GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH PARKINSON S DISEASE (PD) ADMITTED TO HOSPITAL Record Type Clinical Guideline elibrary ID Reference No: CG 1813 Newly developed and approved Trust-wide Clinical Guidelines will be allocated an elibrary reference number following submission to relevant elibrary administrator. Reviewed Clinical Guidelines must retain the original elibrary reference id number. Version: Name of Approving Trust Committee / Forum / Body / Group Date of Approval V2 Coventry and Warwickshire Regional Parkinson s Disease Service Neuroscience QIPS meeting 17/11/14 QIPS 23/12/14 Pharmacy Review Date 01/10/2016 Expiry Date 01/01/2017 Author s Name, Title & email address: Reviewer s Name, Title & email address: Responsible Director s Name & Title: Department / Specialty: Target audience: Dr Lara Teare Consultant Neurologist Lara.teare@uhcw.nhs.uk Dr Lucy Strens Consultant neurologist Lucy.strens@uhcw.nhs.uk Dr Andrea Lindahl Consultant Neurologist Andrea.lindahl@uhcw.nhs.uk Dr Holger Allroggen Clinical Director Neurosciences Neurology All doctors managing patients with Parkinson s disease within the trust.
If printed, copied or otherwise transferred from elibrary, Trust -wide Clinical Guidelines will be considered uncontrolled copies. Staff must always consult the most up to date PDF version which is registered on elibrary. 1
Purpose of Record Key search words for elibrary To be read in conjunction with: Location of Clinical Guideline: (please state no more than 3 elibrary directories / sub directories to be saved in). Superseded Trust wide Clinical Guideline (if applicable): (Should this document completely override a previously approved Trust-wide Clinical guideline, please state full title and elibrary reference number and the document will be removed from elibrary) To ensure that in-patient management of PD conforms to national and best practice guidelines Parkinson s disease, PD, confusion, nil by mouth, dysphagia Guidelines for the out-patient management of PD Guidelines for the use of apomorphine in advanced PD Neurology N/A Version Title of Trust Committee/Forum/Body/Group consulted during the development stages of this Trust-wide Clinical Guideline 1 Coventry and Warwickshire Regional PD Service 1 Neuroscience QIPS forum Date 2
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Contents 1. SCOPE... 5 2. INTRODUCTION... 6 3. STATEMENT OF INTENT... 7 4. DEFINITIONS... 7 5. DUTIES / RESPONSIBILITIES... 7 6. DETAILS OF THE DOCUMENT...8 7. DISSEMINATION AND IMPLEMENTATION... 14 8. TRAINING... 14 9. MONITORING COMPLIANCE... 15 10. STAFF COMPLIANCE STATEMENT... 15 11. EQUALITY & DIVERSITY STATEMENT... 16 12. UHCW ASSOCIATED RECORDS... 16 13. REFERENCES AND BIBLIOGRAPHY... 17 14. EVIDENCE BASED REFERENCES... 18 15. APPENDICES... 19 4
1. SCOPE 1.1 This guideline provides evidence-based and best practice recommendations for the in-patient management of patients with Parkinson s Disease who are admitted to hospital. It is applicable to all UHCW staff who are responsible for the admission or management of patients with Parkinson s disease during their in-patient stay at UHCW. 5
2. INTRODUCTION 2.1 Parkinson s Disease (PD) is the second most common neurodegenerative disease in older people after Alzheimer's Disease. It is estimated that around 1 in 500 people have PD with 127,000 people in the UK living with the condition 1. The prevalence is increasing as the population ages. PD is a progressive condition causing not only movement problems but also a myriad of other non-motor problems including constipation, pain, urinary dysfunction, dysphagia, drooling, speech problems, depression, anxiety, dementia, psychosis, sexual dysfunction, sleep disturbance, orthostatic hypotension and hyposmia. The diagnosis and management of PD is complex and patients should be under the care of a PD specialist team 2. Diagnosis and out-patient management is covered in the Trust document 'Guidelines for the diagnosis and outpatient management of Parkinson's Disease' which can also be found in the UHCW elibrary. This guideline concentrates on what to do if a patient with PD is admitted to hospital. Patients with PD or Parkinsonism are hospitalised approximately one and a half times more frequently than non-pd patients and length of stay is on average 2-14 days longer 3. The commonest reasons for acute admission to hospital for