A CASE SERIES ON LATE-ONSET CATATONIA MISDIAGNOSED AS DELIRIUM

Abstract

Introduction Catatonia is a neuropsychiatric syndrome characterized by motor, behavioral and autonomic signs. It is associated with psychiatric disorders, neurologic disorders and general medical conditions. However, the literature on the occurrence of catatonia in older adults is limited, Methods We present three cases of late-onset catatonia in older adults diagnosed with major depressive disorder initially diagnosed as delirium. Case 1 is a 66-year -old male with a past medical history of sclerosing cholangitis, ulcerative colitis, cerebrovascular disease presented with gradually progressive symptoms of one-month duration of mutism, staring, immobility, withdrawal, depression and delusions of infidelity following the surgery of a hepatic nodule. Case 2 is a 68-year-old female with a past history of chronic kidney disease presented with a one-year history of general deterioration of health along with decreased psychomotor activity, talk, social interaction decreased food, auditory hallucinations and persecutory delusions along with staring, posturing, mutism, rigidity, negativism and immobility. Case 3 is a 66-year-old female with a past history of major depressive disorder and gradually declining cognitive functions suggestive of major neurocognitive disorder presented with gradually progressive symptoms of mutism, staring, withdrawal, negativism and depressive symptoms of two months duration. On admission, the Bush Francis Catatonia Rating Scale Scores for the cases were 15/69, 15/69 and 13/69, respectively. All the cases had a past psychiatric history of major depressive disorder. They had been initially admitted to the medicine unit for assessment of delirium which was later ruled out by the consultation-liaison psychiatry team. Results Case 1 was treated with an adequate trial of oral citalopram, lorazepam, olanzapine and later with a trial of oral venlafaxine, aripiprazole and mirtazapine without any improvement in symptoms. The course of treatment was complicated by chronic hyponatremia. His catatonic and depressive symptoms resolved after 13 sessions of electroconvulsive therapy (ECT) along with oral venlafaxine 225mg daily and oral aripiprazole 10mg QHS (total days of inpatient hospitalization=60 days) . Case 2 was treated with oral lorazepam 1?mg twice daily for catatonia along with oral fluoxetine 20?mg daily for depression. The course of treatment was complicated by a urinary tract infection (UTI), which was treated with antibiotics. The dose of oral lorazepam was gradually increased to 1.5mg BID, following which the catatonic symptoms subsequently improved. The patient was discharged after lorazepam was gradually tapered and stopped. However, the patient was readmitted after two days due to a relapse of catatonic symptoms. Oral fluoxetine was continued at the same dose and oral lorazepam 1.5mg BID was restarted. The catatonic symptoms gradually subsided and 10 outpatient sessions of ECT was provided following which the depressive symptoms improved in the same medications (total days of inpatient hospitalization=67 days). Case 2, after relevant investigations, was treated with oral sertraline 100mg daily and oral lorazepam 3?mg three times a day following which her depressive and catatonic symptoms resolved(total days of inpatient hospitalization=7 days). Conclusions Our case series demonstrates catatonia can present in older patients and can be initially misdiagnosed with hypoactive delirium due to the sharing of common characteristics like stupor, agitation and decreased psychomotor activity. Medical disorders followed by mood disorders are implicated in the common causes of catatonia in older adults. The treatment of the cause along with benzodiazepenes remains the mainstay of treatment. ECT has been found to effective in medication refractory cases evidenced in two of the above -mentioned cases with literature demonstrating a delaying in diagnosis leading to a refractory response to ECT. Discontinuation of lorazepam can lead to a relapse of symptoms, as evidenced in case 2. Medical problems in older patients can complicate the treatment course while catatonia can also lead to medical complications like hyponatremia and UTI which have occurred in our cases. Catatonia can lead to increased duration high-risk complications in the elderly like myocardial infarction, pulmonary embolism and thrombosis requiring prompt identification and management, preferably in an interdisciplinary hospital setting. Thus, the prompt diagnosis of catatonia is important and to be differentiated from delirium in older adults as the management differs in both conditions. In this context, consultation-liaison or geriatric psychiatry services becomes essential in a general hospital setting for identification and care of such cases. This research was funded by: Not applicable