Mental Health, Physical Activity, and Quality of Life in Parkinson's Disease During  COVID ‐19 Pandemic

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Abstract

Patients with Parkinson's disease (PD) might be affected by compromised health care, lockdown restrictions, and global stress during the COVID‐19 pandemic, similar to the general population. 1 , 2 , 3 Therefore, we investigated the impact of the COVID‐19 pandemic on the mental health, physical activities, and quality of life (QoL) of PD patients. Using telephone calls, we were able to reach and interview 38 of 50 PD patients who had recently completed comprehensive assessments in the movement disorders outpatient clinic, Ain Shams Univeristy Hospitals, Cairo (Table 1). They were assessed using 11 questions regarding their perception of impact of COVID‐19 (supplementary document), the Depression, Anxiety, and Stress Scale–21 (DASS‐21), 4 the short form of the international physical activity questionnaire (IPAQ) 5 and the PD questionnaire (PDQ39); and were compared with 20 age‐ and sex‐matched controls who were recruited from volunteers and relatives of patients with other medical problems. We excluded patients and controls with medical comorbidities, that might affect mobility and relatives of PD patients and persons with more risk of anxiety/stress such as healthcare workers as controls. TABLE 1 Demographic and clinical characteristics of PD patients and controls PD patients (n = 38) Controls (n = 20) t test / Mann‐Whitney U test d /chi‐square test e Mean/median/frequency SD/IQR Mean/median/frequency SD/IQR t/z P Age b 55.579 9.956 55.550 5.708 0.012 0.990 Sex (male/female) a 29 (76.3%)/9 (23.7%) 14 (70%)/6 (30%) 0.273 e 0.601 Education (years) a 6.763 5.55 11.65 5.68 −3.161 0.003 Charlson Comorbidity Index b 0.903 0.097 0.938 0.049 −1.837 0.072 MMS a 27.139 2.642 AOO a 50.135 10.522 DOI a 4.726 3.209 MDS‐UPDR III off a 44.351 19.799 MDS‐UPDRS III on a 25.730 16.186 HY scale off a 2.342 0.839 BDI a 18.297 8.300 Pre‐lockdown total IPAQ a (median/IQR) (MET minutes /week) 3012 6504.75 Latency from last visit till phone call (months) b 3.876 1.490 LEDD (mean/SD) b 652.92 307.79 DASS (mean/SD), % b DASS depression 7.026 (60.5%) 5.726 3.500 (30%) 3.606 2.500 0.015 DASS anxiety 4.790 (60.5%) 3.573 2.050 (25%) 2.395 3.472 0.001 DASS stress 7.342 (52.6%) 4.884 4.500 (25%) 3.818 2.261 0.028 DASS total 19.158 12.883 10.050 8.140 2.868 0.006 IPAQ (median/IQR) b Vigorous activity (MET minutes/week) 0.00 d 30 60 1200 −1.864 d 0.062 Moderate activity (MET minutes/week) 280 1680 1080 3840 −2.387 d 0.017 Total score (MET minutes/week) 1009.5 4018.13 4410 7718.50 −2.732d 0.006 PDQ39 (median/IQR) b Mobility 30 d 55 11.25 11.88 −3.610 d <0.001 ADL 33.33 50 0 0 −5.919 d <0.001 Emotional well‐being 29.17 35.42 14.58 19.79 −2.366 d 0.018 Stigma 50 87.50 0 0 −4.752 d <0.001 Social support 0 25 0 14.58 −1.063 d 0.288 Cognition 25 31.25 12.50 21.88 −3.339 d 0.001 Communication 0 20.83 0 8.33 −1.221 d 0.222 Bodily discomfort 33.33 41.67 8.33 16.67 −3.614 d <0.001 PDQ39 total 30.88 32.16 7.84 9.39 −4.899 d <0.001 COVID‐19 related questions b no/frequency of (yes answer) Q1; Adopting protective measures against COVID‐19 35 (92.1%) Q2: family members/neighbors diagnosed with COVID‐19 4 (10.5%) Q3: Patients with questions regarding COVID‐19 5 (13.2%) Q4: worried about regular contact with physician c 29 (76.3%) Q5: Patients reported disrupted contact with physician c 31 (81.6%) Q6: patients reported anxiety/stress due to COVID‐19 c 20 (52.6%) Q7: patients reported decline of physical activity c 26 (68.4%) Q8: patients worry of catching the COVID‐19 c 22 (57.9%) Q9: patients worry about unavailability of their medications c 20 (52.6%) Q10: Patients reported interest of virtual visits 22 (57.9 %) Q11: Patients need medication adjustment 16 (42.1%) MMSE, Mini‐Mental State Examination; AOO, age of onset; DOI, duration of illness; MDS‐UPDRS, MDS Unified Parkinson’s Disease Rating Scale; HY, Hoehn and Yahr scale; BDI, Beck Depression Inventory; LEDD, levodopa‐equivalent daily dose; DASS, Depression, Anxiety, and Stress Scale; IPAQ, international physical activity questionnaire, PDQ, Parkinson’s disease questionnaire; ADL, activities of daily living; IQR, interquartile range, n, number. a Data obtained from prior visits. b Data obtained from recent phone call. c Frequency of positive answers (slight, mild, marked, very marked) vs negative answer (no) Student t test, for normally distributed continuous data comparison. d Mann‐Whitney test, for comparison of skewed distribution of continuous variables. e Chi‐square test for categorical