Parkinson’s disease and preparing for surgery

Parkinson’s disease and preparing for surgery

People with Parkinson’s disease (PD) sometimes face procedures or surgeries due to other medical conditions not related to PD. These could be relatively simple procedures such as a colonoscopy or endoscopy, common surgeries such as cataract removal, gall bladder removal or hernia repair, or more complex surgeries such as open-heart surgery or transplant surgery. I am frequently asked about specific concerns that arise when contemplating surgery for someone with PD.

People with PD, as well as people with other brain disorders, are more prone to side effects from anesthesia as well as negative effects from the stress of the surgery itself. It’s important to remember that not everyone is affected in the same way, and this doesn’t mean people with PD cannot have the surgeries and procedures they need. It is however important to be educated about what potential problems may arise so that you are as prepared as you can be.

Being prepared & anticipating problems

Because of the concerns that we will discuss below, it is prudent to have your neurologist speak to your surgeon and anesthesiologist prior to the surgery so he/she can discuss the potential issues that may arise during and after the surgery. It is also very useful to have your neurologist write a letter with all the necessary information so it can be dispersed to other members of the medical team who will be responsible for your day-to-day care after the surgery.

Depending on the type of surgery, there may be more than one option for anesthesia. General anesthesia (when you are completely asleep) may not be the only option, and a more localized form of anesthesia may be possible. Local anesthesia typically causes fewer side effects.  Discuss what anesthesia options you have with the surgeon and anesthesiologist prior to the surgery.

In addition, if the surgery requires you to stay in the hospital overnight, consider having a family member or friend stay with you. This person can provide a calming presence, helping to prevent agitation or distress. He or she can keep an eye on whether you are taking your own medications correctly and what additional medications you are bring given.

Maintaining your normal PD medication schedule

Maintaining your PD medication schedule is crucial for anyone with PD. The correct timing and dosage are essential to your comfort and well-being. However, oftentimes when undergoing surgery, there may be restrictions regarding when you can and cannot take medications. Here are a few tips to navigate this issue:

  • It is best if you continue to take your regular PD medications with small sips of water prior to the surgery until the time of anesthesia. Check with your surgeon and anesthesiologist if this is acceptable.
  • You should resume your PD meds as soon as possible after the surgery.
  • In some situations, there may be a prolonged period after the surgery when the person with PD is not awake enough to swallow his or her PD meds.  A discussion of this situation is beyond the scope of this article. If you find your loved one in this situation, make sure that a neurologist (and preferably a movement disorders specialist) has been consulted to consider the possible options.
  • If you are someone who needs to take your PD medications at very specific times throughout the day, the hospital setting can be very difficult. The nurses may not be scheduled to dispense medications at the times that correspond to when you need to take them. If meds are not given on time, then PD symptoms could worsen and recovery from surgery becomes more and more challenging. In order to prevent this downward spiral, active and continuous communication with the medical and nursing staff is necessary to explain why medications need to be given on time.
  • In the days immediately after the surgery, it is possible that the sensitivity to PD medications may be temporarily increased or decreased. This may lead to either an increase in dyskinesias or more OFF time after the surgery. If this occurs, make sure that a neurologist (and preferably a movement disorders specialist) has been consulted to aid in temporarily adjusting the PD medications.
  • In the weeks after surgery, PD symptoms may be temporarily worse due to the stress of surgery. Recovery can be slow as compared to someone without PD. Be patient, as typically everything will return to baseline if given enough time.

Adverse medication reactions

When a person with PD comes to the hospital for any reason, there is the danger that he or she will be given a medication that people with PD should not receive. The doctors may be focused on one particular medical problem and not consider the whole patient. For example, if a person with PD is admitted to the hospital for gall bladder removal and complains of nausea afterwards, he or she may be prescribed metoclopramide, a common medication given for nausea. Metoclopromide however, blocks dopamine receptors and should not be taken by people with PD because it can cause motor symptoms to worsen. There are other medications for nausea, such as ondansetron, which do not block dopamine receptors, and can be used safely in PD.

