Parkinson’s disease (PD) is a progressive, neurodegenerative disease associated with loss of dopaminergic neurons and the presence of Lewy bodies within the substantia nigra and other areas of the brain and peripheral autonomic nervous system.1 Cardinal clinical features include rigidity, bradykinesia, and resting tremor. A supportive feature is a consistent response to levodopa. Postural instability, cognitive impairment, and autonomic dysfunction usually occur later in the disease.
As the population ages, PD is becoming more prevalent, affecting approximately 1% of individuals older than 60.2 These patients pose a specific challenge to hospital staff, not only because the multi-organ system manifestations of PD can raise surgical risk, but also due to the direct effects of PD medications, lack of a parenteral route for most of these medications in patients kept nil-by-mouth (NBM), and the risks associated with abrupt withdrawal of these medications. Although the surgical risk in PD patients has received intermittent attention in surgical, anesthesia, and neurology literature, there is no broad consensus statement or treatment guideline for the perioperative approach.
Hospitalisation of PD patients
Patients with PD are admitted to hospitals at higher rates, and frequently have longer hospital stays than the general population. Both facts were revealed in numerous publications,3-4 but little is known about interventions that might reduce the need for hospitalisation or reduce the complications related to hospitalisation. Reasons for admissions and the impact of PD complications on hospital stay have been sparsely characterised in the literature. Studies indicate that PD admissions are more often due to aspiration pneumonia, psychosis, trauma (eg. hip fractures), and sepsis when compared to controls5-6 (Box 1). As a group, PD patients accumulate more inpatient days over their lifetime, (following the diagnosis of PD), when compared to the general population. Length of stay appears to vary by study. A study of 367 PD patients and 246 emergency admissions in the UK found that the mean length of hospital stay was longer for PD patients than for controls (21.3 versus 17.8 days), while a recent longitudinal prospective study from the UK including PD and controls over 12 years, showed similar overnight durations (10 days for PD, 11.4 days for controls), but lower survival rates for PD. However, it should be kept in mind that these findings may be underestimated, as the hospitalisation of a patient with PD may be shortened by a discharge to a long-term care facility and this remains unaccounted for.7 PD motor disturbances are believed to be a causal factor in the higher rates of admissions and complications, but other conditions are in fact commonly recorded as the primary reason for hospitalisation.7 In a recent report, the primary reason for hospitalisation among 761 admissions of Parkinsonian patients was found to be related to PD-relate symptoms in only 116 instances (15%).
The remaining reasons for admission were: falls (12.6%), pneumonia (12%), cardiac disorders (11.6%), genitourinary infections (11%), gastrointestinal disorders (11%), neoplasia (9.9%), encephalopathy (7%), syncope (4%), stroke (3.6%), and dementia (3%).8 Over the years, a number of movement-disorder specialists have independently developed informal recommendations for management of PD patients during hospitalisation. Most of these informal recommendations/guidelines have been focused on facilitating communication between patients and hospital staff. However, it is unknown whether these recommendations/guidelines improve patient care, or whether they address the most important aspects of the hospitalised PD patient.7
Perioperative issues in hospitalised PD patients
There are several organ-system manifestations of PD that are relevant to the perioperative period and can affect the outcome of the surgical procedure or intervention. These may include PD-related motor disturbances, respiratory as well as cardiovascular manifestations and gastrointestinal effects of the disease. In addition, the effects of medications may contribute to some of the perioperative problems seen in PD patients.
The motor features of PD place patients at increased risk for falls and might impair their ability to participate in rehabilitation postoperatively. Clinical studies demonstrated that there is a significantly increased risk of postoperative falls and a higher need for inpatient rehabilitation due to motor difficulties in the PD cohort.4
PD patients in the postoperative period are at risk for swallowing difficulties, which increases the risk of aspiration and might delay initiation of oral medications. Dysphagia is commonly noted in PD patients and it is due to abnormalities in the motor function involving muscles of the mouth, pharynx, and oesophagus.
Barium swallow tests are abnormal in about 80% or even more of PD patients.9 Dysphagia can lead to aspiration, as well as inadequate oral intake, resulting in pneumonia and malnutrition, respectively.10 Dysfunction of the myenteric plexus, which is evidenced by Lewy body deposition, accounts for gastrointestinal dysmotility manifested as gastroparesis, ileus, and slow colonic transit, which results in constipation.11 Postoperative ileus and constipation can pose significant challenges. In addition, gastroparesis threatens appropriate delivery of oral medications for adequate absorption.
