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Problem: One-third of all patients with Parkinson’s disease visit an emergency department or hospital each year, making it a surprisingly common occurrence. 1 The disease affects about 1 million people and is currently the fourteenth leading cause of death in the US.

Hospitalization can be risky for patients with Parkinson’s disease when viewed from the perspective of pharmacological management. Patients with Parkinson’s disease require strict adherence to an individualized, timed medication regimen of antiparkinsonian agents.

Dosing intervals are specific to each individual patient because of the complexity of the disease. It is not unusual for patients being treated with carbidopa/levodopa to require a dose every 1 to 2 hours. When medications are not administered on time, according to the patient’s unique schedule, patients may experience an immediate increase in symptoms.

2,3 Delaying medications by more than 1 hour, for example, can cause patients with Parkinson’s disease to experience worsening tremors, increased rigidity, loss of balance, confusion, agitation, and difficulty communicating. 2 Studies show that three out of four hospitalized patients with Parkinson’s disease do not receive their medications on time, or have had doses entirely omitted. 4 According to the National Parkinson Foundation, 70% of neurologists report that their patients do not get the medications they need when hospitalized. 2 Undergoing surgical procedures can be particularly risky for patients with Parkinson’s disease. Antiparkinsonian agents have been inappropriately withheld because patients were NPO for surgery, and surgical patients have been given a contraindicated anesthetic agent, or a centrally acting antidopaminergic drug such as haloperidol, metoclopramide, or prochlorperazine, postoperatively. One in three patients with Parkinson’s disease has been prescribed contraindicated drugs during hospitalization. Serious complications, mostly neuropsychiatric, have occurred in more than half of these patients.

4,5 Two case examples The first case reported to ISMP involved a woman with Parkinson’s disease who was admitted to a hospital with a urinary tract infection. Upon admission, the patient’s medications were recorded during medication reconciliation. The patient told the nurse that she needed her medications right away.

But she had been uncertain about the dose of a few medications, and it took several hours to collect further information about these doses. Once ordered, the medications were scheduled using the hospital’s standard administration times. However, for patients with Parkinson’s disease, it is safest to administer antiparkinsonian drugs according to the scheduled times the patient takes the medications at home. 2,4 In this case, the patient received all of her antiparkinsonian medications several hours late. While awaiting the medications, the patient found it hard to talk and communicate with hospital staff and her family. Her tremors intensified and she had difficulty maintaining her balance. She became so confused and agitated from not receiving her medications that her physician ordered haloperidol 5 mg intramuscularly.

The physician was not aware that haloperidol can worsen the symptoms of Parkinson’s disease, 6,7 and the pharmacist and nurse did not detect the prescribing error. The adverse symptoms worsened after receiving haloperidol, thus lengthening the patient’s hospitalization. Later, when this patient required hospitalization for an elective surgery, the family selected a facility associated with the patient’s neurologist.

The family assumed the staff would be more knowledgeable about the disease, but they ran into similar problems. The patient did not receive her medications on time and experienced the same symptoms as during the previous hospital admission. Once again, this extended her hospital stay unnecessarily. In another case, reported to the National Parkinson Foundation, a hospitalized patient with Parkinson’s disease had surgery for a herniated disc. 2 During the admission process, the patient’s wife alerted the staff about the need to administer her husband’s antiparkinsonian drugs exactly according to his schedule at home. She found staff were unaware of the need for timely drug administration and, thus, repeated the warning with each shift change. However, when the patient’s wife was not by her husband’s side, he did not get his medications on time.