key: cord-0737391-zokqi4zh
authors: Amouri, Jamelleh; Andrews, Patricia S.; Heckers, Stephan; Ely, E. Wesley; Wilson, Jo Ellen
title: A Case of Concurrent Delirium and Catatonia in a Woman with COVID-19
date: 2020-09-15
journal: Psychosomatics
DOI: 10.1016/j.psym.2020.09.002
sha: 827972fc7692c56ce8dd835b70b0ccfcda039e79
doc_id: 737391
cord_uid: zokqi4zh

INTRODUCTION: Delirium and catatonia are two representations of acute brain dysfunction that can occur in medically ill patients. It has become increasingly evident that delirium and catatonia can co-occur in the setting of medical illnesses. Delirium and catatonia have been separately described as neuropsychiatric sequelae of Coronavirus Disease 2019 (COVID-19) infection; however, to the best of our knowledge the co-occurrence of delirium and catatonia in the setting of COVID-19 has not been previously reported. CASE: We describe a case of concurrent delirium and catatonia in a 70-year-old woman with multiple medical comorbidities but with no prior psychiatric history, who was hospitalized with COVID-19 pneumonia. Her symptoms of both delirium and catatonia improved with administration of low-dose lorazepam. DISCUSSION: We highlight the importance of recognizing catatonia in medically ill patients and the overlap between and co-occurrence of delirium and catatonia in this population. We explore how the conditions imposed by COVID-19 illness and its unique pathophysiology predispose patients to the development of both delirium and catatonia, as well as the challenges imposed by traditionally different approaches to treatment of these two conditions. CONCLUSION: Delirium and catatonia can co-occur in the context of acute COVID-19 illness. Features specific to COVID-19, both pathophysiological and environmental, create a unique set of conditions, which predispose patients to co-occurring delirium and catatonia. Delirium and co-occurring catatonia may improve with administration of low-dose lorazepam in selected patients.

All authors listed above have contributed substantially to the conception or design of the work; 26 or the acquisition, analysis, or interpretation of data for the work and have participated in 27 drafting the work or revising it critically for important intellectual content. Additionally, each 28 author has given their approval to the final version of the manuscript and has agreed to be 29 accountable for all aspects of the work in ensuring that questions related to the accuracy or 30 integrity of any part of the work are appropriately investigated and resolved. 31 32 33 Introduction: Delirium and catatonia are two representations of acute brain dysfunction that 3 can occur in medically ill patients. It has become increasingly evident that delirium and 4 catatonia can co-occur in the setting of medical illnesses. Delirium and catatonia have been 5 separately described as neuropsychiatric sequelae of Coronavirus Disease 2019 (COVID-19) 6 infection; however, to the best of our knowledge the co-occurrence of delirium and catatonia in 7 the setting of COVID-19 has not been previously reported. Case: We describe a case of concurrent delirium and catatonia in a 70-year-old woman with 10 multiple medical comorbidities but with no prior psychiatric history, who was hospitalized with 11 COVID-19 pneumonia. Her symptoms of both delirium and catatonia improved with 12 administration of low-dose lorazepam. 13 14 Discussion: We highlight the importance of recognizing catatonia in medically ill patients and 15 the overlap between and co-occurrence of delirium and catatonia in this population. We 16 explore how the conditions imposed by COVID-19 illness and its unique pathophysiology 17 predispose patients to the development of both delirium and catatonia, as well as the 18 challenges imposed by traditionally different approaches to treatment of these two conditions.

