Linda Peckel

As a year of unchecked surges of coronavirus disease 2019 (COVID-19) infection comes to a close, sleep deprivation among health care professionals (HCPs) has become a major concern. Are they functioning well enough at work? Are they showing other signs of stress outside the hospital? Several reviews and surveys have attempted to evaluate and quantify the effects of these unrelenting stressors on the mental and physical health of HCPs treating patients with COVID-19.

The impact of the pandemic and subsequent lockdowns on sleep has been universal, according to Michael Grandner, PhD, MTR, CBSM, FAASM, director of the Sleep and Health Research Program and the Behavioral Sleep Medicine Clinic at the University of Arizona College of Medicine in Tucson. In an interview with 

, he said, “There is not 1 person anywhere whose sleep has not been affected at all by the pandemic. It’s a foundation of our biology. Paradoxically, everyone’s sleep is affected differently.”

Lack of sleep among HCPs is now a critical problem, as they struggle to cope with the personal aspects of COVID-19 while treating those who become sick. A meta-analysis of 53 studies reported a pooled prevalence of poor sleep quality in up to 61% of nurses in general,

 whereas a 2020 survey in China showed that more than one-third of all medical staff there experienced symptoms of insomnia associated with the COVID-19 pandemic.

“Health care workers, in particular, have had to work long hours with limited resources and in close proximity to COVID-19 patients during the pandemic,” William D. Killgore, PhD, director of the Social, Cognitive, and Affective Neuroscience (SCAN) Lab in the Department of Psychiatry at the University of Arizona, told 

. The SCAN Lab uses advanced technologies to map neurological processes and responses. “As the hospitalization rates continue to surge again, many health care workers are experiencing high levels of stress, anxiety, depression, burnout, and insomnia,” he said.

Sleep parameters affected by the pandemic include sleep latency, duration, and efficiency.

 Some studies suggest that insomnia, or difficulty falling asleep or remaining asleep, is reported by more than half of health care workers who work with patients with COVID-19, Killgore said. “Many health care workers are showing signs of posttraumatic stress, which is often associated with nightmares and disturbed sleep. Unfortunately, sleep is important for the ability to process through emotional experiences, so the sleep disruption due to anxiety, long hours, and stress can lead to a vicious circle that maintains sleep problems and the emotional effects of traumatic experiences.”

HCPs on the front lines experience greater sleep deprivation as a result of increased sleep restriction from extended work schedules, coupled with various insomnias once they return home. Jessica Dietch, PhD, of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California, explained that prior to the pandemic, shift work, particularly that involving rotating shifts, was associated with worse sleep across the domains (latency, duration, and efficiency), which were exacerbated with the changing shift demands that occurred once COVID-19 hot spots were apparent.

Additional stressors have included extreme variability to sleep duration along with increased work and family demands, each of which may limit sleep opportunities for HCPs by restricting the average amount of sleep to less than needed. “Decreased sleep duration, particularly that occurring over multiple days or weeks in a row, can lead to the accumulation of sleep debt,” Dietch told 

. “Additionally, we know that increases in stressors, which abound for HCPs during the COVID-19 pandemic, can precipitate new insomnia, such as difficulty falling or staying asleep, or exacerbate existing insomnia,” she said.

“Insomnia occurs when there is a decreased ability to detach at night,” Grandner added. This causes sleep to become more fragmented and more shallow, although he noted that in laboratory studies, impairments after a night or 2 of sleep deprivation tend to be less than expected. “Impairments accumulate after a few days or nights of sleep deprivation,” he explained. “Your body will entrain arousal when you’re up night after night, leading to a pattern of chronic insomnia.”

The neurologic impact after loss of sleep over multiple nights is significant. According to Killgore, lack of sleep leads to a reduction of metabolic activity in regions of the brain that are critical for attention, decision-making, and emotional regulation. “Sleep loss has been associated with reduced functional connectivity, ie, communication, between the emotional regions of the brain and the regions that normally regulate those areas, potentially leading to an increased tendency to view experiences from an emotionally skewed, usually negative, perspective,” he said.

Sleep deficits begin to lead to pronounced alterations of cognition, Killgore said, with potentially serious consequences. “When a person is lacking restorative sleep, they build up a biological ‘pressure’ to fall asleep, which eventually starts to intrude upon their waking performance in the form of brief attentional lapses. These are momentary glitches, often less than a second in duration, in ongoing cognitive processing where mental activity just seems to stop for a moment. The problem is that these lapses are uncontrollable and occur without warning,” he said, while driving or working, for instance. Consequently, these lapses can be life-threatening.

The most significant impacts on job performance show up not as much in routine, repetitive tasks, according to Grandner, but “when someone has to make a novel judgment call, like when driving home and the light changes or an animal darts into the road.” Such loss of judgment or decision-making abilities resulting from cognitive slowing, in which processing critical information and solving problems take longer, represents potentially the most catastrophic effect of continued sleep loss. Killgore explained that “a sleep-deprived health care provider may not see a simple solution to a simple problem that just takes a different perspective. It also affects judgment and willingness to take risks and how they make moral decisions. So a health care worker who is lacking sleep may make very different life-or-death decisions than they would if they were well-rested.”

Health care workers who do shift work—ie, working at times that are biologically out of alignment with their normal day-night rhythm—also seem to be at greater risk for insomnia and other psychological problems during the pandemic.

A tired baby is a cranky baby, and the same is true for adults, although at work, they may try to hide it. Sleep deprivation alters mood and emotional processing as well as alertness. Without sufficient sleep, individuals are prone to emotional and physical burnout, and normally manageable tasks can easily become overwhelming.

