Deterioration of Parkinson's disease during hospitalization: survey of 684 patients

Parkinson's disease (PD) patients are admitted to hospitals more frequently and longer than the general population [1, 2]. Up to a quarter of the total PD patients are hospitalized each year [1]. There is general consensus that a substantial fraction of these hospitalized PD patients do deteriorate, but the precise proportion and the reasons why have not been studied systematically and the focus has been on surgical wards and on Accident & Emergency departments [3‐6]. We found that, although many PD patients seem to deteriorate during hospitalization and there is concern about the quality of care provided to these patients [7], most hospitals do not have proper guidelines yet to prevent worsening of PD symptoms and complications during hospitalization [8]. Before such guidelines can be formulated, a better understanding of the problems encountered during hospitalization of this group of patients is warranted. Our aim in this study was to assess the prevalence and risk factors of deterioration in hospitalized PD patients including all wards.

PD patients from 3 neurology departments in the southern part of The Netherlands were invited to participate in the survey, i.e. the Maastricht University Medical Centre in Maastricht, Orbis Medical Centre in Sittard-Geleen, and Catharina Hospital Eindhoven in Eindhoven. Only PD patients, of whom the diagnosis had been confirmed by a neurologist according to the UK Brain Bank criteria were selected. All patients with other or unclear parkinsonisms were excluded. The selected patients were sent a questionnaire by mail. This questionnaire consisted of questions concerning general, personal and disease related issues (see additional file 1 and 2). Patients were asked whether or not having cognitive problems. The obtain more accurate data, we asked patients to fill in the questionnaire with the help of a caregiver. Patients who confirmed that they had been admitted to a hospital in the previous year, were asked to answer more detailed questions about this hospital stay (e.g. exact timing or lack of drug administration, complications, and PD deterioration). After 4 weeks we sent a reminder to patients who had not yet returned the questionnaire. We validated the data by comparing the questionnaire-replies with corresponding hospital records. Only patients with a hospital submission in the previous year were included and analysed. Admissions for PD related brain surgery were excluded. Subsequently, we tried to identify possible risk factors for PD deterioration.

PD deterioration we defined as decline in motor function. Receiving incorrect PD medication during the hospital stay was defined as administration of PD drugs during the hospital stay not as home schedule with attention to interruption, wrong timing, and different PD medication. Levodopa Equivalent Dose (LED) was used to calculate the amount of anti-parkinsonian drugs [9].

The ethics committees of the 3 collaborating hospitals approved our study: Medical Ethics Committee academic hospital Maastricht/Maastricht university (reference number 08-5-082), Local Advisory Group Scientific Research Orbis Medical Centre (reference number 10.029), and Medical Ethics Committee Catharina Hospital Eindhoven (reference number M11-015). Research was carried out in compliance with the Helsinki Declaration.

We sought to assess the prevalence and risk factors of deterioration in hospitalized PD patients, as evidence suggests that a substantial proportion of PD patients actually worsen when admitted to a hospital [1, 2]. In our population of 684 PD patients almost one fifth had been hospitalized in the last year. Traumatic injury, infections, direct PD-related problems, and problems with the circulatory and digestive system were the main admission reasons, which accords with prior literature [1, 2]. As in those studies, confusion and infections were the most common complications during hospitalization [1].

To our knowledge this is the first study systematically analysing different risk factors for deterioration of PD patients both for admissions with and without surgery.

There have been earlier studies documenting high rates of incorrect medications given to hospitalized PD patients, some as high as 74%. All these, on surgical wards and on Accident & Emergency departments, found that this was associated with deterioration, but to varying degrees. All these studies were retrospective, and selection of the patient sample was unclear [3‐5]. We found having surgery or not did no matter in terms of medication distribution problems or complications. Somewhat unexpected, neurology wards do not do better, as there was no statistically significant difference between different wards regarding problems with medication distribution, complications, and PD deterioration.

There is one retrospective study suggesting that pre-operative or immediate post-operative neurological consultation of PD patients having surgery may result in higher post-operative improvement of total Unified Parkinson's Disease Rating Scale with most effect on activities on daily living [6]. In our study PD nurse specialists (as part of the movement disorder teams) were involved in a quarter of the admissions on a non-neurological ward. This was associated with a higher risk on deterioration during these admissions. This is probably reverse causation, since PD nurse specialists were asked to see the patient when deterioration had already occurred.

Second to medication distribution problems with a 5.8 higher risk on deterioration, complications are significantly related to PD deterioration, with infections as mean factor with an increased risk of 6.7. Paramedic care did not appear to be of influence. When analysing different patient and PD related factors in relation to deterioration, only a LED-value above > 700 mg/day showed to be a significant risk factor. For higher age and higher Hoehn and Yahr scores there was a tendency towards, but not a significantly, higher risk. When excluding those patients who had no help with answering the questionnaire and had cognitive problems, only wrong medication distribution and a LED-value of more than 600 mg/dag are significant risk factors.

There are significant differences for some variables between the hospitals which can be expected since the Maastricht University Medical Centre is, unlike the others, an university hospital (with more complex PD patients and more patients with deep brain stimulation). There is however no significant difference between the centres in medication distribution problems.

When correcting for different variables, including those that were significant different between the three centres, wrong medication distribution is the most important significantly increased risk factor for deterioration. Comparing our data with data on medication errors in hospitalized patients in general, showing medication errors on average in 6 per 100 hospitalized patients, this study supports the higher vulnerability of PD patients [10].

When validating the reported data by PD patients with clinical files of the admissions there seems to be mainly a strong underreporting of deterioration of PD supporting the lack of knowledge of this problem.

Apparently much more needs to be done to prevent incorrect medication distribution and complications. Better education of health care professionals, both on a neurological and non-neurological wards, to stress the importance of correctly administrated PD drugs and to prevent complications might result in less deterioration. Rigid electronic medication systems in hospitals do not seems to support home schedules of PD medication. Self-administration of PD drugs by able patients could be an option. The effects of an electronic warning system to alert the treating team of the vulnerability of this patient group, and a multidisciplinary approach, with a role for the clinical pharmacist and movement disorder team, should be evaluated in future studies.

This study has a number of limitations. Information was asked about the previous year, causing possible recall bias. Medication administration was assessed through self-report, and patients who died during admission were obviously not included. Since it was not possible to uncover adverse medication prescription during the admissions this aspect was not taken into account. Further studies should be undertaken to shed more light on these aspects. Nevertheless, we believe that these limitations do not invalidate our conclusions.

This is the first study systematically analysing different risk factors for deterioration of hospitalized PD patients both for admissions with and without surgery. There is a high rate of deterioration during hospitalization of PD patients on all wards. Especially incorrect medication distribution, but also infections are related to this. Measures should be taken to improve care and should be incorporated in guidelines.