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Parkinson's disease and medicines management

MEDICINES MANAGEMENT

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Louise Dunsmure MPharm DipClinPharm MRPharmS
Advanced Clinical Pharmacist for Neurosciences,
Leeds Teaching Hospitals NHS Trust
Beverley Lucas PhD FHEA BSc (Hons) RNT
Diploma in Nursing RMN
Senior Lecturer, School of Pharmacy,
University of Bradford
Christopher Acomb BSc MPharm MRPharmS
Clinical Pharmacy Manager,
Leeds Teaching Hospitals NHS Trust
Email: louise.dunsmure@leedsth.nhs.uk
 
This article explores the medicines management issues associated with the admission of patients with Parkinson's disease to hospital. We report some early findings from our research that was undertaken to explore patients’ perceptions of the prescribing and administration of their antiparkinsonian medications during a hospital admission.
 
Parkinson’s disease is a progressive neurological condition that affects more than one million people in Europe, and this number is expected to double by 2030 owing to many countries having an ageing population.(1) The estimated total annual cost of managing the care of patients with Parkinson’s disease in Europe is €13.9 billion.(2) 
 
Patients with Parkinson’s disease have characteristic changes within their brain which include loss of dopaminergic neurons containing neuromelanin from the substantia nigra pars compacta and the presence of intraneuronal inclusions (including Lewy bodies).(3) The motor features of the disease include the cardinal features of tremor at rest, bradykinesia, rigidity and postural instability. Patients can also develop non-motor features of the disease including cognitive impairment, affective disorders and psychosis.
 
Individualised medication regimens
Most patients with Parkinson’s disease will have an individualised medication plan that has been designed to manage the features of their disease. The aim of treatment for ‘early’ Parkinson’s disease is to manage the motor features whereas in patients with ‘later’ disease the treatment aim is to manage both the motor features and the complications caused by the levodopa-based medicines.
 
A patient’s treatment plan should be developed through discussions between the patient and their specialist healthcare professional. Pharmacological treatments should be chosen after consideration of the patient’s previous experience with antiparkinsonian medications, their lifestyle and their ability to manage a complicated medication regimen. Preference about route of administration of medications, the known efficacy of a medication and its adverse effect profile should be factored into the treatment plan.(4)
 
Maintaining a patient's usual medication regimen on admission
On admission to hospital a patient's usual medication regimen should be maintained throughout the admission (where it is clinically appropriate to do so). Omitted or delayed doses frequently lead to significant adverse consequences for the patient for example, increased ‘on-off’ fluctuations and dysphagia. Administration of excessive doses can lead to dyskinesias or psychosis.
 
Obtaining information about a patient's antiparkinsonian medication regimen, including dose timings, often presents a challenge to hospital prescribers. Patients (or their carers) are often best placed to provide this information but when a patient is unable to advise the prescriber (patient has cognitive impairment or unconscious on admission to hospital) alternative resources must be utilised. The information that can be obtained from a GP record is variable because maintaining an accurate record of a patient's medication regimen is a challenge for many GPs due to neurologists frequently adjusting a patient's medication regimen in response to their changing symptoms. 
 
The importance of making accurate and current information about a patient’s medication regimen available to healthcare professionals when a patient is transferred between care providers was a central theme in the document Keeping patients safe when they transfer between care providers – getting the medicines right.(5) The aim of this document is to improve the transfer of information about a patient's medicines when patients are transferred between care providers (for example, admitted to hospital from a care home) and reduce the medicine related errors that can occur following transfer. 
 
In response to this document, members of the pharmacy, medical and nursing teams at Leeds Teaching Hospitals have reviewed the processes used to transfer information about medicines when a patient with Parkinson's disease is admitted to and discharged from hospital. The group have developed a scheme to include information about the specific times of doses of antiparkinsonian medications on GP records. Patients are also being encouraged to carry a medication card to record their current regimen and share this information with all healthcare professionals. Work is currently ongoing to evaluate whether these changes have improved the accuracy of the medication regimen prescribed on a hospital prescription.
 