patients with PD are falls, pneumonia, urinary tract infections, reduced mobility and psychiatric disturbance 4. Of course, people with PD are admitted to hospital for many reasons, often unrelated to their PD. However, if they are not managed appropriately on admission, this can lead to delayed recovery, delayed discharge and poor outcomes. Medication is crucial for the optimal management of PD. Omitting or incorrectly prescribing dopaminergic medication causes significant sequelae in up to 61% of patients 5 including dysphagia with increased risk of aspiration, worsening rigidity/tremor/bradykinesia, increased risk of falls and increasing dependence on nursing staff. PD medications must never be stopped suddenly as there is the serious risk of Neuroleptic Malignant-like Syndrome which can be fatal. Another common error when PD patients are admitted to hospital is for dopamine-blocking drugs to be prescribed. These can potentially worsen Parkinsonism and must be avoided. Patients who are admitted electively to hospital should be encouraged to contact their community PD nurse specialist (PDNS) prior to admission to discuss medication management during their stay. This guideline provides advice for medical and nursing staff to ensure patients with PD are managed appropriately from the time of admission to hospital. However, early referral to the PD Team is important so that specialist advice on complex management can be given. 6
3. STATEMENT OF INTENT 3.1 This guideline is intended as an aid to the management of patients with PD who are admitted to hospital for any reason. Recommendations are in line with national and best-practice guidance. Key messages include: Patients with Parkinson s Disease (PWP) should receive their medication correctly and on time to prevent the complications that can occur when medication is omitted. PD medication should never be stopped suddenly or withdrawn without specialist advice from the PD Team. Prompt management of dysphagia and confusion such that medication is not omitted can reduce length of stay and reduce complications. Dopamine-blocking drugs should be avoided and drug prescription charts checked. 3.2 Early referral to the PD Team for specialist advice is encouraged. Referral details are given in this document. 4. DEFINITIONS 4.1 PD Parkinson s Disease 4.2 NBM nil by mouth. 4.3 PWP patients with Parkinson s Disease. 4.4 CR controlled release 4.5 PR prolonged release 4.6 LED Levodopa equivalent dose 4.7 NGT nasogastric tube 4.8 PDNS Parkinson's Disease nurse specialist 5. DUTIES / RESPONSIBILITIES 5.1 All staff involved in the acute care of PWP should be familiar with these guidelines. 7
6. DETAILS OF THE DOCUMENT 6.1 Upon admission to hospital Upon admission to hospital PWP need to have their medication prescribed correctly. Omission of doses can cause worsening of PD control resulting in the patient becoming stiffer, having difficulty mobilising, cause or worsen dysphagia and cause distress. This is avoidable. Particular syndromes to be aware of include: Neuroleptic Malignant-like Syndrome: This may result from sudden withdrawal of dopaminergic medication. It is a medical emergency characterised by increasing rigidity, fever, hypertension, sweating, fluctuating level of consciousness, rhabdomyolysis (raised creatine kinase levels) and renal failure. It can be fatal so early treatment is essential: seek urgent advice from the PD Team. Dopamine Agonist Withdrawal Syndrome (DAWS): This may result from the withdrawal of dopamine agonist medication. It is characterised by depression, anxiety, fatigue, insomnia and autonomic symptoms (postural dizziness, sweating) 6. Seek urgent advice from the PD Team if you suspect either of the above syndromes. Steps to take on admission: Take a careful drug history and prescribe the patient s usual medication. If the patient is unable to tell you what their usual medication is then please check with the next of kin, GP or patient s pharmacist. If they are a patient seen in UHCW or St. Cross Hospital Rugby clinics check CRRS for the most recent clinic letter. Do not leave the prescription for the next day or next team to do. It is the responsibility of the admitting doctor to write the prescription. Prescribe the correct dose at the correct time. This is the time the patient usually takes their medication, not the times convenient to the ward. It is very important that medication is given at the correct time to prevent worsening of their PD. Patients with PD often take several doses of medication during the day and may take more than one dopaminergic drug. Ensure that nursing staff are aware of the prescription times as they may not occur at usual ward drug round times. Pill timers are available from the PD Team to assist nursing staff with complex drug regimes. Check the formulation of Levodopa is prescribed correctly. For example, Sinemet Plus and Sinemet CR contain different amounts of levodopa. Obtain medication as soon as possible from pharmacy or use the patients' own 8
