Parkinson's Disease in Acute Care

Introduction

This guidance highlights the importance of continuing Parkinson's disease (PD) medication and covers the first-line management of PD patients who have:

Nil by mouth status
Confusion / hallucination / agitation
Constipation / delayed gastric emptying
Dizziness and falls
Nausea and vomiting

Assessment / monitoring

It is crucial not to stop PD drugs for any significant length of time i.e. >2 hours or to miss any doses as there is a risk of Neuroleptic Malignant-Like Syndrome (Parkinson hyperpyrexia syndrome, PHS) which may be fatal. Symptoms include rigidity, pyrexia, and reduced conscious level. There may be features of autonomic instability, and serum creatine kinase (CK) may be elevated. Complications of PHS include acute renal failure, aspiration pneumonia, deep venous thrombosis / pulmonary embolism and disseminated intravascular coagulation.

General management

Prescribing and administration of PD medicines

It is important for PD medications to be administered at exact times. Annotate dose timings clearly on the prescription chart. It is recommended that levodopa should be taken within 30 minutes of its prescribed administration time (NICE guidance - Parkinson's disease 2018 [QS164]).

Location of PD medicines on acute sites

If the patient does not have an individual supply of their PD medication, access supplies via pharmacy or the local main holding areas of PD medications across NHSGGC. See the Parkinson's Disease Medication Stocklist, Acute Hospitals guideline for details.

If PD medicine is not available as above, contact pharmacy (see Appendix 6 for contact details) during working hours, or the on-call pharmacist outwith working hours, for supply.

Inform PD nurse specialist of all PD patient admissions.

Drug therapy / treatment options

Nil-by-mouth (NBM) patients

During working hours contact the PD specialist immediately, and a speech and language therapist if the patient has swallowing difficulties.

Outwith working hours, or if a PD specialist is not available, refer to the NBM algorithm. Additional information is provided in:

Table 1 - administration of PD medicines via enteral feeding tubes
Table 2 - conversion of oral dopamine agonist to rotigotine patch.

Confusion / hallucination / agitation

Only if necessary treat with benzodiazepine.
Avoid first generation antipsychotics e.g. haloperidol or chlorpromazine.
Refer to Management of Acutely Disturbed Patients, including Delirium.
Refer to PD specialist for assessment as soon as possible.

Constipation / delayed gastric emptying

PD medicines and PD itself may be associated with constipation / delayed gastric emptying.
Constipation / delayed gastric emptying may interfere with how well PD medications are absorbed, making them less effective.
Review need for drugs which can precipitate constipation or alter gastric transit time e.g. antacids, iron and calcium containing preparations.
Refer to Management of Constipation for therapeutic management.
Refer to PD specialist as soon as possible if PD symptoms are uncontrolled.

Dizziness and falls

Review need for drugs which precipitate postural hypotension or affect cardiac function e.g. anti-hypertensives, heart failure drugs, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, anticholinergics, acetylcholinesterase inhibitors.
PD medications and PD itself may be associated with orthostatic hypotension (check standing BP).
Refer to PD specialist for assessment as soon as possible.

Nausea and Vomiting

Use domperidone oral 10mg every 8 hours. Use for the shortest duration possible. The maximum duration should not usually exceed one week.
- Caution: Domperidone is associated with a risk of cardiac side effects. See the Drug Safety Update 'Domperidone: risks of cardiac side effects' for further information on contraindications. Avoid with other QT prolonging drugs or potent CYP3A4 inhibitors (see www.crediblemeds.org for further details). Consider alternatives in at risk patients.
Cyclizine oral/IM/IV 50mg every 8 hours (in elderly use 25mg) or ondansetron (unlicensed use) are also appropriate.
- Note: Ondansetron is contraindicated with the concomitant use of apomorphine. Ondansetron may prolong QT interval and may cause / worsen constipation - use with caution.
Avoid metoclopramide and prochlorperazine.
Note: Exercise clinical judgement on the applicability of this guidance to individual PD patients depending on their characteristics. Both risk and benefit should be considered, seek advice from senior if unsure.

Subcutaneous Apomorphine (for infusion)

All patients admitted to hospital on apomorphine should be referred to the PD nurse specialist or movement disorders team for advice as soon as possible.
See the NHSGGC monograph for maintaining 'Apomorphine Subcutaneous Infusion Treatment in Patients Admitted to Hospital'.
Apomorphine should only be instigated with the guidance of a prescriber experienced in PD (it is not suitable for emergency administration in a drug naive patient). If a patient is already established on this then it must be continued.

Co-careldopa intestinal gel (Duodopa^®)

All patients admitted to hospital on Duodopa® intestinal gel should be referred to the PD nurse specialist or movement disorders team for advice as soon as possible.
Refer to the NHSGGC monograph 'Duodopa^® Monograph for Maintaining Co-careldopa (Duodopa^®) Intestinal Infusion Treatment in Patients Admitted to Hospital' for information.
The Duodopa^® support helpline can be contacted if further advice is required and a PD specialist is not available.
Duodopa^® intestinal gel should only be instigated under specialist guidance. It is not suitable in an emergency situation as it requires the insertion of a percutaneous endoscopic gastrostomy with jejunal (PEG-J) tube. If a patient is already established on this then it must be continued.

Guideline reviewed: July 2022

Page updated: September 2022