Killgore and his colleagues also found that lack of sleep leads to an increase in implicit biases, such as those against individuals of different races or ethnicities.

 “In our study, when sleep was restricted to 4 hours per night for 3 weeks, implicit biases against Arab Muslims were high, but when the same people got 8 hours of sleep a night for 3 weeks, these biases against others completely disappeared,” he said.

Loneliness is a unique and damaging effect of the ongoing pandemic among HCPs, who are away from their families for longer-than-usual periods and who often have to avoid close contact with those they love because of heightened exposure to the virus at work. “Our data show that as the pandemic has raged on, the levels of loneliness and lack of social support among those under lockdown restrictions have been much worse than those in open communities. We have found that those under lock-
down report greater loneliness, depression, anxiety, alcohol abuse, and suicidal thinking than those not under restrictions,” Killgore reported. Lack of sleep has been associated with poor memory and difficulty with attention and concentration. Although causality has not been demonstrated conclusively, nearly every major psychiatric disorder is associated with sleep problems, he said. Killgore noted that some studies have suggested that the emotional toll of the pandemic has been greater on women than men in terms of anxiety and depression. “Health care workers who do shift work—ie, working at times that are biologically out of alignment with their normal day-night rhythm—also seem to be at greater risk for insomnia and other psychological problems during the pandemic,” he added.

Long-term sleep restriction can have many adverse health effects, Killgore explained. “Most notably, long-term insufficient sleep is associated with increased metabolic disturbances, weight gain, obesity, hypertension, diabetes, and greater risk of heart attacks and stroke, as well as weakened immune function,” he said. Not surprisingly, continued sleep deprivation also presents a higher risk of acquiring COVID-19. 

“There’s also a potential indirect pathway, in that poor sleep can exacerbate conditions that may be associated with increased risk of infection or complications from COVID- 19, like cardiovascular disease,” Dietch said. “Good sleep health is important to support physical and mental health broadly during the COVID-19 pandemic, although it can be hard to come by for HCPs.”

“Lack of sleep leads to worse mood in healthy people, and sleep is critical for processing through emotions and gaining perspective, so there is strong evidence to suggest that chronic sleep restriction can contribute to greater risk for mental health problems,” Killgore suggested. “Our own research has shown that getting more and better quality sleep is associated with greater resilience during the COVID-19 pandemic.”

Killgore pointed out that a sleep-deprived individual who is normally very wise and judicious will not realize when they are sleepy and are making mistakes. Many individuals with chronic sleep problems can get extremely tired and may even fall asleep frequently throughout the day without knowing. He suggested that it is important to take any errors in performance, even minor ones, as serious indicators of impairment. “The best option is to simply follow the science and assume that if you are sleep-restricted, you are probably impaired without knowing it,” he said. “Most people will start to show performance deficits after they have been awake longer than 18 hours straight. Performance declines rapidly over-night from about 11 PM to about 8 AM the following morning.” He suggested that individuals probably show impairment if they are awake at a time when they would normally be sleeping. Chronic sleep restriction down to even 6 hours a night for 2 weeks is nearly equally as impairing as a single night without any sleep, he said, encouraging HCPs to “take it seriously if [they] are dozing off or making simple mistakes at times when [they] should be awake and alert. These are clear signs that [they] are not getting enough sleep.”

Grandner observed that paradoxically, “one of the best clues to impairment is the feeling that you’re starting to adjust to the stress” or the recognition of a heightened emotional status— feeling unusually annoyed, sad, or anxious, for instance. “Feeling indecisive or defensive about decisions [is another sign] that you may be sleep impaired,” he added.

“Unfortunately,” Killgore stated, “there is no substitute for sleep. Sleep is an absolute need, and the body will start grabbing it wherever it can, even at the most inopportune moments, if you are not getting enough. The solution isn’t to swing the pendulum in the other direction—it’s to find balance,” Grandner counseled. He suggested that one of the most important things to do after work is to try to disengage from the day.

When sleepiness sets in, individuals can employ a few strategies to remain more alert in the short term, at least until they can catch up on sleep. All the experts agreed that in the short term, caffeine can be very helpful to maintain alertness but that individuals should use it judiciously, as it remains in the body and can cause sleeplessness even 6 to 12 hours after ingestion. “Although caffeine is very effective at sustaining immediate alertness and vigilance performance, it often produces no measurable improvements in judgment and decision-making quality,” Killgore said.

Grandner agreed, adding that “stimulants, including caffeine, all improve fatigue, reaction time, and alertness but do not rescue decision-making. People just make bad decisions faster,” he said.

The experts recommended a number of strategies for improving performance and/or wakefulness while at work:

Take a short walk and seek bright light to promote alertness.

Consume caffeine early in a shift and cut it off at least 6 to 8 hours before bedtime.

Eat a snack rather than a large meal during a shift to help promote alertness.

Schedule small naps in the middle of the day to keep balanced (no more than 15-30 minutes for optimum alertness).

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Articles

The pandemic's impact stretches across all aspects of life, and has particularly concerning effects on the sleep of those working on the frontlines providing care of patients.

Sleep Deprivation Among Frontline Health Care Workers During COVID-19 Turns Critical

Technological developments over the past decade are now leading to long-awaited advances in the management of Parkinson disease (PD). These tech-driven approaches—including exergaming, virtual reality, and the use of wearable devices—have not only helped improve rehabilitation but may also provide more accurate measures of therapeutic efficacy for new treatments undergoing clinical trials.

The role of virtual reality and exergaming in PD physiotherapy

Virtual reality has been used to drive purposeful, targeted exercise therapy for a number of progressive disorders affecting muscular function, including traumatic brain injury, cerebral palsy, stroke, and PD.

