Emergency presentations of Parkinson's disease: early recognition and treatment are crucial for optimum outcome

Abstract

Parkinson's disease (PD) is a debilitating condition associated with significant morbidity and mortality. Pathophysiologically the illness is due to a disruption of dopamine production in the basal ganglia and leads to a wide array of symptoms. These symptoms are not restricted to the nervous system; thus, the illness often presents acutely to a wide range of specialties, many of which may have limited experience in the condition. Patients often become unwell with illnesses unrelated to their PD. However, these conditions frequently lead to a deterioration in PD control. In addition, there exist certain acute complications of PD which are often difficult to recognise and carry significant mortality. Discussing the acute presentations of the illness under the umbrella of PD is important as it enables clinicians to focus upon the specific concerns involved in managing patients with the illness. A number of conditions are extremely common in PD and include falls, orthostatic hypotension, swallowing difficulties, psychosis, and hyperkinetic movement disorders. Optimal treatment of these conditions requires the consideration of issues specific to PD. Lesser recognised acute presentations of PD include the serotonin syndrome and neuroleptic malignant-like syndrome. While encountered less commonly, these conditions have been well described in the literature and untreated may prove fatal. They require urgent management, with their importance being further highlighted by the fact they may often mimic other illnesses, making diagnosis difficult. Therapeutic interventions aimed at treating PD and preventing its complications are evolving rapidly.

Neuroleptic malignant-like syndrome with a slight elevation of creatine-kinase levels and respiratory failure in a patient with Parkinson's disease

“…Although the incidence rate has decreased year by year due to doctors’ improved knowledge of NMLS, studies have shown that mortality in NMLS is between 10% and 30% 2. Sudden withdrawal and abrupt reduction of antiparkinsonian drugs are major risk factors, especially dopamine.…”

“…This disease is named after neuroleptic malignant syndrome (NMS), a dangerous adverse response to antipsychotic drugs, due to similar clinical manifestations. The syndrome is characterized by such symptoms as hyperthermia, muscle rigidity or tremor, altered consciousness, autonomic instability, and elevated serum creatine-kinase (CK) levels 2. The incidence rate has decreased year by year due to doctors’ improved knowledge of NMLS.…”

Management of Parkinson’s disease in the acute hospital environment

“…In more severe cases, neuropsychiatric manifestations, altered conscious level and cardiovascular collapse is seen. Dysphagia and hypersalivation are useful signs that can help differentiate NMLS from the main differential diagnosis, serotonin syndrome, 19 which may also be seen in patients treated with selective serotonin reuptake inhibitors (SSRIs), in particular fluoxetine or fluvoxamine (and mainly when these are co-administered with selegiline). Immediate management is essential as there is a significant risk of mortality.…”

The utilisation of one district hospital emergency department by people with Parkinson’s disease

“…A global estimate of the number of people with Parkinson's disease (PD) over the age of 50 years is between 4.1 and 4.6 million [2]. In those 80 years and older PD has a prevalence of 2% [3]. By 2030, this number is expected to double to between 8.7 and 9.3 million people.…”

“…PD is the second most common neurodegenerative disorder after Alzheimer's disease. The risk of developing PD increases with age 3 and is characterised by a progressive degeneration of pigmented neurons in the substantia nigra in the mid brain [6]. This causes a deficiency in dopamine, which is responsible for controlled and smooth muscle movement.…”