Telemedicine in Parkinson’s Disease: How to Ensure Patient Needs and Continuity of Care at the Time of COVID-19 Pandemic

Introduction

The risk of infection from SARS-CoV-2 has raised global public health concerns. The World Health Organization (WHO) has declared COVID-19 pandemic on March 11, 2020.¹ To date, several studies showed that older adults² and patients with chronic neurological disorders may be at increased risk of infection because of either the disease itself or for disruptions in health care provision.³

Parkinson’s disease (PD) is the second most common neurodegenerative disorder with an increasing prevalence with aging, configuring a condition predisposing to a higher risk of COVID-19.

In this emergency, outpatient appointments have been cancelled or postponed, making telemedicine⁴ a useful tool to ensure continuity of care⁵ and to reduce the risk of infection. Therefore, digital health could provide people with PD (pwPD) with customized consultations from movement disorders specialists and general neurologists.⁶

Consultations for pwPD include both motor and nonmotor symptoms (NMSs) evaluation. In outpatient settings, models of care in PD are based on interview of patients and/or caregivers, and targeted neurological examination. In the current context, teleconsultations may help in overcoming outpatient clinic restrictions.⁶

Indeed, over the past years, several studies have highlighted the utility of e-health measures and wearable sensors to assess patients remotely, providing objective parameters of motor and NMSs and connecting movement disorders or rehabilitation specialists to local health care providers.⁷

In pwPD, Beck et al. reported that telemedicine evaluation is no less efficacious than in-person consultations, even with more patient satisfaction.⁸

Methodology

In PD, the smart applications of standardized motor scales, such as the Movement Disorder Society Unified Parkinson Disease rating scale—part III–IV (MDS-UPDRS-III/IV), have demonstrated to be almost as reliable as in typical outpatient visits, although the evaluation of some clinical signs is precluded (i.e., rigidity) or can be checked only if safe and with the help of caregivers.⁹ The app MDS-UPDRS^® (Doctot, Limerick, Ireland) it is available in the European Union (EU) for free at the Apple store and could be used with medical professional guidance during teleconsultation.⁹ Similarly, in smartphones using the Android operating system, another app named CloudUPDRS^® app (Birkbeck College, University of London, London, UK ) can be downloaded free of charge from the Google store.¹⁰

In clinical practice, NMSs of PD may be sought in clinical history with patient-reported outcomes (PROs), including questionnaires assessing patients’ quality of life and functional independence in daily living activities. PROs are feasible online, positively perceived by patients and their caregivers, and can help physicians in decision making.^11,12 Moreover, standardized acquisition of PROs could enable early recognition of NMSs and other potentially life-threatening symptoms, such as falls, autonomic dysfunction, dysphagia, and neuropsychiatric/cognitive symptoms.

The NMS Scale (NMSS) is the most applied tool to assess NMSs. It consists of a 30-item rater-based scale to assess severity and frequency of NMSs. It can be compiled in 10–15 min and is available in multiple languages.¹³

The Conley Scale is a 6-item scale and could be performed to promptly identify the risk of house falls, it can be completed in 2 min and is available in several languages.¹⁴ Caregiver-administered ADL/IADL (Activities of Daily Living/Instrumental Activities of Daily Living)¹⁵ could be informative about rapid deterioration of patients’ autonomy. Questionnaire for Impulsive-Compulsive Disorders in Parkinson’s Disease (QUIP)¹⁶ and Scales for Outcomes in Parkinson’s Disease-Psychiatric Complications (SCOPA-PC)¹⁷ could be used and may help recognizing the onset of neuropsychiatric symptoms, which could reflect adverse effects of ongoing pharmacological therapy or intercurrent medical complications that prompt rapid medical intervention.

Alongside with conventional outcome measures for motor and nonmotor evaluation of PD, digital technology represents a key support for remote monitoring. The use of an easy to fulfill electronic diary could be recommended. The Parkinson’s Diary^® (FieC &YL MIT Lab, Cambridge, Massachusetts) presents a free application available on iOS and Android platforms, may be very useful to record daily activities, feelings, and general health status and is available in the EU.^9,18 Other smartphone applications, with strong correlation with MDS-UPDRS-III total score, could be considered to monitor pwPD and to evaluate some clinical signs otherwise not assessable remotely: Lift Pulse^®, available for free on iOS and Android (Lynx Design, National Institutes of Health [NIH], Bethesda, Maryland), may be used to record resting tremor. PD ME^® (Belles Farm LLC, University of California Los Angeles, San Francisco Art Institute, California), available free of charge at the Apple store can be used to test memory, balance, reaction time, and time perception.⁹

Therefore, we suggest that pwPD should fulfill an electronic diary monitoring physical and mental status and might use the NMSS tool and the Conley scale to assess NMSs and the risk of falls (Table 1).

Finally, when performing the teleconsultation, (1) movement disorders specialists may acquire further anamnestic details, such as symptoms of autonomic dysfunction, dysphagia, and rapid deterioration of cognitive status; (2) motor symptoms can be evaluated with smartphone applications MDS-UPDRS/CloudUPDRS, Lift Pulse, and PD ME; and (3) caregiver-administered ADL/IADL could reveal reduction or loss of patient’s autonomy in daily living.

Conclusions

We acknowledge that telemedicine has many limitations, both device related (access to technology, webcam quality, high-speed internet connection, etc.) and not device related (limited neurological examination, data protection regulation, etc.); however, we foresee that the overall benefits of this approach will render telemedicine progressively part of neurological clinical practice.¹⁹

The current global emergency from COVID-19 has boosted the rapid reorganization of health care systems toward telemedicine, with the priority to defend safety while allowing the patient to continue his or her diagnostic-therapeutic process.

Medical examination remains the cornerstone of practice, but telemedicine decreases the number of patient attendances as consultations take place through telephone, video calls, exchanges of photographic documentation, mobile phone messages, e-mail, or other applications for computers or mobile phones. Neurologists should be encouraged to use telemedicine, as it could reveal as a useful tool to improve quality of care in patients with chronic neurological disorders. Even after the COVID-19 emergency, telemedicine will be essential to streamline outpatient visits, while at the same time limiting costs.

In conclusion, telemedicine can offer a support to the doctors’ activity by facilitating their work. In this sense, the COVID-19 pandemic represents a positive input for the acceleration and enhancement of these tools.

Authors’ Contributions

G.M. and G.S. equally contributed to the conception of the study, literature revision, and article drafting; M.M. and L.L. contributed to the conception of the study and revised the article and table for intellectual content; G.T., S.B., and L.L. contributed to the conception of the study and final revision of the article and table. All authors equally contributed to the final approval of the version to be submitted.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.