The COVID-19 (coronavirus disease) outbreak is a rapidly evolving situation. The expert neurologists from Brain & Life seek to answer the most common questions they are hearing from their patients here.

If you or a loved one has a neurologic condition and would like to submit a question for us to address, please email BrainandLife@wolterskluwer.org.

Alzheimer's Disease

Answered by Victoria S. Pelak, MD, FAAN

Q: I heard that the immune system might not be normal in those with Alzheimer’s disease. I am 55 and in very good health, but I’m also in the early stages of Alzheimer’s disease. Am I at high risk for getting severely ill if I get COVID-19?
We are learning that Alzheimer’s disease might compromise an aging immune system, but there is no evidence that you are more susceptible to infection with COVID-19 or more likely to have severe illness due to COVID-19 simply because you have Alzheimer’s disease. Factors that increase the risk of severe illness during infection with COVID-19 are age (60 and older); living in a group setting such as a skilled nursing facility); history of cancer of the blood, cancer treatment with chemotherapy, organ transplantation, advanced HIV infection, and diseases of the immune system; and use of drugs that suppress the immune system. Those with heart disease, lung disease, and diabetes are at higher risk as well. Thus, continue to practice physical distancing, avoid crowds, stay at home as much as possible, and follow CDC guidelines for prevention of COVID-19.

Q: My mother has dementia and lives in a nursing home. As of yesterday, the facility is prohibiting visitors due to the COVID-19 virus. What can I do to make sure my mom is being taken care of properly during this time, especially since she has difficulty communicating with me by telephone?
If the nursing home has not yet communicated clearly to you about precautions, care, and interaction with family during this time, and the home has stopped allowing visitors, ask to speak to the director to determine what the communication will be moving forward and what will be the best way to check in with your mother. The CDC provides information about the approach that long-term care facilities should take during the COVID-19 pandemic. Familiarize yourself with this information so you can gauge the facility’s response and know what to discuss with them. See the CDC's Nursing Homes and Long-Term Care Facilities toolkit.

amyotrophic lateral sclerosis (ALS)

Q: Are people with ALS at a higher risk of COVID-19 infection?
There is currently no evidence to suggest that people with ALS are at a higher risk of COVID-19 infection. However, if they do become infected, they are very likely at a higher risk of complications or more severe outcomes.
Answered by Alejandro Tobon, MD

Learn more about managing ALS during the COVID-19 pandemic.

Brain Tumor

Q: I am due for a yearly, routine MRI to monitor a brain tumor. Is it safe to get imaging at this time, or should I reschedule for a later date?
At this time, the need for imaging for people with brain tumors depends on many factors, including the type and grade of brain tumor and past and current treatments of the brain tumor, including surgery, radiation, and chemotherapy. It is recommended that you talk with your neuro-oncologist or neurologist about your specific situation, as urgency for imaging should be assessed on a case-by-case basis. 
Answered by Katy Peters, MD, PhD, FAAN  

Epilepsy

Answered by Joseph Sirven, MD, FAAN, and David Spencer, MD, FAAN

Q: Are people with epilepsy more at risk for COVID-19 than the general population?
Early reports from the CDC about COVID-19 suggested that people with epilepsy who had compromised immune systems were considered at high risk for infection. While it’s true that some patients with severe medication-resistant epilepsy who may have other neurologic problems may be more at risk, most patients with epilepsy are no more at risk than the general population. 

Read more about managing epilepsy during the COVID-19 pandemic.

Immune-suppressing Drugs

Answered by Victoria S. Pelak, MD, FAAN

Q: I have moderate vision loss from optic neuritis and am taking steroids. Does my condition and my treatment put me at higher risk for COVID-19?
There is no evidence that you are at a higher risk for contracting COVID-19 infection when taking intravenous (IV) steroids—and taking them can speed recovery. For antibody-associated optic neuritis, such as neuromyelitis optica antibody and anti-MOG antibody, IV steroids likely improve visual outcomes, in addition to speeding up recovery. The usual treatment for optic neuritis is IV steroids for three days followed by an oral taper, or five days of IV steroids without a taper. The immune system returns to normal quickly after this short course of treatment. Furthermore, in the case of antibody-associated optic neuritis, you are likely at a higher risk for poor outcomes without treatment.

