E-Rehabilitation: One solution for patients with Parkinson's disease in COVID-19 era

Effectiveness of remote neuropsychological interventions: A systematic review

OBJECTIVE

Remote healthcare services is an upgrowing dynamic field that has been used to reduce potential disease spread and prevent overloading of the healthcare system during COVID-19 pandemic. The need for online interventions during the pandemic required immediate response with sometimes inadequate preparation. The aim of the present study is to investigate the effectiveness of remote healthcare services in the field of neuropsychological interventions.

METHODS

A systematic literature search was conducted in the electronic databases of PubMed, PsychINFO and Google Scholar. The main search terms were "remote neuropsychological intervention or training." The included articles were RCT studies published in English, examining the effectiveness of remote healthcare services in neuropsychological interventions for adults with neurological disease diagnoses. Studies involving psychiatric disorders were excluded. Two reviewers assessed the quality of the studies and risk of bias using the PEDro Scale.

RESULTS

A total of 10 studies with 2.221 participants were included. All studies concluded that remote healthcare intervention programs can be feasible, safe and effective in the rehabilitation process of neurological diseases.

DISCUSSION

The present review demonstrated that the domains of neuropsychology have opportunities to forge ahead beyond traditional settings and have the ability to adapt to constantly changing environmental conditions with a view to providing patient care. Health policy plans should therefore be reformulated to include these needs in accordance with the social and cultural context of implementation.

Life and disease status of patients with Parkinson's disease during and after zero-COVID in China: an online survey

BACKGROUND

Little is known about the impact of the COVID-19 pandemic on patients with Parkinson's disease (PD) at different stages of the pandemic. This study aims to assess the lives and disease status of PD patients during the zero-COVID policy period and after ending the zero-COVID policy.

METHODS

This multicenter cross-sectional study included two online surveys among PD patients in China, from May 30 to June 30 in 2022 and from January 1 to February 28 in 2023, respectively. The survey questionnaires contained four sections: (1) status of COVID-19 infection; (2) impact on motor and non-motor symptoms; (3) impact on daily and social lives; and (4) impact on PD disease management.

RESULTS

A total of 1764 PD patients participated in the first online survey, with 200 patients having lockdown experience and 3 being COVID-19-positive (0.17%). In addition, 537 patients participated in the second online survey, with 467 patients having COVID-19 infection (86.96%). (1) During zero-COVID, all of the COVID-19-positive patients had mild symptoms of COVID-19 and no death was reported. After zero-COVID, 83.51% of the COVID-19-positive patients had mild symptoms. The overall death rate and inpatient mortality rate of COVID-19-positive PD patients were 3.21% and 30.00%, respectively. (2) During zero-COVID, 49.43% of PD patients reported worsening of PD-related symptoms (lockdown vs. unlockdown, 60.50% vs. 48.02%, P = 0.0009). After zero-COVID, 54.93% of PD patients reported worsening of PD-related symptoms (COVID-19 positive vs. COVID-19 negative, 59.31% vs. 25.71%, P < 0.0001). (3) During zero-COVID, 62.36% of patients felt worried, and 'limited outdoor activities' (55.39%) was the top reason for mental health problems. After zero-COVID, 59.03% of patients felt worried, with 'poor health' (58.10%) being the top reason. The PD patients tended to change their daily activities from offline to online, and their economic and caregiver burdens increased both during and after zero-COVID. (4) Most PD patients would like to choose online rehabilitation during (69.56%) and after zero-COVID (69.27%). The demand for online medication purchasing also increased during (47.00%) and after zero-COVID (26.63%).

CONCLUSIONS

The COVID-19 pandemic aggravated the motor and non-motor symptoms of PD patients either during or after the zero-COVID policy period. The PD patients also experienced prominent mental health problems, changes in daily activities, and increases in economic and caregiver burdens. The COVID-19 pandemic has changed ways of PD management with increasing demands for online medication purchasing and rehabilitation.

Mobile Phone App-Based or Face-to-Face Pulmonary Rehabilitation in COVID-19 Survivors

Background

Pulmonary Rehabilitation (PR) is recommended as a standard, effective, and important treatment for COVID-19 survivors who remain symptomatic after the acute phase. Therefore, we aimed to compare the effect of mobile phone-based PR application with face-to-face PR on the quality of life, anxiety, depression, and daily life activities of COVID-19 survivors.

Materials and Methods

A quasi-experimental was conducted on 65 COVID-19 survivors during 2022. Convenient sampling was done based on the inclusion criteria. The intervention group (n = 31) received PR through a mobile phone application, and the control group (n = 34) received face-to-face PR. Data were collected before and after the intervention in both groups using a demographic information questionnaire, SF-12, the hospital anxiety and depression scale, and Barthel scale. For all tests, a maximum error of 5% was considered.

