Journal of Geriatric Mental Health

EDITORIAL
Year
: 2022  |  Volume : 9  |  Issue : 1  |  Page : 1--3

Catatonia in the elderly: Does it require attention!


Sandeep Grover 
 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Dr. Sandeep Grover
Professor, Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India




How to cite this article:
Grover S. Catatonia in the elderly: Does it require attention!.J Geriatr Ment Health 2022;9:1-3


How to cite this URL:
Grover S. Catatonia in the elderly: Does it require attention!. J Geriatr Ment Health [serial online] 2022 [cited 2022 Dec 2 ];9:1-3
Available from: https://www.jgmh.org/text.asp?2022/9/1/1/353165


Full Text



Kahlbaum gave the concept of catatonia and considered it a distinct syndrome [1],[2] characterized by behavioral, autonomic, and psychomotor abnormalities.[3] Initially, catatonia was mainly understood as a subtype of schizophrenia. However, the concept of catatonia was gradually described in patients with affective disorders and various organic conditions. As more evidence emerged, it was accepted that catatonia is seen in different states, and the same got reflected in the International Classification of Diseases, Tenth Revision (ICD-10)[4] and the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV).[5] This was furthered by the DSM-5, which categorized catatonia as a specifier for all mental disorders, secondary to a general medical condition, and as catatonia not otherwise specified, i.e., when the catatonia is not associated with any specific etiology.[6] ICD-11 has also approached catatonia in a similar way.[7]

Catatonia has been noted across all age groups, i.e., children and adolescents, adults, and elderly.[8],[9] However, the literature on catatonia is limited to the elderly population compared to the adult population.

 Onset and Course



Available data suggest that catatonia among elderly patients mainly presents with acute onset. As with adult patients, it can be transient or long-lasting, varying from weeks, months to years.[10]

 Epidemiology of Catatonia in Elderly



In contrast to an extensive database for catatonia among the adult population, limited data are available for the prevalence of catatonia among the elderly. The studies that have assessed the epidemiology of catatonia among the elderly have focused on the acute psychiatric hospital setting, consultation–liaison psychiatry (CLP) setting, and intensive care setting.[10],[11],[12],[13],[14],[15],[16],[17] The prevalence has been influenced by the assessment instruments and the study setting.

A study evaluated the prevalence of catatonia in the acute geriatric psychiatric ward in 106 persons aged >64 years using different diagnostic criteria. The prevalence of catatonia in this study was evaluated by multiple diagnostic methods (i.e., Bush-Francis Catatonia Screening instrument [BFCSI] [presence of at least two signs and symptoms], Fink and Taylor Criteria, and DSM-5 criteria). The prevalence varied from 18% to 39.6%, with the highest prevalence reported per the BFCSI and least per the Fink and Taylor criteria, with the prevalence as per DSM-5 as 20.75%.[11] Another study that included 98 patients admitted to the acute psychiatry ward reported the prevalence of catatonia to be 6.12% and that with BFCSI as 11.22%.[12] Another small sample study involving 13 patients with dementia admitted to the acute geriatric psychiatry ward that included patients aged 68 years or older reported the prevalence of catatonia to be 42.8%, as per the BFCSI, Fink and Taylor criteria and also DSM-5 criteria.[13]

A study in a CLP setting that included 108 elderly patients aged >65 years reported the prevalence of catatonia to be 5.5% as per BFCSI.[14] Another study that included data from 112 elderly patients (age >65 years) recruited from the CLP setting reported the prevalence of catatonia to be 8.9% per the Research Diagnostic Criteria and 6.3% per the DSM-IV criteria.[15] A study that focused on the prevalence of catatonia among the mixed-age group of patients with delirium reported that catatonia was 32% as per BFCSI and 12.7% as per the DSM-5 criteria, with no significant difference in the prevalence between adult and elderly patients.[16] Only one study has evaluated the prevalence of catatonia, delirium, and coma among 378 adults and elderly admitted to the intensive care unit. This study reported that the prevalence of catatonia was 23%, that of delirium was 66%, and that of coma was 52% during the observation period.[17] However, the prevalence of catatonia and delirium was significantly higher among the elderly (age >66 years), with 38% ever having catatonia, 38% ever having catatonia and delirium, and 23% ever having catatonia and coma.[17]