A second set of medications need to be avoided only by people who take monoamine oxidase inhibitors (MAOIs) for their PD.  MAOIs for PD include rasagiline (Azilect), selegiline (Zelapar) and safinamide (Xadago). A number of medications interact with MAOIs and a person with PD may accidentally be given one of these medications in the hospital setting. For this reason, if a hospitalization or surgery is planned, it is wise to consider stopping an MAOI two weeks prior the scheduled event. Talk with your neurologist about this possibility.

Lists of these two categories of medication can be found on our Medications to Be Avoided page.

In addition to these two groups of medications, many medications have side effects that need to be considered in the context of PD. Because people with PD may be particularly prone to certain non-motor symptoms, they may be more sensitive to particular medication side effects – such as fatigue, confusion, low blood pressure or constipation, among others. For example, particular medications for anxiety or sleep could potentially cause gait unsteadiness and would need to be used with caution in those with balance and gait difficulties. Therefore, all new medications must be carefully considered when being given to people with PD, especially in the post-operative period, when, due to effects of anesthesia, side effects may be more prominent.

Post-surgical delirium

Delirium is a reversible period of confusion which can occur in a number of situations, including after surgery. About one in four people over the age of 60 develop delirium in the post-operative period. People with PD are even more susceptible to this phenomenon especially those with cognitive decline. Delirium can result in agitation, hallucinations, delusions, poor attention and extreme fatigue. It may be wise to anticipate delirium and have family or friends in the hospital to provide frequent reorientation and reassurance. Making sure that the person who just had surgery is out of bed as soon as allowed, has access to his or her glasses and hearing aids and is able to see out of a window, can be helpful in ensuring a quicker return to clear thinking.

It may however become necessary to use a medication to control agitation or hallucinations. If this is the case, it is important to note that most of the standard medications that are given in this situation also block the dopamine receptor and must be avoided in people with PD. Only certain drugs can be used in this situation, such as quetiapine (Seroquel). Benzodiazepines such as clonazepam or lorazepam can be used, although their tendency to cause sedation and gait imbalance may be magnified in people with PD, particularly after anesthesia.

Other concerns to be aware of

There are a few other possible concerns to be aware of when having surgery. Again, not everyone will experience these issues, but it is wise to understand them and be aware so that you can plan accordingly and be prepared.

  • The effect of even mild dehydration may be exacerbated in PD.
  • People with PD may have swallow dysfunction. This can be exacerbated by anesthesia and make people with PD at higher risk for aspiration, defined as the tendency for food or liquid to get into the airway. Therefore, it is best to introduce soft foods slowly after surgery.
  • People with PD may have significant fluctuations of blood pressure which can be magnified in the post-operative period. Episodes of low blood pressure can cause dizziness and even fainting. This problem is most prominent when changing head position – that is moving from lying down, to sitting to standing. Therefore, these changes should be made very slowly.
  • Urinary dysfunction is common in PD, and people with PD may be particularly prone to urinary tract infections (UTIs). It is important to note that UTIs or any infection may first manifest as an unexplained worsening of PD symptoms or initiation of hallucinations.
  • People with PD are particularly prone to constipation and this can be exacerbated in the post-operative period. Taking a daily medication to prevent constipation may become necessary after surgery.

With a fuller understanding of the effects of anesthesia and surgery in a person with PD, then problems can at least be anticipated and hopefully minimized or prevented. Be sure to speak with your medical team about any concerns and ask lots of questions so you feel comfortable and confident. Use the information you learn to prepare yourself for the potential issues and you’ll have a more positive experience.

Tips and takeaways

  • People with PD can have surgery but need to educate themselves regarding the specific potential issues that may arise.
  • The effects of anesthesia and surgery can be more profound in someone with PD.
  • Prior to surgery, have your neurologist speak to your surgeon and anesthesiologist about potential issues. Ask him/her to put all the issues in writing as well.
  • Prior to surgery, talk to your anesthesiologist about the anesthesia options that are available for the type of surgery that you are having. If local anesthesia is an appropriate option, you may want to consider it as it can have fewer side effects.
  • Post-operative delirium may occur, but is almost always reversible. Managing this with frequent reorientation can be helpful.
  • Blood pressure fluctuations, urinary dysfunction, constipation and swallowing difficulties can all be exacerbated in the post-operative period.

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