In Hospital Recommendations for Parkinson paients: Details
Resuming home medications
"AS SOON AS POSSIBLE"
1. Please resume home medications for Parkinson as soon as possible. Parkinson medication may include Sinemet (Carbidopa levodopa)/ Rytary/ entacapone/ Azilect (Rasagiline)/ Selegiline/ Rivastigmine patch/ Donepezil/ Memantine.
2. Some medications should be given every 4 hours. Patients need to receive their medications on time.
3. If the patient is NPO with high risk for aspiration even with medications, you should consider replacement of carbidopa levodopa with equivalent dose of “Parcopa” (sublingual medication), or place a nasogastric (NG) tube or dobhoff (DH) tube as soon as possible to continue Parkinson medications via tube.
4. If the patient is on Rytary capsule at home and has a NG tube (Rytary cannot be crushed), then please switch to the equivalent dose of Sinemet 25/100 that can be given via tube.
[Rytary to Sinemet 25/100 conversion formula: total daily dose of Rytary divided by 2= total daily dose of Sinemet 25/100; divide the total daily dose in 3-4 times a day]
5. Please avoid food or tube feeding 1 hour before and 1 hour after administration of Sinemet / Rytary. The medication should be given with an empty stomach to have maximum absorption.
Management of delirium and hallucinations
6. Please evaluate for any underlying systemic infection (Urinary infection, respiratory tract infection, etc.), dehydration, or metabolic abnormality, causing change in mental status.
7. Please consider Rivastigmine patch 4.6mg daily for fluctuation in mental status, delirium, sundowning in patients with cognitive impairment.
8. If the patient is agitated and psychotic at night during the admission, may consider Quetiapine 12.5mg nightly, if there is no medical contraindication; please monitor cardiac rhythm, EKG, QT intervals.
9. “Pimavanserin/ Nuplazid” is an FDA approved medication for Parkinson’s psychosis. If the patient has a history of Parkinson’s disease with visual hallucinations for more than four weeks, with no underlying infection or metabolic etiology, consider starting “Pimavanserin 34mg” nightly.
Clozapine can be considered in cases with no response to the above medications, with careful CBC monitoring.
10. Please avoid other antipsychotic medications, including Haldol or Risperidone.
Delirium prevention care during hospital admission
- Evaluate for dehydration
- Keep windows open and lights on during the day; provision of cognitively stimulating activities multiple times a day is recommended.
- Use eyeglasses and hearing aids during the day
- Minimize sleep disruptions and unnecessary noise or stimuli at night
- Timely removal of catheters and physical restrictions
Nursing care
11. Aspiration precautions. Keep the head of the bed elevated up to 1 hour after feeding.
12. Constipation care as needed: Docusate senna, Miralax, Magnesium Citrate as needed.
13. Fall precautions
Transition of care
14. It is critical to have evaluation by Physical therapy/Occupational therapy/Speech and swallow evaluation, soon after admission, to prevent unnecessary long hospital admission and inpatient complications.