Electroconvulsive Therapy for Life-Threatening Refractory Hypoactive Delirium in an 87-Year-Old Patient: A Case Report

Delirium is a frequent and serious neuropsychiatric syndrome in older inpatients and is associated with severe negative outcomes. Hypoactive delirium is often underdiagnosed and may become life-threatening when accompanied by sustained refusal of oral intake. Evidence for pharmacological treatment of persistent or refractory delirium remains limited, and the role of electroconvulsive therapy (ECT) is poorly defined. We report an 87-year-old woman with both schizoaffective and major neurocognitive disorder who developed refractory hypoactive delirium in the context of multiple medical precipitants. Despite systematic identification and treatment of precipitants, correction of metabolic disturbances, and optimization of psychotropic medication, she continued to exhibit marked psychomotor inhibition and refusal of food and fluids, leading to clinically significant dehydration and electrolyte abnormalities. Given imminent medical risk and refractoriness to standard management, ECT was initiated twice weekly after multidisciplinary evaluation. Clinical improvement was observed after the first session, with resolution of delirium features and restoration of oral intake after three sessions, without periprocedural complications. This case suggests that carefully monitored ECT may be considered as a rescue intervention in cases of life-threatening refractory hypoactive delirium and underscores the need for clearer escalation guidance and higher-quality evidence.