Elderly catatonia approach for Geriatricians.

Elderly catatonia approach - diagnosis and management for mental health professionals.

1. Approach to Catatonia management in older adults Presenter: Dr Prerak Kumar Assistant Professor Geriatric Mental Health King George’s Medical University, Lucknow Mail : [email protected]

2. OVERVIEW Clinical case vignettes (GMH dept.) Catatonia: History Clinical history points: Catatonia Symptom profile: elderly focus. Neurobiology: etiological models Work up (Investigations) Differential diagnosis Diagnostic criteria (DSM-5 and ICD-11) Scales of measures Management ( Guidelines and challenges in elderly) Recent advances Future directions ? Where we are?

3. Case 1 Domains Socio-demography 66 yrs, female, married female from urban domicile. Chief complains Sadness, refusal to eat, stares for long, and lethargic from 2-3 weeks. Past psychiatric history 1 episode of Severe depression 3 yrs back (2021) Medical history Hypertension, DM-2, Hypothyroidism. MSE positive findings Affect-depressed, Content- Ideas of hopelessness, worthlessness, preoccupied with physical health. Scales HAMD-15, GDS-21, HMSE-30 , BFCRS-12. Diagnosis ICD-10 ICD-11 F33.10 Recurrent depressive disorder (RDD) , current episode moderate without somatic syndrome 6A71.1 RDD , current episode moderate with 6A40 Catatonia associated with another mental disorder Investigations + ve S Na+- 130 (135-145), TLC- 11,500 (4-10,000 ), RBS-379 (70-150). Management Inj Lorazepam 2 mg slow IV dilution ( BFCRS 12 to 4) , T Aripiprazole 2 mg, T Sertraline 50 mg OD, T Tolvaptan 15 mg OD.

4. Case 2 Domains Socio-demography 65 yrs unmarried male from rural domicile. Chief complains withdrawn, poor appetite, poor hygiene, maintain postures, strange vocal sounds from 1 month Past psychiatric history Not present. Medical history DM-2, Covid infection 2021. MSE positive findings PMA-retarded , Affect-restricted , thought flow -decreased. Scales HAMD-3,GDS-3, HMSE-25, BFCRS-13 , BPRS-43 Diagnosis ICD-10 ICD-11 F06.1 Organic catatonia with F70 Mild mental retardation. 6A40 Catatonia associated with another mental disorder, 6A00.00 Intellectual development disorder , mild . Investigations + ve . HbA1c-6.25%, Vit d3- 24 (30-100), TSH-6.55 (0.35-4.95), Vit B12- 248 ( 211-883), Homocysteine- 21 (2.3-13.1) Management Inj. Lorazepam 2 mg IV dilution , BFCRS 13 to 8, T Risperidone 0,5 mg BD, T Lorazepam 1mg BD from OPD, 1 week follow up BFCRS = 5.

5. Case 3 Domains Socio-demography 61 yrs married male from urban domicile Chief complains Refusal to eat, withdrawn, pass urine in clothes, no interaction for 1 month. Past psychiatric history 2011- Severe depressive episode with psychotic symptoms. Medical history Hypothyroidism, BPH, CAD, Hypertension, TB. MSE positive findings PMA- retarded, speech- mutism, affect- flat, thought flow- reduced. Scales BFCRS-18, HMSE-7, DRS-9 Diagnosis ICD-10 ICD-11 F06.1- Organic catatonic disorder. 6E69 Secondary catatonic syndrome Investigations + ve . MRI brain- Atrophy in Fronto -temporal area with lacunar infarcts in Peri-sylvian areas, S Na+=131 (135-145), S Urea- 48 (17-42), Urine RM-8-9 pus cells. Management Inj. Lorazepam IV 14 mg max, BFCRS 18 to 16, Ketamine 1.5 ml dose BFCRS 15 to 14, 2 session ECT BFCRS came down to 12. T Aripiprazole 2mg OD Inj. Pipzo 4.5 G IV TDS, NaCl 500 ml BD, poor response on Lorazepam.

