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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 146-149

Catatonia in dementia managed with electroconvulsive therapy: A case report and review of the evidence


1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-9995.221897

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  Abstract 

There is limited literature on catatonia as a presenting manifestation of dementia. Further, whenever catatonia occurs in patients with dementia, it often responds to lorazepam. There is limited literature on use of electroconvulsive therapy for management of catatonia among patients with dementia. In this report, we present a case of catatonia occurring during dementia of Lewy body which did not respond to lorazepam but responded to use of electroconvulsive therapy.

Keywords: Catatonia, dementia, electroconvulsive therapy


How to cite this article:
Grover S, Sahoo S, Pradeep C, Srinivas B, Singh P. Catatonia in dementia managed with electroconvulsive therapy: A case report and review of the evidence. J Geriatr Ment Health 2017;4:146-9

How to cite this URL:
Grover S, Sahoo S, Pradeep C, Srinivas B, Singh P. Catatonia in dementia managed with electroconvulsive therapy: A case report and review of the evidence. J Geriatr Ment Health [serial online] 2017 [cited 2019 Jun 16];4:146-9. Available from: http://www.jgmh.org/text.asp?2017/4/2/146/221897




  Introduction Top


Catatonia in dementia is rare but not uncommon. Catatonia occurring as part of clinical picture of dementia has been reported with almost all types of dementia, i.e., Alzheimer's dementia,[1],[2] dementia of Lewy body (DLB),[3],[4],[5],[6],[7],[8] frontotemporal dementia,[9],[10],[11],[12],[13] and dementia due to any general medical condition (AIDS, stroke, etc.).[14] In most of these reports, authors have managed catatonia either with lorazepam [1],[9],[10],[11],[15],[16] or antipsychotic medications such as quetiapine.[2],[4],[5],[17] However, there are only occasional reports of use of electroconvulsive therapy (ECT) for management of catatonia in patients with dementia.

In this report a case of DLB who presented with catatonia and was managed with ECT and issues faced during treatment are discussed.


  Case Report Top


Mr. A, 61-year-old, from an urban background who had no significant past psychiatric and family history, presented with catatonia of 4-month duration. Exploration of history revealed a continuous and progressive course of illness of 9 years duration (onset at the age of 52 years), initially characterized by psychotic symptoms in the form of visual hallucinations, recent memory disturbances, aggression, disinhibition, decreased sleep, and reduced work performance. After few months of onset of these symptoms, he was started on antipsychotic medications, with which the symptoms of suspiciousness, visual hallucinations, and sleep improved. However, symptoms suggestive of memory disturbances remained the same. In the subsequent years, even while on medications, patient again had relapse of psychotic symptoms along with progression of psychotic and behavioral symptoms. He was treated with antipsychotic medications from multiple doctors with no improvement in his symptoms. He developed extrapyramidal symptoms in the form of tremors, rigidity, slowness, and hypersalivation with low doses of various antipsychotic medications, which would subside whenever antipsychotic medications would be discontinued. Over the years, his symptoms progressed further and in addition to psychotic symptoms, he developed apathy, incontinence, and his forgetfulness increased. He started having difficulties in performing activities of daily living such as brushing, eating, and dressing and had to be assisted by family members. One year prior to presentation, in addition to above-mentioned symptoms, he started to walk with a stooped posture and had reduced arm swings, frequent falls, and difficulty during turning while not on any antipsychotic medications. He continued in this manner till 4 months prior to presentation. After this, he became bedridden, would refuse feeds and resist to be fed, developed stiffness of the body, would refuse being lifted, had urinary and fecal incontinence, became almost mute or would have echolalia for few minutes, had posturing, and weight loss. Due to all these problems, he was brought to neurology outpatient department and was initially admitted under the neurology services. A psychiatric consultation was sought for the patient while in neurology inpatient setting. Initial general physical examination revealed evidence of malnutrition (body weight of 32 kg) with no abnormalities in cardiovascular and respiratory systems and abdominal examination. There was no history of fever and any kind of skin rash. Mental state examination showed evidence of mutism, negativism, rigidity, staring, posturing, gegenhalten, lability of affect, and catalepsy with a Bush Francis Catatonia rating score of 18. Mini-mental state examination was not possible. Investigations in the form of hemogram, liver function test, renal function test, serum electrolytes, serum B12 levels, serum folic acid level, electrocardiogram, X-ray chest posterior-anterior view, and ultrasound abdomen did not reveal any abnormality. His electroencephalogram (EEG) showed slow-wave activity and magnetic resonance imaging of the brain revealed gross cerebral atrophy of the brain. He was managed with nutritional supplements for next 2 weeks with no improvement. Adequate and essential nursing care was provided with periodic monitoring of vitals and regular dressing of pressure ulcers. Ryle's tube feeding and urinary catheterization were done. Due to nonresolution of catatonia, he was transferred to our psychiatry ward for further management. A diagnosis of possible DLB with catatonia was kept, and lorazepam challenge test was tried, but the patient did not respond to lorazepam. Hence, it was decided to administer ECT after proper informed consent from his family members. Eight sessions of effective modified ECTs were administered with which there significant improvement in catatonia with each ECT and Bush-Francis Catatonia Rating Scale (BFCRS) score was reduced from 18 to 6. After 6 effective ECTs, he began to eat by himself when offered and respond to verbal commands. However, there was no further improvement in residual catatonic signs and symptoms of mutism, staring, and occasional posturing. He was started on tablet donepezil 5 mg/day and tablet quetiapine 25 mg/day. Family members were psychoeducated about the illness, and supportive sessions were taken to address the issues of burnout in the caregivers. The patient was discharged in an improved state after an inpatient stay of 5 weeks. Over the period of next 2 months, his mutism also improved and he continues to follow up (10 months) with no recurrence of catatonic symptoms.