Q: Is it safe to stop taking steroids and could stopping affect my disease?
No. It is important to complete any course of steroids and not stop treatment out of concern for contracting COVID-19. Stopping could result in a flare-up or exacerbation of symptoms.

Q: Where should I be getting my infusions during COVID-19?
If you’re getting a steroid infusion, talk to your health care professional about having it at home instead of at an infusion center. That will decrease your chance of exposure to COVID-19. But bear in mind that many types of medications are not eligible for home infusion. Insurance benefits for home services vary with the insurance carrier, and you should check with both your provider and your insurance to determine the potential for home infusion and your coverage. If it is available, it can be arranged through a health care company that specializes in home infusions and administered by a visiting nurse who can monitor your response.

Q: I’ve been on a medication that suppresses my immune system for many months for my neurologic condition and it is effective. Now I’m wondering if I should stop taking it while COVID-19 is spreading?
For many conditions, such as myasthenia gravis, multiple sclerosis, neuromyelitis optica, and autoimmune nervous system disorders, we do not recommend stopping medication that has been effectively controlling your disease by suppressing the immune system. At any time, and particularly during the pandemic, your neurologist can always consider changing your dose to the lowest most effective dose. However, stopping your treatment could result in a flare-up and your immune system would not immediately be restored. Thus, keep taking your medication and let your doctor know if your condition changes. And most importantly, continue to follow CDC guidelines for prevention of COVID-19: practice physical distancing, avoid crowds, and stay at home as much as possible.

Immunocompromised Patients

Q: What does the phrase “immunocompromised” mean?
It refers to the fact that certain diseases and some of the drugs used to treat them can result in immune systems responding in abnormal and sometimes damaging ways. For example, in autoimmune disorders such as multiple sclerosis, myasthenia gravis, and neuromyelitis optica, the immune system turns on the body’s cells causing damage and disability. To treat these conditions, neurologists use drugs that can redirect the immune system, which protects the body and improves prognosis. Unfortunately, a consequence of this tinkering may be unexpected changes in how patients handle an infection. That’s why patients who are immunocompromised either by underlying disease or by the therapies they take are considered at higher risk from this new infectious threat. They absolutely should be practicing good hygiene, social distancing, and staying at home except for essential activities, such as grocery shopping.
Answered by David B. Clifford, MD, FAAN.

Q: Should neurology patients on immune-modulatory therapy go off medication because of the risk posed by COVID-19?
Although we know COVID-19 can be an extremely serious infection, particularly in individuals who are older, have cardiopulmonary disease, or are immunocompromised, we also know that going off immune-modulatory treatment for multiple sclerosis or other neurologic diseases could have grave consequences that outweigh any possible benefit. If patients and their physicians were already considering stopping or reducing immune-modulatory therapy for other reasons, this would be a good time to continue those discussions. Much more important for these higher-risk patients, however, is to follow the public health recommendations to avoid infection. 
Answered by Felicia Chow, MD, MAS.

Q: Is there special guidance for people with HIV/AIDS?
The Infectious Diseases Society of America (IDSA) and HIV Medical Association (HIVMA)’s document, Special Considerations for People with HIV, covers topics such as the importance of social distancing; converting routine, non-urgent visits to telephone or video visits for stable patients; and maintaining a 30-day supply of medications to prevent the possibility of treatment interruption. In addition, because of the high rates of cardiopulmonary conditions and diabetes in people with HIV that put them at higher risk for more severe illness and death, if they experience fever, cough, shortness of breath, they should be prioritized for COVID-19 diagnostic testing. 
Answered by Felicia Chow, MD, MAS