 Virtual reality–based games are available on widely available gaming systems and have demonstrated specific benefits for improving balance, gait, functional mobility, and overall quality of life for individuals with PD.

 Results of a recent study from Brazil showed that the weekly addition of Nintendo Wii exercises significantly magnified the therapeutic effects of conventional exercise therapy alone.

Exergaming, virtual reality, augmented reality, and their variants come in many shapes and sizes, said Jeffrey Hausdorff, PhD, director at the Center for the Study of Movement, Cognition, and Mobility at the Neurology Institute at the Sourasky Medical Center in Tel Aviv, Israel, who has been involved in many of the trials of digital technologies for PD. “In general, interventions based on these technologies can be very helpful as ways of enhancing and augmenting the impact of other, more conventional behavioral interventions for Parkinson disease. Engaging ‘games’ can heighten motivation and increase [adherence]; this in turn leads to a stronger impact of the therapy. They can also provide specific aspects of therapy that may be difficult to deliver otherwise,” he told 

In one multicenter, randomized, controlled study (RCT) designed to examine the added value of a relatively simple virtual reality system, Hausdorff explained that subjects walk on a treadmill with a screen attached to it that allows them to envision themselves walking through an environment with obstacles and challenging conditions where they have to learn implicitly, in a game-like fashion, how to walk and do other things at the same time, including dual tasks such as motor and cognitive challenges.

 In another study that included older adults as well as patients with PD, Hausdorff and colleagues found a significant reduction in falls among the participants who trained with a treadmill and virtual reality system compared with an active control group who performed treadmill training alone.

 “With this type of system, we can target certain aspects of cognitive function that are important to daily walking and cannot be targeted with treadmill training alone,” he said.

Managing progression in Parkinson disease

Long-term management of PD presents many clinical challenges as the status of the patient deteriorates over time. “In the early phases of the disease, typically patients respond well to pharmacotherapies,” explained Paolo Bonato, PhD, director of the Motion Analysis Laboratory at Spaulding Rehabilitation Hospital in Boston, Massachusetts, “but unfortunately, as the disease progresses, it 

becomes more difficult to control their symptoms.” Patients often report experiencing a roller coaster of parkinsonian symptoms, recognized clinically as motor fluctuations. Bradykinesia might respond well to treatment, but patients might experience severe dyskinesia as a result.

“A significant portion of patients with Parkinson disease experience motor fluctuations, meaning their symptoms are not constant over time,” Bonato said. The severity of dyskinesia often varies within the interval between medication intakes; patients might experience episodes within the first hour of taking their medication (onset dyskinesia), at the peak of the medication’s effects, or at the end, as the effects are wearing off. These symptoms are quite disruptive to their ability to perform activities of daily living, Bonato noted, and they are a significant focus of clinical attention during the later years of the disease.

Although levodopa-induced dyskinesia is a common complication in PD, recent research indicates that dyskinesias develop as a function of disease duration rather than accumulation of levodopa. This has led to recommendations to initiate levodopa therapy without delay early in the disease course, but the problem with motor fluctuations remains once the disease progresses.

Bonato observed that as neurologists titrate the patients’ medications to better manage their symptoms, a major challenge is that patients do not have an objective perception of their motor status, in part because of the cognitive effects of their disease. Patients are simply not able to report reliably on the effects of changes in the medication regimen. But more than that, Bonato pointed out that proper assessment of the severity of symptoms is very challenging, even to clinicians. “In fact, clinical researchers undergo training to administer the MDS-UPDRS [International Parkinson and Movement Disorder Society Parkinson’s disease rating scale], which is the clinical scale to assess the severity of parkinsonian symptoms that is most commonly used,” he said. 

Wearable technology has been able to detect fluctuations occurring in increments of as little as 5 minutes compared with 

patient-reported symptoms in diaries, which monitor changes at only 30-minute intervals at best, according to Bonato, who plans to publish these data soon.

"We used to think that walking was primarily a motor ability that required intact muscle and skeletal function and sensory function for feedback. Those abilities are certainly critical components of safe ambulation. However, there’s a key ingredient that’s missing in that view, and that’s cognitive function," Hausdorff stated. 

Falling is a complex type of dysfunction that involves multiple aspects of cognition. “Safe ambulation also involves executive function, a set of higher-level cognitive functions that include the ability to walk and multitask and the ability to plan and adapt to one’s environment,” Hausdorff explained. “We used to think that walking was primarily a motor ability that required intact muscle and skeletal function and sensory function for feedback,” he said. “Those abilities are certainly critical components of safe ambulation. However, there’s a key ingredient that’s missing in that view, and that’s cognitive function.”

Some of his studies looked at the role of cognition in helping the patient maintain attention to tasks of mobility.

 “The virtual reality technology that we evaluated in the RCT mirrors many real-world walking situations, such as walking outdoors, which requires being able to do multiple things while walking, such as listening to head- sets, talking to companions, thinking about what we’re going to be doing next, and negotiating obstacles. If you just walk on a treadmill alone without that added virtual reality component, it’s training just for the motor part while not focusing at all on the cognitive aspects of walking that are needed for safe ambulation,” Hausdorff said.

Freezing gait is a significant problem in advanced PD, in which motion advancement is very small or does not occur at all. Results of recent studies have indicated that freezing is not limited to gait but can also significantly hinder upper limb movements and speech.

 Digital technologies have been extensively studied as cueing modalities to recover attention to specific motor tasks, to rescue the patient from a freezing episode.

