The BBC reveals that there are currently 4,000 patients on mechanical ventilation as of January 2021.1 These unprecedented numbers are further supported by CNN stating that the United States spent over $200 million on nearly 9,000 ventilators that were sent around the world.2 These reports underscore the severity of the coronavirus on public health. Elderly patients, especially those with Parkinson disease (PD), often bear the brunt of the pandemic due to pre-existing pulmonary disease and/or anatomical disposition.

Elderly patients with PD represent a vulnerable population that presents with a gamut of respiratory ailments, including infections and airway foreign body aspirations, and in some cases, leading to the development of pneumonia.3 From a purely pathophysiological standpoint, COVID-19 launches an assault on the epithelial lining of the airways by binding to ACE2 as a means of infiltrating the respiratory tract.4

Exposure to the virus should be avoided at all costs as studies have indicated that patients with PD in tandem with COVID-19 pneumonia have poor prognosis with respect to issues pertaining to morbidity and mortality.3 It should be noted that overmedicated (ie Levodopa) PD patients also suffer from respiratory dyskinesia.5


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Due to the overwhelmingly respiratory-based symptoms found 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) may abruptly lead to clinical deterioration with fatal consequences.6  Compounding the issue further is the fact that intubated patients with PD cannot be treated with most dopaminergic drugs (lack of an IV formulation), potentially leading to withdrawal, increased rigidity and rhabdomyolysis from neuroleptic malignant syndrome (NMS). 

Identifying overlapping symptoms of COVID-19 and Parkinson disease

COVID-19, also known as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is an infectious disease characterized by mild to severe respiratory compromise for symptomatic patients, including dyspnea, hypoxia, pneumonia, and, in some cases, ARDS. Patients with PD, especially those with end-stage disease progression may also experience respiratory distress. Although the presentation of marked respiratory symptomatology is not particularly common in PD patients, they may sometimes experience a phenomenon known as “wearing off” as the dose of the Levodopa medication begins to wear off, PD symptoms emerge before the next intake. Anxiety can also be included as one of the effects of the “wearing off” and may culminate with palpitations, chest tightness and shortness of breath.7

Levodopa also induces respiratory dyskinesia, which correlates with peak dose effect.5 Furthermore, as discussed earlier, patients with PD are prone to aspiration pneumonia due to an underlying swallowing deficit (dysphagia). As for pneumonia due to COVID-19, it too remains a worrisome prospect, increasing the likelihood of morbidity and mortality in PD patients.5

PD patients with comorbid conditions such as asthma, COPD, and allergies may also experience difficulties with breathing. Aside from these respiratory symptoms that make it difficult to discern manifestations of PD from coronavirus, the presence of non-specific (hot flashes, fatigue, muscle pain) and specific (anosmia) COVID-19 symptoms are also commonly found in the repertoire of non-motor signs in Parkinson disease.6

It should be noted that PD patients exposed to the coronavirus have experienced pronounced deterioration in both motor and non-motor symptoms; it is believed that the mechanism responsible for symptom exacerbation may be mediated by factors such as the inflammatory response from ongoing infection and/or dysfunctional dopaminergic transmission.8 Deconditioning from prolonged debilitation may also contribute towards symptom progression.

Symptoms surveillance, prevention and therapeutic management

COVID-19 patients with severe respiratory compromise are prime candidates for ventilatory support.9 The issue is even more pressing for PD patients exposed to the virus as it may worsen preexisting restrictive or obstructive lung disease, a late manifestation of Parkinson disease.9 PD patients may exhibit a loss of chest wall compliance due to an abnormal posture, namely, pronounced thoracolumbar spinal flexion (camptocormia).9

As far as the ventilation process is concerned, clinicians may encounter resistance while intubating due to dystonia of the neck.9 Furthermore, dyspnea, a non-motor symptom, should be monitored as it may correlate with emotional states (ie anxiety)7 or underlying motor fluctuations.9

PD patients are prone to aspiration and the coronavirus may modulate the cough reflex, leading to further swallowing deterioration and consequently, aspiration pneumonia.9 Oxygen therapy coupled with ventilatory support remains the mainstay of treatment for PD patients with severe COVID-19 respiratory disease.10

Patients with Parkinson disease, as members of the older population, are deemed “high-risk” with regards to contracting the coronavirus.10 While PD patients will need to take heed of general prevention and safety protocols for COVID-19, there are a number of additional measures that are recommended by clinicians.10

Patients should assume a preparatory stance and stock up on essentials (eg medications, toiletries, etc.), wear masks, avoid leisurely travel and adhere to stay-at-home recommendations.10 As SARS-CoV-2 vaccinations continue to roll out nationally, elderly patients with PD should also consider getting the pneumonia vaccinations to decrease the risk of respiratory complications.10 In the event that a patient observes symptoms that are characteristic of COVID-19, he/she should contact the primary care physician, without delay.10 It would be prudent for PD patients to perform exercises that maintain optimal pulmonary health while maintaining adherence to their medication regimen.

Family members and dedicated caregivers are tasked with taking the necessary safety measures in order to minimize the possibility of spreading the virus.10 Outside trips should be avoided except for essential supplies.10 Caregivers/guardians should proactively monitor the development of symptoms in themselves as well as the individuals affected with PD as they may lack the capacity to autonomously carry out instrumental activities.10 However, for family members and caregivers that have already been exposed to the virus, they are urged to self-isolate and refrain from making contact with PD patients in nursing homes and settings of interest.10 A substitute caregiver can be assigned while they continue on the path to recovery.

Disclosures:

Dr. Faisal A. Islam is a medical adviser for the International Maternal and Child Health Foundation (IMCHF), Montreal, and is based in New York. He also is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships.

Dr. Ranbir Dhillon is a staff Neurologist at Brigham and Women’s Hospital in Boston, Massachusetts. He is affiliated with Sturdy Memorial Hospital. Dr. Dhillon is currently on the speaker bureau/advisory board for the following pharmaceutical companies: Genzyme, Teva Neuroscience, Biogen and Bristol Myers Squibb.

Dr. Zia Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.

References

1. O’Conner M. Hand J. Covid: Number of patients on ventilators passes 4,000 for first time. BBC. Published online January 23, 2021. https://www.bbc.com/news/uk-55782716

2. Liebermann O. US spent $200 million sending 8,722 ventilators around the world and can’t find many now, watchdog finds. 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 sorrows and emerging opportunities. J Parkinson’s Dis. 2020; 10(2): 351. doi:10.3233/JPD-202038

4. Learn 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. Respiratory complications of Parkinson’s disease. Semin Respir Crit Care Med. 2002 Jun;23(3):261-5. doi:10.1055/s-2002-33034

6. Hainque E. Rapid worsening in Parkinson’s disease may hide COVID-19 infection. Parkinsonism Relat Disord. Published online May 8, 2020. doi:10.1016/j.parkreldis.2020.05.008

7. Caillava-Santos F, Margis R, de Mello Rieder CR. Wearing-off in Parkinson’s disease: neuropsychological differences between on and off periods. Neuropsychiatr 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 managing Parkinson’s disease 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 about 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