Problem 13: Missing Doses due to Swallowing Difficulty Flashcards
Identify any potential risks and outcomes associated with missing doses of PD medicines
Get it On Time!
If patients don’t get their medication on time their ability to manage their symptoms may be lost.
Patients will experience switch on-off symptoms: switched on when treatment is effective in controlling the symptoms because they have taken their medication. effectively. Off-period may be the end of their medication time and may mean they are due to their next dose of medication. Missed doses reduces ability of patient to manage motor symptoms.
Missing a dose increases the risk of rare potentially fatal neuroleptic-like malignant disease syndrome. Also increases need of care if motor symptoms worsen.
Medication should not be withdrawn suddenly due to poor absorption to avoid potential acute akinesia or neuroleptic malignant syndrome. Sudden cessation may result in Parkinsonism Hyperpyrexia Syndrome (high fever, possibly renal failure, DVT, aspiration pneumonia, intravascular coagulation.)
People admitted to hospital should have; offer to self-medicate (retains autonomy and medication schedule individuals are used to). Their medication given at appropriate times to maintain regime regardless.
Outline the next steps required in order to assess Mr Li’s swallowing issues
Parkinson’s can cause the muscle in patient’s jaw and face to weaken. Also affects muscle of tongue. Dry mouth is also a problem in reducing digestion starting point and lubrication of mouth and oesophagus. Difficult to tighten lips and swallow. Piecemeal swallowing can occur where bits of food remain in the mouth and trickle down throat - choking and coughing.
Swallowing assessment is carried out by a speech and language therapist; general questioning to ask about patient’s difficulties, physical examination, further testing such as fibreoptic endoscopy and videofluoroscopy. Signposting to an ENT specialist or enterologist can also be appropriate.
Compare and evaluate the therapeutic options that are available to Mr Li if he is unable to swallow tablets and discuss what factors need to be considered
Some patients are unable to take medicines in solid oral dosage forms because they have swallowing difficulties or feeding tubes. The choice of medicine for these patients should be made on an individual basis taking into account the patient’s method of feeding, the practicalities of administration, product quality and cost.
Stepped approach: 1. licensed medicine i.e dispersible tablet or licensed liquid medicines, 2. licensed medicines administered in an unlicensed manner for example crushing tablets or opening capsules. (Off-label administration). 3. Special order products; medicines not commercially available in liquid for. (expensive, short shelf-life, no GMP guarantee).
Handbook of drug administration via enteral feeding tubes- Rebecca White
NEWT guidelines- used in hospital setting (you will not have access as a student but useful
have knowledge of resources used in practice)
Discuss what options are available for patients unable to take any medications orally
NG tube - current tablets could be crushed and dispersed in water. Consider switching tablets to patches i.e. switch ropinirole and co-careldopa to rotigotine patch.
Levodopa (main site of
absorption is the jejunum
– NG recommended)
Co-beneldopa (Madopar) Use dispersible versions. For CR doses, because of reduced bioavailability, convert to dispersible equivalent by multiplying total daily levodopa dose by 0.7 and rounding to nearest available dispersible preparation4 – monitor as dose frequency may need to be altered accordingly.
Co-careldopa (Sinemet/Lecado/ Caramet) Use dispersible co-beneldopa versions (using equivalent dosage of levodopa). For CR doses, use co-beneldopa dispersible equivalent conversion equation (see above).
At a pharmacological level, explain what apomorphine is and summarise its role in PD therapy
The treatment of motor fluctuations (‘on-off’ phenomena) in patients with Parkinson’s disease which are not sufficiently controlled by oral anti-Parkinson medication.
Apomorphine is a direct stimulant of dopamine receptors and while possessing both D1 and D2 receptor agonist properties does not share transport or metabolic pathways with levodopa.
Patients selected for treatment with APO-go should be able to recognise the onset of their ‘off’ symptoms and be capable of injecting themselves or else have a responsible carer able to inject for them when required.
Patients should be pre-treated with domperidone (20mg tds) for several days before
starting on apomorphine (see MHRA advice below). The majority are able to stop
the domperidone after a few weeks.
Apomorphine can be administered by either continuous subcutaneous infusion or by intermittent
subcutaneous injection. 100mg per day is maximum dose by either route.
Discuss the risk factors associated with UTI in men
In men, UTIs are rare and normally indicates an underlying urological pathophysiology. Prompt and accurate diagnosis with appropriate abx treatment is paramount.