  Discussion Top


Diagnostic criteria for DLB have been laid down by the consortium on DLB.[18] According to this, the symptoms of DLB can be categorized as central features, core features, suggestive features, and supportive features. Based on the number of these features, DLB can be considered possible or probable diagnosis. The central features (mostly present for possible or probable diagnosis of DLB) include progressive cognitive decline of sufficient amount to interfere with normal social or occupational functioning, in the form of experiences of prominent or persistent memory disturbances which may not necessarily occur during the early stages, but become evident with the progression of disease, exhibits deficits on tests of attention, executive function, and visuospatial ability may be especially prominent. The core features (2 core features are needed for probable DLB, 1 for possible DLB) which are used to define DLB include fluctuating cognition, recurrent visual hallucination, and spontaneous features of  Parkinsonism More Details. The features which are considered to be suggestive of DLB include rapid eye movement sleep behavior disorder, severe neuroleptic sensitivity, and low dopamine transporter uptake in basal ganglia demonstrated by single-photon emission computed tomography or positron emission tomography imaging. Suggestive features are used for the diagnosis in the presence of 1 or more core features of DLB. In addition, certain supportive features for DLB include frequent falls/syncope, unexplained loss of consciousness, autonomic dysfunction, nonvisual hallucinations, systematic delusions, depression, preservation of medical temporal lobes on imaging, low uptake meta-iodo-benzyl-guanidine in myocardial scintigraphy, and slow-wave activity on EEG with transient sharp waves in temporal lobe.[18] Index case exhibited central features, 2 core features, and some of the suggestive features (neuroleptic sensitivity). In addition, the patient did not exhibit any of the first rank symptoms, bizarre delusions, and the cognitive impairments were severe enough to impair his activities of daily living. In view of the presence of definite evidence for DLB and lack of enough evidence for late onset schizophrenia, a diagnosis of DLB was considered.