data comparison. Significance at P < 0.05. Most PD patients reported a negative impact on their mental health, physical activity, and health care and an interest in virtual visits. Compared with controls, patients showed significantly worse stress, depression, anxiety, total DASS, moderate physical activity, walking, total IPAQ, total and most of the PDQ39 dimensions (Table 1). PD patients showed a significant decline in physical activity compared with pre‐lockdown (P = 0.002). DASS‐total, depression, and anxiety were correlated with pre‐lockdown motor severity–off. DASS depression was positively correlated with pre‐lockdown Beck Depression Inventory (BDI) and negatively with cognition. Total IPAQ scores were negatively correlated with total DASS (r s = −0.354, P = 0.029), DASS depression (r s = −0.441, P = 0.006), pre‐lockdown motor severity–on, and BDI, but positively correlated with education and cognition. Total PDQ39 scores were significantly correlated with total and subscores of DASS, pre‐lockdown motor severity, BDI, (Table 2), and patients' worry about unavailability of medication (r s = 0.347, P = 0.035). TABLE 2 Correlations of DASS, IPAQ, and PDQ39 to prepandemic characteristics DASS_depression DASS_anxiety DASS_stress DASS_total IPAQ_total a PDQ‐39_total a Age r 0.206 0.052 0.202 0.183 −0.249 −0.138 p 0.215 0.756 0.224 0.273 0.132 0.416 AOO r 0.149 0.076 0.075 0.116 −0.213 −0.076 p 0.378 0.654 0.659 0.495 0.207 0.661 DOI r 0.174 0.160 0.295 0.234 −0.120 0.290 p 0.302 0.344 0.076 0.164 0.478 0.086 Years of education r −0.189 −0.240 −0.216 −0.233 0.360 −0.233 p 0.255 0.147 0.192 0.160 0.026 0.165 MMSE r −0.379 −0.096 −0.347 −0.326 0.485 −0.331 p 0.023 0.579 0.038 0.052 0.003 0.052 MDS UPDR motor off r 0.430 0.426 0.317 0.432 −0.240 0.632 p 0.008 0.009 0.056 0.008 0.152 <0.001 MDS UPDRS motor on r 0.162 0.205 0.097 0.165 −0.367 0.433 p 0.339 0.223 0.568 0.328 0.026 0.008 HY scale off r 0.397 0.435 0.300 0.411 −0.203 0.486 p 0.013 0.006 0.067 0.010 0.221 0.002 BDI r 0.344 0.213 0.189 0.284 −0.333 0.413 p 0.037 0.206 0.262 0.089 0.044 0.012 DASS, Depression, Anxiety, and Stress Scale; IPAQ, international physical activity questionnaire; PDQ, Parkinson’s disease questionnaire; AOO, age of onset; DOI, duration of illness; MMSE, Mini‐Mental State Examination; MDS‐UPDRS, MDS Unified Parkinson’s Disease Rating Scale; HY, Hoehn and Yahr scale, BDI, Beck Depression Inventory, r, correlation coefficient. a Spearman coefficient correlation, for nonparametric data. Other correlations by the Pearson coefficient correlation (parametric data). Significance at P < 0.05.(boldface). The current report demonstrated that PD patients had worse stress, depression, anxiety, physical activity, and QoL compared with controls during the COVID‐19 pandemic, which were correlated with current mental health and pre‐lockdown characteristics. In addition, subjective negative impact of the pandemic on mental health, physical activity, and health care was reported by most of PD patients. Furthermore, worsening of physical activity of patients was detected compared with their pre‐lockdown state. These findings are consistent with expected indirect sequelae of the COVID‐19 pandemic 2 and previous studies beyond the era of COVID‐19. 1 Consistently, Prasad et al reported increased stress and depression in 9% of PD patients during COVID‐19 lockdown, 6 and the reported 10 PD patients with COVID‐19 showed worsening of anxiety and other nonmotor symptoms. 7 The current findings should be interpreted in the context of possible variability in pandemic severity, degree of lockdown, patients' perception, and cultural characteristics. 6 The smaller number of subjects and higher education of controls were the limitations of the study. The current study confirmed the impaired mental health, physical activity, and QoL of PD patients and identified their correlates during the COVID‐19 pandemic, implying the importance of managing these issues and continuing care of PD patients, particularly by adopting telemedicine. 3 Competing interests: no conflict of interests for any authors. Funding: none. Authors’ Roles Ali Shalash: idea and conception, study design, data collection, statistical design and execution, writing first draft, and review and critique of the manuscript. Tamer Roushdy, Mai Fathy, Noha Dawood: data collection, review and critique of manuscript. Mohamed Essam, Eman Abushady, Hanan Elrassas, Asmaa Helmi: study design, data collection. Eman Hamid: study design, research project execution, data collection, statistical analysis design and execution, writing first draft of manuscript and review.