Most men who present with UTI will have underlying pathology, whether structural or functional, leading to impaired urine flow, incomplete bladder emptying, or a source of recurrent bacteriuria. Some of the cause of UTI in men include: • Benign prostatic hyperplasia • Urethral stricture • Bladder neck obstruction • Bladder stone • Bladder tumour • Bladder diverticula • Prostate cancer • Foreign bodies • Tight phimosis • Detrusor-sphincter dyssynergia
Sexual intercourse, Spermicide and diaphragm use, Antibiotic use Family history, First UTI occurred at young age
Identify the main micro-organism involved in UTIs
Acute uncomplicated male UTI is uncommon9 and
tends to be caused by similar organisms to female UTI,
most commonly E. coli.
10 Men with complicated UTI, however,
show a much greater diversity of pathogens in their
cultures, with antibiotic resistance being more likely.
Common organisms include E. coli, Proteus, Klebsiella,
Pseudomonas and Enterococcus.
Catheter-related infection is notoriously
difficult to clear because of biofilm formation, the aggregation
of ‘walled-off’ colonies of adherent bacteria on the
surface of a foreign bod
Explain the common signs and symptoms of lower UTI and how this differs from upper UTI
Infections confined to lower urinary tract commonly cause dysuria, frequency and urgency. (no fever or flank pain)
Pyelonephritis (inflammation of the renal parenchyma) is a clinical syndrome characterized by chills and fever, flank pain and constitutional symptoms caused by bacterial invasion of the kidney.
Outline and summarise the diagnosis of a UTI
In all men with symptoms suggestive of a urinary tract infection (UTI), confirm the diagnosis by urine culture and sensitivity, by arranging collection of a mid-steam urine (MSU) or catheter specimen of urine (CSU), to determine the infecting micro-organism.
Obtain a urine sample for culture before starting empirical drug treatment.
Do not rely on urine dipstick test or microscopy to confirm the diagnosis. Negative dipstick test to nitrite and leukocyte esterase means a UTI is unlikely.
If the urine sample cannot be transported and processed within 4 hours, it should be refrigerated at 4°C. If the sample is preserved with boric acid, it can be stored at room temperature prior to transport.
Urine that has been refrigerated at 4°C for 48 hours remains suitable for culture, but not microscopy, because most cells will have disintegrated.
Urine preserved with boric acid remains suitable for culture and microscopy for up to 96 hours.
Generally, the threshold for reporting significant bacteriuria is 105 colony-forming units (CFU) per millilitre (CFU/mL). However, if the man is acutely symptomatic, counts higher than 102 CFU/mL can be regarded as significant when there is a single isolate.
Outline the possible and available treatment options for UTI
If not admitted to hospital: Start empirical antibiotic drug treatment with trimethoprim or nitrofurantoin. Prescribe:
Trimethoprim 200 mg twice daily for 7 days.
Nitrofurantoin 50 mg four times daily for 7 days, or 100 mg (modified-release) twice daily for 7 days.
Moderate to severe infection: gentamicin IV or co-amoxiclav or piperacillin/tazobactam.
Severe/life threatening infection: gentamicin inless contra-indicated then meropenem.
If Mr Li cannot swallow or tolerate an NG tube how would you manage the situation and advise on administering antibiotics
Nitrofurantoin IV??
Nitrofurantoin suspension
Trimethoprim oral suspension
or IV
How is Mr Li likely to be feeling in hospital
60% thought patient wasn’t treated with dignity, 92% thought frightening, 90% more confused in hospital, almost 7000 incidents with falls in dementia patients last year
It is clear that too often hospitals are frightening and disorientating for people with
dementia, as well as being places where their overall health and wellbeing often deteriorates
rather than improves.
How can pharmacists in hospital ensure parkinson’s medication is received by patients on time?
Talk to people with Parkinson’s about their experiences and needs.
Introduce a system to alert the local specialist Parkinson’s nurse when a person with Parkinson’s is admitted or moves in.
Introduce a self-administration policy for people with Parkinson’s, including asking them, if appropriate, whether they would like to take their own medication during their time with you.
Abolish visiting hour restrictions for carers and give them the option to support their loved one to take their medication.
Highlight that a person has Parkinson’s in their patient files by using an electronic flagging system.
Use our Get It On Time resources and information sheets below.
Use pill timers or alarm clocks on the ward to remind staff about patients whose medication is due at different times to the standard drug rounds.
Tell your colleagues about the Get It On Time campaign and why the timing of medication is so important.
Contact one of our Parkinson’s UK education advisers to discuss how we can support learning about Parkinson’s.
Report incidents involving Parkinson’s medication to the National Patient Safety Agency (NPSA) or to the local, multidisciplinary medication incident reporting and monitoring system in place at your hospital
