(064) "Benzo Beware:" A Case-Based Discussion of Catatonia in Fronto-temporal Dementia

Abstract:

Background: Catatonia is a psychomotor syndrome shown to be up to 4 times more likely in the geriatric population (Jaimes-Albornoz 2022). There has been an increasing interest in the relationship between frontotemporal dementia (FTD) and catatonia, given the common pathophysiology of frontal lobe dysfunction. Most published cases note the efficacy and tolerability of benzodiazepines in catatonia secondary to FTD (Jaimes-Albornoz 2022). However, there has also been a growing body of evidence which describes subtypes of patients with FTD who respond poorly to classically first-line treatments (Lauterbach 2010). Our case offers an example of benzodiazepine treatment non-response, as well as modest adjunct treatment response, in a patient with catatonia and FTD.

Case History: Mr. C is a 67-year-old male veteran with no psychiatric history other than progressive FTD who presented with worsened wandering behaviors. Following admission, he was quickly diagnosed with catatonia with an initial BFCRS score of 19.

Despite an initial response to a Lorazepam challenge, continued titration led to somnolence without appreciable changes in catatonic symptoms. Lorazepam was discontinued in favor of 10 sessions of bilateral ECT with no symptomatic improvement. Additional trials of Divalproex, Zolpidem and Lexapro yielded no noticeable improvement. Following dual therapy of memantine and high dose amantadine, he began demonstrating spontaneous whispering and mumbling. Mr. C was transferred to a skilled nursing facility with his family understanding that his condition likely represented a new irreversible baseline mental status.

Discussion: Our case demonstrates the heterogeneity of response to benzodiazepines in FTD. Many factors may mediate this variability: neuroanatomic distribution and severity of FTD pathology, previous psychiatric history, and length of disease before treatment (Rasmussen 2016).

Conclusions: Our patient proved to be refractory to first-line treatments of catatonia (Lorazepam and ECT) but showed improvement in speech production with adjunctive treatments (Memantine and Amantadine). In conjunction with existing published literature, this case highlights the idiosyncratic nature of catatonia treatment response in patients with FTD and raises the possibility of distinct clinicopathologic subtypes. Further research is necessary to characterize these potential subtypes and treatment responses, particularly in the elderly, for whom the usual treatment bears an increased risk of complication.

Sources:

Jaimes-Albornoz W, Ruiz de Pellon-Santamaria A, Nizama-Vía A, Isetta M, Albajar I, Serra-Mestres J. Catatonia in older adults: A systematic review. World J Psychiatry 2022; 12(2): 348-367 [PMID: 35317341]

Lauterbach EC, Kuppuswamy PS, Greenway LL. Differential pharmacological responses of catatonia-like signs in frontotemporal dementia. Neurocase. 2010 Oct;16(5):436-50. doi: 10.1080/13554791003623326. PMID: 20859826.

Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World J Psychiatry. 2016;6:391-398