Evaluating psychiatric co-morbidities of Huntington's disease

Abstract

This is a case report of Mrs. A, she is a 76-year-old South Asian woman who was referred to geriatric psychiatry for mood symptoms (primarily anxiety, agitation, and depression) approximately 13 years after gene confirmed Huntington's disease (HD) diagnosis. Possible triggers for worsening of her symptoms included choreiform movement, suicidal ideation with Deutetrabenazine trial, and increased effort to maintain baseline function about 10 years before confirmed HD with worsening of cognition and physical limitations. Family involvement was a strength from before HD and it seemed to provide sufficient and effective emotional support in the early years.In review of her symptoms, they met criteria for Major depressive episode and Generalized anxiety disorder with panic attacks. Initial treatment plan included scheduled Mirtazapine and Lorazepam as needed for panic attacks. Lorazepam was effective though she experienced a return of anxiety after a short time, it was switched to Clonazepam and better tolerated. Trazodone was added to assist with insomnia, specifically onset of sleep, and to decrease breakthrough anxiety. She did not tolerate previous trials of medications including SNRI such as venlafaxine, SSRIs such as Paroxetine, Sertraline, and Citalopram, nor Benzodiazepine such as Diazepam.The anxiety and mood symptoms seemed to stabilize, although her cognitive function was declining. She was initially engaged in follow-up visits, would answer most questions in English, and used full sentences. Over time her responses had increased latency, were more fragmented, and she would reply in her native language. Her family felt confident interpreting and described her vocabulary as simple and child-like. In collaboration with neurology team, we reviewed the use of second-generation antipsychotics for mood and HD symptoms. Low dose Olanzapine was effective in both improvement of chorea and decreased need for daytime Clonazepam and Trazodone. Overall mood symptoms improved though her cognitive and function skills did not return to her evaluation baseline level.This case was especially inspiring to our team for several reasons: 1) Despite anxiety symptoms being commonly reported in HD, this topic has received limited attention in the literature, 2) There is insufficient data for evidence-based guidelines to treat psychiatric symptoms in HD, 3) It was a learning experience for the geriatric psychiatry fellows to handle HD psychiatric manifestations and management of its challenges.