Catatonia as a clinical manifestation of dementia is less often described. PubMed searches using the terms “dementia” and “catatonia,” retrieved only 18 case reports/series and these have been documented in [Table 1]. An important thing to note is that in majority of cases, the duration of catatonia was too long ranging from weeks to year which suggests that recognition of catatonia in elderly patients is many a time missed out, and it happens more frequently if the patient has dementia of any subtype. Almost all of these patients had similar catatonic signs and symptoms. The common symptoms across many of these case reports included presence of mutism, negativism, rigidity, and immobility. Index case also had similar clinical picture. Hence, it can be said that whenever patients with dementia developed these symptoms, catatonia should strongly be suspected and treated so as to improve the quality of life of such patients. Existing literature also suggests that most of the cases of catatonia occurring in the background of dementia do not have comorbid psychiatric and physical illnesses. The same was true for the index case too. Majority of the cases reported in the literature responded well to lorazepam [1],[9],[10],[11],[15],[16],[20] and in few cases, other medications such as quetiapine,[2],[4],[5],[12],[17] amantadine,[12],[17] and memantine [9],[12],[17] led to resolution of catatonia. ECT has also been used for management of catatonia in patients with dementia in few cases [12],[13],[17],[21],[22] who did not respond to initial lorazepam trial. It is well known that around 70% of catatonia patients respond very well to lorazepam while lorazepam refractory cases respond usually to ECT.[23] However, index case did not respond to lorazepam.
Table 1: Catatonia in dementia

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Despite the debatable issue of ECT's likelihood of causing cognitive deficits, there are a few retrospective reviews and case reports which have demonstrated ECT as a safe and effective strategy for treating comorbid depression,[24],[25] mania,[26] and difficult unmanageable behavioral problems such as severe agitation and aggression in patients with dementia,[19],[27],[28] without causing any additional cognitive deficits or worsening existing cognitive deficits. In a review of clinical experience of administration of ECT in 135 patients with dementia, it was found that only 21% experienced significant cognitive or memory side effects, virtually all of which were transient and reversible.[25] Use of ECT in the index case did not worsen his existing cognitive deficits rather led to improvement in his quality of life. Hence, whenever a clinician encounters a patient with dementia with any comorbid condition which requires the administration of ECT, then he should weigh the risk and benefit carefully and ECT should not be withheld in such patients just because of being diagnosed with dementia as ECT can improve the quality of life and reduce caregiver's burden to a great extent in certain situations.

The index case and existing literature suggest that catatonia may be seen as a clinical manifestation of dementia per se. Further, this case highlights the fact that ECT can be safely given in patients of dementia with necessary precautions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alisky JM. Is the immobility of advanced dementia a form of lorazepam-responsive catatonia? Am J Alzheimers Dis Other Demen 2004;19:213-4.  Back to cited text no. 1
[PUBMED]    
2.
Kendurkar A. Catatonia in an Alzheimer's dementia patient. Psychogeriatrics 2008;8:42-4.  Back to cited text no. 2
    
3.
Arahata H, Ohyagi Y, Matsumoto S, Furuya H, Murai H, Kuwabara Y, et al. A patient with probable dementia with Lewy bodies, who showed improvement of dementia and parkinsonism by the administratim of donepezil. Rinsho Shinkeigaku 2001;41:402-6.  Back to cited text no. 3
[PUBMED]    
4.
Fekete R. Renal failure in dementia with lewy bodies presenting as catatonia. Case Rep Neurol 2013;5:10-3.  Back to cited text no. 4
[PUBMED]    
5.
Xiong GL, Palomino A, Kahn DR, Bourgeois JA. Antipsychotic induced catatonia: A case of probable dementia with Lewy bodies. J Neuropsychiatry Clin Neurosci 2009;21:472-3.  Back to cited text no. 5
[PUBMED]    
6.
Lakshmana R, Sundram S, Cairns F. Dementia with Lewy bodies (DLB) presenting with catatonic symptoms. Psychogeriatrics 2006;6:31-4.  Back to cited text no. 6
    
7.
Morita S, Miwa H, Kondo T. A patient with probable dementia with Lewy bodies, who showed catatonia induced by donepezil: A case report. No To Shinkei 2004;56:881-4.  Back to cited text no. 7
[PUBMED]    
8.
Ueda S, Koyama K, Kocha H, Okubo Y. Dementia with Lewy bodies (DLB) accompanied by symptoms of late catatonia: What to consider and how to treat. Seishin Shinkeigaku Zasshi 2011;113:144-56.  Back to cited text no. 8
[PUBMED]    
9.
Utumi Y, Iseki E, Arai H. Three patients with mood disorders showing catatonia and frontotemporal lobes atrophy. Psychogeriatrics 2013;13:254-9.  Back to cited text no. 9
[PUBMED]    
10.
Jaimes-Albornoz W, Ballesteros-Prado A, Serra-Mestres J. Catatonia in patients with frontotemporal dementia. Eur Psychiatry 2015;30:1436.  Back to cited text no. 10
    
