled comparison of amitriptyline and electroconvulsive therapy in the treatment of depression. Am J Psychiatry 1966;122:1427-31.  Back to cited text no. 49
Janakiramaiah N, Gangadhar BN, Naga Venkatesha Murthy PJ, Harish MG, Subbakrishna DK, Vedamurthachar A. Antidepressant efficacy of Sudarshan Kriya Yoga (SKY) in melancholia: A randomized comparison with electroconvulsive therapy (ECT) and imipramine. J Affect Disord 2000;57:255-9.  Back to cited text no. 50
Folkerts HW, Michael N, Tölle R, Schonauer K, Mücke S, Schulze-Mönking H. Electroconvulsive therapy vs. paroxetine in treatment-resistant depression – A randomized study. Acta Psychiatr Scand 1997;96:334-42.  Back to cited text no. 51
Philibert RA, Richards L, Lynch CF, Winokur G. Effect of ECT on mortality and clinical outcome in geriatric unipolar depression. J Clin Psychiatry 1995;56:390-4.  Back to cited text no. 52
Grunhaus L, Dannon PN, Schreiber S, Dolberg OH, Amiaz R, Ziv R, et al. Repetitive transcranial magnetic stimulation is as effective as electroconvulsive therapy in the treatment of non-delusional major depressive: An open study. Biol Psychiatry 2000;47:314-24.  Back to cited text no. 53
Grunhaus L, Schreiber S, Dolberg OT, Polak D, Dannon PN. A randomized controlled comparison of electroconvulsive therapy and repetitive transcranial magnetic stimulation in severe and resistant nonpsychotic major depression. Biol Psychiatry 2003;53:324-31.  Back to cited text no. 54
Eranti S, Mogg A, Pluck G, Landau S, Purvis R, Brown RG, et al. A randomized, controlled trial with 6-month follow-up of repetitive transcranial magnetic stimulation and electroconvulsive therapy for severe depression. Am J Psychiatry 2007;164:73-81.  Back to cited text no. 55
Wilkins KM, Ostroff R, Tampi RR. Efficacy of electroconvulsive therapy in the treatment of nondepressed psychiatric illness in elderly patients: A review of the literature. J Geriatr Psychiatry Neurol 2008;21:3-11.  Back to cited text no. 56
Andersen K, Balldin J, Gottfries CG, Granérus AK, Modigh K, Svennerholm L, et al. A double-blind evaluation of electroconvulsive therapy in Parkinson's disease with “on-off” phenomena. Acta Neurol Scand 1987;76:191-9.  Back to cited text no. 57
Kennedy R, Mittal D, O'Jile J. Electroconvulsive therapy in movement disorders: An update. J Neuropsychiatry Clin Neurosci 2003;15:407-21.  Back to cited text no. 58
Figiel GS. ECT and delirium in Parkinson's disease. Am J Psychiatry 1992;149:1759.  Back to cited text no. 59
Nishioka K, Tanaka R, Shimura H, Hirano K, Hatano T, Miyakawa K, et al. Quantitative evaluation of electroconvulsive therapy for Parkinson's disease with refractory psychiatric symptoms. J Neural Transm (Vienna) 2014;121:1405-10.  Back to cited text no. 60
Sadananda SK, Holla B, Viswanath B, Narasimha A, Sebastian A, Math SB, et al. Effectiveness of electroconvulsive therapy for drug-induced parkinsonism in the elderly. J ECT 2013;29:e6-7.  Back to cited text no. 61
Marino L, Friedman JH. Letter to the editor: Successful use of electroconvulsive therapy for refractory anxiety in Parkinson's disease. Int J Neurosci 2013;123:70-1.  Back to cited text no. 62
Gadit AM, Smigas T. Efficacy of ECT in severe obsessive-compulsive disorder with Parkinson's disease. BMJ Case Rep 2012;2012. pii: Bcr0120125675.  Back to cited text no. 63
Muralidharan K, Thimmaiah R, Chakraborty V, Jain S. Bifrontal ECT for drug-induced psychosis in Parkinson's disease. Indian J Psychiatry 2011;53:156-8.  Back to cited text no. 64
[PUBMED]  [Full text]  
Ueda S, Koyama K, Okubo Y. Marked improvement of psychotic symptoms after electroconvulsive therapy in Parkinson disease. J ECT 2010;26:111-5.  Back to cited text no. 65
