Parkinson’s Disease on AMU and the wards Dr Sally Jones Consultant Geriatrician Birmingham Heartlands Hospital.

Parkinson’s Disease on AMU and the wards

Dr Sally JonesConsultant Geriatrician

Birmingham Heartlands Hospital

Overview

• Parkinson’s Disease – a reminder– Terminology, the Basal Ganglia and Dopamine

• Signs and symptoms in PD• Emergency presentations in PD

– PD related presentations– PD complicating other non –related problems

Parkinsonism or Parkinson’s Disease?

Parkinsonism = signs/symptoms which may be caused by:– Parkinson’s Disease– Lewy Body Dementia– PSP true dopamine deficiency– MSA– Corticobasilar degeneration

– Cerebrovascular Disease/basal ganglia infarct– Drug induced– NPH– Functional/psychogenic– Severe depression (causes psychomotor retardation)

The Basal Ganglia• Group of subcortical

nuclei interconnected with cerebral cortex, thalamus and brainstem– Subthalamic Nucleus– Substantia Nigra– Caudate Nucleus– Putamen– Globus Pallidus

The Basal Ganglia

• Originally thought to be associated purely with motor control

• We now know that there is more to it...– Motor– Associate (cognitive)– Limbic (emotional)

• Progressive cell loss in basal ganglia depletes dopamine• Dopamine loss explains many of the symptoms

L–Dopa

Dopamine

Dopamine receptors

The message is passed on

Patients with Parkinson’s Disease produce less dopamine

Some PD medications replace L-dopa

Some PD medications mimic action of dopamine

Some PD medications stop dopamine breakdown

Some medications CAUSE parkinsonsism by blocking dopamine receptors

L–Dopa

Dopamine

Patients with Parkinson’s Disease produce less dopamine

Some PD medications replace L-dopa: - co-careldopa (sinemet) - co-beneldopa (madopar) - duodopaBoth levodopa combined with decarboxylase inhibitor.

Some PD medications mimic action of dopamine - Dopamine Agonists (ropinirole, pramipexole, rotigotine, apomorphine, amantadine)

Some PD medications stop dopamine breakdown - COMT inhibitors (entacapone) - MAO-B inhibitors (selegeline, rasagaline) Avoid!!!

Some medications CAUSE parkinsonsism - “Dopamine Antagonists” - Phenothiazines - Stemetil - Metoclopramide - Some anti-histamines - most anti-psychotics

Dopamine receptors

The message is passed on

It’s not just a tremor!

Motor Symptoms• Triad of tremor, rigidity and bradykinesia• May manifest as:

– Postural instability– Postural change (disproportionate antecolis)– Reduced facial expression (hypomimia)– Difficulty initiating movements– Difficulty turning corners– Drooling & swallow problems– Quiet mumbling speech

• Other commonly used motor terms:– Freezing, on/off, dyskinesia, dystonia, end of dose deterioration

Non-motor symptoms• Neuropsychiatric

– Hallucinations & perceptual problems, REM sleep disorder, impulse control disorder, apathy, depression, anxiety, dementia

• Autonomic– Postural hypotension, urinary problems, erectile dysfunction

• Sensory– Anosmia, diplopia

• Speech & Swallow– Drooling, Dysphagia, Quiet mumbling speech

• Gastroenterology– Nausea, constipation (severe → impaction, volvulus)

Staging

Traditionally:• Hoehn & Yahr 1-5

Or more clinically useful:• Diagnostic phase• Maintenance phase• Complex phase • Palliative phase

ReflectionHow might understanding this help when seeing these patients in ED/AMU?

Emergency Presentations in PD

1. So how might PD present as an emergency?2. How might PD complicate non-related

emergencies/acute admissions?

Drug related problems & emergencies Cause Complication What to do

PD medication side effect Postural hypotensionNauseaHallucinations/deliriumDiarrhoea with entacaponeMotor fluctuations

Quickly exclude other causes. Domperidone for nausea +/- postural hypotension (can also given fludrocortisone for this). DON’T CHANGE PD DRUGS – let PD team know – can usually be sorted as outpatient unless v unwell

Missed/delayed PD medication

OR

PD patient given a dopamine antagonist (eg stemetil, metoclopramide, risperidone, haloperidol)

Deteriorating swallowDeteriorating mobilityDeteriorating speechDeteriorating consciousnessAspiration pneumoniaFallsPressure ulcersNeuroleptic Malignant Synd.

GIVE THE PD MEDICATION

ITU/HDU support may be needed if appropriate, esp in neuroleptic malignant syndrome

Neuroleptic Malignant Syndrome

• In non-PD patients NMS is typically caused by neuroleptics or other dopamine blocking agents

• In PD patients, the same thing can occur when their dopamine is (abruptly) stopped/reduced– usually precipitated by abrupt withdrawal or malabsorption of

PD medication (or if PD patient is given neuroleptics!)– can be triggered by infection/other acute illness– sometimes called parkinsonism-hyperpyrexia syndrome– characterised by rigidity, hyperpyrexia and stupor, usually with

raised CK

Neuroleptic Malignant Syndrome in PDHistory Recent abrupt discontinuation of PD medication

Recently given dopamine antagonists (neuroleptics, stemetil etc)Recent infection/physiological insult?