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Mental health in the Covid-19 pandemic

W Cullen, G Gulati, B D Kelly (2020)

During any outbreak of an infectious disease, the population’s psychological reactions play a critical role in shaping both spread of the disease and the occurrence of emotional distress and social disorder during and after the outbreak. Despite this fact, sufficient resources are typically not provided to manage or attenuate pandemics’ effects on mental health and wellbeing. 1 While this might be understandable in the acute phase of an outbreak, when health systems prioritize testing, reducing transmission and critical patient care, psychological and psychiatric needs should not be overlooked during any phase of pandemic management. There are many reasons for this. It is known that psychological factors play an important role in adherence to public health measures (such as vaccination) and in how people cope with the threat of infection and consequent losses. 1 These are clearly crucial issues to consider in the management of any infectious disease, including Covid-19. Psychological reactions to pandemics include maladaptive behaviours, emotional distress and defensive responses. 1 People who are prone to psychological problems are especially vulnerable. All of these features are in clear evidence during the current Covid-19 pandemic. One study of 1210 respondents from 194 cities in China in January and February 2020 found that 54% of respondents rated the psychological impact of the Covid-19 outbreak as moderate or severe; 29% reported moderate to severe anxiety symptoms; and 17% reported moderate to severe depressive symptoms. 2 Notwithstanding possible response bias, these are very high proportions—and it is likely that some people are at even greater risk. During the 2009 H1N1 influenza outbreak (‘swine flu’), a study of mental health patients found that children and patients with neurotic and somatoform disorders were significantly over-represented among those expressing moderate or severe concerns. 3 Against this background, and as the Covid-19 pandemic continues to spread around the world, we hypothesize a number of psychological impacts that merit consideration now rather than later. In the first instance, it should be recognized that, even in the normal course of events, people with established mental illness have a lower life expectancy and poorer physical health outcomes than the general population. 4 As a result, people with pre-existing mental health and substance use disorders will be at increased risk of infection with Covid-19, increased risk of having problems accessing testing and treatment and increased risk of negative physical and psychological effects stemming from the pandemic. Second, we anticipate a considerable increase in anxiety and depressive symptoms among people who do not have pre-existing mental health conditions, with some experiencing post-traumatic stress disorder in due course. There is already evidence that this possibility has been under-recognized in China during the current pandemic. 5 Third, it can be anticipated that health and social care professionals will be at particular risk of psychological symptoms, especially if they work in public health, primary care, emergency services, emergency departments and intensive or critical care. The World Health Organization has formally recognized this risk to healthcare workers, 6 so more needs to be done to manage anxiety and stress in this group and, in the longer term, help prevent burnout, depression and post-traumatic stress disorder. There are several steps that can and should be taken now to minimize the psychological and psychiatric effects of the Covid-19 pandemic. First, while it might be ostensibly attractive to re-deploy mental health professionals to work in other areas of healthcare, this should be avoided. Such a move would almost certainly worsen outcomes overall and place people with mental illness at disproportionate risk of deteriorations in physical and mental health. If anything, this group needs enhanced care at this time. Second, we recommend the provision of targeted psychological interventions for communities affected by Covid-19, particular supports for people at high risk of psychological morbidity, enhanced awareness and diagnosis of mental disorders (especially in primary care and emergency departments) and improved access to psychological interventions (especially those delivered online and through smartphone technologies). 7 These measures can help diminish or prevent future psychiatric morbidity. Finally, there is a need for particular focus on frontline workers including, but not limited to, healthcare staff. In the USA, the Centers for Disease Control and Prevention offer valuable advice for healthcare workers in order to reduce secondary traumatic stress reactions, including increased awareness of symptoms, taking breaks from work, engaging in self-care, taking breaks from media coverage and asking for help. 8 This kind of advice needs to be underpinned by awareness of this risk among employers, enhanced peer-support and practical assistance for healthcare workers who find themselves exhausted, stressed and feeling excessive personal responsibility for clinical outcomes during what appears to be the largest pandemic of our times. Even in this emergency circumstance, or especially in this emergency circumstance, we neglect mental health at our peril and to our long-term detriment. Conflict of interest: None declared.

