Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.

OBJECTIVE: To make evidence-based treatment recommendations for patients with Parkinson disease (PD) with dementia, depression, and psychosis based on these questions: 1) What tools are effective to screen for depression, psychosis, and dementia in PD? 2) What are effective treatments for depression and psychosis in PD? 3) What are effective treatments for PD dementia or dementia with Lewy bodies (DLB)? METHODS: A nine-member multispecialty committee evaluated available evidence from a structured literature review using MEDLINE, and the Cochrane Database of Health and Psychosocial Instruments from 1966 to 2004. Additional articles were identified by panel members. RESULTS: The Beck Depression Inventory-I, Hamilton Depression Rating Scale, and Montgomery Asberg Depression Rating Scale should be considered to screen for depression in PD (Level B). The Mini-Mental State Examination and the Cambridge Cognitive Examination should be considered to screen for dementia in PD (Level B). Amitriptyline may be considered to treat depression in PD without dementia (Level C). For psychosis in PD, clozapine should be considered (Level B), quetiapine may be considered (Level C), but olanzapine should not be considered (Level B). Donepezil or rivastigmine should be considered for dementia in PD (Level B) and rivastigmine should be considered for DLB (Level B). CONCLUSIONS: Screening tools are available for depression and dementia in patients with PD, but more specific validated tools are needed. There are no widely used, validated tools for psychosis screening in Parkinson disease (PD). Clozapine successfully treats psychosis in PD. Cholinesterase inhibitors are effective treatments for dementia in PD, but improvement is modest and motor side effects may occur.

Myasthenia gravis mimicking stroke in elderly patients.

Myasthenia gravis is the most common disease of neuromuscular transmission; however, it may be difficult to diagnose in the elderly patient with comorbid illnesses and vague symptoms. We report two cases of myasthenia gravis in elderly women, in whom the initial diagnosis of ischemic stroke by neurologists was inaccurate; radiographic evidence of stroke was considered confirmatory. In light of the high prevalence of silent cerebrovascular disease in elderly patients, incidental neuroimaging findings may mislead clinicians. Current aggressive therapies, including thrombolysis, can cause significant morbidity in patients whose condition is misdiagnosed as stroke. Although myasthenia gravis most commonly occurs in younger people, 13 to 20% of all patients with this disease are in the seventh decade of life or beyond. When faced with new-onset weakness in an elderly patient, particularly of cranial musculature, clinicians should consider myasthenia gravis as a diagnostic possibility.