S5E2: Parkinson’s Disease in the ED - Geriatric EM
Welcome back to another episode of TheCase.Report! In this episode we dive into all things Parkinson’s disease (PD) with 3 of our finest NCHDs - Liam Loughrey, Sarah Daubaras and Conor O’Gara.
They keep their differentials broad as they work up and diligently manage a 78-year-old man presenting with an acute behavioural change on a background of PD. This episode is bursting with clinical pearls as we discuss what to consider and what not to miss in PD patients. It’s not one to miss!
We’re delighted to have Dr Barry Keane, Consultant in Emergency Medicine at St James’s Hospital join us this month as our Adult in the Room. With a fellowship in Geriatric Medicine under his belt there is no one better to correct our homework and offer some pearls of wisdom into the complexities of Geriatric Emergency Medicine, and Parkinson’s Disease in the ED. He kindly lends us some GEM tips. Not to brag, but he gives us a pat(ch) on the back from the outset, so we were pretty happy about that!
As always, sincerest thanks to IAEM for making this podcast possible! And join in on the conversation on X, instagram and facebook. Without any further ado, let’s get stuck into our Geriatric Emergency Medicine (GEM) case!
So, where to begin with this patient?
As with all patients presenting to the emergency department, we want to have a good structured approach to our assessment and we’ll always start with our ABCs. Once we’re happy that we’ve addressed and managed each point we’ll move onto getting a full history. Getting a good collateral history in these patients is so important so if a family member isn’t in attendance pick up the phone!
In Parkinon’s patients getting an accurate list of their regular medications is absolutely crucial - and if a patient doesn’t have this on them you need to move mountains to get it - call their next of kin, pharmacy or GP.
And of course completing your assessment with a full examination is key.
As touched on in our episode from season 1 on Delirium, always perform a quick 4AT and consider whether this patient may have a delirium. With associated longer inpatient stays, higher risk of complications and higher mortality, it's critical that we recognise and treat delirium in the emergency department. Early detection and identification of delirium can aid the patient’s prognosis. Dr Barry Keane, our AITR, acknowledged how a presentation akin to this is quite difficult to manage and takes time to thoroughly go through.
The perfect delirium storm
From our structured approach we complete a thorough assessment and see how a seemingly benign gastroenteritis snowballs from missing sinemet doses and developing an aspiration pneumonia, to the patient receiving metoclopramide, all culminating in an acute delirium. Delirium is a medical emergency.
“If you don’t screen for it, you won’t catch it”
In patients like these with multiple factors leading to their presentation it’s important to identify each problem and manage them appropriately. It’s always useful to create a problem list and Conor sums it up nicely for us in this case:
Gastroenteritis
Likely missed sinemet doses due to vomiting.
Aspiration pneumonia - Parkinson’s patients are at a higher risk of aspirating and we know this patient had been vomiting the last few days.
Given metoclopramide - This can precipitate neuroleptic malignant syndrome.
Delirium - This patient is scoring an 8 on the 4AT. Think of our PINCH ME, SMASHED and DELIRIUM mnemonics from season one. This patient is likely dehydrated, fighting an infection, has missed doses of his regular medications, received contraindicated medications and is now in a change of environment.
Management
PD makes everything more complex for these patients and their potential to get really sick, really quick is higher. We need to be prompt! We order the appropriate investigations revealing a WCC of 16, CRP of 84 and a left lower zone infiltrate on the chest x-ray confirming our suspicion of an aspiration pneumonia. We don’t waste time and administer some antibiotics.
The next item on our agenda is making sure Patrick gets his Parkinson’s medications and doesn’t miss any further doses.
The key element of this case was focusing on the medications. It is essential to replace dopaminergic drugs, noting specifically in this case, our patient could not eat or drink and was potentially too confused to take his medications so this may have affected absorption / administration of medications to begin with. When considering nasogastric tube versus patch application for administration of medication, Dr Barry Keane, our AITR, agrees with the choice of a patch. He acknowledges that the NG might make the patient more agitated in this case.
Parkinson’s medications are complex and specialist - how do we even start to work out the correct doses to give him?
Parkinsonscalculator is an easy to use resource for these exact situations. It helps us calculate Nasogastric or rotigotine patch doses from their normal Carbidopa / Levodopa oral doses. It even takes delirium into account and provides an adjusted lower dose. Again, stressing the importance of identifying delirium early in these patients' care with the 4AT screening tool! This patient gets admitted but makes a quick recovery and is discharged on day 5. His gastroenteritis resolves, pneumonia clears and the rotigotine saves the day getting back on top of his Parkinson's symptoms! He also gets a review from a PD nurse specialist while on the wards.
Dr Keane, agrees with the use of the OPTIMAL calculator, given its built-in correction factor, (the consideration for potential delirium or dementia) and there is less guesswork using it. However, he also notes the PD Med Calc which can be used, caveating that it will not provide a suggested dose. It is important to also consider that some patients can be quite sensitive to high dose patches or they can be dopamine naive, therefore consider the potential to require decreasing dosages and looking to our general medicine and geriatric medicine colleagues for more specific advice.
““Patch on the back … Really clever!””
