Numerous studies have shown that people with PD are hospitalized at higher rates and experience longer stays than those without PD, and as a group accumulate more inpatient days over their lifetime after the PD diagnosis (Aminoff et al., 2011). This was confirmed by an influential Canadian study, in which people with PD were hospitalized at a frequency 44% higher and for longer periods of time (21 days vs. 18 days) than people without PD (Christine, 2011b). However, little is known about what interventions may reduce the need for hospitalization or reduce complications related to hospitalization (Aminoff et al., 2011).
One issue with hospitalization of the PD patient is related to healthcare providers themselves. Because Parkinson’s disease is largely managed on an outpatient basis, often by specialists familiar with the course of the disease and its medical management, hospital-based healthcare providers may not have experience treating someone with PD. They may be unfamiliar with the symptoms of PD, with its complex medication regimens and medication contraindications. Additionally, the specialist responsible for a person’s outpatient care may not have privileges at the admitting hospital or may not be contacted by the hospital when their patient is admitted.
Confounding the picture, people with Parkinson’s disease are usually admitted to a hospital with medical problems unrelated or only partly related to their PD. An Australian study indicated that, among 716 parkinsonian patients admitted to the hospital, only 16% were admitted for reasons related to PD. The remaining admissions were for falls, pneumonia, cardiac disorders, genitourinary infections, gastrointestinal disorders, neoplasia, encephalopathy, syncope, stroke, and dementia (Aminoff et al., 2011).
Whether admitted for a reason directly related to PD or for another reason, the underlying medical and medication complications associated with PD can affect outcomes. A Danish study found that a substantial fraction of hospitalized PD patients deteriorate during their hospital stay (Gerlach et al., 2012).
Despite many hospital’s concerns about the quality of care provided to PD patients, most hospitals do not have proper guidelines in place to prevent worsening of PD symptoms and complications during hospitalization (Gerlach et al., 2012). Several studies have highlighted the need for better Parkinson’s disease training and, alarmingly, this is true even at hospitals designated as a National Parkinson’s Foundation Center of Excellence.
So what are the issues that affect outcomes for a patient with a PD? Among the most important is medication management, particularly related to dosages, schedule, and contraindications. Failure to follow the required medication schedule and regimen for PD patients can cause delirium, anxiety, or depression, and can profoundly and quickly affect mobility and increase the risk of falls. Medical issues related to PD also arise including increased risk of aspiration, hypotension, venous thrombosis, and infections.
In an emergency, PD patients are encouraged to go to the hospital where they are receiving care on an outpatient basis. But even when a PD patient is admitted to a hospital with a PD center, communication with the PD specialist is not always consistent (Chou et al., 2011). Only one-quarter of the participating National Parkinson’s Foundation Centers have a policy in their own hospital that triggers a contact from the hospital alerting the PD specialist a patient has been admitted. Moreover, many NPF Centers have yet to implement a systematic process of patient education and engagement in the hospitalization process. Only 61% of NPF Centers reported that they instructed patients to contact their PD Center if presenting to an ED (Chou et al., 2011).
Risk Factors for Deterioration in Hospital
A survey of 684 PD patients in the Netherlands sought to assess the prevalence and risk factors associated with deterioration during hospitalization. Of the patients surveyed, almost one-fifth had been hospitalized in the past year. Traumatic injury, infections, direct PD-related problems, and problems with circulatory and digestive systems were the main admission reasons, which accords with the literature. As in previous studies, confusion and infections were the most common complications during hospitalization (Gerlach et al., 2012).
Several studies have documented high rates of incorrect medications given to hospitalized PD patients—some as high as 74%—and this was found to be associated with deterioration to varying degrees. In the Netherlands survey, having had surgery or not did not matter in terms of medication distribution problems or complications. Somewhat unexpectedly, neurology wards do no better than other wards; there was no statistically significant difference among wards regarding problems with medication distribution, complications, and PD deterioration. Second to medication distribution problems, infections were significantly related to PD deterioration (Gerlach et al., 2012).
[This section taken largely from Aminoff et al., 2011.]
The failure of hospital staff and hospital pharmacies to provide Parkinson’s medications on the precise schedule needed for the medications to be effective is one of the most pressing problems facing those with PD when admitted to the hospital. Hospitals often place PD patients on standard medication order sets without consideration of contraindications. As a result, a person with PD is at higher risk for complications and even death due to issues that arise from their care in the hospital.
Certain medications should be avoided because they are contraindicated in those with PD. If a PD patient becomes confused while in the hospital, consider urinary or lung infections, pain medications, or benzodiazepines as the potential cause. In cases of prolonged confusion, where an antipsychotic is necessary:
Best Options for Prolonged Confusion
- Quetiapine (Seroquel)
- Clozapine (Clozaril)
These two drugs minimally affect Parkinson’s symptoms.
Drugs to Avoid
- Haloperidol (Haldol)
- Risperidone (Risperdal)
- Olanzapine (Zyprexa)
- Aripiprazole (Abilify)
- Ziprasidone (Geodon)
Safe Options for Nausea
- Trimethobenzamide (Tigan)
- Ondansetron (Zofran)
Drugs to Avoid
- Prochlorperazine (Compazine)
- Promethazine (Phenergan)
- Metoclopramide (Reglan)
These drugs can worsen PD symptoms.