Respiratory problemsPD patients are at increased risk of lower respiratory infections and pneumonia remains the leading cause of mortality among PD patients.12 PD patients have increased risk of abnormal pulmonary function secondary to rigidity and akinesia with increased airway resistance and decreased lung elastic recoil leading to features of obstructive lung disease or sometimes a restrictive pattern.13 In addition, respiratory dyskinesia is a common side effect of levodopa, which can result in restrictive and dyskinetic ventilation.12 As a consequence of disordered respiratory mechanics, especially in combination with disordered swallow mechanics, several cohorts have suggested that PD patients undergoing surgical procedures are at higher risk for atelectasis, pneumonia, and postoperative respiratory failure.14
PD patients with impaired coughing and restrictive lung disease, usually due to muscle rigidity, PD progression, comorbidity, or a combination, will be at risk of developing chest infections. When PD patients aspirate it increases their risk of pneumonia, which is the most commonly reported cause of death in PD.7 Pneumonias in PD are likely due to the same bacterial organisms found in community and age-matched control populations. Bladder infections and decubital pressure sores should be identified and managed early.
Several cardiovascular problems are common in PD, such cardiac sympathetic abnormalities as orthostatic hypotension, postprandial or exercise-induced hypotension, impaired heart rate variability, and dysrhythmias. In addition, researchers found a trend toward increased risk of hypotension and acute myocardial infarction (MI) in PD patients undergoing surgery.15
Some of the medications used to treat PD have prodopaminergic effects that can lead to haemodynamic compromise and are potentially arrhythmogenic. On the other hand, abrupt withdrawal of these medications can lead to a potentially lethal condition called Parkinsonism-hyperpyrexia syndrome (PHS), which is clinically similar to neuroleptic malignant syndrome. PHS is characterised by very high fever, extreme muscle rigidity, autonomic instability, altered consciousness, and multiple severe systemic complications. Systemic complications may include acute renal failure, disseminated intravascular coagulation, autonomic failure, aspiration pneumonia, and infections.16 PHS occurs in up to 4% of PD patients; mortality is reported to be from 4% for treated to 20% for untreated episodes.16 Furthermore, even brief interruption of medications can lead to decompensation of Parkinsonian symptoms, which not only delays recovery from surgery, but also increases the risk for multisystem complications.17
Urinary complaints, such as nocturia with urgency and/or urge incontinence, are common in PD patients. These features correspond to involuntary detrusor contractions (detrusor hyperreflexia) and there is an increased risk of postoperative urinary tract infection in PD patients.15 Cognitive impairment is a recognised feature of advanced PD and studies estimate the prevalence of dementia in cohorts of PD patients is from 28% to 44%. It was noted in clinical studies that there is a trend toward increased incidence of postoperative delirium in PD patients undergoing surgery.15
Management of hospitalisation-related Issues
When PD patients are hospitalised, there are a number of important areas that may affect outcome. Management of anti-Parkinsonian medications in the perioperative period poses unique challenges. PD medications should be administered as closely to the specific home schedule as possible. Aspiration risk may be reduced by the use of mechanical swallowing techniques, including changing the consistency of food, or alternatively teaching chin-down swallowing.18 The use of feeding tubes may be considered for PD patients at higher aspiration risk. An early return to mobility is also important. Most experts agree that mobilising patients as soon as possible is the best approach. Bladder infections and decubital sores should be treated aggressively as would be done for any hospitalised or ambulatory patient with or without PD. Delirium should be identified early, and treated aggressively. It may frequently accompany infection, but anti-cholinergic agents utilised for bladder over-activity may contribute to delirium and/or psychotic symptoms.7 Since orthostatic hypotension is very common in PD and may vary significantly throughout the day, frequent measurements, with recordings of clinical symptoms such as light-headedness can prove useful. Orthostatic hypotension can be treated with reductions of anti-hypertensives, increases in circulating blood volume via intravenous fluids, oral intake, increases in salt intake, fludrocortisones or increases in arterial pro-contraction drugs such as midodrine, or possibly pyridostigmine.19 Night time head elevation and tight thigh high stockings should also be considered.7
Parkinsonism-hyperpyrexia syndrome (PHS) may occur following sudden withdrawal of PD medications during the perioperative period with potentially serious consequences. Traditional anti-Parkinsonian medications can only be delivered orally, presenting significant challenges for NBM patients, especially those undergoing enteric surgery requiring bowel rest. As many as 30% of patients who survive a PHS episode have worsening of their PD symptoms and never return to their pre-PHS baseline. PHS prevention in hospitalised patients by uninterrupted administration of PD medications should be the goal. Early recognition and aggressive treatment is the key to successful recovery.17 In general, abrupt discontinuation of PD medications should be avoided if at all possible. Treatment of PHS is usually via restitution of the discontinued medications. If the patient cannot absorb his/her medications due to GI problems, then, if available, transdermal (rotigotine), subcutaneous (apomorphine), intravenous (dantrolene or amantadine) therapy may be helpful.20 This syndrome is preventable with proper education of staff and physicians. (Box 2)
Case reports describe various approaches to medication management in the perioperative period, but no single consensus statement (or treatment guideline) exists. The most common clinical scenarios are:
Short surgeryPatient undergoing a short surgery and is able to take oral medication, should have the medication immediately after the procedure.21
Patient who undergoes more lengthy surgery and will be able to take enteric medications perioperatively might have them through enteral administration using naso-gastric tube every two hours during the surgery.22 The other approach is to consider administering PD medications immediately, preoperatively and restarting the medications as soon as possible postoperatively.21 However, if unable to tolerate enteric medications, then subcutaneous apomorphine in conjunction with rectal domeperidone, could be considered.23
Lengthy surgery—with bowel rest
Patient undergoes lengthy procedure in which they will be required to adhere to bowel rest could have trans-dermal rotigotine patches or subcutaneous apomorphine therapy.