The addition of applying the patch on the back is noted as a clever ploy by Dr Keane. In our situation, the patient is agitated and the application out of sight reduces the likelihood that it will be pulled off during periods of agitation.
Well done to our TCR NCHD’s for expertly managing this case!
Our love for receptors at TheCase.Report remains as strong as ever.
With this love in mind lets recap over some of the pathophysiology behind Parkinson’s disease.
The symptoms in PD come from an imbalance in dopamine and acetylcholine. This is due to the destruction of the dopaminergic neurons in the substantia nigra at the basal ganglia.
The vast majority of medications that treat PD will target dopamine pathways by
Replacing dopamine with synthetic analogues
Binding to the dopamine receptors
Preventing the breakdown of dopamine either centrally or peripherally
Parkinson’s Disease medications by class
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Description Example: Sinemet - a combination of levodopa and carbidopa
MOA: Levodopa is a dopamine precursor that crosses the blood brain barrier (BBB), converts to dopamine and supplements low endogenous levels of dopamine. Carbidopa is a dopa decarboxylase inhibitor which enhances the effects of levodopa by preventing it being broken down peripherally (before it crosses the BBB)
S/E:
Can relate to having excess dopamine e.g. dyskinesias, choreiform movements
Postural hypotension, cardiac arrhythmias, psychosis
Disinhibitions e.g. gambling or sexual disinhibition or carelessness with money
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Examples: rotigotine, pramipexole, bromocriptine
MOA: Binds directly to dopamine receptors mimicking the effects of dopamine.
Side effects: Nausea, hallucinations and drowsiness. Note: Fibrosis is a side effect specific to bromocriptine in this class.
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Example: entacapone
MOA: Inhibits catechol-O-methyltransferase (COMT) preventing the breakdown of dopamine peripherally and increasing dopamine levels.
Other: Often co-prescribed with sinemet to increase on time and decrease off time.
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Examples: Rasagiline & selegiline
MOA: Inhibits monoamine oxidase-B (we recognise the irony that the MOA is to break down MOA-B), preventing the breakdown of dopamine centrally.
Other: Often co-prescribed with sinemet to increase on time and decrease off time.
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MOA: Releases dopamine from nerve endings in the brain with the addition of some norepinephrine response.
Other: Commonly used when people have been on levodopa for a long time and they begin to develop choreiform movements and dyskinesias.
Some super cool trivia: Used to be used to treat flu-A (some resistance has developed to its use since).
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Obtain an accurate drug history - Go to the ends of the earth/GP/pharmacy if the patient does not have their list with them.
Make sure that the medications are prescribed (Do NOT wait for the admitting team to do this for these patients). Regardless of their presenting complaint.
Avoid any drugs that will exacerbate their symptoms. These are typically anti-dopaminergic drugs. RCEM have a good mnemonic on their website for this “HARM”
Haloperidol
Antipsychotics
pRochlorperazine
Metoclopramide
If the patient has a poor swallow but has good absorption, can consider NGT (use calculator to get the correct dose).
For those who cannot have enteral medications - Rotigotine patch if NGT not suitable e.g. delirious patient
Resume their regular medication regime as soon as possible.
Liaise with a PD specialist at the earliest opportunity
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RCEM recommends domperidone as the antiemetic of choice in PD patients
Despite domperidone acting as a dopamine receptor antagonist it does not cross the BBB so it’s considered quite safe.
Don’t be afraid to ask for advice from your friendly geriatrician colleagues
Clinical tip: Always check an ECG first as it can prolong the QTc
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Dose and timing of PD meds is very specific to each patient.
It’s absolutely critical to make sure that patients get the right medication dose at the right timein the emergency department or we can exacerbate symptoms at best, or at worst we can precipitate neuroleptic malignant syndrome (NMS) if they abruptly stop levodopa.
If a PD patient comes in and they can’t take their medications this is an emergency and must be recognised as one, or else patients can decline very rapidly.
Use the British Geriatrics Society’s parkinson’s calculator to work out correct doses when switching from PO to NGT / rotigotine patch. It takes everything into account including if the patient is on both the patch and sinemet!
Complications of PD
Firstly, it is important to note that patients with Parkinson’s Disease (PD) don’t usually present with the disease itself but more so with the litany of complications that may arise from living with PD. It is important to be cognisant of these complications when meeting a PD patient. In addition to this, PD makes everything more complex and their potential to get really sick, really quick is higher.
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Falls are often multifactorial in PD patients.
The natural progression of PD affects motor function, balance, the autonomic nervous system and cognition placing these patients at higher risk of falling. This is further complicated by fluctuations in symptoms during the day based on their medication regime. Patients can suffer from orthostatic hypotension (OH) which can often be exacerbated during an acute illness.
Autonomic dysfunction leads to a high rate of falls and it's crucial to identify any causative factors.
TCR top tip: Do a Lying and Standing blood pressure (BP) on all of these patients, even those not presenting with OH.
This is an important screening tool for an important risk factor that could be mitigated and prevent falls down the line.
If OH is identified, all patients and carers should be given information and education on standard OH safety measures e.g. increasing fluid and salt intake and completing a medication reconciliation.
