The coronavirus disease 2019 (COVID‐19) pandemic has been rapidly pressing in several countries, and the ability to provide standard neurological care has been compromised by the strain on health care systems. 1 We currently have no specific therapeutics or vaccines, and we need to rely on rigorous implementation of traditional public health measures, such as isolation, quarantine, and social distancing to tackle the spread of the outbreak. There are particular concerns around the increased vulnerability of patients living with neurodegenerative diseases, such as Parkinson's disease (PD), and this is not restricted to those who happen to become infected by the virus. 2 , 3 The adoption of unprecedented preventive social measures during a short period exerted unintended secondary effects, especially on people with chronic neurological diseases that require continuous care and psychosocial support. Contradictory results have been reported on COVID‐19 risk and mortality in patients with PD, 4 , 5 , 6 but few studies focused on the possible indirect impact in this population. 2 , 7 As the acute phase of the crisis subsided, from June 1, 2020, to July 15, 2020, at the Movement Disorders outpatient clinic in Pisa, Italy, we saw 28 patients with PD with cognitive disturbances (10 patients with PD with subjective cognitive impairment, 10 patients with PD with mild cognitive impairment, and 8 patients with PD with dementia) (Table 1). To minimize the effect of PD progression on the change in cognition, in this report we included only patients who performed their last clinical assessment (visit 1) in the 2 months preceding the lockdown (January–February 2020). None of the participants or family members had received a diagnosis of COVID‐19. The patients’ therapeutic regimens were unchanged. At visit 2, patients were administered a structured questionnaire to explore the potential effects of lockdown on cognition. The majority of patients with PD did not experience a subjective worsening in parkinsonian symptoms, depression, or sleep, but reported a subjective worsening of anxiety and cognitive symptoms (particularly of memory and attention), independent of age, education, and disease duration. The mean (standard deviation) Mini Mental State Examination score in patients with PD at visit 1 was 28.2 (1.2) and 27.8 (1.1) at visit 2 in subjective cognitive impairment, 25.5 (1.4) and 24.9 (1.3) in mild cognitive impairment, and 21.1 (1.9) and 20.8 (2.0) in PD with dementia. Functional decline was reported for 1 patient with PD mild cognitive impairment who converted to PD with dementia. These findings may suggest that the COVID‐19 outbreak has indirectly affected nonmotor symptoms such as anxiety and cognition in people living with PD. Increased anxiety and psychological distress may have played a crucial role on cognitive performance, 7 but it should also be emphasized that almost all such patients interrupted exercise programs and cognitive training interventions, which are helpful to maintain cognitive health in PD. 2 , 8 Social distancing and confinement have drastically changed the way of life for patients with PD, breaking regular support systems, increasing physical inactivity, and disrupting daily life routines. Most outpatient clinics have had to suspend their activities, and community‐based nonessential services, including dementia daycare centers and rehabilitation programs, have been forced to close during the COVID‐19 pandemic. Our results, although obtained in a limited study population and based on the perceptions of patients and caregivers, highlight further the profound indirect impact of COVID‐19 in patients with PD.
TABLE 1.
Demographic and clinical characteristics of patients with PD and clinical and cognitive changes
| Variable | PD‐SCI (n = 10) | PD‐MCI (n = 10) | PDD (n = 8) |
|---|---|---|---|
| Age, y | 68.3 ± 6.8 | 70.5 ± 4.9 | 72.5 ± 3.7 |
| Education, y | 10.3 ± 4.0 | 9.36 ± 4.0 | 8.8 ± 4.1 |
| Disease duration, y (visit 1) | 5.1 ± 2.5 | 5.5 ± 3.0 | 5.6 ± 1.6 |
| UPDRS‐III (visit 1) | 18.8 ± 7.8 | 29.2 ± 10.5 | 33.3 ± 7.1 |
| UPDRS‐III (visit 2) | 19.0 ± 7.3 | 30.1 ± 10.2 | 35.8 ± 7.6 |
| Hoehn &Yahr | 1.8 ± 0.4 | 2.4 ± 0.8 | 2.4 ± 0.5 |
| LEDD, mg | 371.0 ± 222.1 | 575.8 ± 274.0 | 622.5 ± 232.8 |
| MMSE (visit 1) | 28.2 ± 1.2 | 25.5 ± 1.4 | 21.1 ± 1.9 |
| MMSE (visit 2) | 27.8 ± 1.1 | 24.9 ± 1.3 | 20.8 ± 2.0 |
| During the past 3 months | |||
| Did you change your daily routine? | 10/0 | 10/0 | 6/2 |
| Did you experience worsening of motor symptoms? | 2/8 | 3/7 | 1/7 |
| Did you experience worsening feelings of depression? | 1/9 | 0/10 | 0/8 |
| Did you experience worsening feelings of anxiety? | 8/2 | 7/3 | 4/4 |
| Did you experience worsening in your sleep quality? | 2/8 | 2/8 | 1/7 |
| Did your memory become worse? | 7/3 | 8/2 | 4/4 |
| Did you have more difficulties planning ahead or staying organized? | 1/9 | 2/8 | 0/8 |
| Did you have more difficulties concentrating on what you are doing? | 7/3 | 8/2 | 1/7 |
| Did you have more word finding difficulty? | 2/8 | 3/7 | 2/6 |
| Did you have more difficulty recognizing familiar faces, objects, or images? | 0/10 | 0/10 | 0/8 |
| Did you interrupt regular exercise programs? | 9/1 | 9/1 | 5/3 |
| Did you interrupt cognitive stimulation activities? | 8/2 | 9/1 | 5/3 |
| Did you reduce daily physical activity? | 10/0 | 9/1 | 6/2 |
| Did you reduce social interaction? | 10/0 | 9/1 | 5/3 |
Continuous variables are expressed as mean ± standard deviation; questions of the structured questionnaire are reported in a yes/no format.
Abbreviations: PD, Parkinson’s disease; SCI, subjective cognitive impairment; MCI, mild cognitive impairment; PDD, Parkinson's disease with dementia; UPDRS, Unified Parkinson's Disease Rating Scale; LEDD, levodopa equivalent daily dose; MMSE, Mini Mental State Examination.
Author Roles
(1) Research Project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the First Draft, B. Review and Critique.
G.P.: 1A, 1B, 1C, 2A, 2C, 3A
L.T.: 1B, 1C, 2A, 2B, 2C
F.B.: 1B, 2C, 3B
E.D.P.: 1C, 2A, 2C
G.S.: 3B
R.C.: 1A, 3B
Financial Disclosures of all authors (for the preceding 12 months): Nothing to report.
Relevant conflicts of interests/financial disclosures: Nothing to report.
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