Case
A 67-year-old female with moderately advanced Parkinson’s disease (PD) had a mechanical fall in her home, which resulted in a humeral fracture. The fall occurred in the morning before she was able to take her medications and was related to her difficulty in initiating movements.
On her current regimen, her PD symptoms are controlled. She is able to perform daily living activities independently and ambulates without assistance. She also performs more complex tasks (e.g., cooking and managing her finances). She has not exhibited any symptoms consistent with dementia. She occasionally experiences dyspnea on exertion and dysphagia, but she has not been evaluated for these complaints. She takes carbidopa/levodopa (CD/LD) 25 mg/100 mg four times a day, amantadine 100 mg twice daily, and ropinirole 3 mg three times a day.
She is scheduled for open reduction internal fixation of her fracture; the orthopedic surgeon has requested a perioperative risk assessment and recommendations concerning her medications. How should PD be managed perioperatively?
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The four primary symptoms of Parkinson’s disease are trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness of the limbs and trunk; bradykinesia, or slowness of movement; and postural instability, or impaired balance and coordination.
Overview
Advances in surgical and anesthetic techniques, in combination with an aging population, have contributed to an increasing number of geriatric patients undergoing surgery. As many as 50% of Americans older than 65 will undergo a surgical procedure; hospitalists will comanage many of these patients in the perioperative period.1
Although cardiopulmonary disorders receive a great deal of attention with regard to perioperative risk assessment, other comorbid conditions also contribute to perioperative risk—namely, disorders specific to the elderly population. Parkinson’s disease is one such condition that deserves attention.
PD is a progressive, neurodegenerative condition associated with loss of dopaminergic neurons and the presence of Lewy bodies within the substantia nigra and other areas of the brain and peripheral autonomic nervous system.2 Cardinal clinical features include rigidity, bradykinesia, and resting tremor. A supportive feature is a consistent response to levodopa. Postural instability, cognitive impairment, and autonomic dysfunction usually occur later in the disease.3,4
As the population ages, Parkinson’s disease is becoming more prevalent, affecting approximately 1% of individuals older than 60.5 These patients pose a specific challenge to the hospitalist, not only because the multiorgan system manifestations of PD can raise surgical risk, but also due to the direct effects of dopaminergic medications used to treat PD, lack of a parenteral route for these medications in NPO patients, and the risks associated with abrupt withdrawal of these medications.
Although surgical risk in PD patients has received intermittent attention in surgical, anesthesia, and neurology literature, there is no broad consensus statement or treatment guideline for the perioperative approach.