Hospitalizations Can Place Parkinson Disease Patients at Risk
One third of all patients with Parkinson disease (PD) visit an emergency department or hospital each year (Hassan et al., 2012). The disease affects about 1 million people and is currently the 14th leading cause of death in the United States. Patients with PD require strict adherence to an individualized, timed medication regimen of antiparkinsonian agents. Dosing intervals are specific to each individual because of the complexity of the disease. It is not unusual for patients treated with carbidopa/levodopa to require a dose every 1 to 2 hours. When medications are not administered according to the patient's unique schedule, they may experience an immediate increase in symptoms. Delaying medications by more than 1 hour can cause worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating (National Parkinson Foundation [NPF], 2012b). Studies show that three out of four hospitalized patients with PD do not receive their medications on time, or have doses entirely omitted (Derry et al., 2010).
According to the NPF (2012b), 70% of neurologists report their patients do not get the medications they need when hospitalized. Surgical procedures can be particularly risky for patients with PD. Antiparkinsonian agents have been inappropriately withheld because patients were NPO for surgery, and surgical patients have been given a contraindicated anesthetic agent, or a centrally acting antidopaminergic drug such as haloperidol, metoclopramide, or prochlorperazine, postoperatively. One in three patients with PD has been prescribed contraindicated drugs during hospitalization. Serious complications, mostly neuropsychiatric, have occurred in more than half of these patients (Derry et al., 2010).
Two Case Examples
The first case reported to Institute for Safe Medication Practices involved a woman with PD who was admitted to a hospital with a urinary tract infection. The patient told the nurse she needed her medications right away, but she had been uncertain about the dose of some medications, and it took several hours to collect this information. Once ordered, the medications were scheduled using the hospital's standard administration times. However, for patients with PD, it is safest to administer antiparkinsonian drugs according to the scheduled times the patient takes the medications at home (Derry et al., 2010; NPF, 2012b). In this case, the patient received all her antiparkinsonian medications several hours late. While awaiting the medications she found it hard to talk and communicate with hospital staff and her family. Her tremors intensified and she had difficulty maintaining her balance. She became so confused and agitated that her physician ordered haloperidol 5 mg intramuscularly. The physician was not aware that haloperidol can worsen the symptoms of PD (Okun, 2012). The adverse symptoms worsened after receiving haloperidol, thus lengthening the patient's hospitalization. Later, when this patient required hospitalization for an elective surgery, the family selected a facility associated with the patient's neurologist, assuming the staff would be more knowledgeable about PD, but they ran into similar problems.
In another case, reported to NPF (2012b), a hospitalized patient with PD had surgery for a herniated disc. During the admission process, the patient's wife alerted the staff about the need to administer her husband's antiparkinsonian drugs exactly according to his schedule at home. She found staff were unaware of the need for timely drug administration and, thus had to repeat the warning with each shift change. When the wife was not by her husband's side, he did not get his medications on time. He was also prescribed and administered a contraindicated drug. The patient suffered significant hallucinations and was unable to communicate until his medications were readjusted to his schedule at home.
The loss of disease control at the hands of those who should be experts undermines the patient's faith in their healthcare team. Healthcare providers should consider the following recommendations to improve the medication management of hospitalized patients with PD.
Other Medication Safety Concerns
Even with correct medication timing based on the patient's home schedule, dosing errors have been reported with carbidopa/levodopa. The drug is available in many different strengths and forms. Levodopa, which converts to dopamine in the brain, can cause episodes of acute psychosis and dyskinesia when given in large doses, which can unnecessarily extend hospitalization. Also, patients may take different strengths of carbidopa/levodopa each time throughout the day, increasing the risk for errors. Even if well understood, documenting a complex schedule may be difficult and even more challenging in some electronic health records.
Expedited reconciliation. Establish an expedited medication reconciliation process upon admission for all patients with PD. Obtain an accurate list of medications within 2 hours of admission that includes the exact doses and timing of medications that the patient takes as an outpatient. Consider an automatic pharmacy consultation when patients with PD are admitted to assist with timely medication reconciliation. Some patients with PD have memory impairment, so family members who have close contact with the patient may need to be contacted. This may also require calling the patient's neurologist.
Build a unique schedule. Establish a method and process to create and communicate the patient's individualized medication schedule in order to control symptoms throughout the day. This requires clear communication between the patient care unit and the pharmacy so patient-specific schedules are not overridden with standard dosing schedules.
