Dementia With A Twist

Transcription

1 Dementia With A Twist Christina Tieu Geriatric Update for the Primary Care Provider November 17 th, MFMER slide-1

2 79 y/o woman originally from Greece CC: paranoia, abulia and mutism Accompanied by daughter and grandson Onset: 8 months ago Progressively worsening symptoms Previously normal, robust Living alone in her own home in Indiana No need for assistance with ADLs 2016 MFMER slide-2

3 79 y/o woman with paranoia, abulia and mutism Abrupt lightheadedness, confusion and disorientation February 16 th, 2016 No inciting events Paranoid delusions of the television recording her Physical aggression towards family members MFMER slide-3

4 Increasingly hypo-verbal and ultimately mute Abulia Rapidly decreasing oral intake felt secondary to poor volition 2016 MFMER slide-4

5 PMH: Hypertension Diabetes mellitus Type 2, last HbA1C 7.2% Hyperlipidemia No prior psychiatric history Medications: Fenofibrate Ezetimibe Linagliptin Lisinopril Cyanocobalamin Vitamin D 2016 MFMER slide-5

6 Family History: Negative for psychiatric, neurologic or autoimmune conditions Social History: No prior tobacco, EtOH or drug use 2016 MFMER slide-6

7 Physical Exam: Alert, cooperative, nonverbal No evidence of hallucinations Questionable masked facies Able to follow one-step commands CN exam normal Bradykinetic, but essentially normal gait No weakness. Rigidity present in bilateral upper extremities. Reflexes normal with bilateral flexor toe responses MFMER slide-7

8 Evaluation CT-A, MRI head, EEG, and extensive laboratory testing including paraneoplastic panel negative PET MRI : patchy bilateral cortical hypometabolism notable in anterior frontal and temporal lobes Depression or frontotemporal dementia? Venlafaxine x 5 weeks without improvement Risperidone aggravated sx paradoxical effect Olanzapine without improvement 2016 MFMER slide-8

9 Evaluation Autoimmune panel: borderline positive rheumatoid factor and ANA Follow up autoantibody panel negative. Empiric course of IV steroids No improvement Low Vitamin B12 Supplemented without improvement 2016 MFMER slide-9

10 Psychiatric Evaluation Physical examination: Essentially mute, use of one word phrases with repetition Indecisiveness with yes/no questions Staring, wooden facial expressions Waxy flexibility Diagnosis: Catatonia 2016 MFMER slide-10

11 Definition of Catatonia DSM V: specifier of other conditions: 1. Catatonia due to general medical condition 2. Schizophrenia with catatonia 3. Major depression with catatonia Bipolar disorder with catatonia 4. Catatonic disorder NOS 2016 MFMER slide-11

12 Diagnosis Requires 3 or more of the following waxy flexibility Tandon et al. Catatonia in DSM-5 Schizophrenia Research Wilson et al. The diagnostic criteria and structure of catatonia Schizophrenia Research MFMER slide-12

13 Not a Zebra Prevalence in 65+ y/o inpatient referrals: 5-9% 35% had no prior psychiatric history 92% had vascular risk factor(s) Common sx: Staring Immobility Withdrawal Mutism Kaelle et al. Prevalence and symptomatology of catatonia in elderly patients referred to a consultation-liaison psychiatry service. Australian Psychiatry MFMER slide-13

14 Treatment Avoid antipsychotics! Psychiatry referral Benzodiazepine challenge I mg IV lorazepam Up to 5 mg per day +/- maintenance therapy 2016 MFMER slide-14

15 Treatment Electroconvulsive Therapy 6-10 treatments Efficacy: 80 - ~100% in catatonia Indications: major depression, bipolar, schizophrenia, refractory PD No absolute contraindications Safer in the elderly? Effect on cognition? Luchini et al. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response World J. Psychiatry Kerner et al. Current electroconvulsive therapy practice and research in the geriatric population Neuropsychiatry MFMER slide-15

16 Post-ECT course After 2 treatments speaking in short sentences; more interactive with family and staff. After 4 treatments returned to her pre-morbid baseline, was capable of conversing, eating well, and wished to return home to her regular activities MFMER slide-16

17 Case Resolution Greek MoCA: 11/30 persistent neurocognitive disorder Dx: Probable frontotemporal dementia with catatonia Psychosis Hypometabolism of frontotemporal regions PT/OT evaluation: requires 24 hour supervision. Dismissed to home with family providing supervision 2016 MFMER slide-17

18 Catatonia and Frontotemporal Dementia Frontalstriatal dysfunction mutism, verbigeration aphasia Catatonia Waxing and waning Responds to treatment FTD Progressive decline 2016 MFMER slide-18

19 Clinical Pearls Catatonia is more common than we realize so look for it! Common symptoms in the elderly are staring, immobility, mutism and withdrawal Highly responsive to treatment High impact on function and avoidance of institutionalization 2016 MFMER slide-19

20 MFMER slide-20