6. Case 4 Domains Socio-demography 60 yrs married male from rural domicile Chief complains Maintain posture, poor hygiene, no food intake, crying spells, sadness from 20 days Past psychiatric history Mania episode 2013, depressive episode – 2022. Medical history CVA, BPH. MSE positive findings Kirby: Mask like face, uncooperativeness in reaction to examiner , posturing present, pupil reaction present, no spontaneity. Scales BFCRS- 20 , BPRS-41. Diagnosis ICD-10 ICD 11 F06.1 Organic catatonic disorder 6A40 Catatonia associated with another mental disorder. Investigations + ve . CPK Mb-221 (38-245), CRP-90 (0-6), Vit b12-209 (211-883), MRI Br.- Chronic ischemic changes with infarcts in Peri Ventricular. white matter Management Inj. Lorazepam 8 mg IV max, BFCRS 20 to 18, Inj. Pipzo . 4.5 g IV TDS, T PCM 650 mg HS, T Olanzapine 5 mg HS. Pt had poor response on lorazepam max dose 12 mg.

7. Catatonia: History

8. Coined term in 1874, Catatonia term means- “stretch tight.” known as Tension insanity . KARL KAHLBAUM Considered it as a disorder not as a symptom .

9. Catatonia: neuropsychiatric syndrome (motor, behavior, emotional, autonomic abnormalities ) Geriatric subjects – its under-recognized, delay in treatment, misdiagnosis and mortality high. Elderly common etiology: infection, trauma, CVA, hyponatremia, dehydration, drug induced . Extensive research on catatonia , but specific to older adults is scarce. Prevalence in elderly : 5.7-9.4%, associated with delirium- 25-31%.

10. Clinical History points in Catatonia

11. Points to ask in history Collateral history from informant and tell about your management plan to them. Physical examination BMI. Muscle mass BP, pulse, respiratory rate, Temp., SPo2, pressure ulcers, dehydrated skin, swelling limbs . Detail neurological examination and detail MSE (Kirby’s method), MMSE, Glasgow come scale . Recent hike dose of neuroleptics or sudden withdrawal or any BZD/ Alcohol withdrawal, Lithium withdrawn . Assess prior precipitating events in catatonia , response to lorazepam dose. Psychiatric : Prior NMS, mood disorder, Acute psychosis, Prior ECT. Neuro-medical: recent CVA, Epilepsy, head trauma, space occupying lesion, Atypical parkinsonism. Recent : alcohol, cannabis, opioid, stimulants, IV drug abuse .

12. Mnemonic: A SLIME- posture (Screen method) to identify catatonia in emergency set-ups. A - acute onset / subacute onset S - speech mutism, poverty L - latency increase response in speech, affect. I - interaction ( stupor, withdrawn)- decreased. M - muscle, increased tone E- eyes , staring Posture - posturing, grimacing, catalepsy.

13. Catatonia subtypes Catatonia Stuporous/Hypokinetic Withdrawn / mutism/ bizarre posturing/ waxy flexibility Periodic Cyclic pattern, brief and recurrent episodes. Malignant Severe rigidity, ANS instability, Altered mentation. Excited Hyperactivity, aggressive, combative, autonomic instability

14. Symptoms Profile: Elderly Catatonia

15. 298 elderly patients admitted , 33 (11.1%) had catatonic symptoms. Tool : BFCRS. Mc symptoms: Mutism (100%)> Staring (94%)> Immobility (84%)> Rigidity(83%)>Posturing (69%) and withdrawal (60%). Comorbid diagnosis in 33 catatonic subjects 28- mood disorders ( Unipolar> Bipolar) 3- Dementia ( Vascular:2, Alzheimer:1) 2-Psychotic disorders

16. More relapses of catatonia, poor prognosis with NMDA encephalitis etiology

17. RISK FACTORS Affective disorders history Age Post partum disorders Past catatonia history Abrupt withdrawal of Antipsychotics, BZDs. Brain trauma Recent CVA CNS infections Recent psychosis Cardiac failure COMPLICATIONS Dehydration Deep vein thrombosis Starvation Pulmonary embolism Progress to NMS Self harm or homicidal Coma Decubitus ulcers

