Physiatry Recommendations for Hospital Inpatients with Parkinson's Disease
Hospitalized patients with Parkinson's disease should receive comprehensive multidisciplinary rehabilitation including physical therapy, occupational therapy, and speech therapy for at least 3 hours daily, along with careful medication management to optimize motor function and quality of life. 1
Medication Management
Critical Medication Considerations
- Ensure strict adherence to the patient's home medication schedule for levodopa/carbidopa to prevent motor fluctuations 2
- Monitor for medication side effects including:
- Dyskinesias (may occur at lower doses with carbidopa/levodopa)
- Depression with suicidal tendencies
- Sudden onset of sleep or somnolence
- Hyperpyrexia and confusion resembling neuroleptic malignant syndrome 2
Medication Optimization
- For patients with cognitive concerns, consider GPi deep brain stimulation rather than STN DBS 3
- For patients with depression risk, pallidal stimulation is preferred over STN stimulation 3
- When medication reduction is the goal, STN DBS is recommended over GPi DBS 3
- For patients with "on" medication dyskinesias without anticipated medication reduction, target the GPi 3
Physical Therapy Interventions
- Implement gait training, balance exercises, and flexibility work daily 4
- Include structured exercise therapy with the following components:
- Monitor for orthostatic hypotension during position changes:
Occupational Therapy Interventions
- Provide ADL training with adaptive equipment recommendations 4, 1
- Assess and address safety concerns for fall prevention
- Implement strategies for energy conservation and fatigue management
- Evaluate need for assistive devices to maximize independence 1
Speech Therapy Interventions
- Address communication difficulties with targeted exercises 4
- Provide swallowing assessment and management to prevent aspiration 4
- Implement strategies for voice volume and clarity
Nutritional Management
- Implement Mediterranean diet rich in vegetables, fruits, and low-fat dairy products 4
- Monitor nutritional status and body weight regularly 4
- Consider timing of protein intake relative to levodopa administration to optimize medication effectiveness
- Avoid excessive alcohol consumption 4
Cardiovascular Management
- Target systolic BP of 120-129 mmHg if tolerated, and diastolic BP <80 mmHg but not <70 mmHg 4
- For older patients (≥65 years), target systolic BP range of 130-139 mmHg 4
- Consider angiotensin receptor blockers (ARBs) like losartan as first-line antihypertensive agents 4
- Monitor cardiac function with particular care during medication adjustments, especially in patients with history of cardiovascular disease 2
Rehabilitation Program Structure
- Provide a combination of physical therapy, occupational therapy, and speech therapy for a total of 3 hours per day, 5-7 days per week 1
- Implement daily pharmacological adjustments based on patient response 1
- Focus on both motor and non-motor symptoms in the rehabilitation program 5, 6
- Enhanced multidisciplinary care should target body axis symptoms (rising from chair, posture, postural stability, falling, walking) and non-motor symptoms (depression) 6
Discharge Planning
- Coordinate with outpatient providers to ensure continuity of care
- Provide education to patients and caregivers about medication management, exercise programs, and safety considerations
- Consider referral to a regional network of allied health professionals specialized in Parkinson's disease for ongoing care 7
The evidence strongly supports that inpatient rehabilitation with a multidisciplinary approach significantly improves functional status in patients with Parkinson's disease 1, 6. Studies have shown that improvements exceed the minimal clinically important difference in 71% of patients receiving this type of care 1.