Nov. 05, 2020 -- One of the complications of COVID-19 may be the development of Parkinson's disease, new data suggests.

At least three case reports have been published of relatively young COVID-19 patients who developed Parkinson’s, either by itself or with other symptoms, within 2 to 5 weeks of contracting the disease. A fourth case has not yet been published.

The three published cases and possible explanation for how COVID-19 could cause Parkinson's are discussed in an article published online Oct. 21 in Trends in Neurosciences.

"If this link is real, we might be in for an epidemic of Parkinson's disease in the future," the lead author of the article, Patrik Brundin, MD, told Medscape Medical News.

Brundin is director of the Center for Neurodegenerative Science at Van Andel Research Institute in Grand Rapids, MI. Co-authors are Avindra Nath, MD, from the National Institute of Neurological Disorders and Stroke, and David Beckham, MD, associate professor of medicine–infectious disease at the University of Colorado Anschutz, in Aurora, CO.

They report that the three patients in the published cases were 35, 45, and 58 years old. All had severe respiratory infection that required hospitalization. For two of three patients, symptoms of Parkinson’s diminished when given traditional Parkinson’s drugs. The third patient recovered without medication.

In all cases, brain imaging revealed classic signs of Parkinson’s disease. None had a family history of Parkinson's disease or prodromal Parkinson’s, where patients do not have traditional signs of Parkinson’s but are at higher risk of developing it. . One patient underwent genetic testing and was not found to carry any Parkinson's risk variants.

"These cases of acute Parkinson's in patents with COVID-19 are truly remarkable," Brundin said. "They occurred in relatively young people ― much younger than the average age of developing Parkinson's ― and none had a family history or early signs of Parkinson's prodrome. That is quite a stunning observation."

COVID-19 and the Threat of Moral InjuryWebMD's Chief Medical Officer, John Whyte, MD, speaks with Rita Nakashima Brock, PhD, Senior Vice President and Director of the Shay Moral Injury Center, Volunteers of America, about COVID-19 and the threat of moral injury.471

[MUSIC PLAYING]

JOHN WHYTE: Welcome, everyone.

You're watching "Coronavirus

in Context."

I'm Dr. John White,

chief medical officer at WebMD.

Today I want to talk

about this concept

of moral injury and the role

it's playing in the COVID

pandemic.

To help provide some insights,

I've asked Dr. Rita Nakashima

Brock, senior vice president

of Volunteers of America.

Dr. Brock, thanks for joining

me.



RITA NAKASHIMA BROCK: It's

a pleasure to be with you.



JOHN WHYTE: Let's start off

with help

explain to our viewers, what

exactly is moral injury?



RITA NAKASHIMA BROCK:

So moral injury happens when we

violate core moral beliefs

in high-stakes situations

and harm happens.

And we may cause the harm,

fail to prevent it,

or witness it.

Um, and ev-- it can even be harm

that's been inflicted on us

by someone, um, in authority

or in power who should have

protected us or done the right

thing, and they didn't.



JOHN WHYTE: OK.

Now we've been talking

about COVID.



RITA NAKASHIMA BROCK: Right.



JOHN WHYTE: How does it affect

frontline workers?



RITA NAKASHIMA BROCK: Well, even

the most competent, seasoned

professionals, in a crisis

like this pandemic,

are facing situations that are

really out of control.

So-- so-- so decisions are

having to be made in-- in very

quick ways when, often, you get

more time to think about them.



There are things going on

that, uh, in-- on a battlefield

would be called triage,

where you have to decide very

quickly who will get

a ventilator

and who won't, and how you're

going to try to save someone.

And those are the kinds

of conditions that can lead

to people, uh,

making mistakes or making

the wrong choice,

e-- even with the best

intentions,

or just feeling completely

overwhelmed

by, uh, the moral chaos

of the whole situation.



JOHN WHYTE: So what does it look

like?

Help our viewers understand.



RITA NAKASHIMA BROCK: It looks

like--



JOHN WHYTE: Maybe they've

experienced moral injury

and don't even know it.

