What is the recommended assessment and treatment plan for a patient with Parkinson's disease in an inpatient hospital setting, involving physiatry?

Assessment and Treatment Plan for Parkinson's Disease in Inpatient Hospital Setting with Physiatry Involvement

The recommended approach for a patient with Parkinson's disease in an inpatient hospital setting should include optimization of antiparkinsonian medications, early mobilization, multidisciplinary rehabilitation, and careful management of nutritional status to improve motor function and quality of life.

Initial Assessment

• Evaluate current medication regimen, focusing on levodopa/carbidopa timing and dosing, as this remains the most effective medication for treating Parkinson's disease 1
• Assess swallowing function before initiating oral nutrition, as dysphagia is common in Parkinson's patients 2
• Evaluate motor symptoms in the "off" medication state when possible, as this provides more accurate information about disease severity and better reflects patient's perception of mobility disability 3
• Focus assessment on turning speed, gait speed, and stride length, as these measures best correlate with disease severity and patient perception of mobility disability 3
• Screen for cognitive impairment, which may influence rehabilitation approach and medication management 2, 1

Medication Management

• Optimize timing of levodopa administration, ensuring it's taken at least 30 minutes before meals to avoid interactions with dietary proteins that reduce absorption 1, 4
• For tube-fed patients on oral levodopa, interrupt enteral nutrition for at least 1 hour before and 30-40 minutes after medication administration 1, 4
• Monitor for side effects of PD medications that might influence nutritional status, including nausea, vomiting, abdominal pain, dyspepsia, constipation, weight decrease, dry mouth, and anorexia 2, 4
• Consider monitoring vitamin B6 levels and homocysteine status in patients on high or increasing doses of carbidopa-levodopa, as these may be affected by the medication 4

Physical Rehabilitation Approach

• Implement early mobilization according to defined inclusion and exclusion criteria with the best possible dosage and frequency 2
• Include strength training to increase walking speed as an adjunct to standard physical therapy 2
• Consider wheelchair cycle ergometer training to improve muscle strength and cardiovascular fitness 2
• Implement inspiratory muscle training using an inhalation trainer to increase respiratory muscle strength and quality of life 2
• Focus rehabilitation on turning, gait speed, and stride length, as these measures best reflect patients' quality of life and balance confidence 3

Nutritional Management

• Monitor nutritional status regularly, with particular attention to changes in body weight 1, 4
• Consider implementing a protein redistribution diet (low-protein breakfast and lunch, with normal protein intake at dinner) to improve motor function and increase "ON" time 1
• Monitor for potential complications of protein redistribution, including weight loss, micronutrient deficits, and hunger 1
• For patients with constipation, consider fermented milk with probiotics and prebiotic fiber, in addition to increased water and fiber intake 1

Management of Non-Motor Symptoms

• For REM Sleep Behavior Disorder (RBD), consider melatonin (starting at 3 mg and increasing by 3-mg increments to 15 mg) as it is only mildly sedating 1
• For cognitive impairment with RBD that is refractory to other treatments, consider rivastigmine 1
• Address depression and anxiety, which are common in Parkinson's disease and can impact rehabilitation outcomes 5, 6

Advanced Treatment Considerations

• For patients with motor fluctuations despite optimal medical therapy, consider referral for evaluation for deep brain stimulation (DBS) 2, 1
• If considering DBS, note that GPi stimulation may be preferable to STN stimulation in patients with significant cognitive concerns 2, 1
• For patients with dyskinesias where medication reduction is not anticipated, consider GPi as the DBS target 2

Discharge Planning

• Ensure a clear plan for medication timing and dosing is communicated to the patient and caregivers 1, 4
• Arrange for outpatient physical, occupational, and speech therapy as needed 5
• Consider a patient-specific index for physiotherapy in Parkinson's disease (PSI-PD) to identify limitations in everyday activities that are important for the patient 7
• Educate patients and caregivers about the importance of maintaining the medication schedule to optimize motor function 1, 3

Common Pitfalls and Caveats

• Avoid strict low-protein diets as they are not supported by evidence and may lead to malnutrition 1
• Be aware that increasing doses of levodopa over time are associated with higher risk for malnutrition, requiring careful monitoring 1, 4
• Recognize that patients may have prejudice against walking aids, which can hinder their use despite potential benefits for functional mobility 8
• Remember that the "off" medication state assessment provides more valuable information about disease severity than the "on" state 3