Signs RigidityHyperpyrexiaStuporAutonomic problemsDysphagia

Lab findings Raised CKMetabolic AcidosisRaised WCCLFTs may be deranged

Management GIVE THEIR PD MEDICATION (convert to NG if needed)Critical care – IV hydration, anti-pyretics, cooling, dialysis if neededDantrolene for severe refractory rigidity

Observe closely for Aspiration pneumonia, DIC, thromboembolism, Renal failure

Falls & PD• Often multi-factorial:

– PD + contributing co-morbidities +/- acute illness

• PD falls risk factors:– Postural instability– Postural hypotension– Difficulty with gait initiation– Freezing– Festination– Perceptual problems– Diplopia

GI problems & emergencies in PD• Nausea & Vomiting

– Common s/e of PD meds– Domperidone is anti-emetic of

choice in PD

• Constipation• Impaction & pseudo-obstruction• SIGMOID VOLVULUS

– Some PD patients get this recurrently

• Don’t forget D&V will impair absorption of PD meds

Respiratory problems & emergencies in PD

Aspiration Pneumoni

a

NBM

PD control worsens

Swallow worsens

Swallowing problems & NBM in PDNEVER miss/delay PD medications – if the patient cannot swallow or is planned to be NBM (eg for theatre), need URGENT alternative:• Plan A

– Take PD meds as usual even if NBM for everything else • Plan B

– Dispersible madopar oral or NG– Convert any sinement/madopar/stalevo to dispersible madopar and give at

same doses and times– Will dissolve in 5-10ml water, thicken if needed – usually safer to swallow

this than to miss/delay PD meds (risk/benefit)

• Plan C– Rotigotine patch (but ensure correct conversion – call PD team if needed)

Flowchart - NBM & swallowing problems in Parkinson’s

Is the gut working and can the patient swallow small 10ml amounts of (thickened) fluid/yoghurt/custard?

Either:Give usual PD meds with 10ml of water, yoghurt, custard, even if NBM for everything else

Or:Contact doctor urgently to convert usual PD medication to dispersible Madopar and give in 10ml of (thickened) fluid, even if NBM for everything else.

Is the gut working and can you pass an NG tube?

Urgent NG TubeContact doctor urgently to convert usual PD medication to dispersible Madopar.

A stat dose of dispersible Madopar can be given if medication already delayed.

Rotigotine PatchContact doctor urgently to prescribe: Rotigotine Patch 4mg as a stat dose.Before next dose due, contact doctor/pharmacist to: convert PD medication to daily rotigotine patch (dose will vary between patients)

Yes No

Yes No

Medicines not available in department?

In hours: Contact ward pharmacist/pharmacy to obtain medicationOut of hours: Check ward stock list or source medication via emergency medicines cupboard

Surgical patients with PD• Parkinson’s patients MUST continue to take some form of PD medication• Place 1st on operating lists• If timing of PD medication is going to clash with surgery, the regimen MUST be

altered – call PD team if necessary• Patients can still receive PD medication with a small amount of water up to 1-2

hours pre-op, even if they are nil by mouth for everything else• If the surgery is expected to last more than 3 hours, or if there is likely to be a

NBM period >6hours, an alternative route of drug administration MUST be arranged – eg NG tube or rotigotine patch (get specialist advice from PD team if necessary)

• If there is a non-functioning gut (eg ileus), convert PD drugs to rotigotine (follow NBM flowchart and contact PD team asap)

• PD team – Dr Sally Jones (BHH), Elderly Care SpR/Cons (all 3 sites), • PD CNS - Maggie Johnson (via switchboard/ext 43768)

Psychiatric problems & emergencies in PDProblem Note Action in ED/AMU

Hallucinations Very common in PD (& in PD dementia). Often “normal for them”, but worse if unwell or if recent PD medication change

Quickly exclude acute medical issue (eg infection, electrolytes). Let PD team know - can usually be managed as outpatient unless v disturbed. NEVER adjust the PD drugs or give anti-psychotic unless the PD team instruct to do so.

Dopamine Dysregulation Syndrome (& impulse control disorders)

Unusual to present as emergency but may “shop” round different hospitals in attempt to obtain more PD drugs.

Let PD team know of any concerns. Can usually be managed as outpatient.

Mood disorders Very common Involve RAID/CMHT if concerns

PD dementiaLewy Body Dementia

Often hallucinate and have perceptual problems

Exclude reversible contributers. Involve PD &RAID teams if concerns. NEVER give haloperidol or risperidone.Delirium PD patients are susceptible

Summary of Emergencies in PDPD related problem

• Neuroleptic Malignant Syndrome• Aspiration pneumonia• Postural hypotension• Falls• Volvulus• Constipation/pseudo-obstruction• Psychosis• Severe motor fluctuations• PD medication side effects

PD complicating other problems

• Nil by mouth• Iatrogenic medication issues• Autonomic instability• Mobility issues• Delirium• Nausea/vomiting• Diarrhoea

Golden Rule 1Parkinson’s is a gradually progressive condition and does NOT get worse overnight, so if a PD patient suddenly deteriorates:

• Either it’s not the PD• Or they’ve missed their medication

Golden Rule 2Never ever miss or delay PD medication

• Stat dose if already late when you see them• NG tube if needed• Dispersible madopar (instead of their usual L-dopa

preparation) at same time/dose equivalent if needed• Rotigotine patch if NG really not an option (but make

sure its the correct dose and let the PD team know)• All PD meds are in the emergency drugs cupboard in

pharmacy

Golden Rule 3 NEVER prescribe metoclopramide, stemetil, haloperidol or risperidone for a PD patient or I will hunt you down

and shoot you!!

• Most anti-emetics and anti-psychotics:– Make Parkinson’s Disease WORSE – CAUSE drug induced parkinsonsim– Can cause life threatening complications

• Anti-emetic of choice in PD = Domperidone• Drug of choice if severely agitated = Lorazepam

Thank you

Questions?