medication to avoid doses of PD medications being missed. Do not stop PD medications! Do not alter PD medications without advice from PD Team. Do not prescribe any drugs with dopamine-blocking actions. These include antiemetics and anti-psychotics (eg Haloperidol, Metoclopramide, Prochlorperazine, Cyclizine etc). Domperidone or Ondansetron can be used if anti-emetics are required. Lorazepam can be used if sedation is required. Please refer to the PD Team for advice and particularly if: - the patient is on Apomorphine or Duodopa - the patient is confused, hallucinating, unable to swallow or is nil by mouth (see sections 6.3 and 6.4 below). During the hospital admission, monitor the patient regularly for: Orthostatic hypotension: record lying and standing blood pressures. Neuropsychiatric symptoms such as sense of presence, illusions, visual hallucinations, dementia, depression, anxiety. Constipation 6.2 Referral to the PD Team For any PD query between 9am and 5pm, please contact the PD nurse specialist or one of the PD consultants. If out of hours, please contact the neurology registrar on call (bleep 1281) or the neurology consultant on call. Parkinson s Disease Team at UHCW: Hannah Martin PDNS (Monday to Friday): Bleep 2382 Extension 24955 Dr Andrea Lindahl (Monday, Tuesday, Thursday): Bleep 1453 Ext 25216 Dr Lucy Strens (Monday, Tuesday, Thursday): Bleep 4222 Ext 25216 Dr Lara Teare (Monday to Thursday): Bleep 2647 Extension 25114 Dr Analiza Grubneac (Monday to Friday): Bleep 1905 Extension 25114 See Appendix 1: Admission of patient with Parkinson s Disease to UHCW or Rugby St Cross 6.3 The confused patient Contact a member of PD Team for advice. Confusion or agitation in a patient with PD can be due to co-morbid medical illness 9
(especially infection), side-effects of the PD medication itself or progression of the Parkinson's disease (ie development of PD dementia). If the patient is agitated or confused please do not prescribe Haloperidol, neuroleptics or any other dopamine-blocking medication. Rule out and/or treat medical causes of confusion eg infection, constipation, dehydration, hypoxia, metabolic disturbance etc. Please do not stop or withdraw dopaminergic medication without advice. Ensure that PD medications have been given correctly by checking the drug chart. In acute confusion consider oral lorazepam 0.5-1mg ( maximum dose 4mg in 24hours). 6.4 Dysphagia or Nil By Mouth situations This may be particularly relevant to surgical patients. If a patient with PD has a compromised swallow or is nil by mouth, they must still get their dopaminergic medication to avoid the complications of sudden withdrawal. Please contact the PD Team urgently if this is the case for medication advice. Patients will also require urgent assessment by speech and language therapy. A nasogastric tube (NGT) can be inserted (unless contraindicated) or other modes of drug delivery considered. Not all PD medications are suitable to be given via a NGT as, for example, they might not be water-soluble. If this is the case, the PD medications will need converting to equivalent daily doses of dispersible, transdermal or subcutaneous formulations. Suitable PD medications for patients who have an NGT or who are NBM include dispersible Co-Beneldopa (Madopar) or transdermal Rotigotine. Very rarely subcutaneous Apomorphine might be considered (see section 6.5.4 below). 6.5 Converting PD medications and calculating the levodopa equivalent dose (LED) If a patient has a NGT or is NBM, oral dopamine agonists can be converted to an equivalent dose Rotigotine transdermal patch. Oral levodopa preparations can be converted to an equivalent dose of dispersible Co-Beneldopa (Madopar). If a patient is strictly NBM and a NGT is not allowed or is contraindicated, either a Rotigotine transdermal patch (or rarely subcutaneous Apomorphine) can be used but please ask for advice from the PD Team before making any medication changes. Apomorphine should only be prescribed by a PD specialist - see section 6.5.4. 10
