INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic imposed several restrictions measures
to reduce severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection,
including the postponement of elective medical procedures and outpatient consultations.[1] Then, Brazil's government exceptionally issued a new decree authorizing the practice
of telemedicine during the pandemic.[2]
Telemedicine allows patients to overcome physical barriers to access health care services
and increases accessibility for people with mobility impairments, such as Parkinson
disease (PD) patients, and those living in areas with minor access to health services.[3] Studies have shown similar effectiveness of virtual consultations versus face-to-face
appointments to address symptoms with higher satisfaction rates.[3]
[4]
[5]
Brazil's public health system faced enormous challenges during the COVID-19 pandemic.
Thus, this study aimed to assess feasibility indicators of a telehealth intervention
for PD patients. We hypothesized that the virtual visits would be beneficial and viable
due to saving money and time, especially during the context of the COVID-19 pandemic
due to limited access to medical care during the period of isolation.
METHODS
Investigar
We conducted a single-center, single-arm study to assess feasibility indicators as
primary endpoints (patient recruitment, attendance, technical issues rates, satisfaction,
travel time and money savings, and benefits) of virtual medical consultations.
The study was conducted at the Department of Neurology of Hospital Universitário Walter
Cantídio (HUWC) in Fortaleza, Brazil, from May 1st to December 31st, 2020. The study was approved by the HUWC ethics committee (registration number 31232720.2.0000.5045)
and the Brazilian Trial Registry (REBEC) RBR-6pq44p. Also, all patients signed a written
informed consent form.
Study participants
We have consecutively drawn the patients from the outpatient clinic's medical appointment
scheduling list. The patients were invited in a phone call to participate. We screened
those who agreed to participate for eligibility. If eligible, we requested them to
attend a remote medical consultation using WhatsApp (Meta Platforms, Inc., Menlo Park,
CA, USA) video calls. We chose this tool because our patient population is familiar
with this technology in their daily lives.
The eligibility criteria included the diagnosis of PD according to the United Kingdom
Parkinson's Disease Society Brain Bank[6] and receiving care at our outpatient clinic in the preceding 12 months. We excluded
those who were uncomfortable with virtual medical consultation, those who did not
have access to communication technology, and patients with dementia whose caregivers
were not available to give us the necessary information about their clinical complaints.
Study intervention
All teleconsultations were held once a week during afternoon hours following an interview
procedure, like face-to-face consultations. The study intervention consisted of teleconsultation
followed by health education. The health education material and oral recommendations
are not part of the regular in-person visit routine. Several steps were involved in
the intervention: taking a list of patients scheduled for recruitment weekly, collecting
outcomes data of pre- and post-teleconsultation sleep and physical activity questionnaires,
interviewing about the type of transportation, time and money spent on face-to-face
consultations, dialogue, and demonstration of health education in a Whatsapp video
call, sending educational material, calling 15 days after the teleconsultation to
reinforce recommendations, and organizing prescriptions and additional requests to
send to patients.
A geriatrician with movement disorders training conducted the consultations. A multidisciplinary
team from the Living with Parkinson's Disease Research and Extension Project at the
Universidade Federal do Ceará performed the health educational approach. This team
was composed of health professionals and students from the following areas: biological
sciences, physical education, physiotherapy, and medicine. We used visual impressions
and tests to conduct the physical examination, which included assessing tremor, bradykinesia,
gait, speaking function, and dyskinesia. As the appointment was online, we did not
evaluate the stiffness, cardiopulmonary auscultation, and blood pressure.
In the final part of the teleconsultation, our team made some health-related recommendations.
We constructed the health education material, and the team explained the content,
demonstrating the exercises via WhatsApp video. Also, we sent the material in portable
document format (PDF) by WhatsApp text message. The patients with mild-to-moderate
disease received advice on healthy eating, sleep hygiene, physical activity, fall
prevention, and non-pharmacological management approaches for urinary incontinence.
