Treatment of catatonia with intravenous biperidene

Catatonia in older adults: A systematic review

BACKGROUND

Catatonia is a complex psychomotor syndrome that often goes unrecognized and untreated, even though its classification has evolved in recent years. Prompt and correct identification of catatonia allows for highly effective treatment and prevention of possible complications. The underrecognition of catatonia in older patients is also frequent, and research in this population is scarce.

AIM

To conduct a systematic review of the literature on catatonia in older people to ascertain its clinical characteristics across settings.

METHODS

Following the PRISMA guidelines, MEDLINE, EMBASE, and PsycINFO databases were searched from inception to December 2021, with a strategy aimed at identifying all articles published on catatonia in older adults. Titles and abstracts were scanned and selected independently by two authors. Papers investigating issues related to catatonia and/or catatonic symptoms in older people, with English abstracts available, were included. References of selected articles were revised to identify other relevant studies.

RESULTS

In total, 1355 articles were retrieved. After removing duplicates, 879 remained. Of the 879 identified abstracts, 669 were excluded because they did not meet the inclusion criteria. A total of 210 articles underwent full text review, and 51 were eliminated for various reasons. Fourteen more articles were selected from the references. Overall, 173 articles were reviewed: 108 case reports, 35 case series, 11 prospective cohort studies, 6 case-control studies, 3 retrospective cohort studies and 10 reviews. We found several particular aspects of catatonia in this population. Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. Older patients, compared to younger patients, have a higher risk of developing catatonia with benzodiazepine (BZD) withdrawal, in bipolar disorder, and in the general hospital. Age, together with other risk factors, was significantly associated with the incidence of deep venous thrombosis, neuroleptic malignant syndrome poor outcome, other complications and mortality. Treatment with BZDs and electroconvulsive therapy is safe and effective. Prompt treatment of its cause is essential to ensure a good prognosis.

CONCLUSION

Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. The risk of developing catatonia in some settings and conditions, as well as of developing complications, is high in this population. Symptomatic treatment is safe and effective, and timely etiologic treatment is fundamental.

[Antipsychotic-induced motor symptoms in schizophrenic psychoses-Part 2 : Catatonic symptoms and neuroleptic malignant syndrome]

In rare cases, pharmacotherapy in schizophrenic psychoses can be associated with life-threatening antipsychotic-induced movement disorders. The two most severe complications are antipsychotic-associated catatonic symptoms (ACS) and neuroleptic malignant syndrome (NMS). Although both constellations necessitate rapid medical care, the diagnosis is still a clinical challenge. Although there is no established treatment of ACS (here designated as a specific subtype of catatonic symptoms), an attempt should be made with benzodiazepines and memantine can also be helpful. In severe drug-refractory cases electroconvulsive therapy (ECT) can be indicated. The NMS represents a life-threatening constellation that frequently requires intensive care unit treatment. The medicinal treatment with benzodiazepines, bromocriptine, amantadine, dantrolene and/or ECT is also advocated. Finally, this review article also summarizes the currently available literature for treatment of genuine catatonic symptoms. In conclusion, the abovementioned clinical syndromes must be rapidly recognized and treated. Early recognition and treatment of these movement disorders can under certain circumstances be lifesaving and favorably influence the later clinical outcome.

Electroconvulsive Therapy for Catatonia in Children and Adolescents

Catatonia may be more common in children and adolescents than previously thought. A boost for the recognition of pediatric catatonia comes from changes in Diagnostic and Statistical Manual of Mental Disorders, 5th edition, facilitating the diagnosis in a wide range of pediatric and adult patients with associated developmental and autistic spectrum disorders; and schizophrenic, affective, and medical disorders. The current status, assessment, and treatment of pediatric catatonia are described. Two case vignettes illustrate diagnostic assessment and treatment. Theories modeling the mechanism of catatonia are reviewed, including a vagal theory.

Pediatric catatonia: review & new vagal theory

Recent studies support that catatonia may be more common in children and adolescents than previously thought. A boost for the recognition of pediatric catatonia comes from changes in DSM-5 accommodating the diagnosis of catatonia in a wider range of disorders, including developmental and autistic spectrum disorders in addition to schizophrenic, affective, and medical disorders including autoimmune conditions such as lupus or anti-N-methyl-D-aspartic acid receptor encephalitis. The current status of pediatric catatonia, its assessment and treatment are described. Theories modeling the mechanism of catatonia are reviewed, including a vagal theory implicating the immobilization reflex mediated by the vagal nerve.

A clinical review of the treatment of catatonia

Catatonia is a severe motor syndrome with an estimated prevalence among psychiatric inpatients of about 10%. At times, it is life-threatening especially in its malignant form when complicated by fever and autonomic disturbances. Catatonia can accompany many different psychiatric illnesses and somatic diseases. In order to recognize the catatonic syndrome, apart from thorough and repeated observation, a clinical examination is needed. A screening instrument, such as the Bush-Francis Catatonia Rating Scale, can guide the clinician through the neuropsychiatric examination. Although severe and life-threatening, catatonia has a good prognosis. Research on the treatment of catatonia is scarce, but there is overwhelming clinical evidence of the efficacy of benzodiazepines, such as lorazepam, and electroconvulsive therapy.

