What’s New in the Patient Safety World

August 2011

Problems Managing Medications in Parkinson’s Disease Patients

An article this month jogged our memory that we had intended to comment on problems in managing patients with Parkinson’s Disease who are hospitalized or managed in settings where input from neurologists is not readily available. An article several months ago (Derry 2010) looked at patients with Parkinson’s disease who were admitted to hospitals for surgical procedures. It should be noted that medication management in patients with Parkinson’s even as outpatients can get incredibly complicated, with complexity of dosing and timing, dietary issues, and the need to avoid many other types of medication. Derry and colleagues found that 12% of all doses of anti-Parkinsonian medications were missed during the surgical hospitalizations. While the reason for missed doses was not always mentioned, reasons like “unable to swallow”, “nil by mouth”, and “out of stock” were sometimes mentioned. Of course, in Parkinson’s it is important to find alternative ways to get patients their medications at all times. Also, inappropriate doses of antidopaminergic medications, which could worsen the Parkinsonian features, were prescribed in 41% of cases (though actually only administered in 22%). The authors note that complications were very frequent in this population, in keeping with previous literature.

The authors do provide some suggestions to improve the management of hospitalized Parkinson’s patients. Though they do mention staff education, they recognize that is likely to have limited impact. Rather, they call for trigger mechanisms to alert the specialty nurse or other clinician who routinely manages patients with Parkinson’s so that they may follow the patient and make recommendations during the hospital stay. Giving the patient a “warning card” may also alert staff to seek additional advice on managing the patients (see our analogous situation for insulin “passports” in our April 12, 2011 Patient Safety Tip of the Week “Medication Issues in the Ambulatory Setting”). They do also mention self-medication as a possibility, though our own bias is that introduces too many risks in this setting. Ideally, in the age of CPOE and EMR’s, rules-based alerts could alert the physician or pharmacist or nurse about critical issues in this patient population. Unfortunately, clinical decision support systems currently in use in most hospitals have difficulty using diagnoses (particularly secondary ones as would be the case here) to trigger actions. Theoretically, one could probably identify most Parkinson’s patients by their medication profile and perhaps use that to trigger alerts. Maybe anti-Parkinsonian medications need to be added to your list of high-alert drugs!

The peripherally related article that jogged our memory about the above paper was one on medications prescribed for psychosis in Parkinson’s patients on an outpatient basis (Weintraub 2011). That study showed a large number of patients are treated with antipsychotic drugs that either may worsen the motor findings, have unproven or limited efficacy in patients with Parkinson’s, or are prescribed despite black box warnings about their use in patients with dementia. It is an interesting article about how some drugs become widely prescribed in certain populations despite evidence bases that suggest limited efficacy.

Parkinson’s is a tough disease for patients and their families/caregivers. The complexities and fragmented nature of our healthcare system further exacerbate the difficulties they have.

References:

Derry CP, Shah KJ, Caie L, Counsell CE. Medication management in people with Parkinson's disease during surgical admissions. Postgrad Med J 2010; 86: 334-337

http://pmj.bmj.com/content/86/1016/334.abstract?sid=4e3b0286-5e2f-40a8-8b2b-bee80d74b576

Weintraub D, Chen P, Ignacio RV, et al. Patterns and Trends in Antipsychotic Prescribing for Parkinson Disease Psychosis. Arch Neurol. 2011; 68(7): 899-904

http://archneur.ama-assn.org/cgi/content/short/68/7/899

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