Hausdorff and Alice Nieuwboer, PhD, of the University of Leuven in Belgium, are currently collaborating on a study funded by the Michael J. Fox Foundation for Parkinson’s Research designed to detect a freezing event. In this study, subjects wear a sensor on their shoes that measures the movement of their feet and any freezing events as they conduct their daily activities. The sensor’s information is wirelessly transmitted to a smartphone that measures walking in real time. The system is designed to detect when a freezing event occurs and then give a cue back to the user, helping the user to quickly become free from the event. “In the future, it’s hoped that it will also be able to warn of a freezing event before it occurs to further ameliorate the problem,” Hausdorff said.

One of the unique aspects of this study is that all the assessments are conducted in the patient’s home and the intervention takes place throughout the day, wherever and whenever the patient walks. “Testing and treating in the home is especially advantageous at this time, when it is often increasingly difficult for people to make their way to a clinic or hospital,” Hausdorff said.

A primary obstacle to many clinical trials of the 1980s and 1990s that may have contributed to negative results, according to Bonato, was the inaccuracy of the self-reported data being collected from patients. He and colleagues

 published a study early in 2020 that made a strong case for the use of wearable technologies to replace patient diaries in making treatment decisions as well as in clinical trials.

"There are 2 problems with the use of patient diaries,” Bonato stated. “The first and more obvious one is that patients display poor [adherence] with the use of diaries. We know that because we track when patients log on to fill out electronic diaries, and hence we know that they are not doing that on a regular basis. The second and perhaps even more important issue is that we have discovered that motor fluctuations evolve more rapidly than we originally thought. Therefore, gathering data at intervals of 30 minutes, as we do by using patient diaries, is not enough to properly capture the characteristics of the motor fluctuations that patients experience.”

Because clinical trials have relied heavily on patient diaries as measurements for outcomes, this new finding is highly significant. Bonato observed that pharmaceutical companies have started wondering whether the negative results of past clinical trials were the by-product of not having access to the right technology to capture the effects of medications on motor fluctuations. “I anticipate that the large body of work in this area will result in important advances in the field and better treatments for patients with Parkinson disease,” he added.

A multinational task force on technology from the MDS convened in 2018 to produce a set of objectives for the use of digital technologies to obtain more usable data to inform treatment decisions.

 They reported that development of mobile digital devices has reached sufficient levels of “sophistication, versatility, and wearability” to warrant recommending their implementation in routine care for patients with PD.

 With different technologies offering opportunities to improve quality of life and outcomes for patients as they begin to develop advanced symptoms, these tools are increasingly being recognized as necessary supportive therapies over the long term.

"Clinicians, researchers, and pharmaceutical companies are very interested in using wearable technology,” Bonato said. “Clinicians are hoping that this technology may lead to significant improvements in the clinical management of symptoms experienced by patients, and researchers are adopting the technology to collect more reliable data and hence improve their ability to study the effects of new therapies.”

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2. Santos P, Machado T, Santos L, Ribeiro N, Melo A. Efficacy of the Nintendo Wii combination with conven- tional exercises in the rehabilitation of individuals with Parkinson’s disease: a randomized clinical trial. NeuroRehabilitation. 2019;45(2):255-263. doi:10.3233/NRE-192771

3. Garcia-Agundez A, Folkerts AK, Konrad R, et al. Recent advances in rehabilitation for Parkinson’s disease with exergames: a systematic review. J Neuroeng Rehabil. 2019;16(1):17. doi:10.1186/s12984-019-0492-1

4. Mirelman A, Maidan I, Herman T, Deutsch JE, Giladi N, Hausdorff JM. Virtual reality for gait training: can it induce motor learning to enhance complex walking and reduce fall risk in patients with Parkinson’s disease? J Gerontol A Biol Sci Med Sci. 2011;66(2):234-240. doi:10.1093/gerona/glq201

5. Mirelman A, Rochester L, Reelick M, et al. V-TIME: a treadmill training program augmented by virtual reality to decrease fall risk in older adults: study design of a randomized controlled trial. BMC Neurol. 2013;13:15. doi:10.1186/1471-2377-13-15

6. Espay AJ, Morgante F, Merola A, et al. Levodopa-induced dyskinesia in Parkinson disease: current and evolving concepts. Ann Neurol. 2018;84(6):797-811. doi:10.1002/ana.25364

7. Maidan I, Nieuwhof F, Bernad-Elazari H, et al. Evidence for differential effects of 2 forms of exer- cise on prefrontal plasticity during walking in Parkinson’s disease. Neurorehabil Neural Repair. 2018;32(3):200-208. doi:10.1177/1545968318763750

8. Ginis P, Nackaerts E, Nieuwboer A, Heremans E. Cueing for people with Parkinson’s disease with freezing of gait: a narrative review of the state-of-the-art and novel perspectives. Ann Phys Rehabil Med. 2018;61(6):407-413. doi:10.1016/j.rehab.2017.08.002

9. Erb MK, Karlin DR, Ho BK, et al. mHealth and wearable technology should replace motor diaries to track motor fluctuations in Parkinson’s disease. NPJ Digit Med. 2020;3:6. doi:10.1038/s41746-019-0214-x

10. Espay AJ, Hausdorff JM, Sánchez-Ferro Á, et al. A roadmap for implementation of patient-centered digital outcome measures in Parkinson’s disease obtained using mobile health technologies. Mov Disord. 2019;34(5):657-663. doi:10.1002/mds.27671

Advances in wearables and virtual reality present an opportunity to maximize rehabilitative efforts and improve outcomes.