Differential pharmacological responses of catatonia-like signs in frontotemporal dementia

Sequential therapeutic trials for catatonoid frontal signs in clinically-evident frontotemporal dementia (n = 2) revealed differential benefits for lorazepam, amantadine, memantine, pramipexole, aripiprazole, quetiapine, citalopram, and donepezil, although certain signs also worsened. Citalopram and donepezil were poorly tolerated. Ramelteon was without effect. While memantine appeared to improve cognition in case 1, this remains to be established by more reliable neuropsychological testing. Parkinsonism (case 2) responded to pramipexole, but not amantadine or levodopa. Possible relationships of catatonoid signs requiring future confirmation include insufficient GABA-A (multiple signs) and D2 (mutism) and excessive NMDA (immobility, rigidity), D2/D3 (mannerisms, verbal perseveration), and 5HT1a (staring) receptor stimulation. Low-dose lorazepam and quetiapine required close monitoring.

The catatonia conundrum: evidence of psychomotor phenomena as a symptom dimension in psychotic disorders

To provide a rational basis for reconceptualizing catatonia in Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), we briefly review historical sources, the psychopathology of catatonia, and the relevance of catatonic schizophrenia in contemporary practice and research. In contrast to Kahlbaum, Kraepelin and others (Jaspers, Kleist, and Schneider) recognized the prevalence of motor symptoms in diverse psychiatric disorders but concluded that the unique pattern and persistence of certain psychomotor phenomena defined a "catatonic" subtype of schizophrenia, based on intensive long-term studies. The enduring controversy and confusion that ensued underscores the fact that the main problem with catatonia is not just its place in Diagnostic and Statistical Manual of Mental Disorders but rather its lack of conceptual clarity. There still are no accepted principles on what makes a symptom catatonic and no consensus on which signs and symptoms constitute a catatonic syndrome. The resulting heterogeneity is reflected in treatment studies that show that stuporous catatonia in any acute disorder responds to benzodiazepines or electroconvulsive therapy, whereas catatonia in the context of chronic schizophrenia is phenomenologically different and less responsive to either modality. Although psychomotor phenomena are an intrinsic feature of acute and especially chronic schizophrenia, they are insufficiently recognized in practice and research but may have significant implications for treatment outcome and neurobiological studies. While devising a separate category of catatonia as a nonspecific syndrome has heuristic value, it may be equally if not more important to re-examine the psychopathological basis for defining psychomotor symptoms as catatonic and to re-establish psychomotor phenomena as a fundamental symptom dimension or criterion for both psychotic and mood disorders.

Reduction of Parkinsonian signs in patients with Parkinson's disease by dopaminergic versus anticholinergic single-dose challenges

We investigated the effect of an anticholinergic (biperiden) and a dopamine agonist (apomorphine) on tremor, rigidity, and akinesia in patients with idiopathic Parkinson's disease. In a standardized, crossover study design 17 patients received single-dose challenges of 5 mg biperiden intravenously and a previously determined dose of apomorphine subcutaneously on 2 consecutive days. Resting (RT), postural (PT), and action tremor (AT) were assessed using spectral analysis of accelerometer data, and Unified Parkinson's Disease Rating Scale (UPDRS) scores for rigidity and akinesia were determined before and after administration of the study drug. Both single-dose challenges significantly reduced the amplitude of RT, PT, and AT, but only apomorphine significantly reduced UPDRS scores for rigidity and akinesia. In only one patient was tremor reduced by the dopamine agonist but not by the anticholinergic. We found that anticholinergic and dopaminergic agents are both effective in reducing tremor in IPD, and there was no evidence for a selective anticholinergic responsiveness of parkinsonian tremor. Akinesia and rigidity, on the other hand, were not improved by biperiden. We therefore conclude that dopaminergic substances are as effective as anticholinergics in patients with parkinsonian tremor and additionally improve other parkinsonian signs.

Somatic treatment of catatonia

OBJECTIVE

The authors reviewed the recent literature regarding the treatment of catatonia as a syndrome of multiple etiologies. Given the historical and clinical association of catatonia with schizophrenia, the authors' examined the assumption that the first-line treatment of catatonia is antipsychotic medication.

METHODS

Articles published between January 1, 1985 and December 31, 1994 were located using the Paperchase medical literature search system. Additionally, references from those identified articles were examined for possible inclusion in this review. To be included in this review, articles had to be written in English and report specific symptoms of catatonia to determine, retrospectively, if DSM-IV criteria for catatonia were met.

RESULTS

Seventy publications met inclusion criteria and reported on a total of 178 patients and included 270 separate treatment episodes. Most of the articles were case-reports, although a few case-series were identified. Multiple causes of catatonia were identified in these reports. The most commonly reported treatment for catatonia was with benzodiazepines which were effective in 70 percent of the cases, with lorazepam demonstrating the highest frequency of use and a 79 percent complete response rate. Electroconvulsive therapy (ECT) was also efficacious (85%) and was more likely to provide a positive outcome in cases of malignant catatonia. Antipsychotics demonstrated poor efficacy.

CONCLUSIONS

Catatonia is a nonspecific syndrome with multiple etiologies. Treatment of catatonia should be based on the underlying cause when it is identifiable. Lorazepam appears to offer a safe, effective first-line treatment of catatonia. ECT should be considered when rapid resolution is necessary (e.g., malignant catatonia) or when an initial lorazepam trial fails.