The impact of Covid-19 on the PD community
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The impact of Covid-19 on the PD community

 

K. Ray Chaudhuri MD, DSc, FRCP

 

Professor of Movement Disorders and Director of the Parkinson Foundation Centre of Excellence, Kings College, Denmark Hill Campus, London, UK

 

Covid-19 is a highly infectious coronavirus (SARS-CoV-2) that was first identified in Wuhan, China, at the end of 2019.  By March 2020, it was afforded global pandemic status by the World Health Organisation and, by the end of January 2021, Covid-19 had infected around 100 million people and was responsible for over 2 million deaths [1]. 

 

Those infected with the Covid-19 present with a range of symptoms.  For many, the clinical presentation is similar to influenza, with fever, cough, hyposmia, loss of taste and shortness of breath [2,3,4].  Diarrhoea as well as neurological symptoms, such as headache and nausea, can also occur.  For many, however, severe upper respiratory tract symptoms can rapidly lead to acute respiratory distress, multi-organ failure and death [5,6]. There is also now recognition of the long Covid syndrome, often characterised by severe fatigue and 3 cases of levodopa responsive parkinsonism have also been described post Covid infection [7-10]. 

 

Those at highest risk of developing severe symptoms following Covid infection include the frail, the elderly and those with underlying health problems [3] along with a disproportionately high morbidity and mortality in black and minority ethnic (BAME) populations in the UK [2].  People with Parkinson’s disease (PD), particularly older patients with more advanced disease, who already have respiratory muscle rigidity as well as impairment of cough reflex alongside pre-existing dyspnoea are an especially vulnerable population, with the potential for Covid infection to aggravate dyspnoea, worsen the cough reflex, and thereby lead to aspiration pneumonia and higher mortality.  An early analysis [11] of a first series of ten cases of PD and Covid-19 found that older age and longer disease duration were associated with both susceptibility to infection and a high mortality rate (40%).  Of additional concern was that those on advanced therapies, specifically deep brain stimulation and/or levodopa infusion therapy, appeared particularly vulnerable with a mortality rate of 40-50% among the four such cases although there is a bias in the case selection. A recent review has supported these observations with a high risk of hospitalisation and morbidity in people with Parkinson’s and so, by default, those who may be even more compromised by Covid-19 infection [12].

 

Whether SARS-CoV-2 infection can precipitate dopaminergic neuronal degeneration, via alpha-synuclein aggregation, inflammation, or some other mechanism, thereby predisposing Covid-infected people to future parkinsonian disorders, has been discussed widely [13] and merits ongoing investigation [14].

 

But while the jury is still out on the potential for a causative link between Covid and PD, it is clear that people with PD do experience a worsening of both motor and non-motor symptoms, which some have termed the ‘hidden sorrow’ [15,16].  Furthermore, government-imposed ‘stay-at-home’ orders, compounded by social distancing and barrier-enforced separation from family, friends and carers, have undoubtedly led to isolation and psychological stress for those with PD [17].  Reduced physical activity has a detrimental impact on both PD symptoms such as pain, fatigue and sleep as well as depression and anxiety in particular [18,19].  The drastic change to lifestyle and routine demanded of us all during the Covid lockdown requires flexible adaptation to changing circumstances; yet this is a cognitive process dependent on normal dopaminergic functioning [16] and therefore potentially challenging for those with PD.

 

The impact of Covid – both infection and lockdown – must also be examined and monitored more widely in the PD community.   On the frontline of healthcare, PD care providers are both at heightened infection risk themselves and prone to situational stress.  Psychological symptoms and poorer quality of life have been reported by 60% of PD caregivers [18].  An inability to work due to Covid infection also presents a risk to the continuity of care within our PD community.  The way in which we deliver healthcare during this pandemic must, and is, changing towards more remote technology-assisted provision. 

 

It is important that we monitor the course and impact of this new coronavirus on PD.  It will also be important to follow those infected with Covid-19 who have developed specific neurological disturbances, such as sustained hyposmia [20] given that the olfactory loss reported in many infected patients closely resembles pre-motor symptomatology in PD [2,21].  From a scientific point of view therefore, we need to have robust longitudinal studies in vulnerable subjects, both with and without Parkinson’s to establish the effect of long Covid or susceptibililty to developing Parkinson’s as occurred after the 1918 influenza pandemic. 

 

It may be many years before we understand the true impact of Covid-19 on the PD community, but we have the opportunity now to develop a comprehensive framework of scientific and clinical enquiry that will ensure we collect pertinent data for future interpretation.
 