The Technology Behind Optimizing Parkinson Disease Management

Developments in stroke care over the past decade have significantly altered outcomes for patients with stroke thanks to the efficacy of clot-busting drugs such as tissue plasminogen activator (tPA) and thrombectomy procedures to remove large clots. The key factor in preventing stroke mortality and disability is time, as every minute without blood flow irrevocably damages brain tissue. As a result, some of the biggest developments in stroke management have focused on logistical strategies to reduce the time between stroke onset and point of care, from the ambulance call to the emergency department bay.

Despite this, much debate exists over how to appropriately route patients with suspected large vessel occlusion (LVO) stroke to hospitals capable of thrombectomy interventions. Many factors play into this challenge, as it involves a major shift in systems of care. Advancements in prehospital prediction of LVO, impact on clinical outcomes, state regulations, and barriers to reimbursement are all major parts of the puzzle that can make or break the adoption of these lifesaving systems.

Many hospitals are now outfitting mobile stroke units (MSUs) with special equipment and trained health care personnel to initiate stroke treatment at the point of pickup.

 In an interview with NeurologyLive®, Andrew N. Russman, DO, head of the Stroke Program and medical director of the Comprehensive Stroke Center at Cleveland Clinic in Ohio, explained that for lack of better words, MSUs are ambulances on steroids. “The 4-person crew includes a CT technologist, a nurse, a paramedic, and an [emergency medical technician]. They have 2-way audio-visual communications with a stroke neurologist and the ability to deliver clot-busting drugs in the field. They have CT scanners and laboratory testing, which brings many of the capabilities of an emergency [department] to the patient’s doorstep. We perform prehospital stroke severity assessments to determine the right hospital to take the patient to for further care.”

Russman pointed to 2 recent abstracts presented at the 2019 American Academy of Neurology Annual Meeting and the 2020 International Stroke Conference that demonstrated that mobile stroke care is associated with reduced time to treatment and possibly better outcomes.

 With the ability to administer tPA upon arrival at the patient’s doorstep, MSUs effectively reduce stroke treatment times without additional risk of adverse events. At the same time, the MSU team can evaluate the stroke severity to determine the presence of an LVO requiring thrombectomy (TABLE).

“We already know that retrieval of the clot is associated with a very significant improvement. If you look at emergent medical treatments in general, thrombectomy of large vessel occlusion in stroke is one of the most beneficial emergent therapies in medicine. It’s comparable to what angioplasty of a coronary artery does for a patient with ST-elevation myocardial infarction,” Russman said, adding that not only do MSUs reduce “the transport time, but they are incredibly efficient compared with traditional emergency departments. They can usually deliver intravenous tPA 30 to 40 minutes faster than a patient could get it if they were transported to an emergency department.”

James C. Grotta, MD, is director of stroke research and the mobile stroke unit consortium at Memorial Hermann-Texas Medical Center in Houston, which covers about 75% of the entire city. “Although we have a catchment area of about an 8-mile radius, we monitor the fire department radio. If there’s a stroke that occurs 20 miles away, we take advantage of a rendezvous system more than other cities do,” he told NeurologyLive®.

“We monitor 911 calls and contact the fire depart- ment medic if we think the patient might be a candidate for the mobile stroke unit. Then we’ll rendezvous with the ambulance halfway to their destination hospital. The inclusion of rendez- vous calls expands our treatment radius to an average of 13 miles.”

Grotta and his colleagues at Memorial Hermann are currently conducting an MSU randomized trial. Every patient they transport is automatically enrolled into the trial. Follow-up data on all patients are collected after they get to the hospital and for a full year thereafter. “That means we can deliver patients to hospitals only where we can obtain a research agreement, usually by being on the staff,” Grotta explained. Although the city is home to several competing health care systems, including Houston Methodist, Baylor St. Luke’s Medical Center, Harris County Public Health, and the Hospital Corp of America Houston Healthcare, the Houston MSU program has been able to work out agreements with all of them and their hospitals.

“Every time we transport a patient, we’re out of service for another call, so if we know that a patient will not fit into the trial, we don’t respond to the call, and the patient is transported by the fire department per their routine,” Grotta explained. “The Houston MSU rotates between 2 sites within the city on a weekly basis.

The week the MSU is in operation on one site, patients within the catchment of the other site are managed by the fire department, per their standard management, and are enrolled into the trial as the control group.” Trial enrollment will be complete when they reach 1038 patients, which is expected soon.

The main limitations of MSUs are the extensive costs to equip and maintain them. For instance, the New York metropolitan area has MSUs at Stony Brook University Hospital in Long Island, at NewYork-Presbyterian Hospital in Manhattan, and 2 others in Brooklyn and Queens; New Jersey has one in Trenton, and Pennsylvania has another in suburban Philadelphia. Connecticut does not have any. “It is very expensive to operate an MSU, and currently, it’s not fully reimbursable,” Grotta said. “And while we believe in the value of the MSU to stroke care, it hasn’t been proved yet. If our study can show that, it would open the door to appropriate reimbursement, which would facilitate establishing more of them.”

The MSU becomes a critical factor in determining which patients should be taken directly to comprehensive stroke centers with endovascular thrombectomy (EVT) capabilities. These interventional treatments have been in use for decades, but only in the past 4 years have study results shown benefits up to 24 hours after symptom onset, Russman said. “You have to be able to figure out in the field that they might have a large vessel occlusion. Mobile stroke care takes this to another level because we can deliver the clot-busting medicine at the scene and deliver the patient to the right hospital the first time,” he said.

This is where hospital bypass becomes important. When patients have a significant blockage, emergency medical services (EMS) takes them directly to an EVT center, often driving past a closer hospital that does not have EVT capabilities, Russman said. “Identifying this need in the MSU spares the patient from being transferred to a second hospital, which causes a significant time delay,” he added (FIGURE).