6.5.1 Dopamine agonists The non-ergot dopamine agonists available are Ropinirole, Pramipexole, Rotigotine and Apomorphine. Ergot-derived agonists are no longer used routinely due to their fibrotic sideeffects. Ropinirole and Pramipexole are given orally whereas Rotigotine is applied as a transdermal patch and Apomorphine given subcutaneously. Convert the total daily dose of oral dopamine agonists to an equivalent dose Rotigotine patch using the table below. For intermediate doses, round down to the nearest equivalent Rotigotine patch dose. Table 1: Converting oral dopamine agonists to Rotigotine Ropinirole (mg / day) Pramipexole (salt mg / day) Rotigotine (mg patch/24 hours) 2 0.375 2 4 0.75 4 6 1.5 6 8 2.25 8 12 3.0 12 16 3.75 16 24 4.5 16 6.5.2 Levodopa preparations There are several different levodopa/dopa decarboxylase inhibitor preparations available. The oral drugs can be immediate-release or controlled-release. Note that controlled-release preparations have reduced levodopa bioavailability compared to the immediate-release preparations (due to poor absorption in the gut). The oral preparations are Co-Careldopa (Levodopa/Carbidopa or Sinemet) and Cobeneldopa (Levodopa/Benserazide or Madopar). Co-Beneldopa also has dispersible preparations, useful for delivery via NGT. Stalevo is a combination drug containing Levodopa/Carbidopa/Entacapone. Duodopa is a preparation of Levodopa/Carbidopa only for delivery via a naso-jejunal tube (PD specialist prescription only). Calculate the total daily Levodopa equivalent dose (LED) by adding the amount of levodopa in the drugs given during a 24 hour period. Convert oral medication to dispersible Co-Beneldopa 11
using the table below and give at regular intervals throughout the day. Table 2: Converting from oral to dispersible levodopa Sinemet (Co-Careldopa) Equivalent Madopar (Co-Beneldopa) dispersible Sinemet 62.5mg tablets Madopar 62.5mg dispersible tablets Sinemet 110mg tablets Madopar 125mg dispersible tablets Sinemet 125mg tablets Madopar 125mg dispersible tablets Sinemet 275mg tablets 2 x Madopar 125mg dispersible tablets Half Sinemet CR 125mg tablets Madopar 125mg dispersible tablets * Sinemet CR 250mg tablets 2 x Madopar 125mg dispersible tablets * * When switching from controlled-release levodopa to Madopar dispersible a dose reduction of about 30% is suggested 7. For example, a patient on Half Sinemet CR x 6 tablets daily is theoretically taking 600mg of levodopa daily. However, due to the poor bioavailability of the controlled-release preparations, only around 420mg of levodopa is actually absorbed. 6.5.3 Other PD medications Other medications that PD patients might be taking include: Monoamine oxidase B inhibitors: Rasagiline, Selegiline Catechol-O-methyltransferase inhibitors: Entacapone, Tolcapone Amantadine These drugs may usually be safely omitted if the patient is dysphagic, although both Selegiline and Amantadine have liquid preparations. Please ask for advice from the PD Team. Table 3 Dopaminergic medication and alternative formulations for NBM patients. Branded Drug Generic Drug Advice Sinemet Co-Careldopa (Levodopa/carbidopa) Convert to equivalent total Madopar Co-Beneldopa (Levodopa/benserazide) daily dose of Co-Beneldopa Stalevo Levodopa/carbidopa/entacapone (Madopar) dispersible Duodopa Co-Careldopa (Levodopa/carbidopa) Continue (seek specialist advice) Requip Ropinirole Can be converted to Requip XL Ropinirole XL Rotigotine patch Mirapexin Pramipexole 12
Neupro Rotigotine Continue patch Apo-go Apomorphine Continue (seek specialist advice) Azilect Rasagiline Omit until safe to swallow Selegiline Selegiline Amantadine Amantadine Comtess Entacapone Tolcapone Tolcapone 6.5.4 Apomorphine use Apomorphine is a potent dopamine agonist given via subcutaneous injection or infusion and should only be prescribed by a PD Specialist. It has significant side-effects including postural hypotension and nausea/vomiting. To use this drug, a patient has to be pre-loaded with Domperidone 10mg three times daily for 3 days. It is therefore not ideal for use in the acute setting. 