Patients with PD are admitted to hospitals at higher rates, and frequently have longer hospital stays than the general population. Although motor disturbances in PD are believed to be a causal factor in the higher rates of admissions and complications, other conditions are in fact commonly recorded as the primary reason for hospitalisation. These include, in addition to PD-related symptoms, falls, pneumonia, cardiac disorders, genitourinary infections and gastrointestinal disorders. PD patients pose a specific challenge to those looking after them while inpatients in the hospital. When PD patients are hospitalised for surgery, there are a number of important steps to be considered during the perioperative period that may affect outcome.
Conflict of interest: none declared
1. Braak H, Del Tredici K, Rüb U, et al. Staging of brain pathology related to sporadic Parkinson’s disease. Neurobiol Aging. 2003; 24(2): 197–211
2. Nutt JG, Wooten GF. Clinical practice. Diagnosis and initial management of Parkinson’s disease. N Engl J Med. 2005; 353(10): 1021–27
3. Klein C, Prokhorov T, Miniovitz A, Dobronevsky E, Rabey JM. Admission of Parkinsonian patients to a neurological ward in a community hospital. J Neural Transm 2009; 116(11): 1509–12
4. Mueller MC, Juptner U, Wuellner U, et al. Parkinson’s disease influences the perioperative risk profile in surgery. Langenbecks Arch Surg 2009; 394(3): 511–15
5. Guttman M, Slaughter PM, Theriault ME, et al. Burden of Parkinsonism: a population-based study. Mov Disord 2003; 18(3): 313–19
6. Vossius C, Nilsen OB, Larsen JP. Parkinson’s disease and hospital admissions: frequencies, diagnoses and costs. Acta Neurol Scand. 2010; 121(1): 38–43
7. Aminoff MJ, Christine CW, Friedman JH, et al. Management of the hospitalized patient with Parkinson’s disease: Current state of the field and need for guidelines. Parkinsonism Relat Disord 2011; 17(3): 139–45
8. Temlett JA, Thompson PD. Reasons for admission to hospital for Parkinson’s disease. Intern Med J 2006; 36(8): 524–26
9. 14.Castell JA, Johnston BT, Colcher A, et al. Manometric abnormalities of the oesophagus in patients with Parkinson’s disease. Neurogastroenterol Motil. 2001; 13(4): 361–64
10. Marcason W. What are the primary nutritional issues for a patient with Parkinson’s disease? J Am Diet Assoc 2009; 109(7): 1316
11. Djaldetti R, Lev N, Melamed E. Lesions outside the CNS in Parkinson’s disease. Mov Disord. 2009; 24(6): 793–800
12. Shill H, Stacy M. Respiratory complications of Parkinson’s disease. Semin Respir Crit Care Med 2002; 23(3): 261–65
13. Chokroverty S. The spectrum of ventilatory disturbances in movement disorders. In: Chokroverty S, ed. Movement Disorders. Great Neck, New York: PMA Publishing Corp; 1990: 365–392
14. Easdown LJ, Tessler KJ, Minuk J. Upper airway involvement in Parkinson’s disease resulting in postoperative respiratory failure. Can J Anaesth 1995; 42(4): 344–47
15. Pepper PV, Goldstein MK. Postoperative complications in Parkinson’s disease. J Am Geriatr Soc 1999; 47(8): 967–72
16. Harada T, Mitsuoka K, Kumagai R, et al. Clinical features of malignant syndrome in Parkinson’s disease and related neurological disorders. Parkinsonism Relat Disord 2003; 9(Suppl 1): S15–23
17. Serrano-Dueñas M. Neuroleptic malignant syndrome-like, or—dopaminergic malignant syndrome—due to levodopa therapy withdrawal. Clinical features in 11 patients. Parkinsonism Relat Disord 2003; 9(3): 175–78
18. Robbins J, Gensler G, Hind J, et al. Comparison of 2 interventions for liquid aspiration on pneumonia incidence: a randomized trial. Ann Intern Med 2008; 148(7): 509–18
19. Singer W, Opfer-Gehrking TL, McPhee BR, et al. Acetylcholinesterase inhibition: a novel approach in the treatment of neurogenic orthostatic hypotension. J Neurol Neurosurg Psychiatry 2003; 74(9): 1294–98
20. Kipps CM, Fung VS, Grattan-Smith P, et al. Movement disorder emergencies. Mov Disord 2005; 20(3): 322–3421. Kalenka A, Schwarz A. Anasthesia and Parkinson’s disease: how to manage with new therapies? Curr Opin Anesthesiol 2009; 22(3):419–24