Managing the older person with Parkinson's in the time of COVID-19

Topics

• Clarifying UK Government advice on social distancing for people with Parkinson’s (i.e. high risk but not shielded)
• Exploring co-morbidities of people with Parkinson’s
• The role of stress and enclosed spaces in Freezing of Gait
• Amantadine – no evidence of benefit in COVID (previous use in influenza)
• What’s changed for our patients: at home, as outpatients, in hospital
• Which NMS may become problematic in this context
• What can we all do / suggest, such as keep to a routine, good sleep, hygiene etc.
• Atypical presentation and the how the research agenda for older people may be applicable to those with PD

Summary

The crossover between Parkinson’s disease (PD) and COVID-19 risk makes it a particularly worrying time for our patient group, and many have seen an exacerbation of symptoms over the last few months.

The panel discussed the reasons for this, how healthcare teams can support older people with PD during the pandemic, and how the best current evidence can guide practice.

Managing non-motor symptoms in the older person with PD in the time of COVID (1:02)

Sarah Marrinan said things had changed considerably for patients, and that coronavirus mitigation measures were having an impact on the non-motor symptoms of people with PD.

“What’s really changed is that we were always encouraging our older people with Parkinson’s to get out and now we are encouraging them to stay home. The implications are wide ranging,” said Sarah.

Because of lockdown, people are getting less exercise, are more socially isolated, more disconnected from sources of social and healthcare professional support and less able to get to the shops. All this, said Sarah, has led to an increased risk of anxiety and low mood.

“The things that are affecting people with Parkinson’s are probably the same things that everyone else is feeling, but they may have an impact on people with Parkinson’s to a greater degree,” said Sarah.

She added that she had seen an increase in the following non-motor symptoms:

• sleep disturbances
• fatigue
• anxiety
• disorientation
• hallucinations
• cognitive impairment
• constipation
• weight loss
• speech deterioration

Teams should also be aware that the current circumstances also lend themselves to an uptick in impulse control disorders and dopamine dysregulation.

“When we’re seeing patients with Parkinson’s in the hospital, or speaking to them by phone, I think we need to spend a bit of time unpicking some of these symptoms and making sure that we’re doing our best to support people in these strange times,” said Sarah.

Her advice, which she said applied to people “if they had Parkinson’s or not”, was:

• encourage people to develop and stick to a daily routine
• signpost people to the Parkinson’s UK website for ideas on how to exercise at home
• talk to people about the importance of good sleep hygiene
• encourage people to maintain social contact via video or phone
• encourage people to get at some sunlight every day
• talk to people about the importance of a balanced diet and avoiding alcohol

“From a PD-specific point of view, we need to keep in contact with our patients… and, importantly, reassure that we are still here… if they have questions or worries,” said Sarah.

Parkinson’s in the time of COVID (18:33)

Dr Richard Genever covered four areas pertinent to the management of older people with PD during the pandemic.

What’s the current coronavirus advice for people with Parkinson’s?

“It’s fair to say that the advice is slightly confused,” said Richard, explaining that:

• up until May 11, everyone over the age of 70 and everyone with one of a list of neurological conditions that included Parkinson’s, was classed as “vulnerable”
• on May 11, the Government advice changed, and Parkinson’s disappeared from the guidance. The reason for this was unclear
• a later press briefing indicated that people with neurological conditions such as Parkinson’s should continue to “take additional precautions”, but not to the degree of those who fell into the shielding category

Are people with Parkinson’s more at risk from coronavirus?

“The truth is that we don’t know at the moment. This is a brand-new condition, and the evidence base is gathering. But there are possibly a couple of things that we can look at,” said Richard.

• there is a close correlation between the age group that is most likely to have PD and those who are more at risk from COVID-19
• people with PD are more likely to have multiple comorbidities, which is another COVID risk factor, than age-matched controls

Is the lockdown influencing Parkinson’s symptoms?

“I feel I’m getting more phone calls than I would normally… talking about worsening of symptoms, and I wonder whether the situation, particularly the lockdown, might be having an impact,” said Richard.

• the literature shows that fatigue, confined spaces, stressful situations, and emotional factors are among the common freezing of gait triggers
• cues, whether visual or auditory, are most likely to be helpful for freezing of gait

Is amantadine useful in COVID-19?

Amantadine was listed in the Daily Mail as an existing drug that may play a role in the future treatment of COVID-19. The story was based on an article in the British Journal of Pharmacology, which said the drug could potentially inhibit the virus’ envelope protein, said Richard.

However, there are currently no clinical trials looking at amantadine in COVID-19, and it is “purely at the theoretical stage”, Richard said.

Parkinson’s in the time of COVID-19 (38:58)

Dr Emily Henderson said she had worked on a rapid clinical review of COVID-19 in older people, which was published in May.

“It was born out of a really quite urgent, unmet clinical need. Working on a COVID ward, we were all really struck by the… lack of evidence and guidelines as to… COVID-19 in older people, both in terms of how it presents, potential testing mechanisms, and treatments,” said Emily, before going on to describe the findings.

Presentation of COVID-19 in older people:

• there was very little literature on the presentation of COVID-19 in older people
• early reports from France suggest atypical presentation that included diarrhoea, balance dysfunction and potential delirium
• Emily’s team have seen delirium either at or during hospital admission
• COVID-19 features on radiological screening, without typical symptoms of cough, fever etc., are frequent

Emily also highlighted a case series of 10 Parkinson’s patients with COVID-19 infection, nine of whom were over the age of 75.

“The really interesting finding was the symptoms and signs that precipitated testing for COVID-19 were the three Fs: fever, fall and fatigue… I think you should be proactively looking for a step change in fatigue as a potential presenting symptom,” said Emily.

She also said important future directions of research included:

• indications for testing in different settings
• understanding typical presentation of COVID-19 in people with Parkinson’s
• improving the sensitivity of testing in varying scenarios
• understanding whether treatments were any more or less effective in particular subgroups
• understanding the impact of COVID public health measures on patients and health

Presentation slides