Catatonic signs during delirium in leptomeningeal melanoma: Treatment trade-offs in end-of-life care
Luis Velez FigueroaAbstract
Objectives
Catatonic and delirious signs overlap, creating treatment dilemmas when sedation obscures diagnostic assessment. We describe serial assessment and medication decision-making in advanced leptomeningeal melanoma during transition to home hospice.
Methods
Inpatient observations, investigations, medication exposures, goals-of-care discussions, and serial Bush-Francis Catatonia Rating Scale (BFCRS) examinations were synthesized.
Results
A man in his late 30s with metastatic melanoma involving the leptomeninges and brain developed fluctuating arousal, inattention, disorientation, mutism, immobility, staring, withdrawal, and waxy flexibility. His Bush-Francis Catatonia Rating Scale (BFCRS) score decreased from 7 to 1 after intravenous lorazepam, although reassessment was limited by sedation and fluctuating wakefulness. Transient improvements in movement and speech did not translate into sustained gains in attention, communication, intake, mobility, or function. Lorazepam was subsequently reduced and discontinued when severe agitation emerged. As catatonic signs became less sustained and agitation threatened safety, scheduled haloperidol was introduced, with improvement in evening agitation and no documented extrapyramidal symptoms, oversedation, or QTc prolongation. A supervised oral-medication trial supported discharge planning, although hospice placement remained delayed by insurance barriers.
Significance of results
A lower BFCRS score after lorazepam does not necessarily indicate meaningful clinical response if arousal, attention, and function remain impaired. In advanced cancer, catatonic signs may occur within a broader delirious or toxic-neurologic encephalopathy. Serial assessment should therefore incorporate wakefulness, attention, mobility, communication, and patient- and caregiver-defined goals. Treatment should be guided by the immediate priorities of interaction, safety, or comfort and continually reassessed in light of prognosis and feasibility of home care.