People with Parkinson’s disease (PD) know the huge difference missed medication dosages can add up to. In some cases, missed medication dosages can lead to complications such as falling and severe mood swings. The results of a study from the United Kingdom conducted by Derry and colleagues should serve as a wake-up call to hospitals around the globe. The study’s authors carefully examined surgical admissions to the Aberdeen Royal Infirmary over an 18 month period. A shocking 71% of Parkinson’s disease patients missed medication dosages. Roughly a third of them missed over 10% of their prescribed dosages. The authors estimated that 0.7 missed dosages occurred per patient per hospital day. Interestingly, in approximately 2/3 of the cases, no reasons were reported for missing dosages. Drugs that acted against Parkinson’s disease symptoms (e.g. dopamine blockers) were “prescribed in 41%, and administered in 22% of cases.”
My suspicion is that as eye-opening as this study’s results are, this likely represents “more of the norm” in hospitals around the world. This study should help us generate and launch educational programs and initiatives aimed at educating hospital staff, physicians, patients, and families about the care of the hospitalized Parkinson’s disease patient. The Parkinson's Foundation 2007 Summer Parkinson Report tackled this issue with an article by Chou and colleagues addressing the most frequently asked questions about Parkinson’s disease hospitalization. The article had “tear out style” checklists for hospital staff, as well as for patients and families. These types of educational materials need to readily available, and we as a Parkinson’s disease community need to advocate for the implementation of programs at every hospital claiming to be in the business of taking care of Parkinson’s disease patients.
There are both simple and complex issues that need to be addressed in managing a hospitalized Parkinson’s disease patient. One simple fix is to have the physician write the medication orders with specific times for medication administration. He or she should stress to the staff and to the staff leadership, the importance of medication timing to successful Parkinson’s disease management. Physicians and staff should be aware that abrupt withdrawal of dopaminergic medications could lead to a potentially life-threatening syndrome called neuroleptic malignant syndrome. Teams should also be aware that many anti-nausea drugs, many sedatives, and many drugs used to improve gastric mobility (e.g. phenergan, haldol, and metoclopramide) block dopamine receptors in the brain, and should not be given to the hospitalized Parkinson’s disease patient. Medication regimens can be complex to manage within the hospital setting, and a neurologist can help to smooth the transition between inpatient and outpatient care. A neurologist can help to make alternative recommendations for drugs, especially when pills cannot be taken by mouth. Therefore, the threshold for neurological consultation should be low. Finally, vigilance in identifying and treating urinary and lung infections especially early in their course, can help to decrease hospital based “confusional” states.
It won’t be easy to change the behavior of hospital-based physicians and their staff, but is possible through carefully designed and focused educational programs it is possible. The good news is that there remains a lot of potential for improvement in the care of the hospitalized Parkinson’s disease patient. I recommend to all of my Parkinson’s disease patients, and to their family members, to go ahead and step up and play the “educator role” when in the hospital. In the current absence of standardized educational programs for the care of the hospitalized Parkinson’s disease patient, families and patients actually have the best chance to effect a positive change, and to improve their own hospital-based management.
For more information:
Derry CP, Shah KJ, Caie L, Counsell CE. Medication management in people with Parkinson's disease during surgical admissions. Postgrad Med J. 2010 Jun;86(1016):334-7.
Kelvin L. Chou, M.D., Michael S. Okun, M.D., Hubert H. Fernandez, M.D., Diane Breslow, MSW, LCSW, Joseph H. Friedman, M.D. Five frequently asked questions about hospitalization for patients with Parkinson disease. The Parkinson Report, Summer, 2007
You can find out more about our National Medical Director, Dr. Michael S. Okun, by also visiting the Center of Excellence, University of Florida Health Center for Movement Disorders and Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life and 10 Breakthrough Therapies for Parkinson's Disease.