PD As A Chronic Neurodegenerative Disease

Introduction

It is estimated that 145,000 people suffer from Parkinson’s disease (PD) in the UK (1), with this figure predicted to rise by approximately 20% by 2025. PD is a chronic neurodegenerative disease for which there is no cure (2). It is caused by the death of nerve cells that make and replace dopamine from the substantia nigra of the basal ganglia and by the formation of lewy bodies (small proteins) in the brain cell (3). Without dopamine firing, the direct pathway, responsible for facilitating voluntary movements is interrupted. The 3 most common symptoms are resting tremor, rigidity and bradykinesia (1).

However, as the disease progresses, non-motor symptoms as well as medication side effects start to appear e. g. hallucinations (4). I believe this study is of extreme importance and interest to health professionals and the NHS as the increasing prevalence of this disease means it is likely to cost the health system a lot of money in the future (5). I am a second year medical student of the University of Bristol. I have been set the task of discovering the effect of hospitalization on sufferers of PD as part of my student choice project in Musgrove hospital, Taunton. I aim to find out what symptoms people with PD present to the hospital with, to uncover the challenges patients with PD face in hospital and lastly, on the basis of the findings, to suggest measures to help patients overcome those challenges.

Method: I identified different databases including Medline, Web of Sciences, PubMed, PMC, PsycINFO and searched for articles containing the keyword Parkinson’s and 2 or more of the following: inpatient, hospital, medication, experience and prevalence. I took note of my chosen research papers’ reference list for further material and to ensure I knew where each article was sourcing its information from. Additionally, I attended handover, ward rounds and spoke with patients who have PD as well as the multidisciplinary team looking after these patients. Results: Using the search methods above 40 articles were deemed relevant to the subject matter. I chose the most suitable 8 from this list which included the chosen studies’ and papers’ reference lists.

1. Symptoms patients with PD present to the hospital with: There are a limited amount of resources and recent studies detailing the presenting complaint which people with PD arrive to the hospital with (9). One study reported that reduced functional ability, including falls (14%), fractures (4%) and general reduced physical ability (8%) was the most common reason patients with Parkinson’s were admitted to hospital (total 26%). Other reasons were infections (total 20%) including pneumonia (11%) and urinary tract infections (UTI) (9%) (6). Another study involving 260 emergency admissions of 173 patients with PD revealed 30% of admissions were to treat an infection (chest infection 22%, UTI 8%). Other reasons for admission included falls (13%), cardiovascular problems (5%), side effects of PD drugs (4%) and depression (3%) (7). During my placement in Taunton I saw 5 patients with PD: patient X had fractured her neck of femur (NOF), patient Y had been acutely confused and had fallen a day prior to admission, patient Z and W had come to hospital with worsening motor ability and patient A had fallen.
2. Challenges faced by patients with PD in hospital:
   1. MEDICATION

   Management of medication in Parkinson’s disease is one of the most challenging aspects of the syndrome.

   This becomes more challenging in a hospital setting for the following reasons

   • The timing of PD medication is very important. Most patients take their medication at specific times during the day and stick to this rigorously (8).
   • The frequency of medication differs from most other medication and can occur up to 5 times a day (9).
   • PD medication can be complex with many different drug combinations and doses.

   Hence this can make life difficult for a patient with PD in the following ways:

   • It can take a long time for a patient’s medication list to be sent from the patients GP surgery to the doctor to the pharmacist.
   • During this time a patient may have missed 2 medication rounds (10).
   • Most medications in hospital are given at a particular time (morning, lunch, evening) whereas PD medications may need to be given at atypical times e. g. 16: 00 hrs (10).
   • Depending on the reason for admission e. g. acute confusion, medication may need to be reviewed and modified. This takes time and could delay administration of medication.
   • Events such as surgery mean medication is stopped pre and postoperatively. One study in Aberdeen Royal Infirmary discovered that during 59 surgical admissions of 51 patients with PD, over 70% of admissions resulted in medication being missed during the patients stay at hospital (11).
   2. LACK OF PD EXPERTISE

   Most patients with PD presenting to the hospital are sent to general wards rather than neurology wards (12), where staff have limited knowledge of PD (9). A retrospective audit was carried out in the Princess Royal University of North Kent that highlighted the challenges faced by doctors and nurses when a patient with PD enters their ward. It showed that only 1 of 16 pre-registrar house officers understood the function of apomorphine (dopamine agonist) and 5 of 20 could name one drug that should not be given to a patient suffering from PD. 26 of 35 patients with PD either didn’t get the correct medication or got no medication, resulting in patients becoming constipated and their muscles stiffening (13).

   3. ENVIRONMENT

      A further difficulty in relation to general wards is that the environment may not be favourable. It might not be designed to give sufficient time to the patients to carry out basic activities, e. g. mobilising, eating and speaking. Sometimes there is not enough access to physiotherapy which is very important for patients with PD.

