Catatonia in older adults: A systematic review

Table 1 Catatonia in a United Kingdom acute psychogeriatric ward

Abstract
Aims	To determine the frequency and characteristics of catatonia in older people in a psychogeriatric ward
Methods	All patients admitted were screened for catatonia with the Bush-Francis Catatonia Screening Instrument over a period of 6 mo. Data was collected on sociodemographics, past medical/psychiatric/drug history, clinical findings, treatment, complications/outcome, and investigations. Treatment with lorazepam orally or intramuscularly was initiated in patients who fulfilled diagnostic criteria for catatonia
Results	37 patients were admitted. Prevalence of catatonia was 27%, 10 out of 37 (Bush-Francis criteria) and 24.3%, 9 out of 37 (DSM-5 criteria). The 10 catatonic patients have a mean age of 75.8 years; range: 67-87; and 8 were female. 90% of these patients had a cardiovascular risk factors. The etiology was multifactorial in 50% of the cases. 6 patients had dementia. In 3 of them catatonia was associated with the use of neuroleptics, in 1 with neuroleptics and a urinary infection (she also had delirium), in another with major depression and in only one dementia was a possible etiology. 40% of the cases developed catatonia secondary to affective disorders and 10% to schizophrenia spectrum disorder. In the total sample there were 14 patients with dementia. The catatonia rate in these patients was 42.8% (6 of 14). 9 patients received treatment for catatonia with lorazepam, all of which achieved complete remission, 1 of the these was also treated with clonazepam. 1 patient was treated with sodium valproate and achieved a partial response. 3 patients developed complications secondary to catatonia. One had an elevated creatine kinase of 1083 IU/L, another a deep venous thrombosis, and the last one, hypokalemia
Conclusions	Catatonia is a very prevalent entity in the psychogeriatric ward. The etiology is usually multifactorial. This condition occurred frequently in patients admitted with dementia. Treatment with lorazepam is highly effective and safe

DSM-5: Diagnostic and Statistical Manual - Fifth Edition.

Table 2 History, antipsychotic exposure and current diagnoses in patients with catatonia in United Kingdom acute psychogeriatric ward

Age/sex	Medical history	Psychiatric history	Current acute medical diagnosis/antipsychotic exposure	Current acute psychiatric diagnosis
67/F	Bowel obstruction resulting in perforation	Bipolar disorder	None	Bipolar disorder, current episode depressive severe without psychotic symptoms
87/M	Hypertension; Hyperlipidemia; Lip carcinoma	Alzheimer's disease	None/(risperidone, quetiapine)	Late onset Alzheimer's disease
76/F	Hypertension; DM2; Hyperlipidemia	Vascular dementia	None/quetiapine	Vascular dementia
75/F	Ischemic heart disease; Irritable bowel syndrome; Hypothyroidism; Pulmonary fibrosis; Diveticulitis	RDD; Health anxiety; Dementia	None	Late onset Alzheimer's disease; RDD, current episode severe without psychotic symptoms
71/F	Hyperlipidemia; Atrial fibrillation; Repeated urinary tract infections; Diverticulitis	RDD; Alcohol misuse; Alzheimer’s disease	Urinary tract infection/(aripiprazole, olanzapine)	Young onset Alzheimer’s disease; Delirium superimposed on dementia
70/F	Hypertension; Osteoarthritis	RDD	None	RDD, current episode severe with psychotic symptoms
74/F	Parkinson’s disease; Glaucoma; Obesity	Schizoaffective disorder	None	Schizoaffective disorder not otherwise specified
68/F	Hyperlipidemia	Young onset Alzheimer’s disease	None/none	Young onset Alzheimer’s disease
85/M	Hypertension; DM2; Jaw osteomyelitis; Isquemic heart disease; Pacemaker	Mixed dementia	None/risperidone	Mixed dementia
85/F	Hypertension; Atrial fibrillation; Breast cancer	Depression	None	Severe depressive episode without psychotic symptoms

RDD: Recurrent depressive disorder; DM2: Type 2 diabetes mellitus.

