NEW ORLEANS – When Parkinson’s disease patients are admitted to hospitals, they often end up on incorrect doses of levodopa during their stay – if it’s prescribed at all – and sometimes inappropriately get metoclopramide or neuroleptics, dopamine-blocking agents that could make their disease worse, according to a study from the University of Calgary (Alta.).
That’s what researchers from the university’s Movement Disorders Clinic found when they compared what 44 of their Parkinson’s patients took at home with what they were given after being admitted to Calgary hospitals.
Dr. Katie Wiltshire
There were medication problems in 44 (80%) of the 55 hospitalizations those patients had in 2010, said lead author Dr. Katie Wiltshire, a neurology resident at the university.
"Our study identifies deficiencies in the in-hospital prescribing of medications for patients with PD [Parkinson’s disease]. This includes a failure to seamlessly continue usual PD medications when patients are admitted, and perhaps of even greater concern, the inappropriate addition of dopamine-blocking agents during their hospital stay," she said at the annual meeting of the American Academy of Neurology.
Similar problems have been found at hospitals in the United States and Britain, perhaps because some hospital services are unfamiliar with PD treatment. "Widespread education of providers and safe-prescribing protocols are urgently needed to address these unsafe care issues," Dr. Wiltshire said.
Patients in her study came in on stable levodopa doses in 53 of the 55 admissions (96.4%); there were subsequent problems with levodopa administration in 26 (49%) of those hospital stays.
During three hospitalizations (5.7%), levodopa was not ordered for people who been on it at home. In 15 of the 53 admissions (28.3%), doses ordered were too high or too low. Dose schedules were off during 8 hospital stays (15.1%). In another12 stays (22.6%), patients were put on either immediate or extended-release levodopa when they had been on the alternate formulation before coming to the hospital. Metoclopramide or neuroleptics were ordered in 24 (43.6%) of the overall 55 admissions.
Dr. Wilshire and her colleagues don’t know yet if the discrepancies hurt patients, but other studies have found that they do, and that many PD patients report bad hospital experiences related to medication mismanagement (Parkinsonism Relat. Disord. 2007;13:539-40; Postgrad. Med. J. 2010;86:334-7). "This is a sobering report," said Dr. Christopher Goetz, director of the Parkinson’s Disease and Movement Disorders program at Rush University in Chicago, who moderated her presentation.
The National Parkinson Foundation is trying to address the problem with an Aware in Care campaign that helps patients and physicians overcome medication challenges during PD hospitalizations.
In Calgary, Dr. Wiltshire and her colleagues are working with the electronic health records system to give admitting physicians access to notes from the Movement Disorders Clinic. "Ideally, we would like to be able to [write the medication orders] and have them sent directly into the admitting orders," Dr. Wiltshire said.
They’ve already put a warning flag in the system that pops up when people order metoclopramide for patients on antiparkinson drugs. They’ve also made sure that immediate-release levodopa comes up first on drug ordering screens. Extended-release levodopa "was coming up first, so that’s what people were clicking," Dr. Wiltshire said.
The team also hopes to give PD patients more control over when they get their medications, perhaps by keeping them on bedside tables, and involve pharmacy staff "right at admission, so that they can work to get the [medication] reconciliation done," she said.
Dr. Wiltshire said she has no disclosures. Dr. Goetz reported personal compensation from several pharmaceutical and medical companies, none of them involved in the study.