Depression as a major component of a gait disorder—Successful multimodal treatment including electroconvulsive therapy

Abstract

This case report describes an 82-year-old patient who was treated in a gerontological psychiatric ward due to a multifactorial gait disorder with falls. The main component of the gait disorder was depression, which was accompanied by a pronounced fear of falling. Other factors were polyneuropathy, gonarthrosis and an exercise deficit after previous inactivity. An important part of the multimodal treatment was electroconvulsive therapy (ECT). A total of nine sessions of ECT in right unilateral stimulation were conducted. The treatment resulted in a significant improvement of the depression and the gait disorder, which was impressively reflected in the geriatric assessment. The presented case shows that depression and fear of falling should not be underestimated as (main) components of a gait disorder. Here, a multimodal treatment including treatment of the depression by ECT was successful.

Supplementary Information

The online version of this article (10.1007/s00391-022-02135-2) contains supplementary material, which is available to authorized users.

Methods

Description of a case report and discussion considering psychiatric and geriatric perspectives.

Anamnesis

An 82-year-old male patient was brought to the interdisciplinary emergency room after two falls. After exclusion of severe trauma sequelae, a gait disorder and depression became apparent. The patient was transferred to a gerontological psychiatric ward of the Department for Psychiatry of the University of Kiel.

The patient reported that he had been feeling lonely and increasingly socially isolated since the death of his wife. He suspected that his inactivity had led to his gait insecurity and blames himself for it. Due to the falls, he had been very insecure and described his biggest worry as not being able to live in his house anymore but having to go to a nursing home. He described himself as joyless and listless and expressed a wish to be able to care for himself again as he used to. The medication consisted of venlafaxine sustained release 150 mg and olanzapine 5 mg per day.

Psychiatric history

The patient suffered from recurrent depressive episodes practically all his life. During his professional training the patient had developed obsessive thoughts for the first time. The patient had been in inpatient psychiatric treatment several times and had had six series of treatment with electroconvulsive therapy (ECT). These took place at the ages of 72, 73, 74, 75, 77 and 78 years. The most recent series of ECT was about 3 ½ years ago. In total, 56 ECT sessions (6–10 per series) were carried out cumulatively. Details are given in Table 1 of the web appendix.

Diagnostic findings

Mental status examination using the Manual for the Assessment and Documentation of Psychopathology in Psychiatry (AMDP system)

Alert and clear, fully oriented, concentration and retentiveness moderately disturbed, short-term memory slightly disturbed, long-term memory not disturbed, no confabulation. Sleep undisturbed. Formal thinking slowed down, circumstantial, preoccupied, constricted. Thought content undisturbed. No disorders of the self. No perceptual disturbance. Depressed mood. Affect sad, blunted, perplexed, anxious. Fears of doing something wrong, of having to go to a nursing home. Fear of falling. Obsessive thoughts and compulsive actions, e.g. regarding toilet procedures, impoverished drive. Feeling of illness and insight into illness present. Reduced appetite with weight loss. Unobtrusive appearance, polite and friendly in contact. No endangerment to self and others.

Physical examination

Reduced general and slightly underweight nutritional status (53 kg, 168 cm, BMI 18.8 kg/m²). Generalized muscular atrophy without paresis. Unsteady gait with slightly bent knee joints and with phobic component. Step length symmetrically reduced, step width fluctuating. Turning with slightly increased number of steps and too small step width. Romberg test unsteady with undirected falling tendency. Pallhypesthesia (1–2/8) of the legs, ankle jerk reflexes extinguished. Genua vara with pain in the right knee joint. Further general medical and neurological examinations were unremarkable.

Diagnostic investigations

The cranial CT scan revealed no trauma sequelae. It showed a generalised brain atrophy and a mild microangiopathy. ECG and EEG were unremarkable.

