The perioperative management of Parkinson's disease revisited

Preoperative Management of Medications for Neurologic Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement

Neurologic diseases are prevalent in patients undergoing invasive procedures; yet, no societal guidelines exist as to best practice in management of perioperative medications prescribed to treat these disorders. The Society for Perioperative Assessment and Quality Improvement tasked experts in internal medicine, anesthesiology, perioperative medicine, and neurology to provide evidence-based recommendations for preoperative management of these medications. The aim of this review is not only to provide consensus recommendations for preoperative management of patients on medications for neurologic disorders, but also to serve as an educational guide to perioperative clinicians. While, in general, medications for neurologic disorders should be continued preoperatively, an individualized approach may be needed in certain situations (eg, holding anticonvulsants on day of surgery if electroencephalographic mapping is planned during epilepsy surgery). Pertinent interactions with commonly used drugs in anesthesia practice, as well as considerations for targeted laboratory testing or perioperative drug substitutions, are addressed as well.

Spinal versus General Anesthesia for Patients with Parkinson's Disease

Background

Anesthesiologists prefer using general anesthesia (GA) in Parkinson’s disease (PD). However, GA may mask neurological symptoms in the intraoperative period and exacerbate them postoperatively. Furthermore, the anesthetics used in GA have clear interactions with the drugs used to control PD. On the other hand, drugs used in spinal anesthesia (SA) might be safer for patients with PD. The aim of this study is to evaluate the effect of SA and GA in patients with PD who underwent hip fracture repairs.

Methods

Retrospectively, we identified those patients with PD who were admitted due to hip joint fracture. The following information were obtained: demographics, preoperative assessment information of the patients, type of anesthesia, and types of fractures and orthopedic procedures. In addition, intraoperative and postoperative complications were studied. The patients were divided based on the type of anesthesia received and were compared.

Results

Ten (8 males) patients with PD who underwent hip fracture surgery included in the study. Six patients received SA and 4 patients received GA. The mean age was 73.2 years. The preoperative assessment was not significant for all patients. Postoperatively, within the inpatient period, 3 out of 4 patients received GA developed complications (two atelectasis and urinary tract infection) while no patient developed complication from the SA group. Postoperative outpatient complications within one-month included 3 out of 4 cases in the GA group and only one complication in the SA group. The mean hospitalization period was 9 days for patients received GA and 5.8 days for patients received SA.

Conclusion

This study reported less perioperative complications in the SA. Accordingly, further investigations and rp-randomized controlled trials evaluating various anesthetic techniques or drugs are needed.

Interventions to minimize complications in hospitalized patients with Parkinson disease

Background

In this study, we sought to evaluate the efficacy of inpatient interventions on hospitalization-related complications in patients with Parkinson disease (PD). Hospitalized patients with PD have an increased risk of complications. Although several interventions have been suggested in the literature, data-driven recommendations are limited.

Methods

This study was designed as a prospective cohort study. A hospital-wide alert system was incorporated into the electronic medical record (EMR) system. The alert was triggered when a patient with PD or on dopaminergic therapy was admitted prompting the inpatient pharmacy to confirm medication details. A warning was also triggered if antidopaminergic medications were ordered. In-services were performed for nursing staff and physicians regarding these measures. Charts of patients with PD admitted 6 months before and after the intervention were reviewed to serve as the 2 comparison groups.

Results

There were 73 patients (mean 73.2 years) preintervention group and 103 patients (mean 72.3 years) postintervention group. There were no significant differences in reasons for admission, admission to neurologic vs non-neurologic floor, or admitting service between the groups. The percentage of patients for whom contraindicated medications were ordered decreased from 42.5% to 17.5% (p < 0.001). Medication administration with doses given over 30 minutes late decreased from 46% to 39% (p = 0.068). Medications ordered correctly were 42.9% vs 54.7% (p = 0.131) before and after the intervention. Length of stay was 5.3 vs 5.2 days (p = 0.896), and mean complications were 0.38 vs 0.37 (p = 0.864).

Conclusion

An intervention involving EMR alerts and in-service didactics for nurses and physicians decreased the frequency of contraindicated medications ordered in hospitalized patients with PD, but it did not change other hospital outcomes or complications.

Treatment of Older Parkinson's Disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder after Alzheimer's disease. The prevalence of PD increases with age. The spectrum of clinical features, the rate of progression of the disease, the burden of nonmotor symptoms, and the response to medications are different in older patients with PD from the relatively younger patients. Management of symptoms of PD in older patients is challenging because of possible existence of several age-related systemic illness. While dealing with older patients, it is crucial not to attribute all the physical symptoms to PD. Thorough evaluation for existence of diseases such as normal pressure hydrocephalus and vascular parkinsonism which partially mimic the symptoms of PD carries immense importance. Medical management of parkinsonian symptoms should be preferred with levodopa monotherapy. However, in patients with significant motor fluctuations, dopaminergic agents may be added with caution, as they are notorious for several adverse reactions. Nonmotor symptoms must be provided high importance as they substantially worsen the quality of life. In addition to parkinsonian symptoms, older patients with PD may need to undergo surgery for several conditions. Meticulous perioperative management is crucial as older patients with PD may face several surgery-related complications compared to the younger patients. Compliance to treatment is an important issue in old age. Hence multidisciplinary approach to management of PD in older patients should be emphasized.