For a number of years concerns have been expressed about the effects that accidental changes from a usual antiparkinsonian medication routine can have on symptom control and length of hospital stay.(6,7) The correlation between the medication prescribed and a patient's usual routine has been explored in studies using both quantitative methods and mixed methods. These studies highlighted that some patients were not prescribed their usual medicines on admission to hospital, had doses prescribed at incorrect times or did not consistently receive their doses of antiparkinsonian medications at the times prescribed.(8–11) 
 
Parkinson’s UK has recognised problems with prescribing and administering the correct antiparkinsonian medication at the correct times when a patient is admitted to hospital for many years and highlighted their concerns to healthcare professionals through the ‘Get it on time’ campaign in 2006. This campaign is still on-going and provides advice for patients and healthcare professionals about the management of a patient's medications during a hospital admission. In 2007, Parkinson's UK conducted a national survey of over 13,000 people with Parkinson's disease and the results highlighted that 40% of patients admitted to hospital did not get every dose of their medicines on time during their admission.(12) 
 
While many practitioners recognise that changes to medication regimens can have detrimental effects on symptom control, there is a paucity of research about patients’ perceptions of the management of their medicines during a hospital admission. The literature suggests that some patients and their carers have expressed concerns that patients’ medicines were inappropriately stopped when they were admitted to hospital and believed that the patients had experienced deterioration in symptom control during their hospital admission.(13) Some of these patients and their carers also expressed concerns about medicines being administered at times that differed from their usual routine and articulated that they had doubts about the knowledge that nursing and medical staff had about the management of their condition.
 
Patients’ perceptions about medicines management issues
We undertook a qualitative study to generate theory about patients’ perceptions of the management of antiparkinsonian medications during an admission to Leeds Teaching Hospitals. A grounded theory approach(14) was adopted to facilitate detailed exploration of patient perceptions of this under-researched area.
 
Semi-structured individual face-to-face interviews were conducted with participants, fully transcribed and analysed using the constant comparative approach. The study population included patients with Parkinson's disease admitted to the hospital either electively or acutely for surgical or medical indications. None of the participants were admitted to hospital for adjustment of their antiparkinsonian medications.
 
Early results from the study suggest that the central phenomenon in the data provided by the participants is ‘patient anxiety’. Most participants articulated that they felt anxious both prior to and during their hospital admission due to concerns about the risk associated with not continuing their usual medication regimen. Participants were anxious about whether the hospital prescription charts would accurately reflect their usual medication regimen and expressed concerns about the availability of their antiparkinsonian medications during a hospital admission. The coping strategies utilised by the participants in response to these stressors involved the patient advising prescribers about their usual medication regimen and bringing a supply of their medicines into the hospital to ensure that the medicines were available throughout their stay. 
 
Most participants had concerns about whether their medications would be administered at the correct times and these participants responded to this stressor by actively prompting nursing staff prior to the time when a dose of medication was due. However most chose not to self-administer their medication during the admission because they did not feel competent to self-administer their medications in the unfamiliar setting of a hospital ward.
 
All participants expressed concerns regarding the lack of knowledge that the healthcare professionals managing their care had about Parkinson’s disease. Participants perceived that many staff were unaware about the role of medication in managing the symptoms of the disease. Participants believed that if they had access to a person that they perceived to be an expert in Parkinson’s disease (either a neurologist or Parkinson's disease nurse specialist) this would provide them with reassurance.
 
Data analysis is ongoing but the early findings of the study suggest that the patients' concerns are related to the processes and behaviours associated with the prescribing and administration of antiparkinsonian medications. These findings are not intended to be generalisable because they reflect the perceptions of a specific group of patients admitted to one hospital in the UK but they do suggest that many of the causes of this anxiety could have implications for practice, for example, raising awareness of prescribers about the importance of ensuring that all of a patient’s antiparkinsonian medications are prescribed at the correct time and making nurses aware of the importance of administering these medications at specific times.
 
