Ma#hew West, MD Assistant Professor Department of Neurology University of Colorado NONE, BUT I SHOULD GET SOME Discuss the effect of Parkinson s Disease on mulmple organ systems Review medicamon management for symptoms in the post- operamve phase Review Parkinson s Disease medicamons, specifically their importance in the post- operamve course
The Shaking Man Terry Allen, 1993 78 year old man diagnosed with Parkinson s disease (PD) 12 years ago presents awer mechanical fall, resulmng in a distal femur fracture requiring internal fixamon surgery. Current PD medicamon regimen is: 1. Carbidopa/levodopa 25mg/100mg 5 Mmes per day 2. Entacapone 200 mg 5 Mmes per day 3. Pramipexole 1 mg 3 Mmes per day 4. Amantadine 100 mg oral twice a day WHY SHOULD WE CARE? Increased risk of nosocomial morbidity Post- operamve stays are longer than non- PD 18 days versus 14.5 days (Mueller, 2009) 11.4 days versus 8.8 days (Pepper, 1999) Overall duramon of inpament treatment significantly longer 21.4 days versus 18.2 days (Mueller, 2009) Trend towards higher inpament mortality 7.3% versus 3.8% (Pepper, 1999) Mueller, et al Lagngerbecks Arch Surg 2009;394(3):511 Pepper, et al. J Am Geriatric Soc. 1999;47(8):967
Mueller, et al Lagngerbecks Arch Surg 2009;394(3):511
Increased risk of post- operamve falls LimitaMons in rehabilitamon Mueller, et al Lagngerbecks Arch Surg 2009;394(3):511 RECOMMENDATIONS Early and aggressive PT/OT Fall precaumons Early reinimamon of parkinson s medicamons
Can have obstrucmve or restricmve pa#ern on PFTs Increased airway resistance and decrease lung elasmc recoil lead to OBSTRUCTIVE pa#ern Rigidity of chest wall and upper airway muscles can lead to RESTRICTIVE pa#ern Pneumonia remains leading cause of mortality among PD paments Increase aspira&on risk in perioperamve period OR 3.825, p<0.001 (Pepper, 1999) Shill et al, Clin Neurosci 1998;5(2):131-135 Pepper, et al. J Am Geriatric Soc. 1999;47(8):967 RECOMMENDATIONS AspiraMon PrecauMons Swallow evaluamon early in course Inspiratory Spirometer (IS) Pulmonary Toilet Early mobilizamon Early reinimamon of parkinson s medicamons SecreMons SucMoning Glycopyrrolate 1 mg PO TID (Arbouw, Neurology 2010) Arbouw, et al. Neurology 2010;74(15):1203-7
Dysphagia is common in PD 50-80% on barium swallow examinamons (Castell, 2001) Secondary to abnormality of muscles in mouth, pharynx, and esophagus Increase risk of aspiramon and malnutrimon GI DysmoMlity Due to Lewy Body deposimon in Myenteric Plexus ConsMpaMon Gastroparesis Ileus Castell, et al. Neurogastroenterol Motil 2001;13(4):361-64 RECOMMENDATIONS Swallow evaluamon! Consider pre- operamve swallow evaluamon AspiraMon precaumons Monitor nutrimon closely Aggressive bowel regimen (smmulant and sowener) MobilizaMon Early reinimamon of parkinson s medicamons Avoid anm- cholinergics if possible GASTROPARESIS: Erythromycin NOT Metoclopramide
OrthostaMc hypotension Post- prandial hypotension Impaired heart rate (HR) variability Risk of arrhythmias with pro- dopaminergic medicamons Katus, et al. American Journal Medicine 2014;127:275-80 RECOMMENDATIONS Fall precaumons Check orthostamcs as necessary Change of posimon slowly CauMon with beta- blockers and other nodal medicamons If have orthosta&c hypotension Adequate hydramon Head- of- bed when sleeping 30-45 degrees Thigh high compression stockings If severe orthostasis!abdominal binder MedicaMon opmons FludrocorMsone 0.1-0.3 mg oral daily Midodrine 10 mg 3 Mmes per day during daymme