Safety of perioperative treatment with intravenous amantadine in patients with Parkinson disease

OBJECTIVES

Surgery in patients with Parkinson disease is associated with a high rate of complications largely because of difficulties in maintaining the antiparkinsonian treatment regimen perioperatively. The aim of the study was to investigate the safety and efficacy of intravenous administration of amantadine on parkinsonian features during and after surgery.

METHODS

The study group included 6 patients being treated for Parkinson disease who were referred for surgery at a tertiary medical center. After providing written informed consent, participants received intravenous amantadine sulfate 200 mg after induction of anesthesia and 24 hours later. The regular antiparkinsonian regimen was stopped immediately before surgery and restarted after surgery. Patients underwent a neurological evaluation with the Unified Parkinson Disease Rating Scale at 3 time points: preoperatively, 24 to 72 hours postoperatively, and 1 month postoperatively, and the scores were compared.

RESULTS

The mean Unified Parkinson Disease Rating Scale score improved from 24.8 (SD, 10.8) at baseline to 21.3 (SD, 11.1) at 24 to 72 hours postoperatively (P = 0.04); the value at 1 month (in the 5 patients assessed) was 22.5 (SD, 15.5) (P = 0.27). No adverse effects of amantadine or postoperative complications were recorded. All patients were discharged home as planned.

CONCLUSIONS

Amantadine improves the parkinsonian symptoms after surgery, which may be beneficial in preventing complications. It appears to have a high safety profile in this setting. Larger, randomized, and blinded studies are warranted to corroborate these preliminary results and evaluate long-term outcome.

Preconditioning as a potential strategy for the prevention of Parkinson's disease

Parkinson's disease (PD) is a chronic neurodegenerative movement disorder characterized by the progressive and massive loss of dopaminergic neurons by neuronal apoptosis in the substantia nigra pars compacta and depletion of dopamine in the striatum, which lead to pathological and clinical abnormalities. A numerous of cellular processes including oxidative stress, mitochondrial dysfunction, and accumulation of α-synuclein aggregates are considered to contribute to the pathogenesis of Parkinson's disease. A further understanding of the cellular and molecular mechanisms involved in the pathophysiology of PD is crucial for developing effective diagnostic, preventative, and therapeutic strategies to cure this devastating disorder. Preconditioning (PC) is assumed as a natural adaptive process whereby a subthreshold stimulus can promote protection against a subsequent lethal stimulus in the brain as well as in other tissues that affords robust brain tolerance facing neurodegenerative insults. Multiple lines of evidence have demonstrated that preconditioning as a possible neuroprotective technique may reduce the neural deficits associated with neurodegenerative diseases such as PD. Throughout the last few decades, a lot of efforts have been made to discover the molecular determinants involved in preconditioning-induced protective responses; although, the accurate mechanisms underlying this "tolerance" phenomenon are not fully understood in PD. In this review, we will summarize pathophysiology and current therapeutic approaches in PD and discuss about preconditioning in PD as a potential neuroprotective strategy. Also the role of gene reprogramming and mitochondrial biogenesis involved in the preconditioning-mediated neuroprotective events will be highlighted. Preconditioning may represent a promising therapeutic weapon to combat neurodegeneration.

Perioperative management of patients with Parkinson's disease

Parkinson's disease is the second most common neurodegenerative disease worldwide, leading to a wide range of disability and medical complications. Managing patients with Parkinson's disease in the perioperative hospital setting can be particularly challenging. Suboptimal management can lead to medical complications, prolonged hospital stays, and delayed recovery. This review aims to address the most important issues related to caring for patients with Parkinson's disease perioperatively who are undergoing emergent or planned general surgery. It also intends to help hospitalists, internists, and other health care providers mitigate potential in-hospital morbidity and prevent prolonged recovery. Challenges in managing patients with Parkinson's disease in the perioperative hospital setting include disruption of medication schedules, "nothing by mouth" status, reduced mobility, and medication interactions and their side effects. Patients with Parkinson's disease are more prone to immobility and developing dysphagia, respiratory dysfunction, urinary retention, and psychiatric symptoms. These issues lead to higher rates of pneumonia, urinary tract infections, deconditioning, and falls compared with patients without Parkinson's disease, as well as prolonged hospital stays and a greater need for post-hospitalization rehabilitation. Steps can be taken to decrease these complications, including minimizing nothing by mouth status duration, using alternative routes of drugs administration when unable to give medications orally, avoiding drug interactions and medications that can worsen parkinsonism, assessing swallowing ability frequently, encouraging incentive spirometry, performing bladder scans, avoiding Foley catheters, and providing aggressive physical therapy. Knowing and anticipating these potential complications allow hospital physicians to mitigate nosocomial morbidity and shorten recovery times and hospital stays.

