How should Parkinson’s disease be managed perioperatively?

Case

A 67-year-old female with moderately advanced Parkinson’s disease (PD) had a mechanical fall in her home, which resulted in a humeral fracture. The fall occurred in the morning before she was able to take her medications and was related to her difficulty in initiating movements.

On her current regimen, her PD symptoms are controlled. She is able to perform daily living activities independently and ambulates without assistance. She also performs more complex tasks (e.g., cooking and managing her finances). She has not exhibited any symptoms consistent with dementia. She occasionally experiences dyspnea on exertion and dysphagia, but she has not been evaluated for these complaints. She takes carbidopa/levodopa (CD/LD) 25 mg/100 mg four times a day, amantadine 100 mg twice daily, and ropinirole 3 mg three times a day.

She is scheduled for open reduction internal fixation of her fracture; the orthopedic surgeon has requested a perioperative risk assessment and recommendations concerning her medications. How should PD be managed perioperatively?

click for large version

Overview

Advances in surgical and anesthetic techniques, in combination with an aging population, have contributed to an increasing number of geriatric patients undergoing surgery. As many as 50% of Americans older than 65 will undergo a surgical procedure; hospitalists will comanage many of these patients in the perioperative period.1

Although cardiopulmonary disorders receive a great deal of attention with regard to perioperative risk assessment, other comorbid conditions also contribute to perioperative risk—namely, disorders specific to the elderly population. Parkinson’s disease is one such condition that deserves attention.

PD is a progressive, neurodegenerative condition associated with loss of dopaminergic neurons and the presence of Lewy bodies within the substantia nigra and other areas of the brain and peripheral autonomic nervous system.2 Cardinal clinical features include rigidity, bradykinesia, and resting tremor. A supportive feature is a consistent response to levodopa. Postural instability, cognitive impairment, and autonomic dysfunction usually occur later in the disease.3,4

As the population ages, Parkinson’s disease is becoming more prevalent, affecting approximately 1% of individuals older than 60.5 These patients pose a specific challenge to the hospitalist, not only because the multiorgan system manifestations of PD can raise surgical risk, but also due to the direct effects of dopaminergic medications used to treat PD, lack of a parenteral route for these medications in NPO patients, and the risks associated with abrupt withdrawal of these medications.

Although surgical risk in PD patients has received intermittent attention in surgical, anesthesia, and neurology literature, there is no broad consensus statement or treatment guideline for the perioperative approach.

Literature Review

Key Points

  • Hospitalists are often asked to comanage or consult on hospitalized patients with Parkinson’s disease (PD) in the perioperative setting.
  • The various organ-system manifestations and treatments place PD patients at increased risk of complications during the perioperative period.
  • PD patients in the perioperative period are at risk for developing Parkinsonism-hyperpyrexia syndrome (PHS), which carries a substantial degree of morbidity and mortality if not prevented or treated in its early stages.
  • By minimizing interruptions in the administration of PD medications, many of the perioperative complications related to PD can be prevented or diminished.
  • PD patients who are undergoing long procedures, undergoing procedures involving the gastrointestinal tract, or are utilizing deep-brain-stimulation treatment typically require more complex perioperative care and might benefit from neurological consultation.

Additional Reading

  • Pepper PV, Goldstein MK. Postoperative complications in Parkinson’s disease. J Am Geriatr Soc. 1999;47(8):967-972.
  • Gálvez-Jiménez N, Lang AE. The perioperative management of Parkinson’s disease revisited. Neurol Clin. 2004;22(2):367-377.
  • Kalenka A, Schwarz A. Anaesthesia and Parkinson’s disease: how to manage with new therapies? Curr Opin Anesthesiol. 2009;22(3):419-424.
  • Nicholson G, Pereira AC, Hall GM. Parkinson’s disease and anesthesia. Br J Anaesthesia. 2002;89(6):904-916.

A retrospective cohort of 51 PD patients undergoing various types of surgery revealed that PD patients have a longer hospital stay than matched cohorts.6 Pepper et al studied a cohort of 234 PD patients in the Veterans Administration population who were undergoing a variety of surgeries.7 They found that patients with PD had a longer acute hospital stay and had higher in-hospital mortality.7 The multisystem manifestations of PD might account for this global increase in perioperative risk.

About Richard Quinn

Richard Quinn is an award-winning journalist with 15 years’ experience. He has worked at the Asbury Park Press in New Jersey and The Virginian-Pilot in Norfolk, Va., and currently is managing editor for a leading commercial real estate publication. His freelance work has appeared in The Jewish State, The Hospitalist, The Rheumatologist, ACEP Now, and ENT Today. He lives in New Jersey with his wife and three cats.

View more by this author»

Comments

Leave a Reply

Your email address will not be published. Required fields are marked *