Makindo Medical Notes

🚑 Management of the Unwell Parkinson’s Patient

1️⃣ Initial Assessment (ABCDE)

• Airway/Breathing: Aspiration risk due to dysphagia, weak cough reflex.
• Circulation: Look for dehydration, infection, orthostatic hypotension.
• Disability: Compare to baseline cognition; screen for delirium.
• Exposure: Constipation, urinary retention, pressure sores.

2️⃣ Key Principles

• 🕐 Never stop Parkinson’s drugs suddenly → risk of Parkinsonism–Hyperpyrexia Syndrome.
• ⏱ Give meds on time – even small delays worsen rigidity & mobility.
• 🚫 Avoid dopamine antagonists (metoclopramide, prochlorperazine, haloperidol).
  ✅ Use ondansetron or domperidone for nausea.

3️⃣ Common Precipitants of Acute Decline

• Infection (UTI, pneumonia).
• Constipation or urinary retention.
• Medication errors (missed or delayed PD drugs).
• Electrolyte disturbance.
• Delirium (multifactorial).

4️⃣ Practical Inpatient Management

• Medication reconciliation: Confirm exact regimen & timing from patient/carer.
• Route of administration:
  • If NBM/dysphagia → dispersible levodopa (Madopar) via NG tube.
  • If NG not possible → consider rotigotine patch.
• Treat underlying cause: infection, constipation, dehydration, AKI.
• Therapy input: Early physio + speech & language (SALT) for swallow safety.
• Monitor: Fluid balance, U&Es, urine output, nutrition.

5️⃣ Escalation & MDT

• Involve neurology / PD specialist nurse early.
• Consider palliative care if advanced disease or recurrent admissions.
• Advance Care Planning: ceilings of treatment, DNACPR discussions.

🚫 Drugs to Avoid in Parkinson’s Disease (especially in the Acutely Ill)

Many commonly prescribed drugs block dopamine and can dramatically worsen Parkinsonism, rigidity, and confusion. Always check compatibility before prescribing.

• Antipsychotics: Haloperidol, chlorpromazine, risperidone (→ severe rigidity, confusion). ✅ Safer: quetiapine, clozapine.
• Antiemetics: Metoclopramide, prochlorperazine (→ acute dystonia, worsening Parkinson’s). ✅ Safer: ondansetron, domperidone (with caution).
• Other dopamine-blockers: Some calcium channel blockers (flunarizine, cinnarizine), tetrabenazine.
• Opioids (high-dose): May worsen confusion, constipation, and postural hypotension.

💡 Key principle: If a Parkinson’s patient suddenly deteriorates on the ward, always check if their usual meds have been withheld or if a dopamine-blocking drug has been prescribed.

💡 Teaching Pearls

• “Time-critical meds” → never delay Parkinson’s medication.
• Avoid dopamine antagonists for nausea or agitation.
• Parkinsonism–Hyperpyrexia Syndrome can mimic sepsis (rigidity + fever + confusion after missed meds).
• Search for common triggers: infection, constipation, medication errors.