If symptoms are still persistent despite these measures, consider referring to local syncope unit or neurology team for full assessment +/- start on medications for this i.e., fludrocortisone or midodrine
As with all falls, it's important to do a full trauma assessment and assess for injuries from the fall. Tease out from the history how exactly the fall happened and consider linking in your EDs frailty intervention team or equivalent early. Early involvement with the FIT team can really boost these patients' quality of life, identify issues early and avoid prolonged admissions and all the associated complications we mentioned above.
Clinical pearl: How to accurately take a lying and standing BP
Lie the patient down and take BP and HR
Stand the patient up and wait for 1 minute before taking BP and HR
Stand for an additional 2 mins before rechecking BP and HR
Making sure that their HR rises appropriately and that their systolic BP doesn’t drop any less than 20mmHg at both checks and diastolic no less than 10mmHg at the 3 minute mark.
It’s important to remember that the most accurate way to assess for OH is by performing the tilt table test but lying and standing BPs is a good screening tool that we can use in the ED.
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This is a common complaint for PD patients and it is often under recognised and under treated.
In the patient presenting with acute abdominal pain and vomiting always have a high suspicion for sigmoid volvulus.
In patients in whom you suspect a potential sigmoid volvulus, carry out prompt routine bloods and VBG, looking carefully at the lactate and pH. Ultimately these patients need definitive imaging with contrast CT, and need to be managed urgently with aggressive fluids, analgesia and stomach decompression with an NGT while awaiting the surgical team's care.
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Always remember that Parkinson’s Patients are prone to delirium - keep family with them and keep them oriented in the ED. Use clocks and place them in quieter cubicles with natural light (a high visibility cubicle where available).
Revise some more simple measures that can reduce the risk of delirium in the ED as discussed all the way back in Season 1!Hallucinations
Up to 75% of PD patients will eventually experience visual hallucinations.These will generally be non-distressing for example, animals, little people and usually occur in evening time.
If someone is presenting to the ED with hallucinations always consider other causes
Infectious causes, changes to medications, delirium
If treating with medications, always remember to avoidhaloperidol in these patients.
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Neuroleptic malignant syndrome (NMS) is often related to neuroleptic agents and manifests classically as altered mental status, hyperthermia and rigidity. Current criteria however reflect a broader range of Autonomic Nervous System dysfunction and lab findings.
It can be a significant effect of rapid withdrawal of dopaminergic agents or as a rare adverse effect of taking dopamine receptor antagonists. Diagnosis is based on clinical courses and findings.
This is a neurological emergency and must be recognised and treated as one.
Management
The most important step is finding the cause and either removing the offending medication or rapid reintroduction of the missed medication.
Treatment is otherwise supportive with aggressive fluids, cooling packs to the groin and axillae and cooling blankets, remaining vigilant for aspiration pneumonia and remembering that these patients are at a higher risk of VTE and rhabdomyolysis so consider sending a CK level if felt to be clinically indicated.
Call ICU early for ongoing monitoring and management.
Frailty teams in the ED
Frailty teams are a really big asset to the emergency department, especially the involvement of the full MDT like OT, Physio, SLT, Nursing staff and Pharmacy. It is a great addition to the patient’s stay when the frailty team or equivalent in your department get involved at presentation and they are proven to reduce length of stay and reduce deconditioning throughout the patient’s hospital admission. Early input is key to these good outcomes and having the frailty team in the ED really enhances this. The Institute for for Healthcare Improvement (2016) discuss the 4M's of an age-friendly healthcare system:
Medications
Mobility
What Matters most to the patient
Mentation
The usage of this model, with the considerations of the patient to the forefront, aid a holistic approach to older patients. Delirium friendliness within the ED is not the easiest thing to do … but, there are things we can help with! Watch out for easy fixes, like delirium triggers such as constipation!
TCR take-home points
The most important thing is the PD medications. Make sure that they are available and prescribed. Under no circumstances do you leave this job to the admitting team!
The most important thing is to be methodical in your approach. Take your time, chat with family and keep the complications of PD in mind when assessing these patients. Small changes can make a huge difference!
Use the PD calculator when needed and always use the proper technique as discussed when taking a lying and standing BP.
PD patients have poor experiences in ED overall due to lack of recognition.
We can reduce the amount of investigations and subsequent testing we do for PD patients by ensuring we recognise how time-sensitive PD medications are.
Involve the family, they know all about their family members condition and meds.
Not only important clinically and for your patients but may also make an appearance on the FRCEM OSCE!
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PD Calculator (https://www.parkinsonscalculator.com/)
RCEM Learning provide a concise and detailed module
British Geriatric Society’s Silver Book II
CUH E-med Parkinson's Meds document
Diagnostic criteria for NMS https://www.researchgate.net/figure/Diagnostic-Criteria-of-NMS
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Main case:
Dr Sarah Daubaras
Dr Conor O’Gara (Main script lead)
Dr Liam Loughrey
AITR
Dr Barry Keane
TCR Innovation Team-Show notes / infographics / website design / social media
Dr Johnny Collins
Ms Sinéad Kelly
Dr Genevieve Callander
Dr Liam Loughrey