Pintor LP, Valldeoriola F, Fernández-Egea E, Sánchez R, Rami L, Tolosa E, et al. Use of electroconvulsive therapy in Parkinson disease with residual axial symptoms partially unresponsive to L-dopa: A pilot study. J ECT 2012;28:87-91.  Back to cited text no. 66
Nasr S, Murillo A, Katariwala N, Mothkur V, Wendt B. Case report of electroconvulsive therapy in a patient with Parkinson disease concomitant with deep brain stimulation. J ECT 2011;27:89-90.  Back to cited text no. 67
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. 68
Nelson JP, Rosenberg DR. ECT treatment of demented elderly patients with major depression: A retrospective study of efficacy and safety. Convuls Ther 1991;7:157-65.  Back to cited text no. 69
Mulsant BH, Rosen J, Thornton JE, Zubenko GS. A prospective naturalistic study of electroconvulsive therapy in late-life depression. J Geriatr Psychiatry Neurol 1991;4:3-13.  Back to cited text no. 70
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. 71
Stoudemire A, Hill CD, Morris R, Martino-Saltzman D, Markwalter H, Lewison B. Cognitive outcome following tricyclic and electroconvulsive treatment of major depression in the elderly. Am J Psychiatry 1991;148:1336-40.  Back to cited text no. 72
Hausner L, Damian M, Sartorius A, Frölich L. Efficacy and cognitive side effects of electroconvulsive therapy (ECT) in depressed elderly inpatients with coexisting mild cognitive impairment or dementia. J Clin Psychiatry 2011;72:91-7.  Back to cited text no. 73
Currier MB, Murray GB, Welch CC. Electroconvulsive therapy for post-stroke depressed geriatric patients. J Neuropsychiatry Clin Neurosci 1992;4:140-4.  Back to cited text no. 74
Murray GB, Shea V, Conn DK. Electroconvulsive therapy for poststroke depression. J Clin Psychiatry 1986;47:258-60.  Back to cited text no. 75
Krystal AD, Coffey CE. Neuropsychiatric considerations in the use of electroconvulsive therapy. J Neuropsychiatry Clin Neurosci 1997;9:283-92.  Back to cited text no. 76
Coffey CE, Hinkle PE, Weiner RD, Nemeroff CB, Krishnan KR, Varia I, et al. Electroconvulsive therapy of depression in patients with white matter hyperintensity. Biol Psychiatry 1987;22:629-36.  Back to cited text no. 77
Coffey CE. Brain morphology in primary mood disorders: Implications for electroconvulsive therapy. Psychiatr Ann 1996;26:713-6.  Back to cited text no. 78
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. 79
Zorumski CF, Rubin EH, Burke WJ. Electroconvulsive therapy for the elderly: A review. Hosp Community Psychiatry 1988;39:643-7.  Back to cited text no. 80
Zervas IM, Calev A, Jandorf L, Schwartz J, Gaudino E, Tubi N, et al. Age-dependent effects of electroconvulsive therapy on memory. Convuls Ther 1993;9:39-42.  Back to cited text no. 81
Kumar S, Mulsant BH, Liu AY, Blumberger DM, Daskalakis ZJ, Rajji TK. Systematic review of cognitive effects of electroconvulsive therapy in late-life depression. Am J Geriatr Psychiatry 2016;24:547-65.  Back to cited text no. 82
Royal College of Psychiatrists. The ECT Handbook: The Second Report of the Royal College of Psychiatrists' Special Committee on ECT. London, England: Royal College of Psychiatrists; 2004.  Back to cited text no. 83
The ECT Guide: The Chief Psychiatrist's Guidelines for the Use of Electroconvulsive Therapy in West Australia, Department of Health, Government of Western Australia; 2006.  Back to cited text no. 84
Flint AJ, Gagnon N. Effective use of electroconvulsive therapy in late-life depression. Can J Psychiatry 2002;47:734-41.  Back to cited text no. 85


  [Table 1]


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
Frequency of Use...
Indications of E...
Predictors of Re...
Continuation and...
Comparison of El...
Efficacy of Elec...
Use of Electroco...
Efficacy of Elec...
Side Effects of ...
Article Tables

 Article Access Statistics
    PDF Downloaded642    
    Comments [Add]    

Recommend this journal