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The Impact of the COVID-19 Pandemic on Parkinson’s Disease: Hidden Sorrows and Emerging Opportunities

Rick Helmich, Bastiaan Bloem (2020)

In the past few months, the world seems to have come to a virtual standstill. As the SARS-CoV-2 virus continues to spread across the globe, many countries have taken drastic measures to slow down infection rates. These include social distancing, and in some countries a complete lock-down of social and economic life. The impact of the corona virus disease (COVID-19) crisis is evident, on the lives of the worst affected families, our healthcare systems, and the world economy. There are particular concerns around the increased vulnerability of patients living with a chronic disease, and this also includes neurological conditions like Parkinson’s disease (PD). Indeed, PD is more common in the elderly, and PD can compromise the respiratory system, as reflected among others by the increased risk of pneumonia that is present in patients with advanced PD. Although documented reports are thus far lacking, it is conceivable that having a diagnosis of PD is a risk factor for worse respiratory complications or even an unfavorable outcome after a COVID-19 infection. This “immediate” impact of a COVID-19 infection for people living with PD has been addressed extensively, among others in webinars and informative websites issued by patient organizations around the globe (for examples, see [1]). However, the potential impact of COVID-19 infections for PD patients extends well beyond these direct threats. Here, we will focus on several less visible—but also potentially grave—consequences of the COVID-19 pandemic for people living with PD, and more specifically, on how the preventive social measures to mitigate the risk of becoming infected have drastically changed the way of life for many affected persons. We also address how this crisis is already beginning to lead to new initiatives that offer help and support for patients and their near ones. The COVID-19 pandemic has profoundly changed people’s normal routines, and this all happened over a very short period. Such drastic changes require a flexible adaptation to new circumstances, which is a cognitive operation that depends on normal dopaminergic functioning. A large body of literature has shown that many PD patients experience cognitive and motor inflexibility, as a result of nigrostriatal dopamine depletion that forms the pathophysiological substrate of PD [2, 3]. Furthermore, it has been hypothesized that dopamine-dependent adaptation is a requirement for successful coping that, when deficient, leads to a sense of loss of control and increased psychological stress [4]. This may explain why stress-related psychiatric symptoms such as anxiety and depression are so common in PD, occurring in up to 30–40% of patients, even outside times of crisis [5]. Thus, the pathophysiology of PD puts patients at increased risk of chronic stress, and a further worsening of this may well be one of various hidden sorrows of the COVID-19 pandemic. Importantly, increased levels of stress during the COVID-19 pandemic may have several short-term as well as long-term adverse consequences for individuals with PD. First, increased psychological stress can temporarily worsen various motor symptoms, such as tremor, freezing of gait or dyskinesias [6–9], while it reduces the efficacy of dopaminergic medication [6]. Second, increased stress may unmask a latent hypokinetic rigid syndrome, possibly by depleting compensatory mechanisms [10, 11]. This could lead to an increase in numbers of new PD diagnoses during the pandemic. In a year from now, it might be worthwhile to investigate incidence levels of PD during this time of crisis, as compared to the period before. Third, animal studies have shown that prolonged episodes of chronic stress may worsen the rate of dopaminergic cell loss in response to a toxin [12]. Comparable studies in human patients are lacking, so it remains presently unclear whether chronic stress can actually accelerate PD. It would be interesting to test this hypothesis, in ongoing longitudinal cohort studies such as the Parkinson’s Progression Markers Initiative (PPMI) [13], the Oxford Parkinson’s Disease Centre (OPDC) Discovery Cohort [14], or the Personalized Parkinson Project (PPP) [15], examining whether the COVID-19 crisis is associated with changes in biological or clinical progression markers of PD that hint at an acceleration of the underlying disease process. Interestingly, there are also factors that protect against the detrimental effects of stress. This has been termed “resilience”, i.e. the ability to maintain or quickly recover mental health during and after times of adversity. Resilience is associated with personality traits such as optimism, creativity, and intelligence, as well as belief of social support and connectedness to the environment [16]. The current crisis offers opportunities to see who copes best with the current situation, versus those who experience the greatest difficulties, including the determinants of these differences. It is also good to mention the availability