Do not mix selegiline or rasagiline (MAO-B inhibitors) with meperidine because the combination can cause a serious reaction characterized by blood pressure fluctuations, respiratory depression, convulsions, malignant hyperthermia, and excitation. Do not stop carbidopa/levodopa or amantadine abruptly—this can lead to neuroleptic malignant-like syndrome.
In cases of PEG or NG tube administration of crushed medication, give at least 1 hour prior to meals, and be aware that controlled-release (CR) formulations may not work as well due to reduced bioavailability and other factors.
Protein may interfere with carbidopa/levodopa absorption. There is a dissolvable form of carbidopa/levodopa (Parcopa) that may be useful in some patients, but despite its ability to dissolve in the mouth it is not orally absorbed. To avoid or reduce protein interference with absorption, give levodopa 1 hour prior to meals or 2 hours after.
Patients and family members are urged to be proactive by bringing a copy of their medication schedule and dosages when they are admitted to the hospital and to make sure this information is included in the doctor’s orders. Patients and family members are also encouraged to talk to the nursing staff about the importance of adhering to the schedule provided and to remind the staff that failure to keep to the schedule of medications can result in motor and cognitive problems.
Patients should bring their medications from home in their original bottles, so they can be used if the hospital pharmacy does not stock a full spectrum of PD medications. The medications brought from home should be given to the nursing staff so they can administer the medications according to the orders provided by the doctor.
Increased Risk for Aspiration
Aspiration is an issue in the hospitalized PD patient and can be exacerbated when medications are not given on time (Christine, 2011b). Aspiration increases the risk of pneumonia, which is the most commonly reported cause of death in those with PD (Aminoff et al., 2011). Aspiration can be reduced by:
- Changing the consistency of food
- Teaching chin-down swallowing
- Teaching expiratory muscle strength training (Aminoff et al., 2011)
Mobility, Falls, and Fractures
A physical therapy evaluation should be initiated so that hospitalized PD patients can be up and moving as quickly as possible. Interdisciplinary training is critical to improve outcomes through prevention and better management (Christine, 2011b).
Falls and fractures may be the reason for admission to the hospital but can also occur after admission. People with PD often have limited mobility and are at increased risk for falls. Poor medication management in the hospital can lead to increased tremors and rigidity and adversely affect balance.
Other Medical Issues
[This section taken largely from Aminoff et al., 2011.]
There are a number of medical issues that affect the hospitalized PD patient more acutely than those without PD. Delirium and encephalopathy (can occur as a result of hospitalization itself—being in an unfamiliar place), infections, changes in medications, changes in the environment, the lingering effects of anesthesia, or pre-existing dementia.
Orthostatic hypotension is common in those with PD and should be closely monitored. Orthostatic hypotension can be treated with reductions of anti-hypertensives, increases in circulating blood volume via intravenous fluids, oral intake, increases in salt intake (salt tablets, diet changes) or fludrocortisone, or increases in arterial pro-contraction drugs such as midodrine or possibly pyridostigmine. Nighttime head elevation and tight thigh-high stockings should also be considered.
A person with PD may be hospitalized as a result of psychiatric problems, including psychosis, anxiety, or depression. For psychotic patients with PD, only two medications—quetiapine (Seroquel) and clozapine (Clozaril)—have been shown in double-blind placebo-controlled trials to not worsen motor dysfunction in PD.
Anxiety should be evaluated to determine if it is generalized anxiety or anxiety related to the wearing off of medications. Depression in PD has been shown in double-blind placebo-controlled studies to benefit from tricyclics as well as SSRIs. Tricyclics in low dose were better tolerated than expected in the PD population (Aminoff et al., 2011).
Perceptions of Hospital Care
A 2010 online survey of fifty-four National Parkinson’s Foundation Centers of Excellence asked a respondent from each center about his or her perception of care when a patient being followed on an outpatient basis is admitted to their hospital. Survey respondents reported several key issues associated with the care provided to PD patients who are hospitalized. Respondents reported a lack of understanding and awareness of Parkinson’s disease, even in the best hospitals, and, somewhat surprisingly, reported that many hospital pharmacies do not stock the full array of PD medications (Okun & Hassan, 2012).
Respondents also noted a lack of awareness among hospital-based healthcare providers that medication timing is critically important in PD. According to the respondents, healthcare providers also lacked the understanding that many common medications for pain, nausea, depression, and psychosis are contraindicated therapies and unsafe for people with PD. For example, anti-emetics such as metoclopramide (Reglan, Metozolv ODT) and prochlorperazine (Compazine) can worsen the symptoms of PD; and, that Clozapine (Clozaril) and quetiapine (Seroquel) are preferred over other antipsychotics. Finally, in the opinion of the survey respondents, hospital-based healthcare providers lacked awareness that poorly managed PD patients might experience mental confusion and other serious symptoms (Okun & Hassan, 2012).
NPF Aware in Care Program
The National Parkinson’s Foundation has designed a program to guide people with PD who are admitted to the hospital. Called Aware in Care, the program promotes best practices by supporting both the patient and the healthcare organization. They recommend that patients create a hospitalization kit that contains:
- Aware in Care materials and extra bottles of Parkinson’s medications
- A hospital action plan that provides instructions for a hospital stay
- A Parkinson’s disease ID bracelet
- A Medical Alert card
- A list of medications currently in use