Table 3 Catatonia signs frequency using Bush Francis Catatonia Rating Scale in older people

Catatonia signs	Country, clinical setting, (n: Patients)					Total (n = 79)	%
	Spain[5] CLS, (n: 10)	Australia[10] CLS, (n: 6)	United Kingdom[7] PW, (n: 10)	Hungary[11] APW, (n: 11)	Spain[12] PW, (n: 42)
Inmobility/stupor	10	5	7	7	24	53	67.1
Staring	10	3	7	7	22	49	62.0
Mutism	8	2	7	4	18	39	49.5
Negativism	7	3	4	0	25	39	49.5
Withdrawal	8	3	4	3	18	36	45.6
Rigidity	9	4	6	2	15	36	45.6
Excitement	0	0	3	3	27	33	41.8
Posturing	7	4	5	6	8	30	37.9
Verbigeration	1	1	2	0	26	30	37.9
Perseveration	1	0	3	2	20	20	33.0
Stereotipies	4	1	4	2	15	26	33.0
Autonomic abnormalities	1	1	3	1	16	16	27.8
Impulsivity	1	0	2	1	15	19	24.0
Automatic obedience	1	1	3	1	16	22	21.5
Combativeness	2	0	4	0	14	20	20.4
Ecophenomena	6	1	2	0	5	14	17.7
Ambitendency	0	1	2	2	8	13	16.5
Grasp reflex	0	1	1	2	9	13	16.5
Grimacing	3	1	0	0	8	12	15.3
Mitgehen	3	0	0	5	1	9	11.4
Gegenhalten	3	0	3	2	0	8	10.2
Waxi flexibility	2	0	4	0	0	6	7.6
Mannerism	0	0	0	0	4	4	5.1

APW: Acute psychiatric ward; CLS: Consultation-Liaison service; PW: Psychogeriatric ward.

Table 4 Catatonia etiology in older people

Psychiatric disorders	General medical conditions	Drugs and toxic substances
Schizophrenia spectrum disorders: Schizophrenia; Schizoaffective disorder; Brief psychotic disorder; Psychosis not otherwise specified. Affective disorders: Major depressive disorder; Bipolar disorder. Others psychiatric disorders: Post-traumatic stress disorder; Conversive disorder; Adjustment disorder; Substance use disorder	Neurologic: Dementia: Alzheimer´s dementia; Frontotemporal dementia; Lewy bodies dementia; Mixed dementia; Organic dementia; Dementia not otherwise specified. Epilepsy. Cerebrovascular disease; Parkinson´s disease. Others: Cerebral anoxia; Creutzfeldt-Jakob’s disease; Epidural empyema; Frontotemporal lobes atrophy; Cerebral Whipple’s disease; Progressive supranuclear palsy. Metabolic: Acute renal failure; Heart failure; Liver failure; Post liver transplantation; Dehydration; Hyponatremia; Hypernatremia. Infectious: Urinary tract infection; Pneumonia; COVID-19. Endocrine: Hyperparathyroidism; Hypothyroidism; Hyperthyroidism. Others: Cyanocobalamin deficiency; Colon tumor	Drugs: Regular use: Antipsychotics: Haloperidol; Droperidol; Loxapine; Pipotiazine; Trifluoperazine; Tiapride; Aripiprazole; Risperidone; Quetiapine. Other drugs: Phenelzine; Allopurinol; Prednisone; Rivastigmine; Donepezil; Azithromycin; Cefepime; Amiodarone; Tacrolimus; Methotrexate; Imiquimod. Withdrawal: Benzodiazepines: Nitrazepam, diazepam, alprazolam, oxazepam, temazepam, clonazepam, chlordiazepoxide and lorazepam. Antipsychotics: Clozapine, olanzapine, risperidone, chlorpromazine, levomepromazine, bromperidol, haloperidol and cyamemazine. Others: Amantadine, lithium, gabapentine. Toxic substances: Manganese

COVID-19: Coronavirus disease 2019.

Table 5 Catatonia treatments used in older people

1º line	2º line	3º line
Benzodiazepines: Lorazepam; Diazepam; Midazolam; Alprazolam; Oxazepam; Flunitrazepam; Temazepam	Electroconvulsive therapy: Bifrontotemporal ECT; Right unilateral ECT; Acute ECT; Continuation ECT; Maintenance ECT	Drugs: Amantadine; Biperiden; Bupropion (as continuation treatment); Bromocriptine; Carbamazepine; Dopamine; Lithium; Memantine; Methylphenidate; Olanzapine; Propofol; Topiramate; Tramadol; Valproate; Zolpidem. Neuromodulation treatments: Repetitive Transcranial Magnetic Stimulation; Transcranial Direct Current Stimulation

ECT: Electroconvulsive therapy.