Q: If I have an immune-altering neurologic disease, how can I prepare for these uncertain times?
Talk to your health care provider about obtaining extra necessary medications. If you cannot get extra medications, consider ordering them through the mail. Be sure you have over-the-counter medicines and medical supplies such as a thermometer to treat fever and other symptoms. You should also have a plan in place if you begin to experience symptoms. Phone numbers for your doctor, after-hour contacts, family, caregivers, and the hospital should be accessible. Also, keep a medication list handy (in your wallet or purse) in case you must be admitted to a hospital. If you receive home infusions, check your home-infusion company's policy on medication delivery during the pandemic. Any patients still receiving infusions at a hospital-based infusion center, may want to convert to home infusions to minimize exposure to the healthcare system. Consult your doctor (and insurance company) about whether this is an option. Do not stop or change your medications without talking to your doctor first. If you rely on a caregiver for help in your home, have a backup plan in case that person becomes ill or must quarantine.
Answered by Shibani Mukerji, MD, PhD

Migraine

Answered by Lawrence C. Newman, MD

Q: I am having more frequent headaches, do I have COVID-19?
Patients who are COVID-19 positive note that their headaches have changed in some way: they are more severe, not responsive to usual acute medications, or totally different.  Many have features of an infectious headache with fever.  Many of my healthy patients with pre-existing migraine have noted that their headaches have increased in frequency.  They often attribute this to several factors that have to do with changes in their routines.  They are feeling stressed from being out of work, trying to help children with schooling; eating poorly, unable to get to the gym, and feeling anxious about the effects of COVID-19 on their lives and health.

I have also seen several patients who report new onset of stabbing headaches and have classic COVID-19 symptoms but test negative or are pre-symptomatic and come down with COVID-19 symptoms after several days.  I think those are virus-related, but thus far, we don't have evidence that the virus enters the central nervous system. It may be that these headaches are the result of activation of the trigeminal system from fever, inflammation, hypoxia, or an infectious process. 

Read more about managing migraine during the COVID-19 pandemic.

Multiple Sclerosis

Q: Will my MS or disease-modifying therapy (DMT) increase my risk of getting infected?
We have no reason to believe that MS, in and of itself, creates greater risk for being infected or the likelihood of more severe consequences of the illness. The answers to questions about DMTs are more complicated. I always preface those concerns by acknowledging that we have virtually no firm data upon which to draw conclusions.  Some organizations and individual authors have released recommendations for care, which sometimes differ, usually in minor ways, from one another.  Virtually all emphasize that, generally speaking, patients should continue on their DMT because of concern that their MS can reactivate if they stop; however, individual situations must always be considered.

Finally, choices about medications and strategies about the timing of infusions should reflect the COVID-19 situation in the particular community.  In some cases, consideration should be given to delaying infusions in select patients in order to avoid travel and increased person-to-person contact during the period of greatest exposure risk.
Answered by Aaron E. Miller, MD, FAAN

Q: I have multiple sclerosis and am due for my yearly, routine MRI. Is it safe to get imaging at this time, or should I reschedule for a later date?
A clinically stable person with multiple sclerosis who is scheduled to have a routine annual or biannual MRI could probably wait for several weeks at the discretion of their doctor. An MRI might be more time-sensitive for people who have new or worsening symptoms as well as those who are taking a therapy that needs to be assessed or are considering a change in their current therapy.
Answered by Barbara Giesser, MD, FAAN

Read more about managing MS during the COVID-19 pandemic.

Myasthenia Gravis

Answered by Alejandro Tobon, MD

Q: Am I more likely to get COVID-19 if I have myasthenia gravis (MG) or Lambert–Eaton myasthenic syndrome (LEMS)?
No data currently exist on how COVID-19 affects people with MG,  LEMS, or people with other autoimmune diseases on immunosuppressive therapies. However, because most people with MG are on immunosuppressive or immunomodulatory therapies and may also have respiratory muscle weakness, they may be at higher risk of contracting the infection or experiencing severe symptoms of COVID-19.  So, like the general population, people with MG/LEMS are encouraged to follow strict CDC precautions with regard to social distancing, practicing good hygiene, and using telemedicine, when available.