Delirium is a syndrome of acute brain dysfunction caused by an underlying medical condition or 2 toxic exposure and is characterized by deficits in attention, awareness and cognition 1 . Because 3 it is the most common psychiatric syndrome observed in medically hospitalized patients 2 and a 4 known predictor of excess mortality, length of stay, long-term cognitive impairment, and 5 increased cost of care in critically ill patients 3,4,5,6 , delirium is routinely screened for in intensive 6 care unit (ICU) settings. The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes 16 1 presence of catatonia, given her persistent altered mental status, withdrawal, and refusal of 2 medications and treatment. Notably, upon review of her medical chart, there had been no prior 3 mention of the term "delirium," nor was there documentation of any Confusion Assessment 4 Method (CAM) assessments, despite use of language in notations in her chart describing 5 features of delirium throughout her hospitalization. This could be due to a failure to recognize 6 less overt delirium, or more likely a failure to document that the condition was present. On examination, Mrs. K exhibited several signs of catatonia, including immobility, mutism, 9 grimacing, catalepsy, echolalia, stereotypy, verbigeration, rigidity, negativism, waxy flexibility, 10 automatic obedience, and gegenhalten. She also exhibited labile blood pressure throughout 11 that day not attributable to another cause. The Bush-Francis Catatonia Rating Scale (BFCRS) was 12 administered. The Bush-Francis Catatonia Screening Instrument (BFCSI) comprises the first 14 13 items of the 23-item BFCRS. The BFCSI score is reported as a tally of the number of items 14 present in items 1-14, while the BFCRS is reported as the total severity score of all 23 items. 15 Mrs. K's initial BFCSI/BFCRS score was 11/21, indicating the presence of catatonia. improvement in signs of both delirium and catatonia. She did not receive neuroleptics during 10 her hospitalization. 11 12 When she was reassessed by the Psychiatry C-L service on HD 14, catatonia was noted to have 13 improved, though she still exhibited negativism and mutism, and she continued to exhibit 14 features of delirium including reduced arousal and inattention. As such, lorazepam was tapered 15 to 0.5 mg BID on HD 14, which led to small improvements in delirium on HD 15, as evidenced by 16 improving alertness and orientation, and her mild symptoms of catatonia remained stable. 17 Lorazepam was subsequently discontinued on HD 16, without return of catatonic signs; 18 however, she continued to exhibit evidence of resolving delirium, primarily inattention, 19 throughout the remainder of her 17-day hospitalization. Given continued physical 20 deconditioning, it was recommended that Mrs. K discharge to a skilled nursing facility, but both 21 J o u r n a l P r e -p r o o f she and her family preferred for her to discharge home where she would receive 24-hour care 1 and supervision. Mrs. K was able to discharge home on HD 17. We describe a case of co-occurring delirium and catatonia in a woman with COVID-19, who 2 responded favorably to repeated doses of low-dose lorazepam. While delirium is routinely 3 screened for in medically ill patients, catatonia is often under-recognized in this population, 4 despite a recent refocus on the co-occurrence of these two conditions 9,10,11 . The ramifications 5 of unrecognized and untreated catatonia can be serious. In some cases, untreated catatonia 6 can progress to its most severe form, malignant catatonia, which is characterized by fever, 7 severe autonomic instability, significant muscle rigidity, and altered mental status, which may 8 result in multi-organ dysfunction and death 20 . It is therefore crucial that catatonia remain on 9 the differential diagnosis of altered mental status in patients with COVID-19, and that formal 10 evaluation for catatonia be performed when it is suspected (e.g., prominent motor 11 abnormalities, mutism, withdrawal, or acute worsening of symptoms after exposure to a 12 neuroleptic, etc.). Evidence suggests there is overlap of delirium and catatonia in the medically 13 ill population, that up to one-third of critically ill patients meet criteria for both delirium and 14 catatonia 9, 11 , and that delirious patients may be particularly vulnerable to the development of 15 catatonia 21 . In the case of a patient with persistent delirium, suspicion for comorbid catatonia 16 should increase and a BFCRS should be performed. of effective blood oxygenation due to acute hypoxemic respiratory failure, leading to brain 10 tissue hypoxia 24,25,26 ; circulating cytokines and acute phase proteins in systemic inflammation 11 activating the vasculature, increasing blood-brain barrier permeability, and activating microglial 12 cells, resulting in neuroinflammation 27, 28, 29 ; and inflammation promoting hypercoagulation, 13 resulting in cerebrovascular disease and other organ system failure 30,31,32 . Iatrogenic and 14 environmental factors such as prolonged mechanical ventilation, use of sedatives, 15 immobilization, and social isolation and separation from family members only further increase 16 the risk for the development of delirium, and therefore catatonia, in these patients 16 . Mrs. K's 17 lingering inattention was likely multifactorial. Given her age and vascular risk factors, it is likely 18 that she had premorbid cognitive impairment, increasing her risk for a prolonged course of 19 delirium, which in turn increases the likelihood that she will experience further cognitive 20 decline. Additionally, new cognitive impairment has been associated with COVID-19 infection 33 . Sedation; Delirium assess, prevent, and manage; Early Mobility and Exercise; Family 9 engagement/empowerment) is a multicomponent safety intervention that that has been shown 10 in over 20,000 patients to yield significant improvements in clinical outcomes such as mortality, 11 length of stay, and effective reductions in delirium duration 37,38 . 12 13 The treatment of catatonia includes use of benzodiazepines as first-line agents as well as a 14 general avoidance of antipsychotics, given their potential to worsen catatonia and precipitate 15 malignant catatonia. As use of benzodiazepines can worsen delirium, electroconvulsive therapy 16 is another treatment option to consider in patients with comorbid catatonia and delirium 39 . 17 Similar to delirium, the management of catatonia often involves a medical workup and 18 treatment of any underlying medical or neurologic causes 10 . Nonpharmacologic treatments for there was concern from her primary medical team for the presence of catatonia. As her exam 1 was unequivocally positive for features of both delirium and catatonia, the decision was made 2 to perform a lorazepam challenge with low-dose lorazepam so as not to potentially worsen her 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders

Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae 4 of Delirium

Delirium as a predictor of mortality in mechanically 6 ventilated patients in the intensive care unit

The impact of delirium in the intensive care unit on 8 hospital length of stay

Delirium as a predictor of long-term 10 cognitive impairment in survivors of critical illness

Costs associated with delirium in mechanically 12 ventilated patients

Structure and neural mechanisms of 14 catatonia. The Lancet Psychiatry

Catatonia in the ICU: an important and 16 underdiagnosed cause of altered mental status. a case series and review of the literature*

Do patients of delirium have catatonic features? An 19 exploratory study

Catatonia vis-à-vis delirium: the significance of recognizing catatonia in 21 altered mental status

Delirium and catatonia in critically ill patients: the 23 delirium and catatonia prospective cohort investigation

COVID-19: A Global Threat to the Nervous System

Delirium in COVID-19: A case series and exploration 28 of potential mechanisms for central nervous system involvement

Clinical features of patients infected with 2019 novel 31 coronavirus in Wuhan

Neurologic Manifestations of Hospitalized Patients With 33

Coronavirus Disease 2019 in Wuhan

COVID-19: ICU delirium management during 35 SARS-CoV-2 pandemic

The neuroinvasive potential of SARS-COV2 may play a role in the 1 respiratory failure of COVID-19 patients

A Case of Catatonia in a Man With COVID-19

Warrants Early Psychiatric-Critical Care Collaborative Management: Two Cases and 6 Literature Review. Case Rep Crit Care

Catatonia in the intensive care unit

Catatonia and the immune system: a review

Evidence of the COVID-19 Virus Targeting the CNS: 12 Tissue Distribution, Host-Virus Interaction, and Proposed Neurotropic Mechanisms

Infrared Spectroscopy-Derived Cerebral Oxygenation and Delirium in Critically Ill Patients: A 16 Systematic Review

Delirium, a syndrome of cerebral insufficiency

Catatonia after cerebral hypoxia: do the usual treatments apply

Effect of intravenous haloperidol on the duration of delirium 1 and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-2 controlled trial

Clinical practice guidelines for the management of pain, 4 agitation, and delirium in adult patients in the intensive care unit

Caring for Critically Ill Patients with the ABCDEF

Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults. Critical care 8 medicine

Rosebush PI, Mazurek MF. Catatonia and its treatment

Orbitofrontal cortical dysfunction in akinetic 11 catatonia: a functional magnetic resonance imaging study during negative emotional 12 stimulation

Lorazepam modulates orbitofrontal signal changes during 14 emotional processing in catatonia

An integrative theory of locus coeruleus-norepinephrine function: 16 adaptive gain and optimal performance