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Submitted by Dr S. Patel on 19 May 2020
Managing stroke dementia parkinsons migraine and other neuro conditions - interview with neurologist Dr Wadia

Dr Wadia helps patients with Neurological Conditions and their primary family caregivers navigate this Covid-19 lockdown period with expert advice on managing emergencies and complications. Click on the video link below to view the webinar recording. 

Let’s discuss the major challenges patients may face during this COVID pandemic:

  1. Identification and management of neurological emergencies, so you know when to avoid unnecessary trips to the hospital. Emergency scenarios will include Stroke, Status Epilepticus, Acute worsening of Dementia or Parkinson’s disease to name a few.
  2. Assistance of other neurological problems can be done via online or telephonic consultations.
  3. Management of rehabilitation which may have been interrupted.
  4. Mental health during lockdown likely to be affected. Depression may worsen.
  5. Renewal of prescriptions which may run out.

 

Dealing with Stroke

Stroke is an emergency! Think of it as the “brain attack” like that of the heart. Rapid medical attention is essential and can save the life of the patient. The time limit of treatment for Ischemic Stroke is 4.5 hours from onset of symptoms. Since time is crucial, the patient should be taken to the hospital right away regardless of the COVID lockdown.

There are two types of Stroke: Ischemic and Haemorrhagic. Ischemic stroke is when there is a blockage of the blood vessels due to a clot and hence needs a clot buster injection to break the clot. If this is not done in time, there can be irreparable damage to the areas of the brain. Infact, if the blood vessel is opened up within an hour, the chances of damage are far less than if opened up after 4 hours. So, this is not a situation where you can afford to sit at home. Beyond 4 hours if IV TPA is contraindicated, the patient may be moved to the angioplasty room for mechanical thrombectomy.

The second type of stroke is Haemorrhagic where the blood gushes out of a blood vessel due to a rupture. Such strokes may need surgical decompression. So, look out for the common signs of stroke such as sudden confusion, trouble speaking or understanding or walking, dizziness, loss of balance, one-sided vision loss or hemianopia or severe headache with no cause.

Major risk factors can trigger stroke like Hypertension, Heart diseases, previous Stroke, Carotid bruit, Diabetes and tobacco use.

Be stroke smart by remembering the 3 Rs:

  • Reduce risk
  • Recognise symptoms
  • Respond by calling emergency helpline

Post acute treatment of Stroke, patient may also require:

  • Rehabilitation: Physical or Occupational therapy, speech therapy, Botulism injections for spasticity.
  • Lifestyle Changes: Cessation of smoking and alcohol consumption, weight reduction and diet changes, exercise.

Stroke and COVID

Acute strokes still need to go to the hospital within the golden hour.

Emergency data from Italy suggests that COVID-19 itself can cause stroke, encephalitis like illness which may be seen even if no other symptoms or fever are present.

Physical therapy and rehabilitation need to be continued as usual for patients.

Do not stop taking any preventive drugs.

 

Dementia & Parkinson’s Disease and COVID

Medications should be continued as before.

Elderly patients ae requested to avoid routine follow-up visits. Opt for online or phone consultations.

Physical and cognitive exercises need to be continued. Keep walking within the confines of your home. Keep the brain active by solving Sudoku, crosswords or playing cards and board games with the family.

Stay positive and stay connected with family and friends. Connect with other patients on Patientsengage where you can ask questions and raise your concerns.

If there is acute worsening of your dementia or Parkinson’s, the commonest cause is likely to be an infection such as an UTI or chest infection or metabolic changes in sodium or potassium levels. In case it is a febrile illness, then every hospital will insist on a COVID test before they admit you. 

Multiple Sclerosis/ Immune mediated Neurological disorders and COVID

Patients who are on immunosuppressive treatment make them highly vulnerable if they get COVID since their immune system is not robust or strong to fight the infection.

Many patients may be on cyclical medication like Rituximab which is a chemotherapy drug. Administering this may be harmful and is best postponed for a while or given at home if possible.

In case there is a relapse of MS, it should be treated as usual with IV steroids etc.

Continue exercising as before and stay positive.

Other Neurological disorders

People with chronic prescriptions for headaches, epilepsy etc. should not make any changes in their medications until the COVID period is over.

If there is any worsening of your chronic condition, these situations are better amenable to online consultations as most often the neurological examination is normal. A lot can be obtained from the history of the patient.

If there is an emergency like status epilepticus or intractable epilepsy (where you get multiple seizures in a day), then you must go to the hospital.

Are any populations with neurological conditions more vulnerable than others for COVID-19?

Although, there is no clear data on this, some people are more at risk than others. These include:

  • People on immunosuppressant drugs for diseases like autoimmune encephalitis.
  • People with respiratory difficulties or those with swallowing difficulties from Stroke or Parkinson’s. These patients in addition do not have a strong immunological make up.
  • People with more complicated disorders than people with migraines or simple epilepsy.

How can one prepare for a teleconsult for a new senior citizen patient with dementia since the usual doctor is unavailable? Patient’s condition is declining, and the cause is unclear.

This is challenging! No doctor will be willing to take on a new patient right now via teleconsultation. If the patient is non-communicative, then the doctor has to solely rely on the information provided by the caregivers or family members. It would be best to check for any markers of infection such as a UTI; constipation is a common problem. A basic blood and urine test would be required. List of all the medications, recent investigations and all past reports should be shared with the doctor prior to the consult. It would be prudent to get tests done after the consult as the doctor may want additional or different tests done. It would be wisest to get in touch with the original doctor who knows the patient’s medical history.

Any there any drugs that are not available via online prescription?

So far, we haven’t had any issues with refilling of prescriptions. Online prescription does not mean a message on WhatsApp or email but is a scan of the paper prescription with the doctor’s letterhead and signature. Most pharmacies are honouring these. They may limit the number of drugs you purchase in one refill and may also check to see that the prescription in no more than 6 months old.

What about people who have headaches during this period?

Headaches are a symptom of many different underlying conditions. It may be difficult to diagnose on a teleconsult because the doctor may want to check the fundus of the eye. Teleconsultations do have their limitations but with any Lockdown we will have limitations. One has to weigh whether the risk of visiting a hospital is more than missing out on some small exam detail. In our hospital, the current SOPs mandate teleconsult for all patients and if a patient needs a physical exam or seems like an emergency, then they are brought in. We triage who needs to come in and this reduces the volume of patients in the waiting room and helps with social distancing.

Since some hospitals in big cities like Mumbai have shut down, where can patients go?

We are managing it case by case. For non-COVID emergencies, we are contacting our colleagues in various hospitals and directing patients according to bed availability. Patients on their own should not go to a nursing home but choose a large tertiary care hospital that preferably has MRI & CT scanning facility and in-house Neurology team with an acute Stroke care ward. If a patient is suspected of having Stroke, don’t waste time attempting first-aid. Dial for an ambulance and take the patient immediately.

Currently, families are having a tough time as a lot of home care has stopped. Any helplines or homecare services?

Initially during the lockdown, that was a challenge as attendants were unable to commute. I have personally provided Certificates to my patients who are incapacitated and need full-time help. On basis of that, police have given these caregivers Emergency passes, which allows them to travel. A lot of volunteer groups are also checking and taking care of senior citizens in their building complexes and neighbourhoods.