Acutely Ill Patient with Parkinson's disease

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.

🧑‍⚕️ Case Examples - Acutely Ill Patient with Parkinson’s Disease

• Case 1 (Missed Parkinson’s medications): 💊 A 78-year-old man with Parkinson’s disease is admitted with pneumonia. Due to swallowing difficulties, he misses several doses of levodopa and becomes rigid, immobile, and confused. His medication is urgently switched to a dispersible levodopa preparation via NG tube, with input from neurology and pharmacy. Teaching point: never interrupt Parkinson’s drugs abruptly - it risks severe rigidity, aspiration, or neuroleptic malignant-like syndrome.
• Case 2 (Delirium and drug interactions): 🧠 An 82-year-old woman with Parkinson’s disease is admitted following a fall. She develops delirium and is given haloperidol on the ward. Within hours she becomes profoundly rigid and drowsy. The antipsychotic is stopped and quetiapine is used instead, with supportive care. Teaching point: avoid dopamine-blocking drugs (haloperidol, metoclopramide) in Parkinson’s - they worsen rigidity and confusion; use Parkinson’s-safe alternatives.
• Case 3 (Aspiration and sepsis): 🌡️ A 75-year-old man with advanced Parkinson’s disease presents with fever, cough, and hypoxia. CXR confirms aspiration pneumonia. He is treated with IV antibiotics, chest physiotherapy, and careful swallow assessment by SALT to adjust diet and fluids. Teaching point: Parkinson’s patients are prone to dysphagia and aspiration; early swallow review and chest care reduce recurrent infections.