Parkinson's disease (Guidelines)

Key Points for referral of person suspected to have Parkinson’s

• Refer people with suspected Parkinson’s disease (PD) early, before beginning treatment, to a clinician with relevant expertise, who should be involved in both initiation and ongoing monitoring of drug therapy.
• All patients given a diagnosis of Parkinson’s disease should have an early referral to the Parkinson’s nurse team.

• Therapy for PD should be multi-disciplinary; drug treatment is only one aspect; physiotherapy, speech and language therapy, occupational therapy, pharmacy and other disciplines may be involved.
• Drug treatment of PD aims to alleviate the symptoms whilst seeking to reduce the potential to develop dopaminergic complications.
• A clinician with expertise in PD should be involved in drug treatment decisions on the initiation and ongoing monitoring of therapy as the disease progresses. Drugs used in the treatment of PD are detailed in the Highland Formulary.
• Tremor generally responds poorly to most drugs. Expectations need to be created at the outset.

Parkinson's disease is associated with an increased risk of complications for inpatients and an increased length of stay in hospital, which can be averted with good care.

Medication

• In hospital, it is important that Parkinson’s medications are given at the times patients take them at home.
• The drug prescription chart should reflect patients’ usual drug timings rather than the hospital drug round timings.
• Parkinson’s medicines need to be prescribed as the correct preparation and dosage, as well as at the correct timing. MR, IR, and dispersible preparations are available.
• Sometimes the use of an audible alarm for nursing staff may be an effective way to achieve compliance, if medicines are to be administered out with routine hospital drug round timings.

Medication that can worsen Parkinson’s or cause delirium:

• Metoclopramide, prochlorperazine (Buccastem®), promethazine, codeine, dihydrocodeine, tramadol, antipsychotics e.g haloperidol
• Caution with anticholinergics e.g. oxybutynin, cyclizine, chlorpheniramine. See Polypharmacy guidance: Anticholinergics | Right Decisions

Blood pressure

• Be aware that hypotension/ postural hypotension is common as part of the autonomic dysfunction in Parkinson’s. This may require the reduction or discontinuation of antihypertensives.

Management of nausea

• Consider reason for nausea; medications and constipation are often involved.
• The choice of antiemetic is limited because of adverse effects.
  • Domperidone could be used after ECG completed.
  • Ondansetron may be indicated depending on the cause of the nausea but is associated with severe constipation. It is contraindicated in patients prescribed apomorphine and used with caution in patients with cardiac issues.

General care

In people with Parkinson’s be aware that there is a higher risk of:

• Delirium, especially if it has occurred before. If it develops look for common triggers: constipation, urinary retention, infection, pain, medication changes.
• Swallowing difficulties and excess salivation
• Orthostatic hypotension
• Urinary difficulties
• Constipation

Acute deterioration of Parkinson’s symptoms suggests acute illness, missed medication or new medication acting as dopamine blockade.

Other complications associated with Parkinson’s

Falls 

• are multifactorial, and can relate to many issues including postural instability, freezing, postural hypotension, osteoarthritis and cognitive deficits.
• Physiotherapy input is essential; walking aids may or may not be relevant.
• A medication review after a fall is required. Post-fall medication review (Guidelines) | Right Decisions

Neuroleptic malignant syndrome 

• may occur on withdrawal of medication or if medication is missed.
• It can present with delirium, (either hyper or hypo-active) rigidity, fever, and dysautonomia (tachycardia, fever, hypertension or labile BP, sweating).
• CK may be elevated.
• It can be fatal.

Dyskinesia:

• involuntary movements which may be normal for a patient.
• It may indicate that they are receiving higher doses of medication than normal, or absorption of medicines is different.

