I have heard of many patients being afraid to have procedures of any kind due to occurrence of psychosis and confusion reported by a number of Parkinson’s patients. This problem is not a myth unfortunately. Forty percent of Parkinson’s patients suffer psychosis commonly as disease advances which usually results in more hospitalizations, and increased procedures resulting in a greater need for anesthesia. Thus perpetuating the cycle. However, in my professional experience the majority of these episodes (psychosis post anesthesia) can be avoided by taking a proactive approach.
If surgery is required one must have evaluation of ones Parkinson’s symptoms for severity along with a complete evaluation of your medical regimen and a mini mental status exam prior to surgical procedure. The mini-mental status exam is KEY!!! The latter is particularly important in the face of long standing PD or advanced aged. This combination presents the highest risk for psychosis and delirium which is unfortunately often overlooked by most surgeons. I often would get consulted on other patients after the fact when a patient was psychotic and it never really was a surprised to me only to family and to rest of medical staff! This is true because if they would have bothered doing a full neurologic exam which included a mini mental status – they would have found cognitive deficits already present over 95% of the time prior to surgical procedures. In my patients I always stressed discussing with me prior to any and ALL procedures small or large especially if routine! This way I could have time to discuss with surgeons plan of action ahead of time and be involved in care. This is not always feasible in emergency cases but my patients and their families always knew to have their doctors put in a consult for me to manage their PD during their surgical procedures if hospitalized and receiving general anesthesia. One thing that everyone involved in care of Parkinson’s patients need to be aware of is that –Yes! PD patients represent a management challenge and need extra attention to have the best outcome.
Some of the common reasons people get psychotic with anesthesia:
- Underlying dementia (often times undiagnosed- in my experience this is the number one reason)
- Advancing age
- Interaction of PD meds with anesthesia e.g. Mao inhibitors
- Pain medication effect in light of PD meds and underlying dementia
- Poor swallowing leading to pneumonia/ atelectasis
- Decrease respiration /acid aspiration
- Urine infections
Things to look at before any surgical procedure:
Preoperative continuation of levodopa
Aspiration prophylaxis Interaction of drugs with PD medications patients are taking
Duration of PD and systems disrupted –i.e. how is their cardiac function, their kidney function, their gastrointestinal function, their cognition, etc.
Surgical procedure – is it elective or emergent
Will hospitalization be required?
Type of anesthesia to be used-general vs. local
Will patient need to be bed bound – thus increasing DVT’s (clots) and also worsening PD symptoms like rigidity
First things we have to know about anesthesia:
1) Avoid halothane with levodopa if possible due to an increase in cardiac arrhythmia.
2) Use of Sympathomimetics with Mao will increase BP- therefore need to suspend things like Azilect, and Eldepryl for up to a week before surgery. At same time recommend increasing other PD meds to compensate for that reduction so that you are the strongest prior to surgery.
3) Mao meds also inhibit metabolism of narcotics therefore narcotic effect can lasts longer in your system after surgery causing greater side effects- so may not want to resume Mao inhibitors right away after surgery if taking pain meds.
4) In advance PD sudden withdrawal of levodopa can be fatal at times causing neuroleptic syndrome. Therefore never recommend stopping this medication always look to take orally dissolvable Sinemet (levodopa/carbidopa) like Parcopa if have to be NPO (nothing by mouth).
5) Keep in mind that often times General anesthesia can relax muscles so much it can delay diagnosis of exacerbation by masking early symptoms.
6) PD patients who undergo general anesthesia have a tendency for increase chest infection due to ineffective cough mechanism and clearing of secretions and poor swallowing.
7) After general anesthesia these is increased nausea and vomiting meds often prescribed for this problem as well as those used with and during anesthesia can worsen PD symptoms.
My recommendations to prevent these common problems with general anesthesia:
Pre -operative care:
I am of the belief that patients should take medications up to the time of surgery by substituting things to bypass the GI system using oral disintegrating tabs such as Parcopa use dopamine agonist patches if necessary and discontinue Mao inhibitors- but increase dose by adding more dopamine after surgery to be able to deal with stress of body.
Don’t forget to evaluate for cognitive status and place on medications to protect many IV/IM/orally disintegrating meds and even patches ( Exelon, Abilify, Geodon, Zyprexa)
Take small sips of liquid if need be to get meds down to avoid exacerbation of symptoms.
If sedation is required Benadryl maybe be best solution because there is an IV form and helps with PD symptoms as well; works great for procedures of the eye.
Also ask for scopolamine patch – this decreases nausea and vomiting due to anesthesia.
Ask for reflux prophylaxis –such as Pepcid IV prior to surgery to avoid reflux and aspiration.
If at all possible get local anesthesia or nerve Block to avoid cognitive side effects as well as gi symptoms. Post- operative: Resumption of meds as soon as surgery over is very important. Because timing is so crucial medication schedule must be adhered to pre-intra, and post operatively. After surgery, broad time schedules of medication intake should be avoided completely! Staff MUST be instructed to stick to specific dosing times and not to deviate for more than 15 minutes (max) otherwise this can lead to erratic behavior and severe symptom breakthrough such as increased pain, depression, anxiety, confusion etc.
If unable to swallow post -surgery consider – nasogastric tube to give meds if needed if unable to get oral dissolvable or tolerate patch, etc.
Give water through feeding tube but also make sure getting fluids to prevent dehydration and getting IV antibiotics post -surgery.
Sometimes patients have difficulty voiding post operatively due to spasms of bladder- I recommend baclofen or macrodantin (nitrofurantuon).
If at all possible try to limit narcotics and use instead Tylenol #3, Toradol IV/PO/Vicodin only as needed. Trust me this works best if we follow all these steps are followed and all involved take a proactive role in the care of the PD patient. Of importance is also a temporary increase in PD medication doses during recovery/convalescing period.
Don’t forget to get ancillary consults like OT, PT, ST, and respiratory to provide breathing treatments and an incentive spirometer to prevent pneumonia. A team effort is the way to ensure a much less chance of having psychosis with anesthesia.
Don’t forget to include your neurologists/MDS for a best outcome and decrease post-surgery psychosis.