Avoid nonformulary delays. To the extent possible, ensure that your formulary provides common PD medications and doses so that drug administration is not delayed while the pharmacy obtains nonformulary medications.
Know the symptoms. Upon admission, obtain information regarding the patient's current symptoms, ability to carry out daily activities, and mental status as a baseline to observe for increasing symptoms potentially due to the effects of drug therapy.
Avoid contraindicated drugs. Some medications alter the brain's dopamine receptors causing symptoms, while others chemically interact with antiparkinsonian medications causing side effects. These contraindicated medications (e.g., dopamine blockers; older antipsychotics and antidepressants; certain antiemetics, pain medications, and anesthesia agents) should be avoided (NPF, 2012a). If the patient is taking selegiline or rasagiline, other medications must also be avoided, for example, meperidine, traMADol, methadone, mirtazapine, St. John's Wort, cyclobenzaprine, dextromethorphan, pseudoephedrine, phenylephrine, and ePHEDrine. There are alternative choices within these categories of medications that are safer to use for patients with PD.
Build alerts. Develop strategies to alert prescribers and pharmacists to drug-drug and drug-disease interactions. For example, develop a pop-up warning to alert prescribers and pharmacists when a contraindicated drug is ordered for a patient who is already receiving carbidopa/levodopa and/or selegiline or rasagiline.
Neurology consultation. Consider consulting the patient's neurologist or other specialist to evaluate antiparkinsonian medications to ensure safety. At a minimum, let the patient's neurologist know the patient has been hospitalized. Only 25% of neurologists are confident they would be contacted if their patients were admitted to the hospital (NPF, 2012b). If the neurologist is not consulted, require a clinical pharmacist or expert in PD to review the patient's medications on the first day of admission. If possible, generate a computer alert, triggered by the patient's diagnosis or prescribed drugs, to let the knowledgeable clinician know that a patient has been admitted, thus enabling their involvement early in the course of the admission (Derry et al., 2010).
Manage NPO status. If a plan to keep a PD patient NPO would interfere with the patient's unique schedule of medication administration, a neurologist or neurology team should oversee the medication regimen change to avoid complications.
Do not abruptly discontinue medications. Never abruptly discontinue antiparkinsonian medications. Serious reactions such as neuroleptic malignant-like syndrome can occur when antiparkinsonian medications are discontinued or the dose of levodopa has been reduced abruptly (Newman et al., 2009). This can result in a high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunctions that can be life-threatening.
Promote swallowing. When taking medications, patients should be asked to sit upright with their hips flexed at 90 degrees, and to remain sitting if possible for 45 minutes. They should also be encouraged to swallow twice after taking pills or drinking liquid (Okun et al., 2014). Do not crush or allow the patient to chew extended- or controlled-release medications (e.g., SINEMET CR).
Optimal surgery time. When possible, schedule surgery as early in the day as possible (8 a.m. to 9 a.m. is optimal) for patients with PD to promote best symptom management (Okun et al., 2013). Antiparkinsonian medications should be administered as close as possible to the patient's medication schedule pre- and postoperatively, and restarted immediately after surgery.
Focused education. Educate staff regarding the importance of timing with antiparkinsonian medications-that they must be on time, every time. Focusing education in particular areas such as the emergency department, orthopedic units, and key medical units may be the most effective strategy given that many units will have a low census of patients with PD (Derry et al., 2010). Identify when patient symptoms are not controlled/managed and consult the neurologist. Also remind staff to be alert to the risk of falls.
Patient education. NPF has an Aware in Care Kit that was developed for people with PD to help ensure they receive the best care possible during hospitalization. The kit includes a plan for hospitalization; a medical identification bracelet; a Medical Alert Card that states, "I have Parkinson's disease....I am not intoxicated," along with space for listing current medications and emergency contacts; medication forms; disease fact sheets; and more. The kit is FREE. Teach patients how to obtain their own Aware in Care kit by calling 800-473-4636 or visiting: http://www.awareincare.org.
Report adverse reactions. All adverse drug events or reactions that happen to patients with PD should be reported to the primary neurologist who is taking care of this patient because a dose adjustment, change to a different medication, or gradual discontinuation of a medication may be necessary (Hou et al., 2012).
ISMP thanksAmy Fox,PharmD, Candidate at Ohio Northern University, for providing the research and framework for this article. ISMP also thanksMohammed Aseeri,BS, PharmD, BCPS, FISMP, from King Abdulaziz Medical City-Jeddah in Saudi Arabia for contributing content to this article.
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