18. NEUROBIOLOGY: CATATONIA

19. Neurobiology models catatonia Epilepsy model Frontal lobe and anterior limbic discharges, spikes. Immune model Infections, antibodies, chemokines, IL-6,12, TNF-@, autoimmune ABs Endocrine model HPA axis, Thyroid abnormalities, PTH low secretions. Autonomic nervous system Vitals unstable, drug induced NMS, Parasympathetic and sympathetic abnormalities Fear model Fear precipitation, Trauma causes social distress Neurotransmitter model GABA decrease Dopamine decrease Glutamate increase Nor epinephrine decrease Serotonin increase Genetic model Genes dominant, proteins in serum, Periodic catatonia, Motor circuitry Frontal basal ganglia, SMA, Limbic and cerebral-thalamic

20. Investigations

21. Ist line Complete blood counts Liver , Renal function Thyroid profile Sugar, lipid profile ESR, Electrolytes CRP Urine drug screen Urine R/microscopy Vitamin B12, D3 Homocysteine Folate 2 nd line( based on systematic examination) ECG CT head/MRI brain EEG Blood/Urine culture S IL-6, S viral markers General blood picture Anti TPO Metal screening D-dimer 3 rd line Functional neuroimaging: FMRI, SPECT, PET NMDA panel workup Lumbar/CSF Color doppler carotid

22. Differential diagnosis: Catatonia

23. DIAGNOSIS Features similar to Catatonia Distinguishing features Encephalopathy Acute onset, bizarre behavior Precipitated head trauma, infection, intoxications. CVA stroke Acute onset, immobility, mutism, refusal to eat. CT/ MRI findings , previous CVA episodes. Parkinson’s disease Immobility, rigidity, depression. Dopamine agonism improves symptoms, cogwheel rigidity, pill rolling tremors . Locked in syndrome Mutism, stupor Preserved blinking and vertical eye movements , rest all paralysis, Pons lesion . Status epilepticus Altered mental status, immobile. EEG changes, previous epilepsy h/o. Elective mutism Mutism. Personality traits, social specific settings, paranoid traits. Malignant hyperthermia Immobility, autonomic instability. Inhalation anesthetic use , muscle biopsy.

24. DIAGNOSIS FEATURES SIMILAR DISTINGUISHING FEATURE Stiff-person syndrome Abnormal posturing, rigidity, refusal to eat. Head retraction reflex, GAD-65 Antibodies positive, lower back, leg muscles weakness. Akathisia Restlessness, hyperactive, anxiety Lack of posturing, rigidity, verbigeration. Serotonergic syndrome Pyrexia, hypertonia, confusion. Myoclonus, Serotonergic drugs. Neuroleptic malignant syndrome Rigidity, Stupor. Anti-psychotics , Levenson criteria Delirium Withdrawn, hyperactive. Fluctuation, disorientation. Haller Vorden Spaatz syndrome Rigidity, refusal to eat, Dementia, Dystonia, Retinitis pigmentosa

25. FEATURES CATATONIA DELIRIUM Clinical status Medically stable except NMC, malignant catatonia. Advance age, medical illness causes it. Arousal Awake and conscious, alert but pt may exhibit reduced arousal. Reduced level and agitation, fluctuations course in day. Thought process Repetitive, stereotyped, perseveration. Disorganized or tangential. Psychopathological symptoms Para kinetic movements, no delusions, no prominent hallucinations, reduce eye blink, staring, negativism. Positive symptoms- Hallucinations, delusions, illusions. Language abnormality Mute, echolalia, verbigeration. Low mumbling or rapid depends on subtype. Orientation Often clear but difficult to assess. Clouded, disoriented Interpersonal Disengaged, withdrawn, Inattentive, often sedated with limited communication during normal period of day. BZDs response Patient become alert, awake, responsive. Leads to worsening, more confusion except in substance withdrawal cases.