Perioperative medication withholding in patients with Parkinson's disease: a retrospective electronic health records review

BACKGROUND

Carbidopa-levodopa (Sinemet), the gold-standard treatment for Parkinson's disease, has a short half-life of one to two hours. When patients with Parkinson's disease are placed on NPO (nil per os, or nothing by mouth) status for surgery, they may miss several doses of carbidopa-levodopa, possibly resulting in exacerbation of Parkinson's disease symptoms. Clear guidelines regarding perioperative symptom management are lacking.

OBJECTIVES

The goals of this study were threefold: to measure the perioperative duration of the withholding of carbidopa-levodopa in patients with Parkinson's disease, to record the time of day surgeries were performed on these patients, and to record perioperative exacerbations of Parkinson's disease symptoms.

METHODS

We conducted a retrospective review of patient electronic health records at a Midwestern public medical center. After applying inclusion and exclusion criteria and evaluating the eligible records, we had a final sample of 89 separate surgical events for 67 discrete patients who had been diagnosed with Parkinson's disease, had undergone any type of surgery excepting Parkinson's disease surgeries, and were taking carbidopa-levodopa.

RESULTS

The median duration of carbidopa-levodopa withholding was 12.35 hours, with most surgical procedures (86%) starting at 9 AM or later. The most commonly reported exacerbation of Parkinson's disease symptoms was agitation or confusion.

CONCLUSIONS

For best symptom management, careful consideration should be given to scheduling surgery at the earliest possible time, administering medications as close to the patient's usual dosing schedule as possible, and providing nursing education about optimal medication management for this patient population.

Nasogastric Medication for Perioperative Parkinson's Rigidity during Anaesthesia Emergence

We present a case of severe rigidity during emergence from general anaesthesia in a 64-year-old man who had suffered from Parkinson's disease for nine years. Controversy still exists over how to optimally manage these patients perioperatively. We successfully managed his Parkinsonism with administration of crushed Sinemet® and amantadine via a nasogastric tube. This case report serves as a reminder of the importance that patients receive their anti-Parkinsonian medications perioperatively, and highlights the potential benefits of inserting a gastric tube to continue anti-Parkinson's medication dosing during prolonged surgery.

[Perioperative management of Parkinson's disease]

One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients.

[Perioperative management of Parkinson's disease]

One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients.

Clinical problems in the hospitalized Parkinson's disease patient: systematic review

The problems Parkinson's disease (PD) patients encounter when admitted to a hospital, are known to be numerous and serious. These problems have been inventoried through a systematic review of literature on reasons for emergency and hospital admissions in PD patients, problems encountered during hospitalization, and possible solutions for the encountered problems using the Pubmed database. PD patients are hospitalized in frequencies ranging from 7 to 28% per year. PD/parkinsonism patients are approximately one and a half times more frequently and generally 2 to 14 days longer hospitalized than non-PD patients. Acute events occurring during hospitalization were mainly urinary infection, confusion, and pressure ulcers. Medication errors were also frequent adverse events. During and after surgery PD patients had an increased incidence of infections, confusion, falls, and decubitus, and 31% of patients was dissatisfied in the way their PD was managed. There are only two studies on medication continuation during surgery and one analyzing the effect of an early postoperative neurologic consultation, and numerous case reports, and opinionated views and reviews including other substitutes for dopaminergic medication intraoperatively. In conclusion, most studies were retrospective on small numbers of patients. The major clinical problems are injuries, infections, poor control of PD, and complications of PD treatment. There are many (un-researched) proposals for improvement. A substantial number of PD patients' admissions might be prevented. There should be guidelines concerning the hospitalized PD patients, with accent on early neurological consultation and team work between different specialities, and incorporating nonoral dopaminergic replacement therapy when necessary.

Transdermal rotigotine for the perioperative management of Parkinson's disease

Continuous delivery of antiparkinsonian medication during a perioperative period is desirable to avoid ‘off’-symptom complications in surgical patients with concomitant Parkinson’s disease (PD). Fourteen PD patients undergoing surgery under general anesthesia were switched from oral dopaminergic medication to transdermally delivered 24-h rotigotine (median dose 12 mg/24 h) for the perioperative period. Rotigotine treatment was considered feasible by patients, their anesthesiologists and neurologists with good control of PD symptoms and easy switching and re-switching of PD medication.

Rotigotine transdermal system for perioperative administration

We present a series of patients participating in clinical trials with the rotigotine transdermal system. All patients were scheduled for surgery with general anaesthesia unrelated to the trial procedure or to rotigotine. Perioperative administration of rotigotine appeared to be feasible and efficacious. No safety issues emerged from these observations.