RECOGNITION AND ASSESSMENT

  • Parkinson’s Disease (PD) is characterised by:
    • tremors, rigidity, akinesia, postural instability
    • decline in swallowing function
    • neuroleptic malignant syndrome
    • range of non-motor complications (e.g. psychiatric and sleep disorders)

History

  • Take an accurate drug history
    • know precisely how PD is managed by patient
    • taking their normal doses in recent days (e.g. too unwell to take as normal)?
  • Consider all sources of information including:
    • patient, usually well informed on their precise treatment
    • summary Care Records/GP fax/GP phone call/previous TTO
    • carer(s)/next of kin
    • transferring hospital/nursing home/residential home prescription charts
    • patient’s own drugs (PODs)/repeat prescriptions
  • Computer letters and notes

INITIAL MANAGEMENT

  • If possible, continue patient’s individualised PD treatment
  • Discuss with a PD specialist whether dose adjustments may be required
  • Prescribe all PD medications, specifying exact timings as necessary
    • e.g. co-beneldopa 12.5/50 mg 6-hrly; 0600, 1000, 1400, 1800
    • ensure supply of required PD medications are available
  • Do not stop or miss doses of levodopa or dopamine agonists
    • prescribe COMT inhibitors (e.g. entacapone) at the same time as levodopa-containing medicines
  • Avoid medicines which may worsen PD
    • antipsychotics (haloperidol). If necessary, consider a benzodiazepine
    • anti-emetics (metoclopramide and prochlorperazine). If necessary, consider domperidone (if nausea not transient, think ECG QTc prolongation)

Apomorphine

  • If already using apomorphine, continue current regimen
  • Do not initiate apomorphine without involvement from a PD specialist
  • APO-go (apomorphine) 24 hr helpline

Nil-by-mouth or compromised swallow

  • Refer for urgent swallowing assessment
  • Consider placing tablets on a teaspoon with thickened fluids/soft foods (e.g. yoghurt), or dispersible/liquid preparations
  • Check for underlying cause and treat accordingly
  • COMT inhibitors and MAOB inhibitors can be safely omitted temporarily
  • If already using apomorphine injection or infusion, continue current regimen
    • do not initiate apomorphine without involvement from a PD specialist

Patient not able to take next oral dose

  • Priority: maintenance of dopaminergic medication
  • Refer patient to PD specialist and swallowing team ASAP. If unable to contact (e.g. out-of-hours):

Rotigotine patch administration

  • Apply patches once a day. Press firmly on back of patch for a minimum of 30 seconds onto skin to activate adhesive – see Figure 1
  • Apply patch at approximately the same time each day
  • Rotate application site daily to reduce risk of skin irritation (do not use same area of skin again for 14 days). See Figure 2 for suggested application sites

Monitor patient

  • 4-hrly observations including
    • sedation
    • respiratory rate
    • application site
    • response
  • If increased stiffness/slowness, increase dose and review daily
  • If increased confusion/hallucinations, decreased

SUBSEQUENT MANAGEMENT

  • Decided by PD specialist