Parkinson’s disease and the emergency department

Compared to other patients, people with Parkinson’s disease (PD) who enter the emergency department (ED) are more likely to be admitted to hospital, and once admitted have a higher chance of being discharged to long-term care instead of back home.A two-pronged approach of preventing the urgent circumstances that send patients to the ED, and properly managing their care once they get there, could drastically impact a patient’s trajectory.Step one: PreventionPatients with PD come to emergency with a number of different symptoms. In the early stages of the disease, patients may visit the ED as their motor and non-motor symptoms progress. In some cases, they may receive a provisional diagnosis in the ED if the wait times to see a neurologist were too long or if their previous symptoms were not textbook. “The disease can be very insidious in terms of progression,” said Dr. Lorraine Kalia, a neurologist specializing in PD and related movement disorders at Toronto Western Hospital, senior scientist at University Health Network’s Krembil Brain Institute and an associate professor at the University of Toronto.In the middle and later stages of PD, “Many of the emergency visits by people with Parkinson’s may not be directly related to Parkinson’s disease,” Dr. Kalia said.FallsA common presentation of patients with PD is injuries or fractures related to falls. To prevent falls, create and adopt a fall prevention strategy and arrange a visit with an occupational therapist early in the disease. Consider ongoing physical therapy to address gait and balance.Don’t wait until they have already had a fall that led to injuries, advised Dr. Veronica Bruno, a neurologist in the Movement Disorders Clinic at the University of Calgary Cumming School of Medicine, an assistant professor at the university and a member of the Hotchkiss Brain Institute. Urge patients who have walking aids to use them and integrate home supports for activities such as bathing or dressing, Dr. Kalia said.Fainting or falls may be due to orthostatic hypotension. Interventions such as compression stockings or salt and fluid loading could help prevent episodes.MedicationThe sensitivity that patients with PD have for their medications and the timing of their medications “is quite unique compared to other diseases,” Dr. Kalia said. Optimizing medication can help control both motor and non-motor symptoms. Always ensure patients take their medications at the right time.All medications should be reviewed for safety and for interactions with existing medications. Any substitutions need to be cleared by the patient and neurologist.Dr. Bruno had a patient who had a severe deterioration of PD symptoms. When they reviewed the medication, they found another physician had prescribed metoclopramide for nausea, a dopamine receptor antagonist that had triggered the exacerbation.Be careful with all medications. Physicians may be so focused on managing risk factors like hypertension or dyslipidemia, “that they don’t see these patients are very sensitive to antihypertensives and they end up having severe drops in blood pressure, and that brings them to hospital,” Dr. Bruno said.Infection“People can present to the emergency department with worse Parkinson’s symptoms, but the reason that their Parkinson’s symptoms are worse is because they have something else medically going on,” Dr. Kalia said.One common cause of the worsening symptoms is urinary or respiratory infection, which may go undetected. “By the time they get that urinary test, the infection is already untreated for many days and the patient is significantly confused, highly delirious. Or, a person with Parkinson’s returning to their baseline after that is extremely complex,” explained Dr. Bruno.Preventing these includes teaching patients and caregivers to be on the alert for illness. They can make a sick day plan that outlines what signs warrant a call to the neurologist or family doctor before it progresses to needing to visit the ED, Dr. Bruno said. Signs could include fever, confusion or sudden worsening of symptoms. Dr. Bruno’s team is researching how to minimize that time between when symptoms begin and the patient understands that something is wrong.Other actions to stave off infections include ensuring up-to-date vaccinations, advising routine swallowing evaluations by a speech-language pathologist to evaluate dysphagia (that raises the risk of aspiration pneumonia) and promptly managing urinary issues, Dr. Bruno said.Patients who have deep brain stimulation may present at the ED with worsening symptoms due to a dead battery or another hardware problem. Ensure patients know the preventative steps to avoid a dead battery.Step two: Proper management in the EDDoctors should remember that patients with PD can have the same reasons for presenting to ED as any other patient. Dr. Kalia once had a patient complaining of chest pains call the clinic thinking it was a Parkinson’s symptom, when they were actually having a heart attack.Avoid categorizing worsening symptoms as a progression in PD. “It’s very unusual for someone to dramatically worsen with their Parkinson’s symptoms,” Dr. Kalia said. “It’s a chronic, slowly progressing disease.“When there is an acute change—the patient is fine one day and substantially different the next—then it is critical to consider that there is something else medically going on.”Not everyone who is confused has a longer-term cognitive impairment. “In Parkinson’s, little changes can make people look very cognitively impaired, but then you treat the cause and they return to their baseline,” Dr. Bruno explained. “So don’t make presumptions about potential goals of care or type of interventions based on what you are seeing at that time, because it is probably very confounded.”Medication on timePhysicians and other healthcare professionals must ensure patients with PD get their medications properly and on time when in the ED. Often, patients are put on a NPO order (nil per os; nothing by mouth) which causes the patients’ symptoms to worsen. “In this patient population, an hour wrong in their schedule makes a huge difference,” Dr. Bruno said. It can lead to worsened motor symptoms, increased rigidity, aspiration and complicate their medical course.At Guelph General Hospital in Guelph, Ont., patients with PD who arrive at the ED are allowed to take their medications from home, even if they’re designated as NPO. The hospital has some safety measures in place to ensure patients get the right dose at the right time. It’s a step Dr. Bruno encourages. “That flexibility of being able to take their meds reduces the odds of having a big problem when they’re in the emergency department,” Dr. Bruno said, acknowledging that it’s a sensitive issue, since the hospital is usually legally responsible for any medication the patient takes while in hospital. Dr. Bruno noted that their team is working to have directives and warnings about medication in the EMR as soon as a patient with PD arrives at triage in the ED.When a patient arrives in the ED, go over their medication list to determine if any new medication is causing the symptoms. When it comes to prescribing anything, check three times to ensure it won’t interact with what the patient is already taking or their PD, Dr. Bruno said. Avoid dopamine-blocking antiemetics or antipsychotics.Suspect infectionFor many of these patients, infections don’t show up the same way as in other patients. For example, patients with urinary infections may not complain of a burning sensation when urinating.“It’s not that I want to give antibiotics to everybody, but maybe keep a lower threshold knowing that an infection treated in time can prevent a six-month admission to hospital,” Dr. Bruno said.Call the neurologistA call came through to Dr. Bruno to see a patient with PD who was having a seizure. The patient was actually having severe dyskinesias, but the medical staff treated it like a seizure and sedated the patient. “Not everything is what they are used to seeing,” Dr. Bruno said. She welcomes calls from the emergency department. “A little intervention can make a huge difference. I would prefer them to call me more often, to be honest.”Be sure to consult with the patient’s main caregiver. “If they say there’s something going on, there’s something going on,” Dr. Bruno said.Movement is medicineAs with any patient, try to get the patient moving, if possible, while working to prevent falls. Immobility can worsen symptoms and lead to complications. Check also for dehydration or constipation.Ideally, people with PD would rarely have to go to the ED if there was the capacity to manage semi-urgent issues in outpatient clinics, Dr. Kalia said. More family physicians, neurologists and PD specialists are needed to make that happen. Until that time, a combination of prevention and good management could help keep these patients out of the hospital.

Parkinson’s disease and the emergency department

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