Correspondence Address:
Dr. Sujita Kumar Kar
Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh
India

Full Text



Sir,

Tic disorder is a common entity in childhood and adolescents. Tics in adults are usually continuation of childhood tics or secondary to a neurological disorder. The onset of tic disorders in adults is relatively rare, and new-onset tic in the elderly is extremely rare.[1] Due to its rarity, it often goes undiagnosed or misdiagnosed.[1],[2] The neurobiological underpinning of tic traces back to the connections of the basal ganglia with cerebral cortex, brainstem, and thalamus.[3] The dopaminergic circuits are mostly implicated in the generation of tic. New-onset tics in adult and elderly population can be due to specific brain lesion or can be due to some psychiatric disorder.[4] Tics may be confused with certain other movement abnormalities such as chorea, dyskinesias, and stereotypy.[4] Phenomenologically, tics can be tonic, clonic, or dystonic type.[5]

Dopamine antagonists such as haloperidol, risperidone, and other antipsychotic drugs may be useful in the management of tic disorders. If the tic symptoms are accompanied by anxiety, depressive, or obsessive–compulsive features, then selective serotonin reuptake inhibitors or tricyclic antidepressants may be useful.[6]

A 60-year-old male priest from a middle-class rural family consulted in the neuropsychiatry clinic with acute-onset repetitive abnormal twitching movements in the left side of the face with a progressive course over the past 1 year. These movements would stop during sleep. The patient complained of distress due to these movements. These symptoms would worsen during stress and sleep deprivation. He would transiently suppress the symptoms voluntarily. There was no immediate precipitating event reported. There was no medical illness, head injury, substance use, or medication use reported before initiation of these symptoms. There was no prior history of any medical or psychiatric illness. The patient had taken some over the counter medications during the year without any proper medical consultation and had reported no benefits.

On evaluation, his general physical and neurological examination was unremarkable apart from the problem mentioned above. Neurology opinion was taken, and other movement disorders are ruled out. On observing the movements, a provisional diagnosis of tic disorder was made. He was advised blood investigations, electroencephalogram, and computed tomographic (CT) scan of the head. The blood parameters were well within normal limits, and CT scan showed mild cerebral atrophy. No abnormality found on EEG. The patient was started on haloperidol (0.5 mg/day), and he reported 20% improvement within 2 months. He was also advised to do relaxation breathing exercises. The dose of haloperidol was gradually increased to 1 mg/day, and around 90% improvement (on subjective reporting) was reported on follow-up visits in 4 months. The patient was maintained well on the same dose of haloperidol, and the improvement was sustained at that level until 7 months of follow-up period.

Tic disorder is an uncommon entity in the elderly age group, especially in those with no prior history of tics. There have only been few case reports of tic disorder in the elderly. Chouinard and Ford found the response of oral medications used for the management of tic disorder to be poor in their study.[1] However, our patient responded to oral medication extremely well and the effect was sustained too. Evidence supports that adult-onset primary tics often respond poorly to treatment and have fluctuating course with male preponderance.[7] Our patient had no underlying brain or other systemic pathology that might attribute to development of tic; however, the patient had shown a significant response to oral medications. The features that make our case unique were – the tic was purely motor and the age of onset was at 59 years of age. Garg et al., in their case report, also reported complete resolution of tic symptoms with clonazepam and that patient had onset of tic symptoms at the age of 55 years.[2] It might be quite possible that primary tic disorders with late onset have good prognosis. The clinician needs to investigate for organicity in late-onset tic disorders. The absence of organicity can also be considered as a good prognostic indicator. However, it cannot be concluded on the basis of a single case report; hence, there is a need for larger studies in this particular area.

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Conflicts of interest

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