Physical health management while catatonic

Dangerously low food and fluid intake in catatonia is of particular concern. This can be seen as a marker of severity of catatonia, and also is an indication for urgent ECT. There are clear risks to the patient’s physical stability if intake is insufficient, and such a condition risks patients requiring transfer to medical hospitals (where ECT is rarely available). Charting intake on NHS Lothian food and fluid charts is therefore of clear importance, and the accuracy of this is key. A weight and height are essential to take initially and monitor weekly to allow MUST scoring, Dietetic referral/consideration, and to allow consideration of the trajectory.

Some patients have very little intake observed, but can appear to achieve more while not under the observation of others. For this reason, patients may be left food/fluids in their bed space to try to capitalize on this phenomenon. However, this can make accuracy of charting difficult, and patients have been known to drink directly from taps/toilets.

When eating and drinking do occur, at times this can manifest as a form of increased activity, with frenzied rushing of intake. This can create a risk of choking if not managed/monitored. However, these times are opportunities for patients to make-up for long periods of withdrawal.

Bloods, in particular for renal function and a refeeding panel, are often required to guide assessment of patient stability. Regular physical observations are also important. It may be useful to review your local refeeding guideline.

Patients who are significantly unwell may progress to ‘losing’ their oral route due to the degree of withdrawal. At such a point, nasogastric feeding, or transfer to a site which can provide this, should be considered. Medications may need to be rationalized, and Lorazepam administered parenterally. The access to subcutaneous and IV fluids is clearly variable across settings. In some circumstances, discussion can be had with the ECT team as to whether a bag of IV fluids can be given in recovery following ECT. However, this may not be possible and shouldn’t be relied upon.

The significance of this is related to both the frailty (and past medical history) of the patient, as well as the degree of immobility. Pressure sores may occur in patients who, based on demographics alone, would be low-risk. Review of pressure areas should be conducted regularly, with a low threshold to consider pressure relieving mattresses, pillows, and other adjustments. Regular turning and assessments for skin vulnerability (Waterlow score) should be considered. Patients who are severely catatonic and incontinent may benefit from catheterisation to prevent skin irritation and breakdown, and to preserve dignity.

Patients who have been severely catatonic for long periods are at risk of developing contractures, which risk leaving patients with permanently reduced function and quality of life. Those who are at risk may be discussed with physiotherapy, who may provide advice around positioning and postural management. There is currently a lack of evidence to support passive stretches as an approach.

Both immobility and some common psychiatric medications can increase the risk of venous thromboembolism. This is compounded by an increased risk of infection (especially aspiration pneumonia). Patients with prolonged stasis should be assessed for the suitability of TED stockings (checking that vascular supply wouldn’t be compromised) and/or prophylactic Dalteparin.

Many aspects of catatonia increase the risk of aspiration: positioning, pace of eating, delayed/poor swallowing ability, antipsychotic use and poor ability to follow instructions/advice. This risk is greater with greater impairment, further emphasising the need for prompt identification and treatment to reduce progressing to higher risk states. Routine physical examinations should include auscultation of the chest. Consideration should be given to optimizing oral hygiene, as this can further reduce aspiration risk.

Alertness level should be considered when encouraging a patient to eat and drink, and it may be that at certain times patients are not sufficiently alert to safely do so. Texture modification of foods, as advised by Speech & Language Therapy, may be beneficial to further reduce risk.

Urinary retention may go unnoticed in patients who aren’t able to verbalise symptoms, are incontinent, or are assumed to be passing urine independently. Routine examination should include palpation for a full bladder, with a low threshold to consider bladder scanning. Undetected retention may result in pain, distress and post-renal acute kidney injury. Catheterisation may be required. Consideration should be given to medical causes for urinary retention, including constipation and urinary tract infections. There should be a low threshold to send urine specimens.

Low oral intake and inability to attend to dental hygiene can increase the risk of candida, painfully dry mouth, cracking lips, and at the severe end, complications including sialadenitis. Moisturiser for lips, hydration sponges and artificial saliva can improve comfort, and make eating more comfortable when this does occur. Good oral care can also reduce the risk of aspiration events.

Catatonic patients can at times have markedly reduced blink rates. Artificial ‘tears’ can be beneficial to reduce the risk of infection and damage to the eye’s surface.

Assistance and encouragement should be provided. Menstrual care and products should be considered, and tailored to individual patient need/preferences. Occupational therapy colleagues may advise on suitable adaptations if mobility is limiting the ability to use nearby toilets. As per skin integrity, catheterisation may be considered for those with severe catatonia.

Many patients have reduced ability to communicate, including about being in pain. In such circumstances systems like the Abbey Pain Scale can be used. A number of components of catatonia syndrome and complications that result can cause pain, and so empirical simple analgesia may be considered.

Low food/fluid intake, reduced mobility and many psychiatric medications being constipating means that these patients are at greater risk of developing difficult constipation. Bowel charts are essential, with a low threshold for regular laxatives.

Regular systematic physical examination should be conducted, with the context of the patient’s past medical history in mind. Clinicians need to be more proactive to identify such issues. Regular bloods may provide more information, especially when the patient cannot provide a history.