of specific treatments that can reduce stress, such as mindfulness-based interventions. Several recent studies have shown that mindfulness can reduce depression and anxiety, and even improve motor symptoms [17]. These courses are usually given in groups of patients, but they may also be offered through online platforms. Such web-based solutions can also provide a means to reduce social isolation, which is yet another hidden consequence of this ongoing pandemic. Children are told to avoid visits to their parents living with PD whenever possible, and grandchildren are best kept away at all. Even social contacts resulting from home-based nursing interventions are now reduced. Online solutions are again essential to diminish this feeling of social isolation, and to provide comfort and hope for people living with PD who are now grounded within their homes. Another hidden but potentially highly disconcerting consequence of the pandemic is a marked reduction in physical activities. Many people are now largely and sometimes completely stuck at home, being unable to go out for a regular walk, let alone to see their physiotherapist or attend a fitness class. Recent evidence has shown that physical exercise may attenuate clinical symptom progression in PD [18, 19]. One recent trial, the Park-in-Shape study, compared a home-based physical aerobic exercise intervention (consisting of 30–45 min of stationary cycling on a home-trainer, three times per week for 6 months) with an active control condition (consisting of 30–45 min of stretching, three times per week for 6 months) [19]. A between-group longitudinal difference of 4.2 points on the motor scores of the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS) was found, which was both significant and clinically relevant. Another study has shown similar effects, also emphasizing the importance of dose: more intense exercise was associated with better outcomes than moderately intense exercise [18]. It is unclear which mechanisms explain these clinical effects, and in particular whether aerobic exercise can potentially slow down disease progression of PD, or whether it is merely a symptomatic effect via stimulation of compensatory cerebral changes that balance nigrostriatal cell loss. Nevertheless, a loss of aerobic exercise during the COVID-19 pandemic may well lead to a worsening of motor symptoms in PD. Nonmotor issues such as insomnia or constipation may also worsen due to lack of physical activity. Furthermore, reduced physical exercise may contribute to increased psychological stress, thereby further aggravating the symptoms of PD, as outlined above. Promoting home-based and adequately dosed exercises, such as cycling on a stationary bicycle, is therefore more important than ever before. In this regard, a hopeful consequence of the current crisis has been the emergence of web-based exercise initiatives, such as online singing, exercise or dancing classes for PD patients (for examples, see [20]). Such interventions are not entirely new, but the current crisis has certainly accelerated their adoption by large groups of patients, paradoxically making the access to these important interventions more accessible than ever before, particularly for those living in loosely populated areas of the world. Taken together, it is clear that the COVID-19 pandemic will have major consequences on our society and our way of life, and this definitely includes people living with PD. Individuals with PD are at increased risk of experiencing the negative sequelae of increased stress and reduced physical exercise, both “hidden sorrows” that can worsen their motor as well as non-motor symptoms. However, there are also emerging opportunities. This crisis calls for the rapid introduction of better self-management strategies that can help patients to better deal with the challenges of social distancing and the other consequences of this crisis. We believe that self-management strategies that reduce stress (e.g., mindfulness), increase coping (e.g., cognitive behavioral therapy) or increase physical exercise (e.g., home-based training programs, alone or in groups) will play an increasing role in the treatment of PD. The implementation of these interventions will have to be accelerated during this crisis, and we are beginning to see persuasive examples of this in many countries, often initiated or supported by large patient associations. Furthermore, this crisis also offers opportunities for research. The COVID-19 pandemic is an external stressor that is aligned in time for large groups of people. This provides a unique opportunity for researchers to test how the pandemic influences the course of PD in existing longitudinal cohorts, e.g., by taking advantage of wearable sensors or biological biomarkers. It also allows researchers to test which factors protect patients from the detrimental consequences of this crisis, increasing our insight in resilience in PD. As such, deleterious as the current crisis may be, it will hopefully also bring some long-term positive outcomes for the many people living with PD worldwide. CONFLICT OF INTEREST The authors have no conflict of interest to report.