The early findings of this study and the findings from previous qualitative studies(13,15) suggest that the causes of anxiety for some patients with Parkinson’s disease admitted to hospital are related to concerns over the accuracy of prescribing and administration of their antiparkinsonian medication. These stressors are reflective of the concerns that have been highlighted by healthcare professionals and members of the Parkinson's UK specialist interest group for many years. 
 
Conclusions
Accurate prescribing and timely administration of antiparkinsonian medications may present a challenge for healthcare professionals but concerns about their ability to receive the correct medication at the correct time is causing some patients with Parkinson's disease to feel anxious during their hospital admission. Work is ongoing within Leeds with patients and GPs to identify a robust method to ensure the effective transfer of information about a patient's medication when they are admitted to hospital and support the timely administration of antiparkinsonian medication during a hospital admission. 
 
Key points
  • Studies have shown that the individualised medication regimens developed for patients with Parkinson’s disease may not be delivered when patients are admitted to hospital. 
  • Deviations from a patient’s usual medication regimen may be due to their hospital prescription not reflecting their usual regimen or medications being unavailable or administered at times that differ from their usual regimen.
  • People with Parkinson’s disease may feel anxious about how their medicines will be managed during their hospital admission. Patients may be anxious about whether their medications will be prescribed accurately or administered on time. 
  • Involving patients in the processes used to prescribe and administer their antiparkinsonian medications may reduce patient anxiety related to the management of  their medicines. 
  • The accuracy and comprehensiveness of information available about a patient's medication regimen is variable and work is required to improve the transfer of accurate and current information when people with Parkinson’s disease are admitted to hospital.
 
References:
  1. European Parkinson’s Disease Association. The European Parkinson’s Disease Standards of Care Consensus Statement;2011.
  2. Gustavsson A et al. Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011;21(10):718–79.
  3. Tugwell C. Parkinson's Disease in Focus. London: Pharmaceutical Press;2008.
  4. Scottish Intercollegiate Guidelines Network. Guideline 113. Diagnosis and pharmacological management of Parkinson’s disease. A national clinical guideline, 2010. Scottish Intercollegiate Guidelines Network: Edinburgh.
  5. Royal Pharmaceutical Society. Keeping patients safe when they transfer between care providers – getting the medicines right. 2011.
  6. Barber M et al. Patient and carer perception of the management of Parkinson’s disease after surgery. Age Ageing 2001;30:171–9.
  7. Donaldson S. Can we improve the inpatient care of those with Parkinson’s disease? Postgrad Med J 2010;86:321–2.
  8. Derry CP et al. Medication management in people with Parkinson's disease during surgical admissions. Postgrad Med J 2010;86:334–7.
  9. Magdalinou KN, Martin A, Kessel B. Prescribing medications in Parkinson's disease (PD) patients during acute admissions to a District General Hospital. Parkinsonism Related Dis 2007;13:539–40.
  10. Mappilakkandy R et al. How far are we from achieving Parkinsons UK recommendations for Parkinson's Disease inpatient drug management in acute hospitals? Neurodegen Dis 2011;8:1660–854.
  11. Elphick H, Bolam D, Liddle B. Managing Parkinson's disease medication in hospital: The patient's perspective. British Geriatric Society 2006;35(S.1): i63.
  12. Parkinson's UK. Parkinson’s (‘Get it on time’) hospital medicines management audit guidelines;2010. www.parkinsons.org.uk/pdf/giot_auditguidelines.pdf (accessed 10 July 2012).
  13. Buetow S et al. Medication timing errors for Parkinson's disease: Perspectives held by caregivers and people with Parkinson's in New Zealand. Parkinson's Dis 2010:doi 10.4061/2010/432983.
  14. Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques.London: SAGE Publications Ltd;1990.
  15. Elphick H, Bolam D and Liddle B. Managing Parkinson's disease medication in hospital: The patient's perspective. British Geriatric Society, 2006. 35(S.1): i64.

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