What are the physiatry recommendations for a hospital inpatient with Parkinson's disease (PD) and acute encephalopathy?

Physiatry Recommendations for Hospital Inpatients with Parkinson's Disease and Acute Encephalopathy

The most critical physiatry recommendation for hospitalized patients with Parkinson's disease (PD) and acute encephalopathy is to ensure exact timing of antiparkinsonian medications to prevent motor function deterioration, with medication errors being the primary risk factor for worsening outcomes. 1, 2, 3

Medication Management

• Implement a hospital-wide alert system in the electronic medical record to identify PD patients on admission 4

• Ensure strict adherence to the patient's home medication schedule:

  • Administer antiparkinsonian medications at precisely the scheduled times (not >30 minutes late)
  • Avoid delays in medication administration which can lead to motor deterioration
  • If pharmacy services are closed, ensure emergency access to PD medications 2

• Allow patients to self-administer their PD medications when appropriate, as this has been shown to prevent motor deterioration 3

• Avoid prescribing contraindicated antidopaminergic medications:

  • Implement pharmacy alerts for contraindicated medications
  • Metoclopramide, prochlorperazine, and typical antipsychotics should be strictly avoided 4
  • For psychosis or nausea, consider mirtazapine (7.5-30mg at bedtime) or low-dose olanzapine (5mg/day) if necessary 5

Neurological Management

• Perform regular neurological assessments to monitor encephalopathy:

  • Assess level of consciousness, cognitive function, and motor symptoms
  • Monitor for signs of worsening encephalopathy or development of seizures 5

• For patients with high-grade encephalopathy (grades 3 and 4):

  • Consider regular monitoring with transcranial Doppler ultrasound rather than invasive ICP devices 6
  • Avoid benzodiazepines which can worsen encephalopathy 6
  • If sedation is required, avoid benzodiazepines and use dexmedetomidine with caution (due to hepatic metabolism) 6

Physical Therapy Interventions

• Implement early mobilization protocols to prevent deconditioning:

  • Gait training with appropriate assistive devices
  • Balance exercises to reduce fall risk
  • Flexibility exercises to maintain range of motion 5

• For patients with limited mobility:

  • Positioning to prevent contractures and pressure injuries
  • Bed mobility training
  • Transfer training with caregivers 5

Occupational Therapy Interventions

• Assess and address activities of daily living (ADLs):

  • Provide adaptive equipment recommendations
  • Implement compensatory strategies for self-care activities
  • Evaluate for cognitive impairments affecting function 5

• Environmental modifications:

  • Ensure bedside setup promotes independence
  • Recommend appropriate seating and positioning devices
  • Evaluate need for assistive technology 5

Speech Therapy Interventions

• Assess and manage swallowing dysfunction:

  • Perform bedside swallowing evaluation
  • Recommend appropriate diet modifications
  • Implement swallowing strategies to prevent aspiration 5

• Address communication difficulties:

  • Assess speech intelligibility and implement strategies to improve communication
  • Provide alternative communication methods if needed 5

Management of Complications

• For orthostatic hypotension:

  • Monitor for drops in blood pressure (systolic ≥20 mmHg or diastolic ≥10 mmHg within 3 minutes of standing)
  • Consider midodrine, droxidopa, or fludrocortisone
  • Acute water ingestion (≥240-480 mL) can provide temporary relief 5

• For infections (common complication in 15% of hospitalized PD patients):

  • Early identification and treatment is crucial as infections can worsen motor function 3
  • Monitor for signs of urinary tract infections and pneumonia

• For confusion/delirium (occurs in 24% of hospitalized PD patients):

  • Identify and treat underlying causes
  • Maintain consistent day/night cycles
  • Ensure familiar objects and family presence when possible 3

Interdisciplinary Approach

• Establish an interprofessional team including:

  • Neurologist
  • Physiatrist
  • Pharmacist
  • Physical, occupational, and speech therapists
  • Nursing staff with education on PD management 7

• Implement medication reconciliation at admission and discharge to prevent errors 2

• Develop specific protocols for:

  • Antiparkinsonian drug interchange
  • Administration timing
  • Management during nil-by-mouth status
  • Handling of nausea/vomiting or psychotic symptoms 2

By implementing these physiatry recommendations, hospitals can significantly reduce complications and prevent motor function deterioration in PD patients with acute encephalopathy, ultimately improving outcomes and reducing length of stay.