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Outcome of Parkinson's Disease Patients Affected by COVID ‐19

Angelo Antonini, Valentina Leta, James Teo … (2020)

There is extensive debate on the neurological consequences of corona virus disease 2019 (COVID‐19) and the impact this might have for patients with neurodegenerative conditions, including Parkinson's disease (PD). Older advanced PD patients may represent a particularly vulnerable population, as respiratory muscle rigidity as well as impairment of cough reflex alongside preexisting dyspnoea may lead to increased severity of COVID‐19. 1 In addition, there are indirect possible effects, such as the impact of stress, self‐isolation, and anxiety, as well as the consequences of prolonged immobility because of the lockdown.2, 3 Several observations make the link between COVID‐19 and PD particularly intriguing. Antibodies against coronavirus were found in the cerebrospinal fluid of PD patients more than 2 decades ago, suggesting a possible role for viral infections in neurodegeneration. 4 Angiotensin‐converting enzyme 2 (ACE2) receptors are highly expressed in dopamine neurons, and they are reduced in PD because of the degenerative process; therefore, severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)–related brain penetration may cause additional harm and worsen symptoms and may increase the requirement of dopamine replacement therapy, as evident in 5 of our cases.5, 6 Interestingly, the ability of coronaviruses to enter the brain through the nasal cavity determines anosmia/hyposmia and ageusia in many infected subjects, a symptomatology that closely resembles one of the most prominent premotor symptom of PD. 7 Finally, the dopamine synthetic pathway is possibly involved in the pathophysiology of COVID‐19, as ACE2 and dopamine decarboxylase coexpress and coregulate in nonneuronal cell types, which may indicate dopamine depletion and the need for considering levodopa as treatment. 8 Outcomes of PD patients infected by SARS‐CoV‐2 are unknown. We present here the outcome of 10 clinical cases (Table 1) collected from the experience at the Parkinson and Movement Disorders Unit in Padua, Italy, and the Parkinson's Foundation Centre of Excellence at King's College Hospital in London, UK, from the beginning of March to the current period. The PD center in Padua has a catchment of 1022 patients, mainly in the province of Padua, which had 3407 cases of COVID‐19, 2 of whom were advanced PD patients. Both were women residing in nursing homes with severe motor manifestations, and both were treated with levodopa therapy (Table 1). One remained asymptomatic, whereas the other, who in the last months had been suffering from deteriorating cognition and hallucinations, developed respiratory problems and died. The King's center has 4000 PD patients in the catchment and is currently following more than 600 patients. In all, thus far, 8 cases have been identified with COVID‐19, and clinical details are presented here. The Kings' COVID‐19 PD group consists of 6 men and 2 women, all older than 60 years of age with severe motor dysfunction, comorbidities, and most requiring additional levodopa dosing following infection (Table 1). Anxiety and other nonmotor features, such as fatigue, orthostatic hypotension, cognitive impairment, and psychosis, also worsened during the infection. Fatigue was a dominant symptom during the SARS‐CoV‐2 infection in all cases on advanced therapies. Three patients died from COVID‐19 pneumonia. Table 1 Clinical features and outcomes of Parkinson's disease patients with corona virus disease 2019. Patients Age Sex PD duration (years) PD therapy Comorbidities Clinical picture requiring SARS‐CoV‐2 testing Therapeutic interventions(antibiotics and intensive care) Outcome 1 76 F 28 Carbidopa‐levodopa 25/100 mg 1 table t 3 times daily and ½ tablet once daily Rotigotine 4 mg 1 patch once daily Safinamide 50 mg 1 tablet once daily Dementia Dysphagia Severe joint deformities Fever No intensive care required Spontaneous recovery 2 79 F 12 Carbidopa‐levodopa 25/100 mg 1½ tablets 4 times daily Dementia Hallucinations Fever Cough Shortness of breath Confusion CPAP required (no resuscitation was advised) Died 14 days after onset of respiratory symptoms 3 81 M 10 Carbidopa‐Levodopa CR 25/100 mg 1 tablet once daily Carbidopa‐Levodopa 25/100 mg 2 tab 3 times daily Hypertension Ischemic heart disease Chronic kidney disease Dementia Fever Dry cough Shortness of breath Antibiotics (piperacillin/tazobactam + clarithromycin) No intensive care or CPAP required Required increased levodopa dosing Transferred to rehabilitation ward after 11 days of hospitalization 4 94 M 2 Carbidopa‐Levodopa 25/100 mg 1 tablet 3 times daily Angina pectoris Osteoporosis Multiple falls and head injury Cough Delirium Arrhythmia Antibiotics (amoxicillin/clavulanic acid + clarithromycin) No intensive care or CPAP required Transferred to rehabilitation ward for respite care; 10 days of hospitalisation 5 87 M 6 Carbidopa‐Levodopa 25/100 mg 1 tablet twice daily Carbidopa‐Levodopa 25/100 mg 1½ tablets twice daily Congestive Cardiac