11.
Ducharme S, Dickerson BC, Larvie M, Price BH. Differentiating frontotemporal dementia from catatonia: A complex neuropsychiatric challenge. J Neuropsychiatry Clin Neurosci 2015;27:e174-6.  Back to cited text no. 11
[PUBMED]    
12.
Sheikhi L, Li Y, Jimenez XF. A case of familial frontotemporal dementia presenting with malignant catatonia. Neurol Clin Pract 2015;5:521-3.  Back to cited text no. 12
    
13.
Holm AC. Neurodegenerative and psychiatric overlap in frontotemporal lobar degeneration: A case of familial frontotemporal dementia presenting with catatonia. Int Psychogeriatr 2014;26:345-7.  Back to cited text no. 13
[PUBMED]    
14.
Takata DT, Takaoka K, Fujigaki M. Catatonia in the elderly. Int J Psychiatry Clin Pract 2005;9:230-7.  Back to cited text no. 14
    
15.
Alisky JM. Lorazepam-reversible catatonia in the elderly can mimic dementia, coma and stroke. Age Ageing 2007;36:229.  Back to cited text no. 15
    
16.
Eisenstock J. On catatonia and dementia: A case report. Neurol Bull 2010;2:12-6.  Back to cited text no. 16
    
17.
Lauterbach EC, Kuppuswamy PS, Greenway LL. Differential pharmacological responses of catatonia-like signs in frontotemporal dementia. Neurocase 2010;16:436-50.  Back to cited text no. 17
[PUBMED]    
18.
McKeith IG, Dickson DW, Lowe J, Emre M, O'Brien JT, Feldman H, et al. Diagnosis and management of dementia with Lewy bodies: Third report of the DLB Consortium. Neurology 2005;65:1863-72.  Back to cited text no. 18
    
19.
Grant JE, Mohan SN. Treatment of agitation and aggression in four demented patients using ECT. J ECT 2001;17:205-9.  Back to cited text no. 19
[PUBMED]    
20.
Maeda K, Ogawa N. Amitriptyline and lorazepam improved catatonia and occipital hypoperfusion in a patient with DLB. Intern Med 2011;50:363-6.  Back to cited text no. 20
[PUBMED]    
21.
Suzuki K, Takano T, Matsuoka H. A case of catatonia resembling frontotemporal dementia and resolved with electroconvulsive therapy. World J Biol Psychiatry 2009;10:245-7.  Back to cited text no. 21
[PUBMED]    
22.
Rodríguez-Sosa JT, Suárez-Lovelle A, Navarrete-Betancort E, González-Hernández A. Electroconvusive therapy in dementia. Actas Esp Psiquiatr 2013;41:204-7.  Back to cited text no. 22
    
23.
Koek RJ, Mervis JR. Treatment-refractory catatonia, ECT, and parenteral lorazepam. Am J Psychiatry 1999;156:160-1.  Back to cited text no. 23
[PUBMED]    
24.
Weintraub D, Lippmann SB. ECT for major depression and mania with advanced dementia. J ECT 2001;17:65-7.  Back to cited text no. 24
[PUBMED]    
25.
Price TR, McAllister TW. Safety and efficacy of ECT in depressed patients with dementia: A review of clinical experience. Convuls Ther 1989;5:61-74.  Back to cited text no. 25
[PUBMED]    
26.
McDonald WM, Thompson TR. Treatment of mania in dementia with electroconvulsive therapy. Psychopharmacol Bull 2001;35:72-82.  Back to cited text no. 26
[PUBMED]    
27.
Carlyle W, Killick L, Ancill R. ECT: An effective treatment in the screaming demented patient. J Am Geriatr Soc 1991;39:637.  Back to cited text no. 27
    
28.
Roccaforte WH, Wengel SP, Burke WJ. ECT for screaming in dementia. Am J Geriatr Psychiatry 2000;8:177.  Back to cited text no. 28
    



 
 
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