Weíve done a couple previous columns highlighting the problems that patients with Parkinsonís Disease run into when they get hospitalized for any reason (see our Whatís New in the Patient Safety World columns for August 2011 ďProblems Managing Medications in Parkinsonís DiseaseĒ and December 2012 ďMore on Hospitalized Parkinsonís Disease PatientsĒ). Patients with Parkinsonís typically require specific timing of their medications in order to minimize the ďon-offĒ phenomenon and to avoid hyperkinesias. This results in their requiring multiple dosing throughout the day and often at unusual times. Meeting this very precise timing of doses is problematic for most hospitals and hospital units because they are used to their own standardized times for medication dispensing and administration. And most anti-Parkinsonian medications are available only in oral form so it is especially problematic when the patient is NPO or is otherwise unable to swallow. Some anti-Parkinsonís formulations are also of the extended-release variety and should not be crushed. Moreover, drugs that worsen extrapyramidal function are often used in the hospital and these may significantly worsen Parkinsonian features. Patients with Parkinsonís also seem to get temporary declines in function when they get a systemic problem, like an infection.
ISMP has recently done another column on this very problem (ISMP 2015). They provide two case examples that illustrate some of these critical problems. In one case, there was a several hour delay in getting the patientís medications even though she informed hospital staff immediately about the doses and times. The hospital then scheduled her medication administration for the standard hospital medication administration times. As a result several hours went by in which the patient failed to receive her medications. This led to accentuation of difficulty talking and communicating, increased tremor and difficulty walking. She then became confused and agitated and was given haloperidol, which further worsened her Parkinsonian state.
In the second case, a Parkinsonís patient did not receive his anti-Parkinsonian medications when his wife was not present at the bedside. He, too, was given a contraindicated medication when he developed hallucinations and lost the ability to communicate until his medications were readjusted to the schedule he used at home.
In our December 2012 Whatís New in the Patient Safety World column ďMore on Hospitalized Parkinsonís Disease PatientsĒ) we noted a study from The Netherlands (Gerlach 2012) found that 21% of Parkinson patients admitted to a hospital experienced deterioration of motor function and 33% had one or more complications. Moreover, 26% received incorrect anti-Parkinson medications, which was the most significant reason associated with clinical deterioration. And somewhat surprisingly, the researchers found the situation no better in those patients admitted to neurological wards rather than other wards. This simply suggests an overall relative lack of understanding of Parkinsonís disease in healthcare workers who work primarily in inpatient settings. It also reflects some of the rigid medication administration practices we have in most hospitals. Interestingly, in the new ISMP column the first patient scheduled a subsequent elective admission to a hospital where her neurologist worked but she ran into all the same problems even under that arrangement.
ISMP goes on to provide a list of important actions that should be undertaken for inpatients with Parkinsonís Disease:
We encourage you to read the ISMP article for details under each of the above bullet points.
Itís tough enough to manage Parkinsonís Disease as an outpatient. Recognizing these vulnerabilities when patients with Parkinsonís are admitted to hospitals is a first step in preventing complications, minimizing hospital lengths of stay, and avoiding functional deterioration.
ISMP (Institute for Safe Medication Practices). Delayed administration and contraindicated drugs place hospitalized Parkinsonís disease patients at risk. ISMP Medication Safety Alert! Acute Care Edition. March 12, 2015
Gerlach OHH, Broen MPG, van Domburg PHMF, et al. Deterioration of Parkinson's disease during hospitalization: survey of 684 patients. BMC Neurology 2012, 12: 13 (8 March 2012)
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