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Parkinson’s disease

Learning objectives

  • Describe the clinical presentation of Parkinson’s disease
  • Diagnose and treat Parkinson’s disease
  • Manage Parkinson’s disease patients presenting for surgery

Background

  • Parkinson’s disease (PD) is an idiopathic neurodegenerative disorder, characterized by bradykinesia, muscle rigidity, and asymmetric resting tremor
  • Most common movement disorder (~1% prevalence in the population >65 years of age)
  • Loss of dopaminergic neurons in the pars compacta region of the substantia nigra

Etiology

  • The etiology of PD is unknown but may be induced by genetic, environmental, or infectious factors
  • Increasing age is the most consistent risk factor

Signs & symptoms

Clinical featuresTiming
Primary motor featuresResting tremor (usually asymmetrical)Usually at diagnosis
Bradykinesia
Rigidity
Early non-motor featuresFatigueMay precede diagnosis
Depression/anxiety
Sleep disturbance
Constipation
Later featuresGait change: Stooped posture, shuffling gait with small steps, loss of arm-swing5–10 years after onset of symptoms
Dysphagia
Expressionless face
Small handwriting
Soft speech
Postural instability
Cognitive disturbance, slowed cognitive speed, inattention, poor problem solvingIncreasing likelihood as time from diagnosis increases
Dementia>80% at 20 years after diagnosis
AutonomicPostural hypotension5-10 years after onset of symptoms
Sialorrhea
Urinary dysfunction
Sexual dysfunction

Diagnosis

  • There are no specific diagnostic tests for PD
  • Clinical diagnosis based on the hallmark symptoms (tremor at rest, muscle rigidity, bradykinesia)

Treatment

  • Treatment is symptomatic and usually pharmacological
MedicationsIndicationSide-effectsAnesthetic implications
Dopamine agonistsPramipexole, ropiniroleMonotherapy in early and established PD, adjunct to levodopa-DDI regimeNausea, orthostatic hypotension, impulsive control disorders, somnolenceRisk of dopamine agonist withdrawal syndrome on acute withdrawal
Rotigotine‘Bridging’ therapy in patients who are
unable to take or absorb antiparkinsonian medication, adjuncts to levodopa-DDI regime		Nausea, orthostatic hypotension, impulsive control disorders, somnolenceParenteral transdermal preparation
Apomorphine‘Bridging’ therapy in patients who are
unable to take or absorb antiparkinsonian medication, adjuncts to levodopa-DDI regime		Nausea, dyskinesias, cognitive impairment, postural instabilitySubcutaneous infusion or injectable ‘pen’ for patients with troubling motor fluctuations, very emetogenic, risk of severe hypotension
Dopamine precursors with peripherally acting dopa decarboxylase inhibitor (DDI)Levodopa-carbidopa, levodopa-benserazideMotor symptoms in established PDNausea, orthostatic hypotension, dyskinesia, hallucinationsRisk of parkinsonism-hyperpyrexia syndrome on acute withdrawal; short halflife (1.5 h) - need to continue enteral administration in prolonged procedures
Monoamine oxidase B inhibitorsSelegiline, rasagilineUsed as monotherapy in early PD, or as adjunct to levodopa-DDI regimeHeadache, arthralgia, exacerbation of levodopa side-effects when used as adjunctRisk of serotonin syndrome (fever, hypertension, tachycardia, agitation) with meperidine
Catechol-O-methyl transferase inhibitors (COMTIs)Entacapone,
Tolcapone		Adjunct to levodopa-DDI regime Dark-colored urine, exacerbation of levodopa side-effectsReduce dose of other drugs metabolized by COMT pathways, e.g., epinephrine
  • Abrupt withdrawal of medications can result in withdrawal complications:
    • Parkinsonism-hyperpyrexia syndrome
      • Due to withdrawal of levodopa
      • Symptoms: Muscle rigidity, fever, cardiovascular instability, altered mental status (agitation, delirium, coma). 
      • Significant mortality, up to 20% in untreated cases
    • dopamine agonist withdrawal syndrome (DAWS)
      • Symptoms: Anxiety, nausea, depression, pain, orthostatic hypotension
      • Withdrawal of dopamine agonists should be planned electively and simultaneously replaced with levodopa therapy

Anesthetic management

  • Preoperative

Parkinson's disease, ECG, spirometry,vital capacity, portoperative delirium, urinary catheter, atelectasis, aspiration, laryngospasm, fixed flexion deformity, obstructive sleep apnea, cardiac arrhythmias, orthostatic hypotension, hallucinations, dysphagia, sialorrhea, glycopyrrolate, neostigmine, reflux, ileus, enteral, urinary tract infection, anti-parkinsonian medications, nasogastric tube, parenteral, apomorphine, domperidone, rotigotine,

  • Intraoperative

parkinson's disease, neuraxial block, opioids, neuromuscular block, muscle rigidity, tremor, hypotension, nausea, vomiting, enteral, pneumonia, atrial flutter, ventricular fibrillation, arterial pressure, autonomic dysfunction, mepridine, selegiline, propofol, thiopental, ketamine, hypertension, volatile, halothane, hypotension, neostigmine, rocuronium, sialorrhea, glycopyrrolate, dysphagia, rapid sequence induction, gastroparesis, reflux, fixed flexion deformity, antiemetics, ondansetron, cyclizine, domperidone

  • Postoperative
    • Consider ICU admission
    • Assess the feasibility of enteral anti-parkinsonian medication
    • Adequate analgesia, tremor, and rigidity may hinder patient-controlled analgesia
    • Postoperative delirium: Non-pharmacological management is preferred, avoid haloperidol, benzodiazepines are safer
    • Physiotherapy facilitates early mobilization

Suggested reading

  • Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
  • Chambers DJ, Sebastian J, Ahearn DJ. Parkinson’s disease. BJA Education. 2017;17(4):145-9.

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