6.6 Non-pharmacological management considerations The early involvement of speech and language therapists, physiotherapy, occupational therapy, dieticians and, where appropriate, social services should also be considered. Multidisciplinary team input is essential to avoid complications of hospitalisation, to help reduce length of stay and to promote early discharge planning. 6.7 Palliative care PD is a progressive disease with increasing morbidity. After 20 years of disease up to 80% of patients may have dementia 8. Although advanced care planning should ideally have taken place before a patient with PD approaches the end of life, it is unfortunately inevitable that some patients will be admitted to hospital acutely without an advanced care plan in place. Dopaminergic medications begin to lose their efficacy as the disease progresses and side-effects become more prominent than benefits. Medication may therefore need to be gradually withdrawn. For patients with significant nausea or vomiting, please only use Domperidone or Ondansetron. All other anti-emetics have the potential to cross the blood-brain barrier and cause worsening of Parkinsonism due to their dopamine-blocking actions. For advice and support regarding end of life and palliative issues, please contact: Hannah Martin, PDNS, bleep 2382, extension 24955 13
6.8 Surgical patients Patients with PD who undergo surgery have an increased risk of mortality and longer hospital stays than people without PD 9. Some of the risks relate to the PD itself and some to the effects of missing medication. Patients who are admitted electively to hospital should be encouraged to contact their community PD nurse specialist (PDNS) prior to admission to discuss medication management during their stay. For patients admitted acutely, please contact the PD Team for advice as management of the PD medications can be complex, especially if the patient cannot have a NGT. Please refer to the sections above for more specific advice on dysphagia, nil by mouth patients and confusion. 7. DISSEMINATION AND IMPLEMENTATION 7.1 This guideline will be disseminated to all neurology consultants, associate specialists, PD nurse specialists and trainees involved in the care of people with PD. It will be highlighted at the neurology trainees induction and added to the induction pack for juniors. 7.2 This guideline will be available to all UHCW staff via the UHCW Trust elibrary. none 8. TRAINING 8.1 Consultants managing patients with PD must ensure they have the appropriate expertise in the diagnosis and continuing management of the condition. 14
9. MONITORING COMPLIANCE 9.1 Monitoring Table Aspect of compliance or effectiveness being monitored Prompt and correct prescription of PD medications on admission Avoidance of dopamineblocking medications in PD patients Monitoring method Individual department responsible for the monitoring Frequency of the monitoring activity Group / committee which will receive the findings / monitoring report Audit Dr Teare annual Coventry and Warwickshire regional Parkinson s Disease Team Audit Dr Teare annual Coventry and Warwickshire regional Parkinson s Disease Team Group / committee / individual responsible for ensuring that the actions are completed Coventry and Warwickshire regional Parkinson s Disease Team Coventry and Warwickshire regional Parkinson s Disease Team 10. STAFF COMPLIANCE STATEMENT Clinical Guidelines assist in decision making; they do not replace clinical judgement. Regardless of the strength of evidence, it remains the responsibility of the clinician to interpret the application of the clinical guidance to local circumstances and the needs and wishes of the individual patient. Where variations of any kind do occur, it is important to document the variations and the reason for them in the patient s health record. 15
11. EQUALITY & DIVERSITY STATEMENT Throughout its activities, the Trust will seek to treat all people equally and fairly. This includes those seeking and using the services, employees and potential employees. No-one will receive less favourable treatment on the grounds of sex/gender (including Trans People), disability, marital status, race/colour/ethnicity/nationally, sexual orientation, age, social status, their trade union activities, religion/beliefs or caring responsibilities nor will they be disadvantaged by conditions or requirements which cannot be shown to be justifiable. All staff, whether part time, full-time, temporary, job share or volunteer; service users and partners will be treated fairly and with dignity and respect. 12. UHCW ASSOCIATED RECORDS Clinical guideline for the use of Apomorphine in advanced Parkinson's Disease Clinical guideline for the diagnosis and outpatient management of Parkinson's Disease 16
