To kick off #worldparkinsonsday here's a thread on some of the most common questions we're asked for inpatient #Parkinson's referrals.
#medtwitter #juniordocs #tweetorial

Number one, top of the charts, all referrals ever...ask us
"please can you review, the medication isn't working".

So let's get started...

If the medication is truly not working, think about 3 things.....
Number 1. You're not giving it because:

a) NBM: separate thread follows on this not infrequent car crash disaster
b) Meds aren't prescribed correctly.
c) Meds are late: "Get it on time". Everytime

2: The person with Parkinson's is not taking their medication.

Consider confusion, swallowing ability, concordance, undeclared side effects. Prescribed ≠ taking at home.

See, for example, the 3 months worth of PD tablets in tupperware not tummy.

3: They are not absorbing it.
This paper shows the levodopa tablet chilling in the stomach and not the brain: https://pubmed.ncbi.nlm.nih.gov/25987282/ 

Be forensically interested in bowels.
TREAT constipation. Can they manage the fluid volume for macrogol?
Consider ileus.

OK, all done.
The normal meds are prescribed immaculately. Adminsted on the dot.
Absorbed beautifully with regular bowel opening.
Your local PD specialist asks if you're considering a career in movement disorders.
But....all is still not well...what next?

Has someone been a bit fearless and some metaclopramide / haloperidol etc has found it's way past border control? Because that that would be bad. Very bad.

Next up. Could there be TOO MUCH dopamine causing mischief?
Quite possibly.
Frail, older PwP who are in and out of hospital frequently OR have had prolonged stay lose A LOT of weight.
Worth a bit of sleuthing to ascertain whether this is the case.

Supratherapeutic levels of dopamine sloshing about tends to manifest differently in younger and older people.

Younger people may be dyskinetic = writhing & wriggling mvmt. Often not troubling 4 PwP as clinicians and familiy members. Ask "how bothersome is this for the pt?"

Supratherapeutic dopaminergic levels in older people is all sort of badness: falls, orthostatic hypotension, confusion, worsening of delirum, nausea & vomiting.

Please DON'T STOP anything abruptly.
We'll come and help space or lower the doses. Easy does it.

So there's not too MUCH. There's not too LITTLE. But all is not well. Just think through:
1. Is the acute illness worsening PD sx?
2. Is there delirium? This needs time and correction of precipitants and accelerants (and there will be many....)

And finally, if you've thought through all of that, you are brilliant and even if you haven't, but you've got to the end of this little tweetorial, thank you.

We will come and help you!

Another thread on NBM / first 24 hour scenarios follows....