The participants were encouraged to engage in regular physical activities for at least
30 minutes 3 times a week. We emphasized the need to reduce sedentary time by incorporating
multiple short breaks at least every 60 minutes during continuous bouts of sedentary
behavior.
The patients were taught to follow instructions about a healthy sleep routine and
train their brains and bodies to receive the full amount of sleep they required. Techniques
to prioritize sleep and maintain consistency in their routines were discussed, such
as having a fixed get-up time, whether it is on weekdays or weekend, not napping too
much during the day, avoiding substances that may cause sleep interruptions (like
caffeine, nicotine and alcohol late in the afternoon as well as heavy meals), and
unplug electronic devices as cell phones, tablets, and computers (as they may reduce
the melatonin synthesis). They were also instructed to be physically active, to obtain
daylight exposure, since sunlight is a crucial promoter of circadian rhythms, and
trying relaxation methods that might help prepare them to sleep, including meditation,
mindfulness, and timed breathing.
Those with severe PD and limited mobility received advice on healthy nutrition, sleep
hygiene education (SHE), approaches to reduce the risk of aspiration pneumonia and
to prevent skin lesions, contractures, and pain. We sent health education materials
and medication schedules to improve adherence ([Supplementary Tables 1] and [2]).
Table 1
Baseline demographic and clinical characteristics of the study participants
Variable
|
Values
|
Sex
|
Male
|
63 (58.9%)
|
Female
|
44 (41.1%)
|
Age
|
65.7 ± 17.1
|
Education
|
Illiterate
|
10 (9.3%)
|
Incomplete primary education (1–8 years)
|
48 (44.9%)
|
Complete primary education (9 years)
|
7 (6.5%)
|
Incomplete secondary education (10–11 years)
|
3 (2.8%)
|
Complete secondary education (12 years)
|
20 (18.7%)
|
Incomplete tertiary education
|
7 (6.5%)
|
Complete tertiary education
|
7 (6.5%)
|
Graduate education
|
5 (4.7%)
|
Disease duration
|
10 ± 6.7
|
Antiparkinsonian drugs
|
Levodopa
|
101 (94.4%)
|
Pramipexole
|
51 (47.7%)
|
Amantadine
|
27 (25.2%)
|
Entacapone
|
25 (23.4%)
|
Rasagiline
|
15 (14%)
|
Extended-release levodopa
|
32 (29.9%)
|
Levodopa equivalent dose
|
1060.5 ± 880.4
|
Medications used
|
Antihypertensive drugs
|
45 (42.1%)
|
Antidepressants
|
44 (41.1%)
|
Benzodiazepine
|
22 (20.6%)
|
Statins
|
23 (21.5%)
|
Vitamin D
|
23 (21.5%)
|
Calcium
|
19 (17.8%)
|
Oral antidiabetics
|
22 (20.6%)
|
Atypical antipsychotics
|
14 (13.1%)
|
Bisphosphonate
|
12 (11.2%)
|
Number of medications used
|
5.9 ± 3
|
Visual hallucination
|
34 (32.7%)
|
Motor fluctuation
|
65 (63.1%)
|
Urge incontinence
|
44.7%
|
Constipation
|
37 (35.2%)
|
Impulse-control disorders
|
22 (21.2%)
|
SE ADL
|
70.3 ± 25.8
|
Dyskinesia
|
51 (49%)
|
Abbreviation: SE ADL, Schwab & England activities of daily living.
Note: Data expressed in frequency (percentage) or mean ± standard deviation (median).
Table 2
Medical interventions adopted in the TeleParkinson study
Variables
|
Values
|
Antiparkinsonian drug adjustments
|
63 (58.9%)
|
Request of laboratory tests
|
65 (60.7%)
|
Vitamin D supplementation
|
38 (35.5%)
|
Physical rehabilitation care
|
31 (29.0%)
|
Laxative medications
|
31 (29.0%)
|
Antidepressant medications
|
23 (21.5%)
|
Pharmacological treatment of insomnia
|
20 (18.7%)
|
Request of bone densitometry
|
34 (31.8%)
|
Calcium supplementation
|
22 (20.6%)
|
Request of brain imaging
|
17 (15.9%)
|
Pharmacological treatment of urge incontinence
|
14 (13.1%)
|
Average duration of teleconsultation
|
64.33 ± 23.97
|
Note: Data expressed in mean ± standard deviation (median) or frequency (percentage).