13. REFERENCES AND BIBLIOGRAPHY 1.1 References 1. Parkinson's UK: Parkinson's prevalence in the United Kingdon (2009). 2. National Institute for Health and Clinical Excellence. Parkinson s Disease. National Clinical guidelines for diagnosis and management in primary and secondary care. London: NICE 2006 3. Gerlach OH, Winogrodzka A, Weber WE. Clinical problems in the hospitalized Parkinson s Disease patient: systematic review. Mov Disord. 2011 Feb 1;26(2) 197-208 4. Woodford H, Walker R Emergency hospital admissions in idiopathic Parkinson s Disease. Mov Disord. 2005 Sep;20(9):1104-8 5. Magdalinou KN, Martin A, Kessel B. Prescribing medications in Parkinson s Disease (PD) patients during acute admissions to a District General Hospital. Parkinsonism Relat Disord 2007;13: 539-40 6. Pondal M, Marras C, Miyasaki J et al. Clinical features of dopamine agonist withdrawal syndrome in a movement disorder clinic. JNNP 2013 vol 84 (2): 130-135. 7. Brennan KA, Genever RW. Managing Parkinson s disease during surgery. BMJ 2010; 341:c5718. http://dx.doi.org/10.1136/bmj.c5718 8. Hely MA, Reid WG, Adena MA, Halliday GM, Morris JG. The Sydney multicenter study of Parkinson's disease: the inevitability of dementia at 20 years. Mov Dis 2008 Apr 30;23(6):837-44. doi: 10.1002/mds.21956. 9. Pepper PV, Goldstein MK. Postoperative complications in Parkinson s disease. JAGS 1999 ; 47 : 967-72. 1.1 Bibliography 1.2 Further reading 17
14. EVIDENCE BASED REFERENCES (If there are none, write NONE) Properly reference sources of evidence that underpin the procedural document) (Delete upon insertion of text) 14.1 References Grade of evidence (See Table 1.) Parkinson's UK: Parkinson's prevalence in the United Kingdon (2009). 4 National Institute for Health and Clinical Excellence. Parkinson s Disease. National Clinical guidelines for diagnosis and management in primary and secondary care. London: NICE 2006 Gerlach OH, Winogrodzka A, Weber WE. Clinical problems in the hospitalized Parkinson s Disease patient: systematic review. Mov Disord. 2011 Feb 1;26(2) 197-208 Woodford H, Walker R Emergency hospital admissions in idiopathic Parkinson s Disease. Mov Disord. 2005 Sep;20(9):1104-8 Magdalinou KN, Martin A, Kessel B. Prescribing medications in Parkinson s Disease (PD) patients during acute admissions to a District General Hospital. Parkinsonism Relat Disord 2007;13: 539-40 Pondal M, Marras C, Miyasaki J et al. Clinical features of dopamine agonist withdrawal syndrome in a movement disorder clinic. JNNP 2013 vol 84 (2): 130-135. Brennan KA, Genever RW. Managing Parkinson s disease during surgery. BMJ 2010; 341:c5718. http://dx.doi.org/10.1136/bmj.c5718 Hely MA, Reid WG, Adena MA, Halliday GM, Morris JG. The Sydney multicenter study of Parkinson's disease: the inevitability of dementia at 20 years. Mov Dis 2008 Apr 30;23(6):837-44. doi: 10.1002/mds.21956. Pepper PV, Goldstein MK. Postoperative complications in Parkinson s disease. JAGS 1999 ; 47 : 967-72. 1 1 4 4 3 5 3 5 Table 1 Grade of evidence Based on 1 Systematic review or meta-analysis 2 Randomised controlled trial/s 3 Controlled study without randomisation (e.g. case controlled) or quasiexperimental study, such as a cohort study 4 Descriptive studies such as case series and reports. 5 Expert opinion, narrative review Adapted from: Oxford Centre for Evidence Based Medicine, 2009. Levels of evidence. [online] Available at: http://www.cebm.net/index.aspx?o=1025 [Accessed 25 th August 2011]. 14.2 18
Evidence supporting recommendations Are there any relevant Cochrane Reviews related to this topic area? Has this been fully incorporated? Is there any relevant NICE guidance related to this topic area? Has this been fully incorporated? Is there any relevant Royal College guidance related to this topic area? Has this been fully incorporated? Is there any other relevant national guidance related to this topic area? Yes Yes No No No Has this been fully incorporated? 15. APPENDICES Appendix 1: Referral pathway to the PD Team (see separate attachment labelled Appendix 1 inpt PDNS referral pathway) 19