Neurological
Assessment and treatment of respiratory decompensation in Parkinson’s patients with COVID-19
The BBC announces that it currently ventilates 4,000 patients as of January 2021.1 These unprecedented numbers are further confirmed by CNN, which said the US spent over $ 200 million on nearly 9,000 ventilators sent around the world. 2 These reports highlight the severity of the coronavirus on public health. Older patients, especially those with Parkinson’s disease (PD), often bear the brunt of the pandemic due to pre-existing lung disease and / or anatomical disposition.
Elderly Parkinson’s disease patients represent a vulnerable population who have a range of respiratory diseases, including infections and foreign body aspiration of the airways, and in some cases lead to the development of pneumonia.3 From a purely pathophysiological perspective, COVID-19 starts an attack on the epithelial lining of the Airways by binding to ACE2 as a means of airway infiltration. 4
Exposure to the virus should be avoided at all costs, as studies have shown that patients with PD associated with COVID-19 pneumonia have a poor prognosis for morbidity and mortality problems.3 It should be noted that PD is overmedicated is (i.e. levodopa) patients also suffer from respiratory dyskinesia. 5
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Because of the predominantly respiratory symptoms in patients with SARS-CoV-2, PD patients with exposure should be monitored extensively for COVID-19 respiratory symptoms. The development of acute respiratory distress syndrome (ARDS) can abruptly lead to clinical deterioration with fatal consequences.6 The problem is exacerbated by the fact that intubated patients with Parkinson’s cannot be treated with most dopaminergic drugs (lack of an IV formulation) possibly resulting in withdrawal, increased rigidity and rhabdomyolysis from Neuroleptic Malignant Syndrome (NMS).
Identifying Overlapping Symptoms of COVID-19 and Parkinson’s Disease
COVID-19, also known as Coronavirus 2 (SARS-CoV-2) with Severe Acute Respiratory Syndrome, is an infectious disease characterized by mild to severe respiratory disease in symptomatic patients, including shortness of breath, hypoxia, pneumonia, and in some cases ARDS. Patients with Parkinson’s disease, especially those with terminal disease progression, may also experience shortness of breath. Although the appearance of severe respiratory symptoms is not particularly common in PD patients, a phenomenon known as “wear and tear” can sometimes occur as the dose of levodopa drug decreases. However, PD symptoms appear before the next dose. Anxiety can also be viewed as one of the effects of “wearing out” culminating in palpitations, chest tightness, and shortness of breath
Levodopa also induces respiratory dyskinesia, which correlates with the peak dose effect.5 In addition, as already mentioned, patients with Parkinson’s are prone to aspiration pneumonia due to an underlying swallowing deficit (dysphagia). Pneumonia due to COVID-19 also remains a worrying prospect, increasing the likelihood of morbidity and mortality in PD patients
PD patients with comorbid conditions such as asthma, COPD, and allergies may also have difficulty breathing. Aside from these respiratory symptoms, which make it difficult to distinguish manifestations of PD from coronavirus, the presence of non-specific (hot flashes, fatigue, muscle pain) and specific (anosmia) COVID-19 symptoms are also often found in Non’s repertoire – Motor signs in Parkinson’s. 6
It should be noted that PD patients exposed to the coronavirus have experienced a marked deterioration in both motor and non-motor symptoms; It is believed that the mechanism responsible for worsening symptoms may be mediated by factors such as the inflammatory response due to persistent infection and / or impaired dopaminergic transmission.8 Deconditioning due to prolonged debilitation can also contribute to the progression of symptoms contribute.
Symptom monitoring, prevention and therapeutic management
COVID-19 patients with severe respiratory illness are prime candidates for ventilatory assistance.9 The problem is even more pressing for PD patients exposed to the virus as it is pre-existing restrictive or obstructive pulmonary disease, a late manifestation of Parkinson’s disease, 9 PD patients may experience loss of chest wall compliance due to abnormal posture, namely excessive flexion of the thoracolumbar spine (camptocormia) .9
Regarding the ventilation process, doctors may encounter resistance during intubation due to dystonia of the neck.9 In addition, dyspnea, a non-motor symptom, should be monitored as it can correlate with emotional states (i.e., anxiety) 7 or the underlying motor fluctuations. 9
PD patients are susceptible to aspiration, and the coronavirus can modulate the cough reflex, causing further worsening of swallowing and, consequently, aspiration pneumonia.9 Oxygen therapy combined with ventilatory support remains the mainstay of treating PD patients with severe COVID -19 respiratory disease. 10
Patients with Parkinson’s disease are considered to be members of the elderly population as a “high risk” of contracting the coronavirus.10 While PD patients must adhere to the general prevention and safety protocols for COVID-19, there are a number of additional measures recommended by clinicians 10
Patients should adopt a preparatory attitude and stock up on essentials (e.g. medication, toiletries, etc.), wear masks, avoid leisurely travel and follow the recommendations to stay at home. 10 As SARS-CoV-2 Vaccinations continue to be rolled out nationally. Older people with Parkinson’s disease should also consider getting vaccinated against pneumonia to reduce the risk of respiratory disease.10 If a patient experiences symptoms characteristic of COVID-19, they should contact your family doctor immediately. 10 For PD patients, it would be advisable to perform exercises that will ensure optimal lung health while ensuring compliance with their medication regimen.