Remote reassessment was determined by the attending geriatrician or at the patient's/caregiver's
request. We virtually reassessed patients who needed earlier reassessment due to prescription
changes or clinical complications. The decision of whether the reassessment should
be remote or in person depended on the patient complaint and its gravity. We used
the Research Electronic Data Capture (REDCap) software (Vanderbilt University, Nathville,
TN, USA) for data collection and management.
Sample size
The study sample was drawn consecutively from a population of 350 PD patients attending
our outpatient clinic who meet the eligibility criteria, 4 patients per week. We established
the recruitment period based on logistics and financial considerations.
Characterization measures
We collected the data through a chart review and patient questionnaires. We defined
the levodopa equivalent dose (LED) of an antiparkinsonian drug as the dose that produces
the same level of symptomatic control as 100 mg of immediate-release L-dopa.[7] We used the Schwab and England Activities of Daily Living (SE ADL) scale. We questioned
the participants about functional decline due to social restriction measures imposed
during the pandemic.
We administered three questionnaires before and between 30 and 45 days after the telehealth
intervention to assess its benefits, and the following questions to evaluate patient
adherence to treatment (i.e., to what extent did the patient adhere to medical recommendations
such as medications and new management approaches?) and health recommendations (i.e.,
has the patient been engaging in physical activity at least 30 minutes 3 times a week?).
The three questionnaires were validated for the Brazilian population and were as follows:
the Pittsburgh Sleep Quality Index – PSQI[8]; the Epworth Sleepiness Scale – ESS[9]; and the International Physical Activity Questionnaire – Short Form - IPAQ-SF.[10] The IPAQ-SF is an instrument recommended by the United States Center for Disease
Control and Prevention to assess self-reported physical activity. We classified the
respondents as sedentary, insufficiently active A, insufficiently active B, active,
and very active.[10]
Feasibility indicators
We calculated the recruitment rate by the number of patients who agreed to participate
in the study divided by the number of patients contacted. We obtained the attendance
rate by the proportion of virtual consultations completed as scheduled. We considered
the intervention feasible if at least 80% of the consultations were entirely done
based on previous studies of telemedicine. In 2017, a national randomized controlled
study of virtual house calls was performed in 5 states in the United States to determine
whether this model of specialty care delivery is feasible.[4] Virtual house calls were considered feasible if 80% of participants in the intervention
arm completed at least one visit and if at least 80% of virtual visits were completed
as scheduled. Also, the Virtual visits for Parkinson disease study evaluated participants from a multicenter cohort in the United States and defined
its feasibility by the proportion of visits completed as scheduled with at least 80%
of completion. They considered that the visits were acceptable to PD patients if at
least 80% were interested in future virtual visits for their illness.[11] Achey et al.[12] and Dosey et al.[13] also evaluated the feasibility of telemedicine for patients with PD as primary outcome,
and prespecified a threshold of 80% of the completed visits.
We provided some instructions to optimize the remote consultation: choose an adequate
room with adequate wi-fi signal, have a caregiver or family member present during
the entire appointment for those with dementia, and have the most recent blood test
results and the list of medications at hand during consultation.
Patients answered a self-administered questionnaire to evaluate whether the telehealth
intervention was safe, feasible, satisfying, and well-accepted for future use. In
cases in which the patients had dementia, the caregiver answered the questions.
The questionnaire consisted of 10 questions with a visual analog scale (VAS) to evaluate
satisfaction (worst on the left end and best on the right end). Each question uses
a graphical scale with five satisfaction faces. We requested the participants to mark
the point that was a representation of their level of satisfaction. They could only
select one answer. A score of 75 indicated satisfaction (i.e., easy; they were satisfied
and felt safe). A score of 100 indicated higher satisfaction (i.e., very easy; they
were very satisfied and felt very safe) ([Figure 1]).
