How to manage parkinsonism in a critical care setting?

Management of Parkinsonism in Critical Care Settings

Multicomponent, non-pharmacological interventions should be the first-line approach for managing parkinsonism in critically ill patients, followed by appropriate medication management when necessary. 1

Assessment and Recognition

• Screen all critically ill patients with ICU stays ≥48 hours for parkinsonism symptoms:

  • Rigidity
  • Bradykinesia
  • Tremor
  • Postural instability
  • Swallowing difficulties

• Use validated delirium assessment tools (CAM-ICU or ICDSC) to differentiate parkinsonism from delirium 1

Non-Pharmacological Management

First-Line Interventions

1. Early Mobilization

   • Begin within first few days in ICU (Grade A recommendation) 1
   • Adapt to patient's resilience and condition
   • Progress from sitting on edge of bed to walking with therapist

2. Multimodal Sensory and Cognitive Stimulation 1

   • Orientation aids (clocks, calendars)
   • Cognitive stimulation
   • Purposeful engagement
   • Family contact
   • Communication aids (letter boards, tablets, speaking valves for tracheostomy)

3. Environmental Modifications 1

   • Noise reduction
   • Light management
   • Minimize sensory overload
   • Create quieter spaces

4. Stress Reduction 1

   • Pain management
   • Anxiety control
   • Sleep optimization
   • Family involvement

Adjunctive Physical Therapies

• Consider supplemental ergometer training (bed cycling) 1
• Inspiratory muscle training for patients with respiratory weakness 1
• Swallowing assessment before oral feeding if dysphagia is present 1

Pharmacological Management

For Patients Who Can Take Oral Medications

1. Levodopa Administration

   • Continue levodopa therapy at the same total daily dose as pre-admission 2
   • Divide into more frequent, smaller doses if necessary
   • Ensure doses are not delayed or omitted to prevent significant drops in brain dopamine levels 3
   • Target at least 70-100mg of carbidopa per day 2

2. Sedation Considerations

   • Use light sedation rather than deep sedation (conditional recommendation) 1
   • Prefer propofol or dexmedetomidine over benzodiazepines 1
   • Avoid haloperidol for delirium in parkinsonism patients 1

For Patients Who Cannot Take Oral Medications

1. Alternative Administration Routes 3

   • Use dispersible levodopa preparations in thickened fluids for mild dysphagia
   • Administer via enteral tube if available
   • Consider transdermal dopamine agonist patches as temporary measure
   • For severe cases, subcutaneous apomorphine may be considered

2. Delirium Management

   • Dexmedetomidine is preferred for agitated delirium in mechanically ventilated patients with parkinsonism 1
   • Avoid haloperidol and other typical antipsychotics 1
   • If antipsychotics are absolutely necessary, quetiapine is preferred 4

Special Considerations

Preventing Complications

• Neuroleptic Malignant-like Syndrome Prevention 2, 3

  • Monitor for hyperpyrexia, confusion, muscle rigidity
  • Never abruptly discontinue dopaminergic medications
  • Resume usual medications as soon as possible after procedures

• Medication Timing

  • Administer levodopa at precise intervals to maintain steady blood levels 5, 6
  • Coordinate medication administration with procedures and feeding schedules

Monitoring and Follow-up

• Regularly assess for:
  • Motor symptom control
  • Swallowing function
  • Respiratory status
  • Medication side effects
  • Signs of infection or metabolic disturbances that may worsen parkinsonism

Common Pitfalls to Avoid

1. Abrupt discontinuation of dopaminergic medications, which can precipitate neuroleptic malignant-like syndrome 2
2. Using typical antipsychotics (haloperidol) for agitation or delirium 1
3. Deep sedation, which can mask parkinsonism symptoms and worsen outcomes 1
4. Delayed or omitted doses of dopaminergic medications 3
5. Failure to implement non-pharmacological interventions before resorting to medications 1

By following this comprehensive approach to managing parkinsonism in critical care settings, clinicians can minimize complications, optimize symptom control, and improve outcomes for these vulnerable patients.