Parkinson's disease - inpatient management (inc nil by mouth) (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Parkinson’s is a neurological disease affecting mobility, mood and the autonomic nervous system. It can have an impact on movement and function, mental health and other ‘non motor’ aspects in varying amounts between different individuals.

Unfortunately it 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.

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. See Comprehensive Geriatric Assessment.

Medication: ensure good concordance pre-admission and maintain this throughout admission.

Elective and unscheduled admissions

  • It is important that Parkinson’s medications are given in hospital 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.

Note: If compliance of Parkinsons’ medicines is not achieved this will impact on mobility, swallowing, communication, feeding independently, mood and anxiety, along with general function in ADLs.

Medications which can worsen Parkinson’s or cause delirium

  • metoclopramide, prochlorperazine, promethazine, codeine, tramadol, antipsychotics ie haloperidol
  • caution with anticholinergics ie oxybutynin, cyclizine, chlorpheniramine (see Scottish Polypharmacy Guidance 2015, Section 3.1 Anticholinergics)
  • be aware that hypotension/postural hypotension is common as part of the autonomic dysfunction in Parkinson’s  which may allow the reduction or discontinuation of antihypertensives

Management of nausea

  • use domperidone, after ECG completed
  • ondansetron can be used, but is associated with severe constipation and caution 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 issues
  • urinary difficulties
  • constipation
  • saliva control, swallowing difficulties
  • hypotension.

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

Surgery

Place patients first on operating list where possible, ensure usual morning medication given.

Post-operatively it is important to consider the need for early physiotherapy, hydration and nutrition, along with a healthy bowel habit.

Advanced treatments for Parkinson’s

DBS advice

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 advice

Apomorphine is a potent dopamine agonist given by subcutaneous injection. There are small numbers of people where it is prescribed either in bolus form or with a pump. It is not normally used in the short term as a replacement therapy. Seek advice from relevant Parkinson’s team regarding this.

Duodopa®

Intrajejunal levodopa infusion – frequent difficulties with equipment failure/tube dislodged. 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.

Other complications associated with Parkinson’s

Falls relate to many issues including postural instability, freezing, postural hypotension, OA , cognitive deficits. Physiotherapy input is important; walking aids may or may not be relevant.

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

Dyskinesia: this may be normal for patient, it may indicate that they are receiving higher doses of medication than normal, or absorption of medicines is different.

For Parkinson’s patients who have impaired oral intake

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 SALT and Dietetics teams

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

Advice is given below as to:

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

Parkinson’s Nurse Specialist ext 6378, Medicine for Elderly ext 5471/5751 or Neurology Secretaries ext 6229/6613.

Impaired oral intake advice for patients with Parkinson's

The conversions below are estimates and clinical review of patients is always necessary to achieve maximal benefit of medication.

Advice for patients prescribed both dopamine agonists and levodopa therapy

Refer to Optimal calculator.

The patient’s normal Parkinson’s team should be notified of their admission within 1 working day if following this advice. Review rotigotine patch after 72 hours at the latest, and consider if return to routine medication achievable. Do not discharge from hospital on Rotigotine patch if new prescription, unless PD team aware. Contact either Sharon Sutherland, Parkinson’s Nurse Specialist ext 6378, Medicine for Elderly Secretaries ext 5471/5751; Neurology Secretaries ext 6229/6613.


OPTIMAL calculator - http://www.parkinsonscalculator.com/

  • Rotigotine patches, round to nearest 2mg (to max of 16mg) and prescribe as 24-hour patch.
  • Patches available as 1mg/2mg/3mg/4mg/6mg/8mg strength. More than one patch can be applied. DO NOT cut patches.
  • These formulations will have slightly different bioavailability and therefore effect: Parkinson’s team will advise further.
  • MAOIbs such as rasagiline and selegiline can be withheld for short periods of time if necessary.

Editorial Information

Last reviewed: 30/04/2024

Next review date: 30/04/2024

Author(s): Neurology Department .

Approved By: TAM subgroup of ADTC

Document Id: TAM283