Figure 1. Box plot for satisfaction.
The questionnaire has five domains: feasibility (items 1–2); a sense of safety (items
3–4); satisfaction (items 5–6); effectiveness (items 7–8); and a future use of the
intervention (items 9–10). The VAS scale was sent on WhatsApp as a REDCap link.
We calculated the rate of technical issues during consultations by dividing the number
of virtual visits with internet connection issues by the number of consultations.
We asked patients about transportation, average travel time from the clinic to their
home, and travel expenses associated with a face-to-face consultation.
Statistical analysis
For numerical variables, we presented data as means, standard deviations, and medians.
For categorical variables, we described the data as frequencies. To investigate the
existence of an association between the variables, we used the Mann-Whitney and McNemar
tests. We built box plots to demonstrate the distribution of satisfaction scores and
adopted a significance level of 5%. All statistical analyses were performed using
the Jamovi 1.8 software.
RESULTS
We contacted the first 191 patients from the clinic's medical appointment scheduling
list, and 118 agreed to participate. The recruitment rate was 61.7%, and the attendance
rate was 90.7%. [Figure 2] shows the study flowchart.
Figure 2. TeleParkinson study flowchart.
We selected 118 patients for the intervention, but 11 of them did not receive it because
of caregiver unavailability (n = 2), communication technology unavailability (n = 2),
PD diagnosis not completely defined (n = 2), and death (n = 5). Seventeen (15.8%)
patients requested remote reassessments. The reasons for reassessment included motor
fluctuations (n = 14), pain control (n = 1), depression treatment optimization (n = 1),
and sleep disturbances (n = 1). Eight (7.4%) patients were advised to come to the
clinic for a face-to-face consultation because they required physical examination.
Technical issues were evidenced during the teleconsultation for 12 (11.2%) patients
due to internet connection problems.
[Table 1] describes the demographic characteristics of our sample. Most participants were
male, with a mean age of 65.7 ± 17.1 years old and mean disease duration of 10.0 ± 6.7
years. A small proportion (8.6%) was attending physical therapy sessions; 25.7% engaged
in physical activity for at least 30 min, 3 times per week, and 36.5% needed walking
aids. Thirty-five patients (32.7%) reported perceived functional decline and worsening
of parkinsonian symptoms during the pandemic.
[Table 2] describes the medical interventions adopted in the teleconsultation. Also, we requested
laboratory tests, bone densitometry, physical rehabilitation care, and brain imaging.
[Table 3] shows the patient's adherence to non-pharmacological and pharmacological approaches.
Table 3
Patient adherence to TeleParkinson intervention
Variable
|
n (%)
|
Patient adherence to nonpharmacological health recommendations
|
1
|
20 (20.4%)
|
0.75
|
33 (33.7%)
|
0.5
|
33 (33.7%)
|
0.25
|
9 (9.2%)
|
0
|
3 (3.1%)
|
Patient adherence to prescribed medications
|
1
|
62 (63.3%)
|
0.75
|
24 (24.5%)
|
0.5
|
6 (6.1%)
|
0.25
|
2 (2%)
|
0
|
4 (4.1%)
|
Are patients exercising for at least 30 minutes, 3 times a week, post intervention?
|
Yes
|
58 (59.2%)
|
No
|
40 (40.8%)
|
Note: Data expressed in mean ± standard deviation (median) or frequency (percentage).
The impact of the intervention on sleep and levels of physical activity are described
in [Tables 4] and [5]. There were improvements in PSQI total score and in one of its component : sleep
duration (component 3). As for the level of physical activity, there was an increase
in the number of days of walking for at least 10 continuous minutes and the number
of days of moderate activities for at least 10 minutes continuously ([Table 5]). Also, the satisfaction with remote consultations is shown in [Figure 1].
