What’s New in the Patient Safety World

December 2012

More on Hospitalized Parkinson’s Disease Patients

In our August 2011 What’s New in the Patient Safety World column “Problems Managing Medications in Parkinson’s Disease” we highlighted an article (Derry 2010) that looked at patients with Parkinson’s disease who were admitted to hospitals for surgical procedures. 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.

A new 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. Infections also increased the risk for deterioration (though not after adjustment for confounding variables) and of patient-related factors higher doses of L-dopa were associated with increased risk of deterioration.

Patients with Parkinson’s often require specific timing of their medications in order to minimize the “on-off” phenomenon and to avoid hyperkinesias. This results in their requiring multiple dosing throughout the day and often at unusual times. It is very difficult for hospitals to have medication administration times that correspond to how those patients take their drugs at home. One suggested intervention is to allow the patients to self-medicate with their anti-Parkinson’s medications while hospitalized.

Interestingly, 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 Parkinson’s disease in healthcare workers who work primarily in hospitals. It also reflects some of the rigid medication administration practices we have in most hospitals.

The results were based upon patient-supplied answers to a questionnaire. However, when a sampling of inpatient charts was reviewed there was a striking paucity of recognition of deterioration by physicians and nursing staff.

In a review on the perioperative management of the geriatric patient, Ersan notes that Parkinson’s patients require special attention (Ersan 2011). She notes that withholding medications in patients who are NPO can cause significant worsening of symptoms, including enough stiffening of chest wall muscles to cause hypoxia. In addition, tremor and dysphagia may worsen.

We’ve discussed before the phenomenon of deterioration in functional status that often occurs when a geriatric person is admitted to a hospital. That applies especially to patients with Parkinson’s whether they are geriatric or not. They really do require special attention to avoid potential complications and to minimize the risk of that functional deterioration.

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. 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. Recognizing these vulnerabilities when patients with Parkinson’s are admitted to hospitals is a first step in preventing complications, minimizing hospital lengths of stay, and avoiding functional deterioration.

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

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)

http://www.biomedcentral.com/1471-2377/12/13

Ersan T. Perioperative Management of the Geriatric Patient. Medscape Reference. Updated: June 20, 2011

http://emedicine.medscape.com/article/285433-overview

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