Genko Oyama, MD, Michael S. Okun, M.D., University of Florida Movement Disorders Center
Parkinson’s disease (PD) is a common neurodegenerative syndrome and emergency room physicians and hospitalists may frequently encounter patients with PD. These patients may seek help at a hospital for a variety of reasons including bone fractures, cardiovascular/lung issues, and gastrointestinal problems. Recently, an emerging number of patients with PD have also undergone deep brain stimulation and these patients have been presenting to emergency rooms and hospitals for routine care (Resnick 2009). To date there is a paucity of evidence-based medical guidelines regarding the care of the hospitalized PD patient regardless of the reason(s).
Patel and colleagues recently reviewed previous publications concerning the potential hospitalization risks in PD patients. They described the risk of falling and cognitive dysfunction that may commonly result from among other things, postoperative delirium. Furthermore, they emphasized that the surgical risk may be higher in PD due to multi-organ manifestations of the disease, and due to unique medication requirements. Medication interruption in these patients can result in parkinsonism-hyperpyrexia syndrome, which is a serious and fatal complication characterized by severe rigidity and hyperthermia. These authors proposed recommendations based on the available literature, and they suggested that these may be helpful in managing PD patients during a hospital stay. The authors stressed the importance of consulting a neurologist or movement disorders specialist.
The review by Patel is well written and easy to understand, especially for general doctors and for allied health care professionals. The review is complete in listing the risks that may be encountered during hospital stays, and includes a discussion of the use of nasogastric tubes, the use of intravenous infusions, and the employment of other special techniques that may be unique to the PD population. For hospital-based physicians the authors stress that perhaps the most important key for medication management in the perioperative period is the continuation of dopamine replacement therapy (at typical doses if possible). In complex cases there may be a need for more in depth peri-operative care, (long OR cases, procedures involving the gastrointestinal tract, DBS, etc.) and neurological consultation may be critical.
Consensus guidelines are needed for PD hospitalization and should be established. An interdisciplinary team approach is probably best, but this will require an evidence base.
Swati G. Patel, MD, Chad R. Stickrath, MD, Mel Anderson, MD, and Olga Klepitskaya, MD, University of Colorado Denver, The Hospitalist, June 2010.
Resnick AS, Foote KD, Rodriguez RL, Malaty IA, Moll JL, Carden DL, Krock NE, Medley MM, Burdick A, Haq IU, Okun MS. The number and nature of emergency department encounters in patients with deep brain stimulators. J Neurol. 2010 Jan;257(1):122-31. Erratum in: J Neurol. 2010 Jan;257(1):158-9.