Table 4
Effect of TeleParkinson in sleep questionnaires
Variable
|
Baseline
|
Post virtual appointment
|
p
|
ES
|
PSQI total score
|
12.1 ± 3.6 / 12 (9–15)
|
10.7 ± 3.6 / 11 (8–13)
|
< 0.001a
|
d = 0.44
|
Component 1- Sleep quality
|
1.5 ± 0.8 / 1 (1–2)
|
1.4 ± 0.8 / 1 (1–2)
|
0.216b
|
r = 0.24
|
Component 2- Sleep onset latency
|
1.9 ± 1 / 2 (1–3)
|
1.6 ± 1.3 / 2 (0–3)
|
0.067b
|
r = 0.28
|
Component 3- Sleep duration
|
1.7 ± 1.3 / 2 (0–3)
|
1.1 ± 1.3 / 1 (0–3)
|
< 0.001b
|
r = 0.63
|
Component 4 - Sleep efficiency
|
2.9 ± 0.6 / 3 (3–3)
|
2.9 ± 0.4 / 3 (3–3)
|
0.299b
|
r = 0.43
|
Component 5 - Sleep disorders
|
2.3 ± 0.8 / 2 (2–3)
|
2.1 ± 0.7 / 2 (2–3)
|
0.066b
|
r = 0.31
|
Component 6 - Hypnotic drug use
|
1.5 ± 1.5 / 1 (0–3)
|
1.3 ± 1.4 / 0 (0–3)
|
0.607b
|
r = 0.12
|
Component 7- Daytime repercussion
|
1.7 ± 1 / 2 (1–3)
|
1.7 ± 1 / 1 (1–3)
|
0.532b
|
r = 0.10
|
ESS score
|
11.2 ± 5.9 / 11 (6–16)
|
10.1 ± 7.4 / 8 (3–17)
|
0.567b
|
d = 0.09
|
Abbreviation: PSQI, Pittsburgh Sleep Quality Index;
Notes: Data expressed as mean +/− standard deviation, median (25th percentile − 75th
percentile). a: Teste t de Student; b: Teste de Mann-Whitney; d: Cohen d; r: Rank
Biserial Correlation.
Table 5
Effect of TeleParkinson in physical activity questionnaire-short version
PAQ- SV
|
Baseline
|
Post virtual appointment
|
p
|
ES
|
1a. How many days in the last week did you WALK for at least 10 continuous minutes
at home or at work, as a form of transportation to get from one place to another,
for leisure, for pleasure or as a form of exercise? (Say the number of days)
|
2.6 ± 2.8 / 2 (0–5)
|
4 ± 3.8 / 4 (0–7)
|
0.009
|
0.42
|
1b. On days when you walked for at least 10 continuous minutes, how much time in total
did you spend walking each day? (In minutes)
|
18.5 ± 29.1 / 6 (0–30)
|
17.7 ± 19.4 / 15 (0–30)
|
0.888
|
0.02
|
2a. On how many days in the past week, have you performed MODERATE activities for
at least 10 continuous minutes, such as cycling lightly on the bike, swimming, dancing,
doing light aerobics, playing recreational volleyball, carrying light weights, doing
housework at home, at yard or garden like sweeping, vacuuming, gardening, or any activity
that moderately increased your breathing or heartbeat (PLEASE DO NOT INCLUDE WALK)
(Say the number of days)
|
2.1 ± 2.7 / 0 (0–4)
|
3.5 ± 2.7 / 3 (0–7)
|
0.001
|
0.49
|
2b. On the days that you have done these moderate activities for at least 10 continuous
minutes, how much time in total have you spent doing these activities each day? (In
minutes)
|
18.2 ± 30.4/0 (0–30)
|
23 ± 24.7/20 (0–30)
|
0.064
|
0.32
|
3a. On how many days in the past week, have you performed STRONG activities for at
least 10 continuous minutes, such as running, doing aerobics, playing football, cycling
fast, playing basketball, doing housework
|
0.7 ± 1.8/0 (0–0)
|
0.7 ± 1.7/0 (0–0)
|
0.74
|
0.05
|
3b. On how many days in the past week, did you do VIGOROUS activities for at least
10 continuous minutes, such as running, doing aerobics, playing football, cycling
fast, playing basketball, doing heavy housework at home, in the yard or digging in
the gardening, carrying heavy weights or any activity that has greatly increased your
breathing or heartbeat. (Say the number of days)
|
8.6 ± 22.6/0 (0–0)
|
5.8 ± 14.4/0 (0–0)
|
0.274
|
0.28
|
4a. How much time in total do you spend sitting on a weekday? (in minutes)
|
335.4 ± 285.9/300 (120–480)
|
354.1 ± 285.4 /300 (180–480)
|
0.782
|
0.03
|
4b. How much time in total do you spend sitting on a weekend day? (in minutes)
|
346.5 ± 304.3/300 (120–480)
|
361.1 ± 286.2/300 (180–480)
|
0.91
|
0.0
|
Note: Data expressed as mean + standard deviation, median (25th percentile - 75th
percentile).
