Electroconvulsive Therapy for Aggression and Agitation in Dementia: A Systematic Review With Exploratory Meta-analytic and Ethical Perspectives

Aggression and agitation are among the most distressing and treatment-resistant behavioral and psychological symptoms of dementia (BPSD), and conventional pharmacological or behavioral interventions often provide limited benefit and carry substantial risks in frail older adults. We conducted a systematic review in accordance with PRISMA guidelines, searching PubMed, EMBASE and the Cochrane Library through September 24, 2025 for clinical studies of electroconvulsive therapy (ECT) for agitation and/or aggression in dementia, including case reports, case series, observational cohorts, chart reviews and randomized trial protocols. Data on patient characteristics, ECT parameters, outcomes, adverse events and consent procedures were extracted, and exploratory random-effects pooling of clinical response rates was performed. Thirteen studies including 206 patients met inclusion criteria. Across studies, most patients showed clinically relevant improvement, with reported response rates typically between 70% and 90%; exploratory meta-analytic pooling yielded a clinical response proportion of 77.7% confidence interval CI (95% CI 71.0%-83.3%), which remained stable in sensitivity analyses (n ≥ 5: 81.2%, 95% CI 71.7%-88.0%). Improvement usually emerged within 2-4 treatments (median = 3 sessions), and reductions in agitation and aggression were supported by validated instruments such as the Cohen-Mansfield Agitation Inventory (CMAI) and Pittsburgh Agitation Scale (PAS). ECT was generally well tolerated, with mostly mild and transient adverse effects and no reported treatment-related deaths or persistent severe complications. Available evidence suggests that ECT may provide a rapid, effective and relatively safe last-resort option for otherwise refractory aggression and agitation in dementia, but confirmatory prospective and ethically informed controlled studies are needed.