For more information, read Managing Myasthenia Gravis During the COVID-19 Pandemic.

Parkinson's Disease

Answered by Lisa M. Shulman, MD, FAAN

Q: How does the COVID-19 pandemic affect my Parkinson's disease?
Parkinson's disease isn't likely to pose a special risk for infection with the coronavirus and there should be little confusion between Parkinson's disease symptoms (slowness, tremor) and COVID-19 symptoms (fever, cough, or shortness of breath). Nonetheless, many people with Parkinson's disease are more vulnerable to infection due to age and general frailty, and if COVID-19 infection occurs, Parkinson's disease symptoms are likely to worsen, as with any infection.

Wearing masks, sheltering in, and social distancing can affect people with Parkinson's disease, in particular. Masks pose problems for people with impaired speech who may speak at a lower volume or slur their words or have a problem with drooling. Personal protective equipment, including masks and gloves, may exacerbate problems with dexterity, gait, and balance by interfering with vision or managing assistive devices. Physical, cognitive, and social activity are vital components to delay Parkinson's disease-related disability, and they have all become more difficult as the pandemic fosters stress and isolation. Even the basic routines of health care—visiting the neurologist, continuing physical therapy, and refilling prescriptions are difficult. Responding to these obstacles demands creativity, proactive behavior, and learning from one another.

Stress and social isolation with limited opportunities for physical, cognitive, and social activity pose a special threat for people with Parkinson's disease. The uncertainty about when "normalcy" will return underscores the need to establish new guidelines for our patients so they remain active, reduce stress, and delay disability.

Sleep Apnea

Answered by Jennifer Molano, MD, FAAN

Q: I have sleep apnea. Am I more at risk for COVID-19?
No data suggest that sleep apnea (a disorder in which breathing is briefly and repeatedly interrupted during sleep) in and of itself increases your risk. However, if you have sleep apnea and one or more known risk factors for COVID-19—obesity (which is also a risk factor for sleep apnea), diabetes, high blood pressure, heart or lung disease, or a condition that compromises your immune system; take medication that suppresses the immune system; are over age 60; or smoke—you are more vulnerable.

Learn more about managing sleep apnea during the COVID-19 pandemic.

Stroke

Answered by Ralph L. Sacco, MD, MS, FAHA, FAAN

Q: I am older and have hypertension and diabetes, what should I do if I think I may be having a stroke but want to avoid the hospital?
Stroke is a medical emergency and urgent treatment is necessary to reduce morbidity and improve functional outcomes. Our stroke teams are operating 24/7 and we are maintaining our commitment to high-quality evidence-based stroke care. Stroke care can be accomplished safely even in a COVID-19 pandemic with the proper protocols and precautions to maintain the safety of our patients and staff. For example, our hospital separates patients with COVID-19 from other patients who have suspected strokes and need medical care.  All patients are screened through survey questions and any suspected COVID-19 patients are tested and triaged to places where they can be separated and treated appropriately.  At Jackson Memorial Hospital, we started testing suspected large vessel occlusion with rapid polymerase chain reaction (rRT-PCR) tests to allow for appropriate placement and health care protection. 

At the University of  Miami UHealth Tower, we are testing all patients in the emergency department.  Our stroke team is fully active and working to respond rapidly to all cases with suspected stroke that are brought into the hospital by Emergency Medical Services. We have instituted virtual telemedicine systems in our emergency department and brain imaging suite so we can rapidly examine, diagnose, and treat stroke patients. Our staff have the proper personal protective equipment to properly care for possible COVID-19 patients with stroke. We have special protocols for intravenous rtPA and mechanical thrombectomy that have been adopted based on guidelines by the American Stroke Association and other professional organizations such as the Society of NeuroInterventional Surgery to maintain safety of our patients and health care providers.

We need to make sure that the public is aware that we are here to urgently treat them if they think they are having a stroke and not to delay calling 911.

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