Comprehensive geriatric assessment

In the Geriatrie-Check, the patient scored 1 point in part A and 2 points in part B and was classified as a probable geriatric patient [1, 2]. In the short physical performance battery (SPPB), the patient achieved 7 points as an expression of the risk of falling. In the DemTect the patient scored 6/18 and in the mini-mental status test 26/30 points. In the Barthel index, the patient scored 75/100 points. The falls efficacy scale international (FES-I) revealed 45/64 as an expression of a pronounced fear of falling [3]. In the visual analogue scale of the EQ5D (standardised measure of health-related quality of life), the patient rated his quality of life with 20%. In the geriatric depression scale (GDS), the patient scored 9/15 points indicating mild to moderate depression. The patient was not able to answer the Beck’s depression inventory (BDI) II due to obsessive thoughts to give a wrong answer. The first assessment of the BDI II was after the third ECT with 10 points, reflecting a normal score. The course of the results of the geriatric assessment is shown in Fig. 1.

Fig. 1.

Overview of course and therapy effects of treatment in geriatric assessment. Assessment of depressiveness with Beck’s depression inventory (BDI) and geriatric depression scale (GDS), fear of falling with falls efficacy scale (FES‑I), mobility with short physical performance battery (SPPB) and quality of life with EQ5D. The blue arrows indicate the individual treatments using electroconvulsive therapy (ECT)

Clinical course and therapy

At the beginning of the inpatient stay, the patient appeared very anxious, was ruminating, and very constricted to his gait disorder. Compulsive actions also occurred, especially in personal hygiene. He reported that his own rules would protect him from doing something wrong. As a result, he repeatedly found himself in situations that made him very insecure when something deviated from the usual pattern. In the activities of daily living, the patient demanded support especially in personal hygiene but could usually be encouraged to carry this on his own. He stayed mainly in his room at the beginning and reported a great fear of falling. He used a walker when walking.

We classified the gait disorder as multifactorial and planned further treatment accordingly. Besides the pre-existing polyneuropathy, a known gonarthrosis on the right side and an exercise deficit due to the previous inactivity, fear of falling and depression were the main components.

The patient explicitly wanted ECT treatment because ECTs had shown good effects in the past and nine right unilateral ECTs were performed with a stimulation intensity of 60–110%. Anesthesia was performed with propofol and succinylcholine. Convulsion durations of up to 55 s were achieved. The detailed parameters of ECT are listed in Table 1. Initially, two treatments were given per week, after the fifth ECT one per week. After the third ECT, an effect could be observed. After the fifth ECT, also the patient noticed an improvement. The improvement was also reflected in the geriatric assessment (see Fig. 1).

Table 1.

Overview of the parameters of the electroconvulsive therapy sessions

Nr.	Position of the stimulation electrodes	Dose of propofol (in mg)	Doss of succinylcholine (in mg)	Energy set (in %)	Stimulation strength (in mC)	Seizure duration in EEG (in s)	BIS
1	Right unilateral	90/30	50	60/80	299.7/400.7	13/20	32
2	Right unilateral	90	80	80	400.1	34	53
3	Right unilateral	120	50	90	450.4	52	32
4	Right unilateral	140	60	90	449.9	55	33
5	Right unilateral	100	60	90	450.0	46	30
6	Right unilateral	100	60	90	449.9	41	31
7	Right unilateral	120	60	90/110	554.6	20/13	36/41
8	Right unilateral	100	60	110	551.6	54	54
9	Right unilateral	100	60	110	553.3	40	40

BIS Bispectral Index, EEG Electroencephalography

Before ECT was performed, the medication venlafaxine sustained release was reduced to 75 mg per day, olanzapine was taken unchanged. After the last ECT, venlafaxine sustained release was increased again to the original dose of 150 mg per day.

The patient regularly participated in group therapies for occupational therapy, physiotherapy and music therapy. He received also individual physiotherapy with the aim of improving mobility and preventing falls. In addition to gait training, he received training on the ergometer to improve leg strength, and stair training. In weekly individual therapy sessions, the cycle of “falls → fear of falling → inactivity → lack of training → new falls” was worked out and behavior therapy with elements from acceptance and commitment therapy (ACT) and exposure exercises were carried out. The patient received high-calorie drinks and gained weight from 53 to 59 kg during the inpatient stay.

The treatment resulted in a significant improvement in mobility, depression, anxiety, and compulsions. Three successful stress tests at home were carried out, so that the patient could be discharged home after 10 weeks of inpatient treatment. At discharge, the patient was able to walk safely without a walker.