The main types of transportation used for the face-to-face consultation were own car
(49.0%), Uber (34.2%), and bus (10.8%). Eighty-one participants (82.8%) used to live
in the Fortaleza metropolitan area. Thirty-four (34.7%) of the caregivers missed work
to attend face-to-face consultations. The average travel time saving was 289.6 ± 177.8 minutes,
and money-saving was 106.67 ± 202.50 reais (around USD 18; almost 10% of the current
minimum wage in Brazil).
DISCUSSION
To our best knowledge, this is the first study to assess the feasibility of a telehealth
video consultation using WhatsApp for delivering care directly at home to PD patients
in Brazil public health system. We provided remote specialized care and health education
to PD patients with a 90.7% attendance rate. The low recruitment rate (61.3%) was
likely due to a high proportion of patients that could not be reached by their phone
number. It is worthy to mention that this study was performed in a public health system
located in a poor region of Brazil. Forty-three patients could not be contacted for
providing the wrong phone number, or because they changed the phone number, or because
their telephones were unable to receive calls. Most likely, the patients did not update
their data, or the responsible health professionals did not properly re-register the
individuals. The inability of outpatient clinics to get the patients registration
data reveals a lack of training of health professionals. Another challenge in the
recruitment is due to technical difficulties related to social problems. Some of the
study's participants lived in very undeveloped areas or what we call “favelas”, often
considered marginalized areas. Due to the absence of governmental investments, these
areas lack proper infrastructure, safety, energy, and recreation, providing their
residents with a low quality of life. With that being said, the access to technology
and internet is very challenging and something not every individual can obtain it.
The northeast region had the lowest percentage of residencies with internet access
(69.1%). The three most alleged reasons for not using the internet were lack of interest
in accessing it, internet access service not being available in the neighborhood,
and internet service being expensive. The other reason for the loss of patients in
the recruitment–unavailability of caregiver–also shows the Brazilian social problems.[14]
The scores in the satisfaction survey were above 80, except for the question on effectiveness
(median score of 75): “Do you think video consultations may help improve Parkinson's
disease symptoms?” It suggests that a single consultation is insufficient to address
all the problems and concerns, especially for those patients that require rehabilitation
care with a multidisciplinary approach.[15] The participants were referred to rehabilitation care services, but care was not
provided in most cases due to few public rehabilitation centers available.[16] Home care rehabilitation services are scarce in the public health system, especially
in the Northeast of Brazil.[17]
We found good adherence (54.1%) to non-pharmacological treatment and a higher adherence
rate (87.8%) to pharmacological prescription. The World Health Organization (WHO)
defines adherence to therapy as “the extent to which a person's behavior—taking medication,
following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations
from a health care provider[18]”.
