The Perfect Storm: When Parkinson Patients Enter the Hospital
JANUARY 15, 2019
Hooman Azmi, MD
Hooman Azmi, MDWhen a patient enters a hospital, regardless if it were in an elective or more urgent manner, the main focus of the care team is to address the chief complaint. Additional diagnoses, while important, may not get as much attention.
While this may not be detrimental to patients in most circumstances, it can be very impactful on patients who have Parkinson disease (PD). Studies have demonstrated that when patients with PD enter the hospital, they are more susceptible to developing hospital related complications. Patients with PD generally have a greater length of stay than those entering the hospital for the same diagnosis without PD, and can develop complications such as dysphagia, confusion and falls impacting their outcomes and increasing the LOS.
Awareness about PD and its treatment and implications are critical in ensuring reduced risks for this patient population. People with PD are very dependent on their medication and timing of this medication is critical to maintaining good symptomatic control. In the outpatient setting, the main goal of medication management for these patients is to provide as much ‘ON’ time as possible while minimizing side effects of the medications such as dyskinesias.
Burden of timing
ON time describes a period of time when the medications are working and symptoms are controlled. Patients with advanced PD may have difficulty with motor fluctuations where they go from the ON state to an ‘OFF’ state, where the medication effect has worn off and they are symptomatic. The fine tuning of the medication regimen is painstaking, and are often the result of many office visits and telephone calls to arrive at the best schedule customized for the patient.
This can often result in seemingly unconventional timings, and deviation from these regimens as minor as 15-minute delays can have deleterious effects on patients with PD as detailed above.
When patients with PD enter the hospital, attention to the exact timing of medication administration is often not made. If a patient takes a particular medication 6 times daily, ordering the medication 6 times daily in the hospital defaults to standard timings that often are different from the patients’ own regimen, causing timing errors. Almost 75% of PD patients who enter the hospital have delays in their medications, and more than 60% of these patients can have complications during their hospitalization because of these delays.
Other factors also contribute to worse outcomes in PD patients, including that many of the PD medications are not routinely carried in hospitals. Replacing a patient’s medication with seemingly similar alternatives that may be available at the hospital is not recommended, and indeed can be as detrimental as delays or omissions in medications.
Differing priorities of care
Also, several drugs used particularly in the hospitals, are contraindicated in PD patients. Some antiemetics such as prochlorperazine (Compazine) and metoclopramide (Reglan), and several antipsychotics have dopamine antagonist properties which worsen PD symptoms, and indeed administration of these medications can increase risk of hospital-acquired complications for patients with PD, and increase their lengths of stay.
The challenge that care providers face in hospitals in tackling these issues is compounded by the nature of why PD patients come to the hospital. The majority of PD patients that enter the hospital, do so for non-PD related issues. In fact, over 85% of patients come in for conditions completely unrelated to their PD, such as pneumonia, heart attack, gall stones and elective surgeries. Parkinson is often somewhere lost in the list of problems, and these patients are admitted throughout the hospital based on their presenting issues. Any effort to address the suboptimal care of patients with PD has to be hospital-wide, not unit-based.
Simple solutionsThere is hope, however, to address these shortcomings. Studies have shown that education can improve awareness for these issues. A hospital wide education program which addresses PD, its management, and the importance of timing of medications for this patient population as well as contraindicated medications is the cornerstone of any effort to improve the care of PD patients. This educational campaign needs to be hospital wide and continuous.
Ensuring that all or as many PD medications as possible are on formulary is very important. While these medications are expensive and may not be as commonly used as antihypertensive agents or hyperglycemics, substitution of the medication for an alternative which may be less expensive and is on the hospital formulary is not appropriate. The efficacy will be different for the patients, and giving the patient an alternative to what they are taking may be as detrimental as delays or omissions of their medications.
Working with different services to eliminate contraindicated medications from routine order sets for PD patients will also help advance this cause greatly. Education is a critical part of any protocol. Many different services come in contact with these patients and contraindicated mediations can be ordered. Direct discussions with the hospitalist groups, ER, and anesthesiologists among other departments are critical to ensure reduction in these errors.
But what may be the most important point is ensuring that PD meds are ordered in a custom fashion, and that general hospital medication schedule defaults are avoided. It is critical that the staff is educated to the importance of timing of medications, and that these medications are not just ordered as 4-6 times daily, but that they are ordered according to the actual time that the patient takes the medicine at home. Most EMRs have custom medication timing options, which should be encouraged.
We have instituted the above efforts at our own institution, and over time have experienced a reduced length of stay and readmission rate for patients with PD. More importantly, it has enabled us to better care for this vulnerable patient population.
It’s important to note that The Parkinson’s Foundation provides an excellent resource for patients with PD who are going to the hospital, as does The Aware in Care program for both patients and healthcare providers. The kit provides information enumerating the importance of medication timing, avoidance of contraindicated medications and educational points regarding Parkinson disease that patients can share with their health care team, aimed to address the knowledge gaps that are present for the care of PD patients.
Hooman Azmi, MD, FAANS, is the director of the Division of Functional and Restorative Neurosurgery at Hackensack University Medical Center in New Jersey and the co-author of Parkinson's Disease for the Hospitalist: Managing the Complex Care of a Vulnerable Population. The piece reflects his views, not necessarily those of the publication.
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