Further treatment

The further treatment after the inpatient stay was carried out with medication and psychotherapy in the psychiatric outpatient department of the clinic. No maintenance ECT was considered because the patient had been stable for 3.5 years after the last ECT series and because the local structural conditions during the COVID-19 pandemic did not permit this.

Diagnoses and ICD-10 classification

Psychiatric diagnoses.

• Recurrent depressive disorder, current episode severe without psychotic symptoms F33.2.

• Predominantly obsessional thoughts or ruminations F42.0.

Geriatric diagnoses.

• Multifactorial gait disorder consisting of:

  • Gait disorder in the context of depression and fear of falling R26.8.
  • Right gonarthrosis with genu varum M17.1.
  • Polyneuropathy, unspecified G62.9.

• Unspecified protein-energy malnutrition E46.

• Sarcopenia M62.50.

Discussion

In geriatric patients, gait and balance disorders are very common and often multifactorial. In the case presented here, the leading contribution of depression and anxiety is particularly impressive.

In a recently published model, important factors in the relationship between fear of falling and falls are discussed. Experienced and observed falls lead to fear of falling, which in combination with fall efficacy leads to avoidance behavior [4]. In this model, depression influences both fear of falling and fall efficacy, but is also directly associated with falls. Avoidance behavior (of situations that can lead to falls) plays a central role, as it leads to inactivity, lack of exercise and muscle atrophy. These factors are themselves risk factors for falls.

In the described case the multilayered treatment led to success. The depression was mainly treated by ECT. As the depression improved, so did the anxiety, compulsions, gait and balance disturbance. Individual therapies included exposure exercises and walking. In physiotherapy, gait and stair training and improvement of leg strength took place. Activation took place throughout the entire therapy concept. In the geriatric assessment, the improvement of depression, gait and balance disturbance, fear of falling and resulting quality of life is reflected (see Fig. 1).

In the literature, the effect of ECT on gait and balance disorders is described only in few studies. In one study, a gait and balance assessment was carried out after ECT. The aim was to investigate the association of falls as a side effect after ECT. No (short-term) deterioration of gait and balance in the assessment was found [5]. A study with wearable sensors showed an improvement of mobility after ECT [6]. Studies analyzing quantitative parameters to describe gait quality (i.e. with an instrumented assessment [7]) after ECT have not yet been published to our knowledge.

In principle, it can be assumed that the effect of ECT is not directly on the gait disorder but is a consequence of the improvement of the depression. Under effective drug therapy, the same result would probably have been achieved, but possibly later [8]. In the case described here, treatment with ECT was chosen for various reasons without first trying another medication: treatment with ECT was wanted by the patient. In the past, ECT had shown a faster and better effect than treatment with tranylcypromine, olanzapine and flupentixol. From a geriatric point of view, a rapid improvement of the depression is preferred to treat the main component of the gait disorder and to break the cycle of immobilization, muscle atrophy, worsening of the gait disorder and falls. This patient showed a relevant improvement after the third ECT, i.e. in the fourth week of the inpatient stay.

ECT is an important therapy option in old age for therapy-refractory depression. The response rate is even somewhat higher compared to younger patients [9]. It is discussed that older age may increase the risk of intervention due to somatic, especially cardiovascular, disease [12, 14]. Cognitive side effects of ECT are discussed [10]. In some cases, an improvement in cognition after ECT, at least in the medium term, is described [11, 12]. An increased risk of dementia due to ECT has not been confirmed [13]. In the case described, no cognitive side effects occurred, and cognition improved (DemTect 6/18 points before the first ECT and 12/18 points after the last ECT) due to the improvement of depression.

Practical conclusion

The case presented shows that depression and anxiety should not be underestimated as (main) components of a gait disorder. Multimodal treatment, including treatment of the depression by ECT, led to success here.

The use of the geriatric assessment of motor function and fear of falling is also useful in the gerontological psychiatry. Effects of therapy can also be reflected in the geriatric assessment, as described in the case presented.

Declarations

Conflict of interest

M.A. Hobert, D. Bruhn, J. Koch and S. Studt declare that they have no competing interests.

The patient provided consent to publish his medical history as a case report. A written declaration of consent is available.