3. Patient view on experience in the hospital

To supplement my reading and research, I planned to talk with various different patients with PD who entered the hospital over the course of three weeks. However, only one patient was able to converse with me. Thus it was necessary to speak with several members of staff to get more information. Patient X was admitted to the orthopaedic ward with a fractured NOF. After the procedure she did not receive pain medication immediately as the staff on the orthopaedic ward were unsure how such medication would interact with the PD medication. This patient had a further complication as she had a duodopa pump (liquid form of levodopa that is more potent than oral tablets). She had to be transferred to a ward with PD specialists.

During this time her pain relief medication as well as her routine PD drugs were delayed leading to further complications such as low mood. Patient X was too unwell to speak with me so I got the case history from one of the consultant geriatricians on the ward. Patient Y was able to converse with me. He came in with severe confusion following a fall. He told me he often does not get his medication at the times he is used to. Patient Y’s main complaint now is that his muscles are very stiff and he finds it hard to get out of bed or go for short walks. The physiotherapist confirmed that patient Y has been unable to engage fully with his last 2 physio appointments during his time in hospital. He is in a bay with 7 other patients none of whom have the same condition. He finds it hard to sleep at night as it’s very noisy with bells ringing regularly. Patient Z and W have been very anxious since last week, mainly due to a new patient with dementia having been admitted to their bay.

Discussion

From my research and time spent on the wards, it would appear that patients with PD are admitted for several different reasons, some directly related to PD (decreased functional mobility), some indirectly related to PD (side effects of medication e. g. hallucinations, depression) and some possibly unrelated such as infections (7). However, for this question to be answered more conclusively, more studies would need to be conducted on the presenting complaints of patients with PD attending hospital. In addition I would visit more hospitals in order to see more patients and thus accumulate more reliable data. As we can see from the results above, there are significant obstacles for a patient with PD in hospital. When PD medication is missed, given late or the wrong dose is administered, the patient becomes unwell (13) as is illustrated by patients X’s and Y’s experience. Patient X has already been in hospital 3 weeks. People without PD getting a hip replacement usually leave the hospital approximately 26 hours after the procedure (14).

Similarly, patient Y has been an inpatient for the last 2 weeks. His acute confusion and decreased functional mobility has worsened since his admission which may be partly due to mistimed medication. It appears that a patient’s stay in hospital is lengthened if they have PD. One study conducted over a 4 year period revealed patients’ average stay in hospital was 3. 5 days longer than patients without PD, 21. 3 versus 17. 8 (6). I believe the obstacles mentioned above contribute to this.

Conclusion

I wished to investigate if a hospital setting provided significant challenges for patients with PD. I researched several studies and articles on the subject matter, I spoke with all members of the multidisciplinary team including doctors, nurses, physiotherapists, occupational therapists social care workers, home first co-ordinators and spoke and observed patients on the wards where possible. It is clear PD is a very specialised disorder that requires extensive knowledge of the disease, including understanding the importance of regular administration of medication at specific times and of appropriate therapies. Patients with PD are regularly treated by health care professionals that are not experts in their condition and this can pose problems that ultimately mean patients with PD stay longer in hospital than patients without PD. RecommendationsIn view of the potential detrimental effects through admission to hospital, it may be beneficial to make more use of day hospital type management. For example where the presenting problem is decreased motor ability, the person could attend a day hospital regularly for monitoring medication changes and intensive physiotherapy. In relation to inpatient care I think there should be more specific education.

This would hopefully lead to less errors being made regarding treatment. Where the patient can’t be in a specialised unit a more integrated approach to their care would be beneficial, e. g. involvement of a geriatrician on an orthopaedic ward.

In addition, the patient with PD could be identified early during admission for physiotherapy input. Lastly, some simple approaches in a hospital to encourage mobility would also benefit the patient with PD. The NHS campaign ‘End PJ Paralysis’ encourages hospital staff to get patients up, dressed and out of pyjamas and moving while in hospital. Patients with PD that are bed bound in hospital lose motor ability. This simple initiative could particularly benefit the patients with PD make one’s experience in hospital more enjoyable and shorter.

Reflection

This has been such a worthwhile project as I have learned so much in a field that I had little experience in. Before I started this project all I knew about PD was that it resulted from a reduction in dopamine firing in the brain. However, I now have a comprehensive awareness of the disease, it’s prevalence, the symptoms as well as the treatment side effects. Most importantly I have gained invaluable insights into a patient’s perspective of having the disease in a hospital setting. Throughout this project I have practiced talking to patients and listening in an active manner. I have learned the layout of the charts and I have observed how to clerk a patient. This project has inspired me to do further research on the subject matter possibly during my intercalation year or after I finish medical school.