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Parkinson’s Disease on AMU and the wards Dr Sally Jones Consultant 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 MSA Corticobasilar degeneration – – – – – Cerebrovascular Disease/basal ganglia infarct Drug induced NPH Functional/psychogenic Severe depression (causes psychomotor retardation) true dopamine deficiency 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 Patients with Parkinson’s Disease produce less dopamine Some PD medications replace L-dopa L–Dopa Dopamine Some PD medications stop dopamine breakdown Some PD medications mimic action of dopamine Dopamine receptors The message is passed on Some medications CAUSE parkinsonsism by blocking dopamine receptors Patients with Parkinson’s Disease produce less dopamine Some PD medications replace L-dopa: - co-careldopa (sinemet) - co-beneldopa (madopar) - duodopa Both levodopa combined with decarboxylase inhibitor. L–Dopa Dopamine Some medications CAUSE parkinsonsism “Dopamine Antagonists” - Phenothiazines - Stemetil - Metoclopramide - Some anti-histamines - most anti-psychotics Some PD medications stop dopamine breakdown - COMT inhibitors (entacapone) - MAO-B inhibitors (selegeline, rasagaline) Some PD medications mimic action of dopamine - Dopamine Agonists (ropinirole, pramipexole, rotigotine, apomorphine, amantadine) Avoid!!! 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 Reflection How 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 hypotension Nausea Hallucinations/delirium Diarrhoea with entacapone Motor 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 Deteriorating swallow Deteriorating mobility Deteriorating speech Deteriorating consciousness Aspiration pneumonia Falls Pressure ulcers Neuroleptic Malignant Synd. GIVE THE PD MEDICATION OR PD patient given a dopamine antagonist (eg stemetil, metoclopramide, risperidone, haloperidol) 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 PD History Recent abrupt discontinuation of PD medication Recently given dopamine antagonists (neuroleptics, stemetil etc) Recent infection/physiological insult? Signs Rigidity Hyperpyrexia Stupor Autonomic problems Dysphagia Lab findings Raised CK Metabolic Acidosis Raised WCC LFTs may be deranged Management GIVE THEIR PD MEDICATION (convert to NG if needed) Critical care – IV hydration, anti-pyretics, cooling, dialysis if needed Dantrolene 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 Pneumonia Swallow worsens NBM PD control worsens Swallowing problems & NBM in PD NEVER 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? Yes No Is the gut working and can you pass an NG tube? Either: Give usual PD meds with 10ml of water, yoghurt, custard, even if NBM for everything else Yes Urgent NG Tube 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. Contact doctor urgently to convert usual PD medication to dispersible Madopar. A stat dose of dispersible Madopar can be given if medication already delayed. No Rotigotine Patch Contact 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) Medicines not available in department? In hours: Contact ward pharmacist/pharmacy to obtain medication Out 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 PD Problem 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 dementia Lewy Body Dementia Often hallucinate and have perceptual problems Delirium PD patients are susceptible Exclude reversible contributers. Involve PD &RAID teams if concerns. NEVER give haloperidol or risperidone. Summary of Emergencies in PD PD related problem PD complicating other problems • • • • • • • • • • • • • • • • Neuroleptic Malignant Syndrome Aspiration pneumonia Postural hypotension Falls Volvulus Constipation/pseudo-obstruction Psychosis Severe motor fluctuations PD medication side effects Nil by mouth Iatrogenic medication issues Autonomic instability Mobility issues Delirium Nausea/vomiting Diarrhoea Golden Rule 1 Parkinson’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 2 Never 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?
