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