26. Diagnostic criteria (DSM-5 and ICD-11)

27. ICD-10 ICD-11 (Separate diagnosis) DSM-5 (Episode specifier-Mental health disorders) F06.1 organic catatonic disorder 6A40 Catatonia associated with another mental disorder 293.89 Catatonia associated with another mental disorder F20.2 Catatonic Schizophrenia 6A41 Catatonia induced by substances or medications 293.89 Catatonia associated due to another mental disorder 6E69 Secondary catatonic syndrome 293.89 Unspecified Catatonia. 6A4Z Catatonic, unspecified.

28. Objective scales: Catatonia

29. Bush Francis Catatonia rating scale (BFCRS) Hypokinetic Stupor Mutism Staring Posturing/Catalepsy Rigidity Withdrawal Muscle resistance Ambitendency Negativism Hyperkinetic Excitement Impulsivity Combativeness Para kinetic Grimacing Echopraxia Echolalia Stereotypy Mannerism Verbigeration Waxy flexibility Automatic obedience Passive obedience Grasp reflex Perseveration

30. Management of catatonia

31. Treat underlying medical cause just like delirium. 1 st line Benzodiazepines , Lorazepam IV or Oral low dose 1-2 mg. If poor response to Lorazepam, consider ECT bilateral (2 times / week minimum) Case reports: Zolpidem, Amantadine, Methylphenidate, Valproate, Lithium, Carbamazepine, Acamprosate, Memantine, Topiramate, Bupropion, Olanzapine, Metformin, Tramadol. (Level 5 )

32. Existing guidelines for catatonia British Association of Psychopharmacology German Association for Psychomotor disorders Psychotherapy and Psychosomatic guidelines for Catatonic Schizophrenia NICE guidelines ( Catatonic Schizophrenia) CANMAT for Major Depressive Disorder 2023. World Federation of Societies of Biological Psychiatry in Schizophrenia Guidelines for the Academy of Consultation-Liaison Psychiatry.

33. Management challenges : Elderly cases

34. Catatonia: underrecognized, undertreated delays management, mortality issues, poor outcomes, multifactorial etiology. Comorbid delirium , clear delineation with Hypokinetic catatonia vs Hypoactive delirium, use of BZDs (worsens organic delirium or improves catatonia) Dementia underlying diagnosis, BZDs use how much evidence supports. Organic etiology in elderly over-looked, past psychiatry h/o present in subjects generally associated with catatonia. Pharmacodynamics challenges, drug interactions, neuroleptics sensitivity, safety of antipsychotics.

35. Recent advances: Catatonia

36. Future directions: where are we?

37. Definition of Catatonia syndrome, specific catatonic subtypes and threshold for separate diagnosis. More clinical RCT on different drugs modalities and even other BZDs diazepam, midazolam and other mood stabilizers. Large database of electronic healthcare records with prescribing data. More research on Genetic and Environmental predisposing factors for catatonia. More Neuromodulation techniques for Catatonia treatment, more safety parameters for ECT modality in Catatonia.

38. Extensive pathophysiology research with strong evidence for all age cohorts, different symptom network analysis for all age cohorts. Psychosocial treatment research are we well sufficient for catatonia. More immunological markers relevant to catatonia diagnosis. Indian validated tools to assess catatonia , for our populations. How long BZDs to be used after recovery from catatonia, strong RCT clinical trials methodology for different BZDs use in catatonia , relevant to specific age cohorts. Psychomotor clinic concept, Consul. Liaison integration management approach in ward, trained nursing professionals for such emergencies.

39. CONCLUSION Catatonia highly prevalent in older adults because of multifactorial etiologies its challenging sometimes delay in treatment, misdiagnosis and mortality. To differentiate catatonia from other differentials is important in older adults specially delirium with judicious use of BZDs and other drugs for catatonia is important. In future more prospective studies and more clinical trials with strong methodologies are required to accurately identify the clinical correlates of catatonia in older adults .