It was a very busy day on the consultation psychiatry service today. Besides that, I gave a lecture about delirium and dementia to the medical students. The talk is similar to the one below:
As a reminder, Dr. Wes Ely, MD will be in Iowa City at the University of Iowa Hospitals and Clinics to talk about delirium, “A New Frontier in Critical Care: Saving the Injured Brain.” It will be at noon.
I’m urging medical students and residents to attend. Unfortunately, I’ll probably be too busy in the hospital to go.
I sometimes see what is called a catatonic variant of delirium in patients who are medically very sick.
A condition called catatonia can occur in the setting of delirium. Most commonly, patients with this condition are mute and immobile. They may have a fever and muscular rigidity that leads to the release of an enzyme associated with muscle tissue breakdown called creatine kinase (CK). The level of CK can be elevated and detectable on a lab test.
Many patients will have a fast heart rate and fluctuating blood pressure. They may sweat profusely which can lead to a sort of greasy facial appearance. They may have a reduced eye blink rate or seem not to blink at all. They may display facial grimacing.
The patient may exhibit the “psychological pillow” (some call this the “pillow sign”). While lying in bed, the patient holds his head off the pillow with the neck flexed at what looks like an extremely uncomfortable angle. The position, like other odd, awkward postures can be held for hours.
Catatonia can be caused by both psychiatric and medical disorders. It tends to be more common in bipolar disorder than in schizophrenia even though catatonia has historically been associated with schizophrenia as a subtype. You can also see it in encephalitis, liver failure, and in some forms of epilepsy and other medical conditions.
The patient may perseverate or repeat certain words no matter what questions you ask. He may simply echo what you say to him and that’s called “echolalia”.
Although catatonic stupor is what you usually see, less commonly you can see catatonic excitement, which is constant or intermittent purposeless motor activity.
The usual way to assess catatonic stupor in order to distinguish it from hypoactive delirium is to administer Lorazepam intravenously, usually 1 to 2 milligrams. A positive test for catatonic stupor is a quick and sometimes miraculous awakening as the patient returns to more normal animation. The reaction is usually not sustained and the treatment of choice is electroconvulsive therapy (ECT), which can be life-saving because the consequence of untreated catatonia can be death due to such causes as dehydration and pulmonary emboli.
Another less invasive test that doesn’t use medicine is the “telephone effect” described in the 1980s by a neurologist, C. Miller Fisher. It was used to temporarily reverse abulia, which in a subset of cases of stupor is probably the neurologist’s word for catatonia. Sometimes the mute patient suffering from abulia can be tricked into talking by calling him on the telephone. It’s pretty impressive when a patient who is mute in person answers questions by cell phone. I have never tried texting.
The goal is to identify any medical condition left undiscovered and treat it. Both delirium and catatonia should be thought of as ominous indicators of a medical emergency.