failure Chronic obstructive pulmonary disease Atrial fibrillation Orthostatic hypotension Asthma Syncopal episodes Hallucinations Fall with facial trauma Cough Antibiotics (amoxicillin/clavulanic acid) No intensive care, CPAP not possible because of facial trauma (no resuscitation was advised) Required increased levodopa dosing Died after 10 days of hospitalization 6 83 F 3 Carbidopa‐Levodopa 25/100 mg 2 tablets twice daily and 1½ tablets twice daily Anxiety disorder Worsening of mobility with fall and hyperCKemia Dry cough Fatigue Worsening of anxiety No intensive care or CPAP required Required increase in levodopa dosing Transferred to neurorehabilitation after 25 days of hospitalization 7 61 M 17 IJLI 1684 mg daily Carbidopa‐levodopa 25/100 mg 1 tablet once daily Rotigotine 4 mg 1 patch once daily Opicapone 50 mg 1 tablet once daily Traumatic fractures secondary to falls Orthostatic hypotension Fever Cough Fatigue Antibiotics CPAP required Died during hospitalization 8 75 M 10 IJLI 1262 mg daily Opicapone 50 mg 1 tablet once daily Carbidopa‐Levodopa CR 50/200 mg 1 tablet once daily Carbidopa‐Levodopa CR 25/100 mg 1 tablet once daily Levodopa‐ Benserazide 100/50 mg 1 tablet 3 times daily Orthostatic hypotension Osteoporosis Benign prostatic hyperplasia Depression Neuropathic pain Fever Cough Fatigue Antibiotics CPAP required Died during hospitalization 9 72 M 15 DBS bilateral STN Subcutaneous Apomorphine infusion 46 mg daily Rasagiline 1 mg 1 tablet once daily Ropirinole CR 2 mg 1 tablet once daily Levodopa‐benserazide 50/12.5 mg 1 tablet 4 times daily Carbidopa‐Levodopa CR 25/100 mg 1 tablet 3 times daily Asthma Diabetes mellitus type II Fever Fatigue Worsening of motor symptoms Required increase in levodopa dosing No intensive care or CPAP required Spontaneous recovery, waiting for transfer for rehabilitation 10 75 F 24 IJLI stopped due to recent PEG‐J tube malfunctioning Levodopa‐Benserazide 100/25 mg six times daily Carbidopa‐Levodopa CR 25/100 mg once daily Atrial fibrillation Cognitive impairment Fatigue Cough Required increase in levodopa dosing No intensive care or CPAP required Recovering CPAP, continuous positive airway pressure; CR, controlled release; DBS, deep brain stimulation; IJLI, intrajejunal levodopa infusion; F, female; M, male; PD, Parkinson's disease; PEG‐J, percutaneous endoscopic transgastric jejunostomy; SARS‐CoV‐2, severe acute respiratory syndrome coronavirus 2; STN, subthalamic nucleus. These findings suggest that PD patients of older age (mean, 78.3 years) with longer disease duration (mean, 12.7 years) are particularly susceptible to COVID‐19 with a substantially high mortality rate (40%). Those on advanced therapies, such as deep brain stimulation or levodopa infusion therapy, seem especially vulnerable, and a mortality rate of 50% among our 4 such cases is of concern. Although 2 recent articles have addressed the issue of COVID‐19 in PD, none specifically showed cases directly affected by COVID‐19, and we believe ours is the first report of this nature.2, 3 The report of Prasad et al focuses on the perceptions of SARS‐CoV‐2 infection in 100 PD patients and some symptoms listed tally with our observations in a real‐life population with COVID‐19. 2 Many national and charity guidelines do not list PD or specifically older subjects on advanced therapies as a susceptible group, and this information needs to be amended in light of these new data. 9 Author Roles Angelo Antonini: conception, data collection, manuscript, review and critique. Valentina Leta: data collection, review and critique. James Teo: data collection, review and critique. K Ray Chaudhuri: conception, data collection, manuscript, review and critique. Financial Disclosures of all authors (for the preceding 12 months) Angelo Antonini has received compensation for consultancy and speaker‐related activities from UCB, Boehringer Ingelheim, AbbVie, Zambon, and Lundbeck; he receives research support from Chiesi Pharmaceuticals, Lundbeck, Horizon 2020 ‐ PD_Pal grant 825785, and Ministry of Education University and Research (MIUR) grant ARS01_01081. He serves as consultant for Boehringer–Ingelheim for legal cases on pathological gambling. Valentina Leta reports grants from BRC, Parkinson's UK, speaker‐related activities fees from Britannia Pharmaceuticals, and consultancy fees from Invisio Pharmaceuticals, outside the submitted work. James Teo has received research support and funding from InnovateUK, Bristol‐Myers‐Squibb, and iRhythm Technologies and holds shares < £5000 in Glaxo Smithkline and Biogen. K. Ray Chaudhuri has received honoraria for advisory board from AbbVie, UCB, Pfizer, Jazz Pharma, GKC, Bial, Cynapsus, Novartis, Lobsor, Stada, Medtronic, Zambon, Profile, Sunovion, Roche, Theravance, and Scion; hnoraria for lectures from AbbVie, Britannia Pharmaceuticals, UCB, Mundipharma, Zambon, Novartis, Boehringer Ingelheim, Neuroderm, and Sunovion; grants (investigator‐Initiated) from Britannia Pharmaceuticals, AbbVie, UCB, GKC, and Bial; academic grants from IMI EU, Parkinson's UK, NIHR, PDNMG, EU (Horizon 2020), Kirby Laing Foundation, NPF (USA), and MRC.

