Delirium and Catatonia in Critically Ill Patients: The Delirium and Catatonia Prospective Cohort Investigation*

Abstract

Objective Catatonia, a condition characterized by motor, behavioral and emotional changes, can occur during critical illness and appear as clinically similar to delirium, yet its management differs from delirium. Traditional criteria for medical catatonia preclude it’s diagnosis in delirium. Our objective in this investigation was to understand the overlap and relationship between delirium and catatonia in ICU patients and determine diagnostic thresholds for catatonia. Setting Convenience cohort, nested within 2 ongoing randomized trials at a single institution. Patients We enrolled 136 critically ill patients on mechanical ventilation and/or vasopressors, randomized to two usual care sedation regimens. Measurements and Main Results Patients were assessed for delirium and catatonia by independent and masked personnel using Confusion Assessment Method for the ICU (CAM-ICU) and the Bush Francis Catatonia Rating Scale (BFCRS) mapped to DSM-5 criterion A for catatonia. Of 136 patients, 58 (43%) patients had only delirium, 4 (3%) had only catatonia, 42 (31%) had both and 32 (24%) had neither. In a logistic regression model, more catatonia signs were associated with greater odds of having delirium. For example, patient assessments with ≥3 DSM-5 symptoms (75th percentile) had, on average, 27.8 times the odds (IQR 12.7, 60.6) of having delirium compared with patient assessments with 0 DSM-5 criteria (25th percentile) present (p< 0.001). A cut-off of ≥4 Bush Francis Catatonia Screening Instrument (BFCSI) items was both sensitive (91%) 95% CI (82.9 – 95.3) and specific (91%) 95% CI (87.6 – 92.9) for DSM-5 catatonia. Conclusions Given that about 1 in 3 patients had both catatonia and delirium, these data prompt reconsideration of DSM-5 criteria for “Catatonic Disorder Due to Another Medical Condition” that preclude diagnosing catatonia in the presence of delirium.

A Rare Presentation of Catatonia due to Primary Adrenal Insufficiency

“…Additionally, the patient was inattentive, disoriented, and had generalized slowing on EEG, consistent with a diagnosis of delirium. These findings reinforce recent research that shows that delirium and catatonia can coexist, despite the DSM-V criteria that preclude the diagnosis of both conditions concurrently(6).…”

Benzodiazepine Withdrawal Catatonia, Delirium, and Seizures in a Patient With Schizoaffective Disorder

“…An intensive care unit–based study found that about a third of patients with delirium have catatonia and patients with more signs of catatonia are more likely to have delirium. 25 It has been pointed out that some of the ICSD-5 diagnostic criteria for delirium 2 ( Table 1 ) can paradoxically result in the underdiagnosis of delirium. 16 For example, diagnosing delirium is forbidden in the presence of an arousal disorder that precludes assessment of attention and cognition.…”

Persistent catatonia following epileptic seizures: a case report and systematic literature search

“…Another important distinction that must be made in this case is between postictal delirium (occurring in 35% of seizure cases and reported to last sometimes up to 10 days) [ 25 – 27 ] and postictal catatonia as it may substantially influence treatment decision-making [ 28 – 30 ]. Whereas benzodiazepines are used first in cases of catatonia, in delirium such compounds may aggravate symptoms [ 28 – 30 ]. The distinction between the two may be cumbersome given clinical overlap.…”

“…The distinction between the two may be cumbersome given clinical overlap. According to the DSM-5 it is impossible for the two to co-occur since catatonia cannot be diagnosed in the presence of delirium; others question this notion [ 30 ]. In addition, Grover [ 28 ] found that 12 to 30% of patients with delirium showed symptoms matching the criteria for catatonia.…”