Because it's not a term

we've often used.



RITA NAKASHIMA BROCK: That's

right.

And it's-- and it's important

to note that it's not a mental

health disorder.

It isn't that something's

wrong with you, it's actually

that your conscience is still

working.

But it's become unmoored

from your normal ways

of operating

and your moral system.



And so you may feel very

discouraged and--

and like everything is futile.

There's nothing you can do.

You may feel extremely guilty.

You may feel ashamed we may feel

outraged that you didn't get

more PPE.

And so people in your center

got sick.

There are all kinds of things

[INAUDIBLE]

stir up what we call

moral emotions.

And moral emotions are emotions

that aren't based in fear,

they're based

in moral judgments.



JOHN WHYTE: So how do we manage

that?

What-- what do we do about it?



RITA NAKASHIMA BROCK: Y--

well, rest and a vacation

won't help.

They can make you better

able to cope

with those feelings,

but those feelings will continue

to haunt you until you begin

to process them.

And that means get-- finding

people to talk to.



JOHN WHYTE: And you have

an approach at Volunteers

of America

as to how to help address this.

Walk us through.



RITA NAKASHIMA BROCK: Yeah.

We-- we did a-- we did a program

with veterans with moral injury,

which is where the-- where

the original research was done,

was with veterans.

Um, and we've taken some

of the strategies

that-- out of that program

that worked.

Um, and we've applied them

to a one-hour, online,

peer-facilitated program

for people who need to unload

those feelings with other peers

and with peer facilitators.

There's not a mental health

expert in the group.

It's just peers who are trying

to facilitate the groups.



And it's a chance to, um,

talk to other people who aren't

going to judge you, uh, who are

going to understand what you're

feeling, uh,

and validate

the truth of those feelings.

And once you begin to express

them then you can begin to mull

them over, process, and think

about them.



JOHN WHYTE: So this could be

frontline responders, not just

health care workers,

but police officers, fire

personnel.

But it could also be, you know,

bus drivers as well, right,

and people that, you know,

are at increased risk,

maybe, because of their jobs,

or even caregivers, correct?



RITA NAKASHIMA BROCK: That's

right, that's right.

And our program's open pretty

much to anybody who thinks they

need it.

Um, and, uh, it-- it can-- you

know, you can, uh, start to feel

like you're not a very good

person because you actually

caught the COVID from your job

and then spread it

to your family.



JOHN WHYTE: So how do people

find out about, uh,

these different programs?

How do we raise awareness?



RITA NAKASHIMA BROCK:

The program is called REST.

It stands for Resilience

Strength Time, REST.

And you just go to VOA.org/rest,

and there is a website with

information about it.

And you can sign up to register

to attend sessions.

Um, and we offer, right now,

sessions three days a week.

We're going to begin to expand

that.



JOHN WHYTE: You have

to acknowledge our feelings,

right, and talk about it, even

in simple terms.

Is-- is that correct?



RITA NAKASHIMA BROCK: That's

right.

And it's easy if you are

a-- a high-competent

professional

to set those feelings aside

and to sort of compartmentalize

that emotional pain so that you

can do your job

and focus directly on what's

in front of you,

and get the job done all day.

But often that kind of working

to avoid the feelings

can lead you to, um, getting too

exhausted, that you keep working

not to feel those things.

And so to stop and just

be with them, uh, and, uh,

and share them with someone

else--

it's sort of like once you share

it, it's like popping a blister.

It's like, OK, now the healing

can begin.



JOHN WHYTE: Yeah.

But Dr. Brock, what about

if it's not you

that maybe sustained

the moral injury,

but it's a coworker, a friend, a

loved one.

How do you broach

that conversation with them?



RITA NAKASHIMA BROCK: I would

ask, you know, how-- how are you

doing?

What's-- how's your day been?

Sort of specific questions

about experiences rather

than what--

I wouldn't say,

what's wrong with you?



JOHN WHYTE: OK.



RITA NAKASHIMA BROCK: That is,

like, the worst thing you could

do?