About one- third PD paments have demenma AddiMonal one- quarter to one- third have mild cognimve impairment (MCI) High risk of post- operamve delirium OR 2.6 versus controls (Pepper, 1999) Aarsland D, et al. Mov Disord. 2005;20(10):1255 Pepper, et al. J Am Geriatric Soc. 1999;47(8):967 RECOMMENDATIONS Delirium precaucons " Sleep/wake cycle " Hydra&on/nutri&on MedicaCons (for PD) AnMcholinergics>>Amantadine/Dopamine Agonists>>Levodopa/MAOI- B worsen delirium If need pharmacologic restraint AVOID typical anmpsychomcs (e.g., Haldol) CauMon with atypical anm- psychomcs QueCapine and Clozapine have low dopamine- blockade and are owen used
Undergoes successful surgery Complaining of pain in post- operamve period that is appropriately addressed Develops nausea/vomimng, cross- cover physician writes for an anm- ememc On your next examinamon, you note worsening rigidity and tremor Why? What medicacon may have been given? An#- eme#cs with dopamine (D2) blockade Metoclopramide Prochlorperazine Promethazine USE INSTEAD: Ondansetron An#- psycho#cs with high D2 blockade Typical antipsychotics Most atypical antipsychotics USE INSTEAD: Quetiapine Clozapine If on MAO- B inhibitor (selegiline, rasagiline) Cau&on with Meperidine Tramadol Methadone Dextromethorphan New SSRI, SNRI, and TCAs
Over the next 3 days, the pament declines clinically: Consciousness level worsens Unable to follow commands Becomes febrile to 40.2 Fluctuating heart rate Tone increased axially and in all four limbs Develops leukocytosis and elevated CK (9,000) What happened and what should be done? Similar to NeurolepMc Malignant Syndrome (NMS) Occurs about 3-4 days awer cessamon/decrease of dopaminergic medicamons Signs/symptoms High fever Muscle rigidity Autonomic instability Altered mental status (reduced consciousness) Complications Acute kidney injury Rhabdomyolysis Disseminated intravascular coagulamon Pro- Dopaminergic Carbidopa/Levodopa (Sinemet ) Dopamine Agonists Pramipexole (Mirapex ) Ropinirole (Requip ) Rotigotine (Neupro patch ) Amantadine MAO- B Inhibitors Selegiline (Eldepryl, Zelapar ) Rasagiline (Azilect ) AnC- cholinergics Trihexyphenidyl (Artane ) COMT inhibitor Entacapone (Comtan ) Tolcapone (Tasmar )
Start pacent s PD regimen ASAP! As close to home regimen as possible Pay azencon to dose and TIMES Consider NG- tube if unable to take PO Consider Parcopa Oral- dissolvable Similar efficacy to convenmonal Levodopa Dosing similar to home Carbidopa/Levodopa Tube feedings Affects Levodopa absorpmon Consider bolused tube feeds or starmng at night Start pament s PD regimen ASAP! As close to home regimen as possible Pay a#enmon to dose and TIMES Consider NG- tube if unable to take PO Consider Parcopa Oral- dissolvable Similar efficacy to convenmonal Levodopa Dosing similar to home Carbidopa/Levodopa Tube feedings Affects Levodopa absorpmon Consider bolused tube feeds or starmng at night
Start pament s PD regimen ASAP! As close to home regimen as possible Pay a#enmon to dose and TIMES Consider NG- tube if unable to take PO Consider Parcopa Oral- dissolvable Carbidopa/Levodopa Similar efficacy to convenconal Levodopa Dosing similar to home Carbidopa/Levodopa Tube feedings Affects Levodopa absorpmon Consider bolused tube feeds or starmng at night Start pament s PD regimen ASAP! As close to home regimen as possible Pay a#enmon to dose and TIMES Consider NG- tube if unable to take PO Consider Parcopa Oral- dissolvable Similar efficacy to convenmonal Levodopa Dosing similar to home Carbidopa/Levodopa Tube feedings Effects Levodopa absorpcon Consider bolused tube feeds or starcng at night In post- operamve seong, Parkinson s Disease can have impact on mulmple organ systems Important to avoid medicamons that may worsen their disease Start pament on home parkinson s regimen as soon as possible Low threshold to consult Neurology colleagues!