Parkinson healthcare provision during the COVID pandemic – the shape of the new normal?
Bastiaan R. Bloem MD, PhD, FRCPE
Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology; P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
Well ahead of the current COVID pandemic, we had begun to realise that our current model of care is less than optimal for the many patients with a chronic disorder such as Parkinson’s disease (PD). The COVID situation has perhaps forced our hand and accelerated the move to more remote healthcare provision. Depending on the circumstance of the consultation, remote assessment and care may generate many opportunities. However, it is important to understand when such an approach is appropriate and beneficial, and when the traditional in-person consultation is still preferable.
For a reliable initial diagnosis, it is important to emphasise that in-person visits, performed within a hospital or other institutional setting, remain crucially important. Necessitated by the ongoing COVID pandemic, we have been forced to try and perform neurological examinations remotely in previously undiagnosed patients; yet the many nuances of a detailed examination can simply not be obtained remotely. Importantly, various critical elements of the neurological examination, such as assessing postural stability or rigidity, are impossible to perform remotely Even a gait examination can be very tedious when this has to be performed remotely in an apparently rather unstable person. In-person visits also remain vital when it comes to establishing an intimate and personal relationship between the patient and his or her family on the one hand, and the medical specialist and other healthcare professionals working in the hospital (or another institutional setting) on the other hand.
The situation is very different for the long-term management of persons with a chronic disorder, once a reliable diagnosis has been established. Asking these patients to routinely come to the hospital for their follow-up visits is not only not always necessary, but also imposes a tremendous burden on patients in terms of travel time, and often also in terms of waiting time within the clinic. Furthermore, neurological examinations performed in the hospital may give a falsely positive impression of the person with PD where, paradoxically, patients can sometimes perform unexpectedly well (a phenomenon termed kinesia paradoxica). During the relatively brief follow-up consultations in the hospital, it often proves impossible to reliably ascertain several crucial disease features that can have a tremendous impact on the quality of life of patients; examples include freezing of gait, falls or complex response fluctuations in response to the dopaminergic medication. An important lesson from the current COVID pandemic is that many of these follow-up consultations can be performed remotely, sometimes using video consultations, but sometimes simply using telephone discussions. Surprisingly, many patients are both able and willing to deploy new technologies, in order to access remote follow-up care. The inability to perform a detailed neurological examination is offset by the ability to observe patients as they move about in their homes. It is likely that these remote telemedicine visits will soon be supplemented with digital information provided by wearable sensors, digitised utensils or smart homes, allowing us to obtain objective and longitudinal information about patients in their own natural environment. In my presentation, I will discuss the pros and cons of telemedicine, in light of the unfolding hands-on experience during the current COVID pandemic.
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