JOHN WHYTE: Right, exactly.



RITA NAKASHIMA BROCK: Right?

You could just say,

I-- you know, I've noticed

you've been feeling a little

down.

Is there something going on?

Uh, or just, how is it with you?

Those-- those are sort

of neutral questions.



But I have to say,

if you ask that question,

you have to be prepared.

You may hear things that are

upsetting, um, because of what

we're looking at right now

in the pandemic.

Th-- awful things are happening.



JOHN WHYTE: So it can't be

these rhetorical questions.

We really have to wait

for the answer.

Some people have said we should

say, how are you doing really?

And then pause to-- to truly

take time to listen.

Or-- or maybe what about even

saying, to folks,

tell me about your day.

Because that could be an opening

as well.



RITA NAKASHIMA BROCK:

[INAUDIBLE].

And-- and as long as I think--

and I think most of us

can sense this.

If the person is genuinely

interested in hearing, and isn't

looking for, um,

a way to ask a question

or-- or voice an opinion,

but is really empathetically

and compassionately listening,

um, that can be

a miraculous thing, that gift

of listening.



JOHN WHYTE: Well, Dr. Brock,

I want to thank you for helping

raise awareness of moral injury

and really offering solutions,

uh, to address it.



RITA NAKASHIMA BROCK: Thank you

for having me.



JOHN WHYTE: And thank you all

for watching "Coronavirus

in Context."

I'm Dr. John Whyte.



[MUSIC PLAYING]



John Whyte, MD, MPH, Chief Medical Officer, WebMD.<br>Rita Nakashima Brock, PhD, Senior Vice President and Director of the Shay Moral Injury Center, Volunteers of America./delivery/aws/8f/39/8f39ac3e-b0c4-3127-b472-e5a9472624b0/Brock_100220_,4500k,2500k,1000k,750k,400k,.mp410/22/2020 12:00:0018001200Brock_100220_1800x1200/webmd/consumer_assets/site_images/article_thumbnails/video/covid19-images/Brock_100220_1800x1200.jpg091e9c5e8202f44e

He added: "Parkinson's is normally a very slowly developing disease, but in these cases, something happened quickly."

Brundin believes COVID-19 may make patients more likely to develop Parkinson's disease either sooner or later.

"It may be that a younger patient will recover from the infection but be left with neurological symptoms, such as brain fog and depression ― we know that this can happen in long-COVID. This is consistent with damage to the brain, and maybe Parkinson's disease will develop later."

He says that mounting evidence suggests COVID-19 can cause long-term effects, including neurologic problems, one of which could be Parkinson's disease.

"It does not appear to be just an acute condition which you survive or don't survive. There are many people for whom long-term outcomes may be affected," he commented.

If such serious conditions as Parkinson's are proven to be a complication of COVID-19, it is even more important for the population to avoid contracting the virus, he notes.

"This really should discourage the idea of trying to achieve herd immunity. It is a very bad idea to expose a large percentage of the population to a virus that we don't understand," Brundin stated. In the article, the authors say this could have "disastrous long-term implications."

The authors say that these cases do not prove that COVID-19 causes Parkinson’s disease.

"Possibly, the reported patients were destined to develop Parkinson's disease … and the viral infection only accelerated an ongoing neurodegenerative process around a critical timepoint.”

The authors say there is a growing number of reports of patients who developed Parkinson’s and later died from COVID-19. One such study of 43 patients found signs associated with Parkinson's disease.

Note: Brundin is supported by funding from the Van Andel Institute and the Farmer Family Foundation on projects related to infections and Parkinon's disease. He has received commercial support as a consultant or for research from Axial Biotherapeutics, Calico Life Sciences, CuraSen, Fujifilm-Cellular Dynamics International, Idorsia, IOS Press Partners, LifeSci Capital LLC, Lundbeck A/S, and Living Cell Technologies LTD, and Roche. He has ownership interests in Acousort AB and Axial Biotherapeutics and is on the steering committee of the NILO-PD trial.