Journal Article Annotations
2023, 4th Quarter
Annotations by Nathan Praschan, MD, MPH, Laura Duque, MD
This systematic review examined the utility of rivastigmine—a cholinesterase inhibitor—for a variety of neuropsychiatric symptoms commonly present in Parkinson’s disease (PD) before the onset of Parkinson’s disease dementia. The review systematically examined multiple databases to collect 93 original studies. Review of the relevant articles demonstrated that rivastigmine may reduce severity and caregiver burden of apathy, visual hallucinations, REM sleep symptoms, and fall risk. The benefit for cognition was mixed, with some studies demonstrating significant differences on cognitive screening metrics, while others did not. Similarly, rivastigmine was not found to reduce time to developing dementia nor psychotic symptoms.
Strength and weaknesses:
Few studies have systematically evaluated the benefits of cholinesterase inhibitors earlier in the course of illness. To that end, these authors set out conducted a wide sweeping review a variety of neuropsychiatric symptoms, finding benefits for rivastigmine earlier than has previously been established. The systematic review identified a small number of original articles to include, and the heterogeneity of these studies across multiple different outcomes makes their findings difficult to interpret and integrate. Furthermore, several of the included studies were subject to bias due to small N and incomplete data reporting.
Despite the weakness of the paper described above, this paper describes reasonable indications for the use of rivastigmine in PD patients earlier than previously thought. CL psychiatrists are often called upon in hospital and outpatient settings to manage neuropsychiatric consequences of PD. CL psychiatrists would do well to familiarize themselves with rivastigmine, as patients may prefer to use a patch or have trouble tolerating other cholinesterase inhibitors. Furthermore, given the broad range of benefits in PD, cholinesterase inhibitors may be among the first interventions for PD patients with neuropsychiatric illness.
This review provides an overview of patient-centered care for Functional Neurological Disorder (FND), spanning from evaluation to treatment. The article emphasizes the critical role of a comprehensive neurological examination and the review of adjunctive testing, such as vEEG data for FND-seizure diagnosis, to achieve diagnostic precision (rule-in diagnosis). It underlines the importance of effective communication and education regarding FND diagnosis. The authors recommend ongoing clinical monitoring and utilizing the biopsychosocial framework to adjust treatment recommendations as needed, promoting an adaptable approach to managing FND.
Strength and weaknesses:
This review offers a set of valuable recommendations derived from a specialized FND clinic’s approach, incorporating expert opinion and existing literature. While there is absence of detailed information on the literature search and methodology for recommendation selection, this falls outside the review’s intended scope. Despite this potential limitation, the recommendations showcase a robust evidence-based foundation.
Consultation-liaison (C-L) psychiatrists frequently provide the initial assessment for patients with FND, so we play an important role in the initial stages of evaluation and management. Hence, establishing a framework for assessment and initial management becomes crucial for inpatient care, allowing for adaptability based on the consult question by the primary team. Additionally, the article acknowledges that FND is a ‘rule-in’ diagnosis, based on specific physical signs and semiological features discernible during routine bedside clinical examinations. It also introduces an emerging standard of care that endorses therapeutic roles for education, physical therapy, occupational therapy, and psychotherapy in the management of FND.