Parkinson's Disease in Acute Care

Drug therapy / treatment options

Compromised swallow and nil by mouth (NBM) patients

During working hours contact a PD specialist immediately, and a speech and language therapist if the patient has swallowing difficulties. 

Outwith working hours, or if a PD specialist is not available, refer to the NBM algorithm. Additional information is provided in:

• Table 1 - administration of PD medicines to patients with swallowing difficulties.
• Table 2 - conversion of oral dopamine agonist to rotigotine patch.

Advice can also be sought from a clinical pharmacist, Medicines Information (see Appendix 6 for contact details) or on-call pharmacist (out of hours) regarding alternative formulations.

Confusion / hallucination / agitation

• Only if necessary treat with benzodiazepine.
• Avoid first generation antipsychotics e.g. haloperidol or chlorpromazine.
• Refer to Management of Acutely Disturbed Patients, including Delirium.
• Hallucinations are common in PD with up to half of all patients experiencing these. It should be recognised that this does not necessarily indicate delirium or confusion. Dopamine agonists can worsen hallucinations and should be used with caution in those patients who are dopamine naïve and those with dementia/delirium. If an antipsychotic is indicated for hallucinations, then quetiapine would be the agent of choice.
• Refer to PD specialist for assessment as soon as possible.

Constipation / delayed gastric emptying

• PD medicines and PD itself may be associated with constipation / delayed gastric emptying.
• Constipation / delayed gastric emptying may interfere with how well PD medications are absorbed, making them less effective.
• Review need for drugs which can precipitate constipation or alter gastric transit time e.g. antacids, iron and calcium containing preparations.
• Refer to Management of Constipation for therapeutic management.
• Refer to PD specialist as soon as possible if PD symptoms are uncontrolled. 

Dizziness and falls

• Review need for drugs which precipitate postural hypotension or affect cardiac function e.g. anti-hypertensives, heart failure drugs, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, anticholinergics, acetylcholinesterase inhibitors.
• PD medications and PD itself may be associated with orthostatic hypotension (check lying and standing BP).
• Refer to PD specialist for assessment as soon as possible.

Nausea and Vomiting

• Use domperidone oral 10mg every 8 hours. Use for the shortest duration possible. The maximum duration should not usually exceed one week.
  • Caution: Domperidone is associated with a risk of cardiac side effects. See Drug Safety Update 'Domperidone: risks of cardiac side effects' for further information on contraindications. Avoid with other QT prolonging drugs or potent CYP3A4 inhibitors (see www.crediblemeds.org for further details). Consider alternatives in at risk patients.
• Cyclizine oral/IM/IV 50mg every 8 hours (in elderly use 25mg) or ondansetron (unlicensed use) are also appropriate.
  • Note: Ondansetron is contraindicated with the concomitant use of apomorphine. Ondansetron may prolong QT interval and may cause / worsen constipation - use with caution.
• Avoid metoclopramide and prochlorperazine.

  Note: Exercise clinical judgement on the applicability of this guidance to individual PD patients depending on their characteristics. Both risk and benefit should be considered, seek advice from senior if unsure.

Subcutaneous Apomorphine

• All patients admitted to hospital on apomorphine should be referred to the PD nurse specialist or movement disorders team for advice as soon as possible.
• See NHSAAA's Guidelines for the Treatment of Parkinson’s with Apomorphine (APO-go^®).
• Apomorphine should only be instigated with the guidance of a prescriber experienced in PD (it is not suitable for emergency administration in a drug naive patient). If a patient is already established on this then it must be continued.

Co-careldopa intestinal gel (Duodopa^®)

• All patients admitted to hospital on Duodopa® intestinal gel should be referred to the PD nurse specialist or movement disorders team for advice as soon as possible.
• The Duodopa^® support helpline can be contacted if further advice is required and a PD specialist is not available.
• Duodopa^® intestinal gel should only be instigated under specialist guidance. It is not suitable in an emergency situation as it requires the insertion of a percutaneous endoscopic gastrostomy with jejunal (PEG-J) tube. If a patient is already established on this then it must be continued.