The latest policy statements from the American Heart Association

 suggest that EMS should drive an extra 15 minutes to get to an EVT-capable center for patients who have prehos- pital stroke severity scale scores suggestive of LVO. “Time is brain, so for every minute the brain goes without blood flow, 1.9 million neurons are dying,” Russman said. “If you are having a severe stroke and live in a community that doesn’t have a stroke center with thrombectomy capability, then EMS should bypass the closest hospital to get you directly to the hospital that does have thrombectomy capability, as long as you don’t have to drive more than 15 minutes extra, according to the current recommendations. That time you’re saving—15 to 30 minutes or more&mdash; means reduced disability for the patient.”

The bypass model significantly reduces time to thrombectomy for patients with the most severe strokes. A large study of 1941 US stroke centers

 found that 713 (37%) had EVT capabilities, which an estimated 61 million (19.8%) Americans could access within 15 minutes. Extending the time frame to 30 minutes meant access for 95 million (30.9%) individuals. This varied by state. In Texas, an estimated 22% of the state’s population lives within 15 minutes of the 65 existing EVT centers. Rates in New York were 20.9%; in California, 25.5%; and in Illinois, 15.3%.

 supported these data, demonstrating that following prehospital assessment by EMS of a suggested LVO and appropriately bypassing to hospitals within this 15-minute margin for thrombectomy increased EVT access to millions of people.

Grotta pointed out that “the problem with bypass is that most ambulances do not have CT scanners that the MSUs have. Without an [MSU], you have to rely on the medic’s judgment, and using imprecise grading scales in the hands of medics is not all that reliable and will miss LVOs.” Although taking a patient who does not need EVT to a comprehensive stroke center is not efficient, he noted, it is a better alternative than missing patients who do need it. The added benefit is that for patients who do not have CT evidence of an LVO, the trained team in the MSU can immediately begin tPA treatment en route to the primary stroke center.

The decision to bypass rests on a balance of 2 factors: time versus the probability of an LVO, according to Grotta. “Within Houston, almost all hospitals are comprehensive stroke centers, so for us, bypass is not a big issue. In more rural or suburban areas, the MSU staff will have to weigh the evidence of an LVO against the time it will take to get to an EVT stroke center,” he said. This represents the crux of the current debate over MSUs, as the average ambulance team is simply not equipped to make these decisions. On a standard EMS call, in settings where an EVT-capable hospital is farther away than a local primary stroke center, EMS will often take the patient to the closer hospital first for an evaluation, only to have the patient transported again for thrombectomy. “In our MSU, we do a CT angiography for anybody we suspect of having a larger artery stroke. If it shows that the patient has an LVO, we take them directly to an endovascular center. It doesn’t matter how far it is,” Grotta said. “In reality, about 80% of the US population lives in urban areas, so bypass does not really present as much of an issue in metropolitan areas.”

Should More Hospitals Become EVT Capable?

Although certain urban areas are successfully implementing MSUs and bypass, health providers must modify their use in each community to meet the specific demands of the population. Geography, topography, state regulations, and political climate all contribute to the type of systems that are needed to succeed.

The models suggest 2 main solutions: to expand availability of MSUs or convert more hospitals into EVT stroke centers. The current distribution of thrombectomy-ready hospitals would suggest that conversion, or “flipping,” of standard non-EVT stroke centers to ones that are EVT capable would solve the problem. However, this comes at a sacrifice to other types of care and with high costs that have to be justified by need within a community. The Sarraj study

 reported that almost one-fifth of Americans have direct access to EVT centers. Their predictive model estimated that nationwide, flipping the top 10% non-EVT centers to EVT-capable ones in all states would result in an increase of 7.5% in 15-minute direct access. This was less than half of the gain in coverage of 16.7% achieved by bypassing non-EVT centers for existing thrombectomy centers by 15 minutes.

For the most part, MSUs have not been evaluated in rural areas and might present a time solution there. “Generally, if you know that it’s an LVO, it’s better to just travel to a thrombectomy center than to turn more hospitals into them,” Grotta said. “Through rendezvous with EMS units farther out, the MSU would end up getting the patient treated with tPA halfway to the stroke center, saving half the time of the long drive; but all of this is modeling. It needs to be proved in real-world settings.”

Everything boils down to getting the right patient to the right treat- ment in the shortest amount of time. As studies evaluate the benefits of MSUs, states and communities also need to consider whether building more stroke centers with thrombectomy capability makes more sense than rerouting more patients to the centers that already exist.

The policies for a given region need to be more clearly exam- ined and identified, Russman suggested. “Bypassing one hospital for another has a lot of political and financial ramifications, which is why states have to lay down EMS triage, transfer, and destination protocols. You have to have the right system to bypass hospitals, taking into account time and distance factors to get to the hospital, with the capability that you need. Most states do not require that stroke severity scale scores be factored into the destination decision, nor do they provide directions to EMS agencies that hospital bypass is needed to get the right patient to the right hospital the first time,” he said.

Grotta agreed. “Everybody is looking at these questions, and there are no 1-size-fits-all solutions,” he said. “If we were to recommend a strategy within a dense metropolitan area, it would be to bring everybody to the comprehensive stroke center. But the right fit definitely reflects geographic and population differences.” Using the example of Connecticut, which has several large cities surrounded by suburban and rural populations and no MSUs, he suggested, “If you’re in an area that’s busy enough that patients are being bypassed to Hartford and New Haven all the time, then you might be better having physicians in your area learn to do thrombectomy because they might have enough local cases, and then it would be better to convert the hospital to an EVT center.”