Family members and dedicated caregivers are tasked with taking the necessary safety measures to minimize the possibility of the virus spreading.10 Outside travel should be avoided except for necessary supplies.10 Caregivers / guardians should also be proactive in developing symptoms in themselves monitor Because those affected by PD may not be able to perform instrumental activities autonomously.10 However, for family members and caregivers who have already been exposed to the virus, they are encouraged to self-isolate and not contact PD patients in nursing homes and facilities of interest.10 A substitute caregiver may be assigned while she continues on the path to recovery.
Disclosure:
Dr. Faisal A. Islam is a medical advisor to the International Maternal and Child Health Foundation (IMCHF) in Montreal and is based in New York. He is also a postdoctoral fellow, psychopharmacologist, and medical specialist. Dr. Islam did not disclose any relevant financial relationships.
Dr. Ranbir Dhillon is a neurologist at Brigham and Women’s Hospital in Boston, Massachusetts. He is affiliated with the Sturdy Memorial Hospital. Dr. Dhillon currently serves on the speakers / advisory boards of the following pharmaceutical companies: Genzyme, Teva Neuroscience, Biogen and Bristol Myers Squibb.
Dr. Zia Choudhry is Scientific Director and Head of the Mental Health and Clinical Research Department at IMCHF. He has no information.
References
1. O’Conner M. Hand J. Covid: The number of patients on ventilators is 4,000 for the first time. BBC. Published online January 23, 2021. https://www.bbc.com/news/uk-55782716
2. Liebermann O. US spent $ 200 million shipping 8,722 ventilators around the world and can’t find many now, says Watchdog. CNN. Published online January 29, 2021. https://www.cnn.com/2021/01/29/politics/trump-administration-ventilators-gao/index.html
3. Helmich RC, Bloem BR. The Impact of the COVID-19 Pandemic on Parkinson’s Disease: Hidden Concerns and New Opportunities. J Parkinson Dis. 2020; 10 (2): 351. doi: 10.3233 / JPD-202038
4. Learn more about COVID-19. American Lung Association. Updated April 14, 2021. https://www.lung.org/lung-health-diseases/lung-disease-lookup/covid-19/about-covid-19
5. Shill H, Stacy M. Parkinson’s Respiratory Diseases. Semin Respir Crit Care Med. 2002 Jun; 23 (3): 261–2 5. doi: 10.1055 / s-2002-33034
6. Hainque E. Rapid worsening of Parkinson’s disease can hide COVID-19 infection. Parkinson’s Relat Disord. Published online on May 8, 2020. doi: 10.1016 / j.parkreldis.2020.05.008
7. Caillava-Santos F., Margis R., de Mello Rieder CR. Parkinson’s wear and tear: neuropsychological differences between switch-on and switch-off periods. Neuropsychiatric Dis Treat. 2015; 11: 1175. doi: 10.2147 / NDT.S77060
8. Brown EG, Chahine LM, Goldman SM et al. The effect of the COVID-19 pandemic on people with Parkinson’s disease. J Parkinsons Dis. 2020; 10 (4): 1365- 1377. doi: 10.3233 / JPD-202249
9. Garg D, Dhamija RK. The Challenge of Treating Parkinson’s Patients During the COVID-19 Pandemic. Ann Indian Acad Neurol. 2020 Apr; 23 (Suppl 1): S24 – S27. doi: 10.4103 / aian.AIAN_295_20
10. Information on COVID-19 for Parkinson’s patients. Parkinson’s News Today. https://parkinsonsnewstoday.com/information-about-covid-19-for-parkinsons-patients/
This article originally appeared on Psychiatry Advisor