Surgery

• Consider duration of surgery and consequences of missed doses and when oral medication can resume.
• Pre-assessment: consider medication compliance and whether temporary use of a rotigotine patch to cover period of surgery is required.
• Post-operatively: it is important to consider the need for early physiotherapy, hydration and nutrition, along with a healthy bowel habit.
• Medication: ensure good concordance pre-admission and maintain this throughout admission.
• Elective admissions: It is important to consider how to maximize an individual’s health pre-admission. This should take consideration of a general medical review, including nutrition, hydration, mobility and function, and cognition. 

Seek advice from the relevant Parkinson’s team, as required.

Deep Brain Stimulation (DBS)

• Deep Brain Stimulators are used in people with Parkinson’s and sometimes severe tremors. MRI scan is contraindicated.  Monopolar diathermy has been used with caution in patients with a DBS implanted, see manufacturer’s advice. (Heating of electrodes may occur and has resulted in 2 documented cases of severe neurological damage with coma.)

Apomorphine

• Apomorphine is a potent dopamine agonist given by subcutaneous injection. There are small numbers of people where it is prescribed either in intermittent injection or with a pump. It is not normally used in the short term as a replacement therapy.
• If the patient is able to self-administer with their own pump, then this is the best option. If the patient is not able to self-administer, apomorphine runs in mL/hr and routine hospital pumps can be used at the same rate as pre-admission.
• Apomorphine is stocked in pharmacy, if the patient is not able to bring in their own. This is a time critical medicine so would require to contact the on call pharmacist if out of hours.
• Rotation of injection sites is routine to avoid skin reactions.

Duodopa^®

• Intrajejunal levodopa infusion. There are frequent difficulties with equipment failure/ tube dislodged.
• This is a non-formulary medicine that is not stocked at Raigmore Hospital. The patient will need to provide their own Duodopa^®.
• Continue at prescribed rate, providing gastric emptying is not delayed and the PEJ tube is patent.
• Individual patients should have their own protocols for conversion to oral medications if Duodopa^® is unable to be administered and they retain a safe swallow. Check recent clinic letters for dosing switch to oral medication.
• For patients who's Duopdopa^® system is not functioning, and who are unable to take medication effectively by the oral route, rotigotine transdermally can be initiated at a dose calculated from the PDmedcalc. The conversion will be from the dose of levodopa described on their clinic letter.

Produodopa^®

• Subcutaneous infusion of foslevodopa / foscarbidopa administered via pump over 24 hours. This runs in mL/hr, and routine hospital pumps can be used if a patient is not able to self-administer.
• This is a non-formulary medicine that is not stocked at Raigmore Hospital. The patient will need to provide their own Produodopa^®.
• Rotation of injection sites is routine to avoid skin reactions.
• Individual patients should have their own protocols for conversion to oral medications if Produodopa^® is unable to be administered and they retain a safe swallow - check recent clinic letters for dosing switch to oral medication.
• For patients whose Produodopa^® system is not functioning, and who are unable to take medication effectively by the oral route, rotigotine transdermally can be initiated at a dose calculated from the PDmedcalc. The conversion will be from the dose of levodopa described on their clinic letter.

Patients who are unwell may be deemed ‘nil by mouth’ if awaiting surgery or investigations, or their swallow may not be effective due to their Parkinson’s, an acute illness or general weakness and frailty.

Appropriate referrals should be made to the SLT and Dietetics teams

Every effort should be made to ensure that Parkinson’s medicines are NOT stopped abruptly.

Advice is given below on:

• How to switch from oral tablets or capsules to dispersible forms of Levodopa to be administered via nasogastric tube.
• How and when to convert to a transdermal dopamine agonist patch.
• To establish which medications are suitable to be given via a nasogastric tube, see section on 'Administration via enteral feeding tubes or for those with an impaired swallow'. 

Any patients undergoing a switch away from their normal medication should be referred to the relevant Parkinson’s team for a review within one working day of admission.