Ultimately, Russman and Grotta concluded that each county in each state should make its own determinations of what is best for their populations. The current studies under way will help point the direction to building systems that function best in each area. 

1. Yamal JM, Rajan SS, Parker SA, et al. Benefits of stroke treatment delivered using a mobile stroke unit trial. 

 2018;13(3):321-327. doi:10.1177/1747493017711950. Published correction appears in Int J Stroke. 2018;13(3):NP4. doi:10.1177/1747493017743617

2. Russman A, Shimbo D, Sheikhi S, et al. Clinical outcomes after pre-hospital thrombolysis on a mobile stroke unit. 

3. Ebinger M, Siegerink B, Kunz A, et al. Effects of pre-hospital acute stroke treatment as measured with modified Rankin scale; the Berlin — Prehospital Or Usual Care Delivery (B_PROUD) trial. Presented at: 2020 International Stroke Conference; February 19-21, 2020; Los Angeles, CA. Abstract LB2. Accessed May 1, 2020. https://www.abstractsonline.com/pp8/#!/7927/presentation/5405

4. Ehntholt MS, Parasram M, Mir SA, Lerario MP. Mobile stroke units: bringing treatment to the patient.

. 2020;22(2):5. doi:10.1007/s11940-020-0611-0

5. Thrombectomy-capable stroke center certification. The Joint Commission. Accessed May 1, 2020. https://www.jointcommission.org/accreditation-and-certification/certification/ certifications-by-setting/hospital-certifications/stroke-certification/advanced-stroke/ thrombectomy-capable-stroke-center/

6. Sarraj A, Savitz S, Pujara D, et al. Endovascular thrombectomy for acute ischemic strokes: current US access paradigms and optimization methodology. 

. 2020;51:1207-1217. doi:10.1161/STROKEAHA.120.028850 

The “time is brain” mantra continues to drive innovation in a specialty that will not settle for mediocrity.

Improving Stroke Systems of Care for Better Outcomes

Treatment of multiple sclerosis (MS) has reached a new milestone, in which discontinuation of therapy for some patients may be possible. This is a unique therapeutic situation, a crossroads of the benefits of long-term treatment with disease-modifying therapies (DMTs) in preventing progression of disability and a point when the disease course naturally wanes. In theory, if patients with MS can maintain function long enough, they will outlive the active period of the disease and no longer need therapy.

Since their introduction in the 1990s, DMTs have demonstrated significant efficacy in reducing the incidence of relapses and the appearance of new T2 lesions indicative of disease activity in MS, as well as the capacity to slow progression of disability.

 Perhaps one of the most significant clinical realizations recently is that DMTs are most effective in slowing progression of MS when they are initiated in the disease’s earliest preclinical stages, at the first sign of clinically isolated syndrome.

 Results of research have shown that aggressive treatment at the time of the first attack with drugs such as interferon beta, glatiramer acetate, and terifluno-mide can delay conversion to clinically definite MS and lead to a milder course of disease that preserves patient function longer.

The notion of being able to “retire” from a costly, long-term therapy associated with adverse effects and the risk of life-threatening infections holds great appeal to many patients who have for decades faced the effects of MS and its treatments. “It’s all rooted in the idea that the window of opportunity for most effectively treating MS is early on in the disease,” Robert Bermel, MD, director of the Mellen Center for Multiple Sclerosis at Cleveland Clinic in Ohio, told NeurologyLive®. “Additionally, there’s been some research showing that not only are the DMTs less effective the older people are, but the disease is less active the older people are.” Taken together, he said, these factors suggest that continued lifelong therapy may not be necessary or even bene-ficial, but determining which patients will remain disease free after discontinuation has been a major obstacle to implementing a general plan for stopping MS treatment.

As the efficacy of DMTs has allowed patients to achieve and main-tain very low levels of disease activity, the question of whether these benefits would continue even with cessation of drug therapy has become increasingly relevant. According to Tanuja Chitnis, MD, an MS neurologist at Brigham and Women’s Hospital and Massachusetts General Hospital, and professor of neurology at Harvard Medical School, both in Boston, Massachusetts, “We’re entering an era where we have more patients who have been on DMTs long term and have been doing well, so we have a unique situation now.” Unfortunately, previous studies of interruption of DMTs focused on patients with ongoing disease activity who were nonadherent or who could not tolerate their therapies at earlier disease stages. Data on the outcomes after deliberate, medically endorsed discontinuation of DMTs in patients with stable disease are still largely lacking.

Bermel and his colleagues at Cleveland Clinic have been increasingly introducing patients who have been on long-term therapy to the concept of discontinuation. “We do believe that at some point, it’s appropriate to consider discontinuing DMT. We usually require that the person [has] been stable for 5 years or more, with no relapses and no new MRI [magnetic resonance imaging] activity,” he said. 

Chitnis, who is also the director of the Partners Pediatric MS Center at Massachusetts General Hospital for Children in Boston, takes a more conservative approach—at least for now. “There were some early studies, including ours,

 that suggested that there might be some patients for whom it might be safe to discontinue treatments,” she told NeurologyLive®, “but I think we are finding now in our further work, as we and others are looking into our cohorts of patients who have discontinued, that some patients continue to have disease activity. So I think we need to have better indicators, such as maybe biomarkers or biological mechanisms, to identify who might be safely discontinued.”

Early treatment with DMTs significantly modifies the natural course of MS. Tobin and Weinshenker

 noted “prolonged periods of disease quiescence during long term treatment of patients with clinically isolated syndrome,” suggesting the opportunity for discontinuing DMTs in these patients. However, the risks of relapse and accumulating disability associated with premature discontinuation of therapy were too high to ignore.