References

1.    WHO Coronavirus Disease (COVID-19) Dashboard.  https://Covid19.who.int.  Accessed 27 January 2021

 

2.    Sulzer D, Antonini A, Leta V et al.  COVID-19 and possible links with Parkinson’s disease and parkinsonism: from bench to bedside. NPJ Parkinsons Dis 2020;6:18

 

3.    Chen N, Zhou M, Dong X et al.  Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020;395(10223):507-13

 

4.    Menni C, Valdes AM, Freidin MB et al. Real-time tracking of self-reported symptoms to predict potential COVID-19. Nat Med 2020;26(7):1037-40 

 

5.    Li X, Ma X. Acute respiratory failure in COVID-19: is it "typical" ARDS? Critical Care 2020;24:198

 

6.    Saviano A, Wrensch F, Ghany MG, Baumert TF.  Liver disease and COVID-19: from pathogenesis to clinical care. Hepatology 2020 Dec 17. doi: 10.1002/hep.31684. Online ahead of print

 

7.    Méndez-Guerrero A, Laespada-García MI, Gómez-Grande A et al. Acute hypokinetic-rigid syndrome following SARS-CoV-2 infection. Neurology 2020;95(15):e2109-e2118

 

8.    Cohen ME, Eichel R, Steiner-Birmanns B et al. A case of probable Parkinson’s disease after SARS-CoV-2 infection. Lancet Neurol 2020;19:804–5

 

9.    Faber I, Brandão PRP, Menegatti F et al. Coronavirus disease 2019 and parkinsonism: a non‐post‐encephalitic case. Mov Disord 2020;35(10):1721-2

 

10.    Hand A, Chaudhuri KR. British Journal of Neuroscience Nursing 2020;16(3):121-4

 

11.    Antonini A, Leta V, Teo J, Chaudhuri KR. Outcome of Parkinson’s Disease patients affected by COVID-19. Mov Disord 2020;35(6):905-8

 

12.     Vignatelli L, Zenesini C, Belotti LMB et al. Risk of hospitalization and death for COVID-19 in people with Parkinson's disease or parkinsonism. Mov Disord 2020 Nov 16:10.1002/mds.28408. doi: 10.1002/mds.28408. Online ahead of print

 

13.    Beauchamp LC, Finkelstein DI, Bush AI et al. Parkinsonism as a Third Wave of the COVID-19 Pandemic? J Parkinsons Dis 2020;10(4):1343-53

 

14.    Pavel A, Murray DK, Stoessl AJ. COVID-19 and selective vulnerability to Parkinson's disease. Lancet Neurol 2020;19(9):719

 

15.    Cilia R, Bonvegna S, Straccia G et al. Effects of COVID-19 on Parkinson’s disease clinical features: a community-based case-control study. Mov Disord 2020;35(8):1287-92

 

16.    Helmich RC, Bloem BR. The impact of the COVID-19 pandemic on Parkinson's disease: hidden sorrows and emerging opportunities. J Parkinsons Dis 2020;10(2):351-4

 

17.    Salari M, Zali A, Ashrafi F et al. Incidence of anxiety in Parkinson’s disease during the coronavirus disease (COVID-19) pandemic. Mov Disord 2020;35(7):1095-6

 

18.    Shalash A, Roushdy T, Essam M et al. Mental health, physical activity, and quality of life in Parkinson's disease during COVID-19 pandemic. Mov Disord 2020;35(7):1097-9

 

19.    van der Heide A, Meinders MJ, Bloem BR, Helmich RC.  The impact of the COVID-19 pandemic on psychological distress, physical activity, and symptom severity in Parkinson's disease. J Parkinsons Dis 2020;10(4):1355-64

 

20.    Lechien JR, Chiesa-Estomba CM, De Siati DR et al. Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study.  Eur Arch Otorhinolaryngol 2020;277(8):2251-61

 

21.    Heinzel S, Berg D, Gasser T et al. Update of the MDS research criteria for prodromal Parkinson’s disease. Mov Disord 2019;34:1464-70.

 

Further reading:

Tan EK, Albanese A, Chaudhuri K et al.  Adapting to post-COVID19 research in Parkinson's disease: Lessons from a multinational experience.  Parkinsonism Relat Disord 2020;82:146-9

Chaudhuri KR. Focus on Covid-19 and Parkinson’s disease.  Kinetic 2020;2(1):4-5.

 

UK-APO-2100023

January 2021