8. TO GIVE OR NOT TO GIVE (LORAZEPAM): A CASE REPORT OF CATATONIA MASQUERADING AS DELIRIUM IN A GERIATRIC PATIENT

Introduction

Catatonia is a complex clinical syndrome defined by a variety of motor and behavioral symptoms. Given the heterogeneity and non-specificity of its symptoms, catatonia is often confused with other psychiatric conditions, such as delirium and apathy. Few guidelines exist in the literature for differential treatment approaches for older adults who may manifest with unclear diagnoses. Here we describe a single-case example of catatonia, the process of diagnostic clarification and treatment, and a review of the relevant literature with the aim of demonstrating the importance of accurate catatonia diagnosis and treatment in the geriatric population.

Methods

We present a case of a 73-year-old woman with a past psychiatric history of Major Depressive Disorder, Alcohol Use Disorder in sustained remission, history of Wernicke Encephalopathy 3 years prior, and a history of ischemic stroke who presented with new onset disorientation in the setting of decreasing oral intake and ongoing auditory hallucinations. The initial working diagnosis was delirium, but further examinations and lorazepam trial revealed a diagnosis of catatonia. We review the literature on catatonia in geriatric patients, with an emphasis on differentiating catatonia from delirium in complex patients who are at risk for both.

Results

Catatonia is common in older adults in acute psychiatry inpatient and consult-liaison settings, with an estimated prevalence of 5.5-39.6%. The most common catatonic symptoms seen in this population include immobility/stupor, staring, and mutism. Accurate diagnosis and treatment are vital, as catatonia can have serious medical consequences in older adults, such as skin breakdown, urinary tract infections, dehydration, DVTs, or even death. Treatment recommendations in older adults are consistent with those in younger adults, with a benzodiazepine trial as first line and ECT indicated as second line. However, presenting clinical features are often complex, may evolve, and can be confused with delirium. In our case, the patient presented as withdrawn, with psychomotor slowing and paucity of speech suggestive of hypoactive delirium and was initially maintained on neuroleptics. While awaiting lab results, she developed mutism, rigidity, and stereotypies, which is aligned with the reports in the literature of common catatonic symptoms seen in the geriatric population. This patient responded well to a lorazepam trial, consistent with current treatment recommendations for catatonia in older adults, and neuroleptics were discontinued. An important consideration remains whether her history of alcohol use disorder in sustained remission increased her risk for catatonia. There is a notable paucity of literature on the contribution of alcohol use history to the development of catatonia in older adults.

Conclusions

Our case demonstrates that catatonia can present similarly to delirium in older adults, highlighting the phenotypic overlap between hypokinetic catatonia and hypoactive delirium. It is aligned with the current evidence that catatonia is common yet potentially challenging to diagnose in older adults, while the standard treatments remain effective. Future work targeted at aiding clinicians in diagnostic tools to differentiate delirium and catatonia in older adults would be vital to improving psychiatric care in this population. Of particular importance demonstrated by this case is the potential role of remote alcohol use as a risk factor for catatonia, which warrants further research. Downstream, as our ability to quantify individual phenotypes becomes more precise, reports such as ours will provide a framework to guide clinical precision in similarly complex cases of geriatric psychiatry patients.