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Ali Shalash: ali_neuro@yahoo.com , drali_shalash@med.asu.edu.eg

Journal

Journal ID (nlm-ta): Mov Disord

Journal ID (iso-abbrev): Mov. Disord

Journal ID (doi): 10.1002/(ISSN)1531-8257

Journal ID (publisher-id): MDS

Title: Movement Disorders

Publisher: John Wiley & Sons, Inc. (Hoboken, USA )

ISSN (Print): 0885-3185

ISSN (Electronic): 1531-8257

Publication date (Electronic): 07 June 2020

Electronic Location Identifier: 10.1002/mds.28134

Affiliations

[ ¹ ] Department of Neurology, Faculty of Medicine Ain Shams University Cairo Egypt

[ ² ] Okasha institute of Psychiatry, Faculty of Medicine Ain Shams University Cairo Egypt

Author notes

[*] [* ] Correspondence to: Ali Shalash , PhD, MD, Professor of Neurology, Department of Neurology, Faculty of Medicine, Ain Shams University, 168 Elnozha St, Saint Fatima Square, Heliopolis, Cairo, Egypt; ali_neuro@ 123456yahoo.com ; drali_shalash@ 123456med.asu.edu.eg

Article

Publisher ID: MDS28134

DOI: 10.1002/mds.28134

PMC ID: 7276909

PubMed ID: 32428342

SO-VID: bb7131ec-9ccb-48bd-88af-28bc466cd923

License:

This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.

History

Date received : 04 May 2020

Date revision received : 12 May 2020

Date accepted : 13 May 2020

Page count

Figures: 0, Tables: 2, Pages: 3, Words: 1749

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source-schema-version-number 2.0

edited-state corrected-proof

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:5.8.4 mode:remove_FC converted:08.06.2020

ScienceOpen disciplines: Medicine

Keywords: covid‐19,parkinson's disease,physical activity,quality of life,stress

Data availability:

ScienceOpen disciplines: Medicine

Keywords: covid‐19, parkinson's disease, physical activity, quality of life, stress

Mental Health, Physical Activity, and Quality of Life in Parkinson's Disease During COVID‐19 Pandemic

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Abstract

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