Abstract
Catatonia is defined as a neuropsychiatric syndrome in which striking motor signs, such as mutism, negativism, posturing, stereotypy and rigidity are present. Catatonic syndrome may be a manifestation of idiopathic psychiatric disorders, neurological diseases and toxicmetabolic conditions. Although historically associated with schizophrenia, catatonia is more common in bipolar disorder than any other psychiatric disorder [1]. Pharmacological strategies are based mainly on benzodiazepines, especially lorazepam [2]. There are also anecdotal reports of benefit of atypical antipsychotics, including clozapine, olanzapine and ziprasidone [2–4]. These reports comprise only adult patients and data from elderly subjects are lacking. Herein we report on a case of an old bipolar patient with catatonic stupor who responded to olanzapine.
An 85-year-old white Brazilian man with a history of bipolar I disorder since he was 20 years old presented to our department in a stuporous catatonia, exhibiting hypo-activity, negativism, gegenhalten, catalepsy and mutism. According to his relatives, for 1 week, he remained in his bed with the eyes closed, often refusing beverage and food. He had no previous history of catatonia or substance abuse. In the previous year he was not compliant with mood stabilizer treatment based on lithium. Other aspects of his medical history were unremarkable. His general physical examination displayed no abnormality. Despite his frequent refusal of oral intake, he was not dehydrated or malnourished. Laboratory work-up, including complete blood count, creatine kinase level, electrolytes, renal, liver and thyroid function tests, and computer tomography of the skull were unremarkable. Initially he was medicated with oral lorazepam (up to 6 mg day−1) for 7 days, but no improvement was noticed. On the contrary, he became drowsy, making his care more difficult. As his family did not allow electroconvulsive therapy; an alternative for refractory cases to benzodiazepines [2], olanzapine 2.5 mg per day was started. This antipsychotic was chosen as there was former evidence of its efficacy in catatonia [3] and because of its mood stabilizing effect [5]. Within 4 days, the catatonic symptoms remitted. On a 6-month follow-up the patient remained asymptomatic without any side effects. Of note, no sign or symptom of dementia could be detected after his recovery.
This case highlights the efficacy of olanzapine in the management of catatonia in elderly bipolar patients. Furthermore, olanzapine can be used as a maintenance treatment in bipolar disorder in old age as previously described for adult subjects [5]. However, as recent concern about the use of atypical antipsychotics in elderly patients has been raised, vigilance must be maintained, especially towards metabolic effects of these drugs.