 Etiology of Catatonia



In contrast to the prevalence, medical conditions have been reported to be the most common underlying etiology for catatonia among the elderly irrespective of the study setting. One study that evaluated catatonia across different diagnostic groups among patients admitted to the acute geriatric psychiatry ward patients reported the prevalence of catatonia (as per BFCSI) to be 48.6% in patients with depression, 36.8% among those with psychotic disorders, 47% among those with mania, 66.7% among those with delirium, and 58.8% among those with dementia.[11] Data from case reports and other studies have reported catatonia among the elderly to be associated with varied underlying medical illnesses.[10]

 Symptom Profile of Catatonia Among the Elderly



When one reviews the symptom profile of catatonia among the elderly, the symptom profile suggests a higher prevalence of retardation symptoms, with most studies reporting immobility/stupor and staring gaze, rigidity, mutism, withdrawal, posturing, and negativism as commonly occurring symptoms (all prevalence studies). However, an occasional study has listed excitement too among the commonly reported symptoms.[11] A review of symptom profile reported in five studies that included data of 79 patients suggests that the most common symptoms of catatonia among the elderly includes: immobility (67.1%), followed by staring (62%), mutism (49.5%), negativism (49.5%), withdrawal (45.6%), rigidity (45.6%), excitement (41.8%), posturing (37.9%), verbigeration (37.9%), perseveration (33%), stereotypy (33%), autonomic abnormalities (27.8%), impulsivity (24%), automatic obedience (21.5%), combativeness (20.4%), echophenomena (17.7%), ambitendency (16.5%), grasp reflex (16.5%), grimacing (15.3%), mitgehen (11.4%), gegenhalten (10.2%), waxy flexibility (7.6%), and mannerism (5.1%).[10]

 Outcome



Data suggests that, in general, acute onset catatonia is associated with a good outcome if identified early and managed appropriately. When the outcome is assessed as per the underlying etiology, it is suggested that catatonia associated with structural brain lesions is associated with poorer outcomes compared to metabolic causes.[10]

 Misdiagnosis and Impact of Delayed Identification



It is sometimes challenging to identify catatonia among the elderly, and it is misdiagnosed as delirium,[18],[19] psychosis,[19] stroke, coma, or irreversible dementia.[20] Further, available evidence suggests that delay in identification of catatonia among the elderly can lead to severe complications such as pulmonary embolism,[21],[22] use of physical restraint, pneumonia, mislabeling (as advanced dementia, and Do-Not-Resuscitate orders, and death),[21] and deep venous thrombosis.[15] One study focused on catatonia among the elderly in CLP setting estimated the prevalence of complications to be 40% and the mortality rate to be 20%.[15]

 Management of Catatonia Among the Elderly



Benzodiazepines are the mainstay of treatment of catatonia in adults and the same also applies to the management of catatonia among the elderly. However, it is essential to note that elderly patients may respond to lower doses.[23]

Patients who do not respond to benzodiazepine, should be considered for Electroconvulsive therapy (ECT).[10] However, some of the case reports suggest the effectiveness of methylphenidate and zolpidem. Case reports also suggest that topiramate, antipsychotics (olanzapine), memantine, bromocriptine, propofol, biperiden, bupropion, lithium, tramadol , repetitive transcranial magnetic stimulation and transcranial direct current stimulation may also be useful in the management of catatonia.[10] However, it is essential to note that some reports suggest beneficial effect, whereas, some reports do not support the beneficial effect of amantadine, valproate, or carbamazepine.[10]

 Conclusion



The available evidence suggests that catatonia is not uncommon among the elderly. In contrast to the adult population, available literature on catatonia among the elderly in terms of prevalence and symptom profile is limited. Accordingly, there is a need to expand the literature in this regard. Catatonia among the elderly is mainly related to medical conditions. However, this could be because only occasional studies have evaluated the prevalence of catatonia among the elderly in the geriatric psychiatry ward setting. This also suggests a need to expand the literature on the etiology of catatonia among the elderly. The catatonia among the elderly responds to lorazepam and ECT as in the adult population. Although many other treatments have been tried, lorazepam and ECT remain the preferred treatment modalities among the elderly. If not identified, it can be associated with various complications and mortality.

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