Advice for patients with no oral route available

1. If NG tube appropriate: see section on 'Administration via enteral feeding tubes or for those with an impaired swallow' and refer to the PDMedCalculator
2. If NG tube not appropriate: convert levodopa and dopamine agonists to rotigotine patch by referring to the PDMedCalculator 
3. Other Parkinson’s medication
   • MAOIbs such as rasagiline and selegiline can be withheld for short periods of time if necessary.
   • Opicapone is not essential in the acute situation and can be withheld.

Rotigotine patches

The conversions are estimates and clinical review of patients is always necessary to achieve maximal benefit of medication. In particular, people with delirium and dementia are likely to need lower doses to avoid worsening confusion.

• Prescribe as 24-hour patch.
• Round to nearest 2mg (to max of 16mg).
  • Patches available as 1mg/2mg/3mg/4mg/6mg/8mg strength.
  • More than one patch can be applied.
  • DO NOT cut patches.
• Review rotigotine patch after 72 hours at the latest:
  • Consider whether return to routine medication achievable.
  • If changing back to oral medication, remove rotigotine patch at the time of the next oral Parkinson’s medication.
• If new prescription, DO NOT discharge from hospital on rotigotine patch, unless PD team aware.

The table below gives information on changing medicines to an alternative formulation e.g capsules to dispersible tablets when the patient has a reduced swallow or if a feeding tube has been inserted.

• This is general information and may not apply to all patients. If necessary, seek advice from the prescriber, specialists or Medicines Information.

Administration by enteral feeding tube

1. Flush enteral feeding tube with 15 to 30mL water.
2. Crush and/or disperse tablet in 10 to 15mL water (or more if required).
3. Immediately administer dose using an oral syringe.
4. Rinse crusher, medicine pot and syringe with 10mL water and administer rinsing fluid.
5. Re-flush enteral feeding tube with 15 to 30mL water.
6. Flush tube between each medication and at the end.

• Use tap water to flush enteral feeding tubes.
• For administration beyond the stomach sterile water is advised.
• In fluid restricted patients revise the recommended flush volume to meet prescribed fluid restriction.

Notes:

• Always clearly prescribe the route of administration, eg ‘crush tablet and give by nasogastric (NG) tube’.
• Crushing or dispersing non-dispersible tablets means that the medicine will be administered outwith the terms of its product license with liability being assumed by all those involved in the medicines administration process, including prescriber, dispensing pharmacist and nurses administering the medicine.
• Use tablet crushers designed specifically for this purpose, these can be obtained through PECOS system.
• Where tablets are dispersed ensure that the whole tablet content is rinsed from tablet crushers, medicine pots and oral syringes and administered to the patient.
• Poorly soluble, crushed tablets may pose an aspiration risk for patients with swallowing difficulties. Aim for a liquid with a uniform consistency.
• Crush or disperse tablets immediately prior to administration.
• The information in the table has been obtained from a variety of resources including the manufacturer, NEWT guidelines and Drug Administration via Enteral Feeding Tubes.

Covert medication is the administration of medication in a disguised form without the individual’s knowledge.  This is a clinical decision and should NOT be used for someone capable of deciding about medical treatment.  To avoid this, advise the individual that they are receiving their medication by NG, PEG, patch, etc.  If they do not have capacity or are unconscious this may need to be discussed with their welfare attorney or guardian. See Policy for the Administration of Medicines by Nurses and Midwives in NHS Highland.

Administering medicines via an enteral feeding tube or orally in patients with an impaired swallow

Notes: Problems with enteral administration of preparations containing levodopa (Madopar^®, Sinemet^®)

• Levodopa is absorbed mainly in the jejunum. Administering directly to the site of absorption (J or NJ) may result in unexpected drug levels and side-effects.
• High protein in the gut provided from enteral feed may alter absorption of levodopa and cause fluctuations in response to the drug. Drug administration should be consistent in relation to feed administration times.

• BP: Blood pressure
• DBS: Deep brain stimulation
• ECG: Echocardiogram
• IR: Immediate release
• MR: Modified release
• PD: Parkinson's disease
• SLT: Speech and language therapy