Parkinson's disease in the ED

I was inspired to write this post after attending the Hector Course at Birmingham’s Heartlands Hospital. The course is designed to improve the care of elderly patients with trauma. One of the key messages I came away with was the vital importance of ensuring patients with Parkinson’s disease get their medications on time and that we do not poison them with drugs that will make their condition worse. If not, we risk causing distressing and potentially devastating consequences for our patients. Complications of missed PD medications include: prolonged length of stay, falls, pressure ulcers, rapidly deteriorating swallow, aspiration pneumonia and neuroleptic malignant-like syndrome (NMLS) —which can be life threatening.

Background

Parkinson’s disease (PD) affects 1:500 people in the UK. It is more common over the age of 50, but younger people can develop the disease. PD affects both sexes but is slightly more common in men. Many people think Parkinson’s is just a tremor, but it is much more than this —Parkinson’s is a complex neurodegenerative condition. It is still not completely understood, but the pathophysiology is related to the progressive loss of dopamine-producing neurons within the brain.
Patients with PD rarely come into hospital because of the disease itself. However, patients often present to hospital with complications of their PD (e.g. falls, delirium, severe constipation, aspiration pneumonia). Patients may also present to hospital for any other reason and then suffer additional complications as a result of their PD.

With thanks to the Hector Course, Heart of England NHS Trust, for this slide

Signs & Symptoms

The triad of symptoms and signs that commonly characterize PD are tremor, rigidity and bradykinesia (slowness of movement). However, Parkinson’s has many different symptoms and signs affecting a range of systems —PD can affect patient’s lives in many different ways:

Motor symptoms

• Tremor
• Rigidity
• Bradykinesia (slowness of movement)
• Dyskinesia (abnormal movement)
• Dystonia
• Difficulty initiating movement
• Postural instability
• End-of-dose deterioration (motor deterioration before next tablet is due)
• Freezing (periods of being unable to move)
  
• Motor fluctutations (alternating between dyskinesia / moving too much and bradykinesa / freezing)

Non-motor symptoms
AUTONOMIC

• Postural hypotension
• Urinary urgency
• Erectile dysfuntion

GASTROINTESTINAL

• Nausea
• Constipation (can be severe) / ileus
• Recurrent volvulus

NEUROPSYCHIATRIC

• Apathy / depression / anxiety
• Hallucinations
• REM sleep disorder
• Cognitive impairment (including PD dementia)
• Impulse control disorders (e.g. gambling, hypersexuality, risk taking behaviour)
• Increased risk of delirium

SPEECH & SWALLOWING

• apathy / depression / anxiety
• drooling of saliva
• slow quiet monotonous speech
• impaired swallow (neuromuscular dysphagia)
• risk of aspiration pneumonia

Golden rule

Parkinson’s medication is time critical —if Parkinson’s medications are delayed or omitted, patients can deteriorate very quickly in terms of their ability to move, speak and swallow safely.
Some drugs will interfere with PD medications or exacerbate the condition.
Do not prescribe metoclopramide or prochlorperazine (stemetil), use domperidone first line for antiemetic.
Do not prescribe haloperidol or risperidone, use lorazepam if patient is severely agitated.

The trust guideline is accessible on intranet
ED Home Page > Adult Guidelines > Adult Medicine > Neurology

Further Reading

1. http://staffnet.plymouth.nhs.uk/Departments/Medicine/HealthcareoftheElderly/ParkinsonsDiseaseTeam.aspx
2. The PHNT Parkinson’s nurses are: Fiona Murphy (85047) and Emma Pearson (85075)
3. This is a great presentation from an old colleague of mine from the Midlands:​ www.acutemedicinebhh.com/files/medical/Parkinsons.pptx
4. And this is their website: http://www.acutemedicinebhh.com/parkinsons.html

Clare Bosanko
July 20th 2016