The intervention improved sedentary behavior and the level of physical activity for
at least 30 minutes, 3 times a week. Also, the intervention improved perceived sleep
duration, sleep disorders, and daytime sleep disturbance. A systematic review of the
prevalence of sleep problems during the COVID-19 pandemic showed that their prevalence
is high and affects approximately 40% of people from health care populations.[19] Some studies have demonstrated relevant health benefits when the intervention encompasses
several behavior changes.[20]
[21] Some authors have reported better outcomes when behaviors generate synergy and are
combined in a single intervention.[22]
[23] Sedentary lifestyle and sleep problems are highly prevalent in adults and may even
have a reciprocal relationship.[23]
Our intervention improved the PSQI total score value that changed from 12.1, in the
baseline, to 10.7 (p < 0.001) and d = 0.44 (medium effect size), and the subdomain 3 (subjective sleep
duration) from 1.7 to 1.1 (p < 0.001) and r = 0.63 (large effect size). The perceived sleep duration improvement
observed in our data is most likely related to pharmaceutical treatments such as depression
therapy, pain management, sleep disorder management, overactive bladder management,
SHE, and physical activity recommendations. Yang et al.[20] conducted a meta-analysis of randomized trials investigating the effects of an exercise
training program on sleep quality in middle-aged and older individuals with sleep
complaints. According to pooled analyses of the data, exercise training had a moderately
favorable influence on sleep quality, as seen by decreases in the overall PSQI score,
subdomains of subjective sleep quality, sleep latency, and sleep medicine consumption.
Other sleep time characteristics, such as sleep length, efficiency, and disturbance,
did not significantly improve. In general practice, SHE is widely used to treat insomnia.
According to a meta-analysis conducted by Chung et al.[21] in 2018, SHE was related to sleep improvements based on substantial pre to postintervention
changes in PSQI. However, it was less effective than cognitive-behavioral treatment
and mindfulness-based therapy.[24]
The participants showed good acceptance of virtual consultations despite cultural
and technological barriers to digital communications in Brazil. However, some people
still have limitations in using the technology, especially older adults, due to the
difficulty in learning how to use it, and due to high costs still imposed on access
to telephones, and few incentives to digital media.[25]
[26] Our sample of patients was mostly older adults with low education, which poses a
challenge to the feasibility of virtual consultations.[26] Some studies have shown similar results in face-to-face and virtual consultations
with good feasibility.[3]
[27] It is noteworthy that, compared to our sample, the participants in these studies
were more educated and reported regular internet use.
Before the COVID-19 pandemic, there was evidence showing that social isolation can
affect the physical and mental health of older adults,[28] leading to a higher incidence of depression, in addition to cognitive decline, declining
physical performance, and higher mortality.[29] We believe that good adherence to treatment and to a behavior recommendation reflects
a positive impact of virtual interactions with our patients during this challenging
period of social isolation.
Possibly, the TeleParkinson project was well accepted because our sample study has
a mean disease duration of over 10 years and a high proportion of motor complications
and hallucinations. Also, the mean SEADL was approximately 70. The modality of the
consultations was more suitable for our sample once it prevented the dislocation of
patients with severe neurological complications, hallucinations, and low SEADL rates.
Van den Bergh et al.,[30] in 2021, cited consultations satisfaction and the importance of telemedicine for
more severely ill patients with access restriction, as well as palliative patients.
The major limitation of this study is the absence of a control group. Second, our
sample comprised mostly participants from the city of Fortaleza and its metropolitan
area, and teleconsultation feasibility studies for rural areas are needed. Third,
the sample size calculation did not include a power analysis. Fourth, the study involved
only single consultation with a geriatrician, and longitudinal patient care is likely
to have substantial benefits. Therefore, it is unknown if individuals in this study
would have gone to a second telemedicine visit if they had firsthand knowledge of
what it entails. About 38.2% of screened patients were not enrolled in the study,
which calls the generalizability of patient satisfaction reports into question. Besides,
the recruitment of assistant physicians who already care for these patients for teleconsultation
does not represent the recruitment of services without this prior involvement.
In conclusion, we indicated that direct-to-home telehealth video consultation using
WhatsApp for delivering care to PD patients seems feasible and effective in improving
some components of sleep and physical activity level. Further efforts and policy solutions
will hopefully make this care model increasingly available for PD patients in Brazil's
public health system.