 This illuminated the second challenge, that if patients might indeed no longer need therapy for active MS, at what age could they safely discontinue treatment without reactivating disease?

The answer is not yet apparent. Chitnis was coauthor of a 2019 study by Yano et al

 that found a similar clinical course after 2 years among patients with relapsing-remitting MS who discontinued treatment compared with those who remained on therapy. This pattern was consistent across measures of clinical relapse, MRI event, disability progression, and disease activity, although the results varied by age at the time of discontinuation. “Older subjects (age >45) had a better disease course after discontinuation in terms of risk of MRI event and disease activity, while younger subjects (age ≤45) were more likely to experience disease activity after treat-ment cessation,”

 the authors reported. Likewise, Kister et al

 found that although relapse rates were equivalent between patients with MS (age >18) who discontinued first-line DMTs and with those who continued, time to disability progression was shorter following discontinuation.

Although these studies did not look specifically at outcomes in older patients who discontinued treatment, they did suggest that cessation at a late stage of MS was less likely to result in relapse or renewed activity on MRI. Supporting this, a 2019 investigation by Hua et al

 found that stopping DMTs in patients with MS over age 60 had only a minimal effect on outcomes, yet quality of life (QoL) was reduced. Studies suggest that older patients make better candidates for cessation because they have a more stable course of disease, whereas younger patients are more likely to discontinue therapy on their own.

 Bermel observed that as a result, the strategy of discontinuing DMTs after a certain age is becoming more common. 

"We do believe that at some point, it's appropriate to consider discontinuing DMT. We usually require that the person [has] been stable for 5 years or more, with no relapses and no new MRI activity," Bermel said.

Bermel and Chitnis both observe similar guidelines for discon-tinuation as those outlined by Tobin and Weinshenker,

 who determined, “It may be reasonable to stop immunomodulatory medications in patients who have experienced a progressive disease course for 5 years or longer, particularly those who are over the age of 60 years, if there are no accumulating T2 lesions or gadolinium enhancing lesions on MRI brain or spinal cord after a period of observation of several years. Earlier discontinuation, particularly in patients with active disease, may lead to increased disease activity, especially in patients treated with natalizumab. Clinical and MRI monitoring for recurrent disease activity is warranted in those discontinuing treatment.”

Continuation of immunomodulating therapy in older patients is associated with increased risk of infection and a higher susceptibility to malignancy, as well as a greater potential for drug inter-actions.

 Because it is now common for patients to have been on DMTs for decades, concerns are growing over the adverse effects of these powerful drugs. Adverse events range from non—life-threatening events such as flulike symptoms and local injection site reactions to dangerous infections like progressive multifocal leuko-encephalopathy associated with several DMTs.

"The primary risk to discontinuing is that the patient would have a relapse that would otherwise have been prevented, but we think we can minimize that risk by selecting patients who have been stable for 5 or more years and also who are above age 60, when the immune system becomes more senescent and they are less prone to disease activity,” Bermel said. “The other reason to consider stopping DMTs is [adverse] effects. Interferon is one of the medica-tions that may be worsening spasticity or depression that can make the patient’s quality of life worse, and in that setting, we definitely want to think about at least switching, if not stopping, DMTs.”

Chitnis agreed with the idea of switching therapies. Deciding not to discontinue does not necessarily mean that patients continue on the same therapy, she said. “I think there’s also the concept with older age of immunosenescence, and patients may not need to be on a stronger DMT, as there’s a lesser likelihood of relapse or developing new lesions, which presents an opportunity to either discontinue or step down to a milder therapy,” she said. “That is something I am increasingly considering doing. As patients who are on very high-efficacy treatments are nearing 50 or 60, I start to have the conversation about paring down to something that is milder. Although there are fewer relapses in older age, we know that patients do progress, and there might be benefits to a different profile of DMTs.”

As their base of patients with MS on aggressive drug therapies grows older, clinicians have been weighing the idea of discontinuing DMTs without reaching any definitive conclusions. Chitnis reserved judgment on whether DMT discontinuation is warranted. “I rarely discontinue patients,” she said, noting that they some-times bring up the idea of discontinuing because they might have seen an article on the topic. She will also discuss it with patients over 60, by letting them know this is something being studied and considered. “There are some I will discontinue, if I think based on the literature that they might be a good candidate, especially if they are having difficulty with their disease-modifying treatment, but usually at an older age above 60, at about 70,” she added.

Currently, no protocol exists for how or when to discontinue DMTs. The decision comes down to patient preference and clinical judgment. And although most patients are likely to look forward to not having to take medication (especially by injection) for the rest of their lives, Bermel has had some patients who prefer to remain on treatment, even in the absence of disease activity on MRI. “People who are stable on medication sometimes attribute that to being on the medication, and they’re not comfortable making a change. They feel protected and choose to stay on to avoid risk of relapse,” he said. “The only time we truly object to that is if the patient is having infectious complications or [adverse] effects of the drug, where I feel they would benefit by going off. But if the patient is tolerating it well, it’s perfectly fine for them to continue.”

Bermel reported that Cleveland Clinic has been successfully discontinuing DMTs in older patients in routine clinical practice for at least the past 5 years. “Discontinuation is not for everyone,” he said, “and it’s not across the board but in patients who have been very stable for 5 years or more, and where we consider the risk of the disease activity returning is low, we certainly consider it and may suggest that people discontinue after the age of 60.”

As the treatment of multiple sclerosis continues to evolve and improve, the proposition of lifetime therapy has come under scrutiny.

Linda Peckel

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