Results

The two studied groups had no statistically significant difference with respect to all the investigated variables at baseline (p > 0.05). After the intervention, the mean anxiety and depression score of the patients in the control group was significantly lower than the intervention group (t = -3.46, f = 63, p = 0.01). After our intervention, there was no statistically significant difference in the mean quality of life and daily life activity scores between the two groups (t = -0.68, f = 63, p > 0.05).

Conclusions

The application of PR does not show a statistically significant difference in terms of improving the quality of life and daily activities compared with the face-to-face method; we suggest that the PR application be used as a cost-effective method when face-to-face PR is not possible.

Voice improvement following conventional speech therapy combined with singing intervention in people with Parkinson's disease: A three-arm randomised controlled trial

BACKGROUND

Although speech and voice disorders are common in Parkinson's disease (PD), there is insufficient evidence to support the effectiveness of behavioural speech therapies in these patients.

AIMS

This study aimed to examine the effects of a new tele-rehabilitation program, a combining of conventional speech therapy and singing intervention, on voice deficits in patients with PD.

METHODS & PROCEDURES

This study was a three-armed, assessor-masked, randomised controlled trial. Thirty-three people with PD were randomly assigned to the combination therapy, conventional speech therapy, or singing intervention group. This study followed the Consolidated Standards of Reporting Trials guidelines for non-pharmacological treatment. Each patient participated in 12 tele-rehabilitation sessions over 4 weeks. The combination therapy group received speech and singing interventions simultaneously (respiratory, speech, voice, and singing exercises). Voice intensity as a primary outcome and the voice handicap index (VHI), maximum frequency range, jitter and shimmer as secondary outcomes were evaluated 1 week before the first intervention session, 1 week after the last intervention session and 3 months after the last evaluation.

OUTCOMES & RESULTS

The results of repeated measures analysis of variance showed a significant main effect of time on all outcomes in all three groups after treatment (p < 0.001). There was a significant group effect for voice intensity (p < 0.001), VHI (p < 0.001), maximum frequency range (p = 0.014) and shimmer (p = 0.001). The combination therapy group demonstrated a significant outperformance in the VHI and shimmer than the speech therapy (p = 0.038) and singing intervention (p < 0.001) groups. The results of this study also indicated that combination therapy group compared to singing intervention group had a larger effect on voice intensity (p < 0.001), shimmer (p < 0.001) and maximum frequency range (p = 0.048).

CONCLUSIONS & IMPLICATION

The results demonstrated that combining speech therapy with a singing intervention delivered through tele-rehabilitation might be more effective in improving voice problems in patients with PD.

WHAT THIS PAPER ADDS

What is already known on the subject Parkinson's disease (PD) is a neurological disorder that frequently causes disturbances in speech and voice, which negatively affect patients' quality of life. Although speech difficulties occur in 90% of patients with PD, evidence-based treatment options for speech and language problems in these patients are limited. Therefore, further studies are required to develop and assess evidence-based treatment programs. What this study adds The findings of this study showed that a combination therapy program including conventional speech therapy approaches and individual singing intervention provided through tele-rehabilitation may have a greater effect on the improvement of voice problems in people with PD compared to speech therapy and singing intervention alone. What are the clinical implications of this work? Tele-rehabilitation combination therapy is an inexpensive and enjoyable behavioural treatment. The advantages of this method are that it is easy to access, appropriate for many stages of voice problems in PD, requires no prior singing training, encourages voice health and self-management and maximises treatment resources available to people with PD. We believe that the results of this study can provide a new clinical basis for treatment of voice disorders in people with PD.

Links between COVID-19 and Parkinson's disease/Alzheimer's disease: reciprocal impacts, medical care strategies and underlying mechanisms

The impact of coronavirus disease 2019 (COVID-19) pandemic on patients with neurodegenerative diseases and the specific neurological manifestations of COVID-19 have aroused great interest. However, there are still many issues of concern to be clarified. Therefore, we review the current literature on the complex relationship between COVID-19 and neurodegenerative diseases with an emphasis on Parkinson's disease (PD) and Alzheimer's disease (AD). We summarize the impact of COVID-19 infection on symptom severity, disease progression, and mortality rate of PD and AD, and discuss whether COVID-19 infection could trigger PD and AD. In addition, the susceptibility to and the prognosis of COVID-19 in PD patients and AD patients are also included. In order to achieve better management of PD and AD patients, modifications of care strategies, specific drug therapies, and vaccines during the pandemic are also listed. At last, mechanisms underlying the link of COVID-19 with PD and AD are reviewed.

Feasibility and usability of a non-immersive virtual reality tele-cognitive app in cognitive rehabilitation of patients affected by Parkinson's disease

BACKGROUND

Cognitive impairment is one of the most common non-motor features of Parkinson's disease (PD). The aim of the present study was to evaluate the feasibility and acceptability/usability of a protocol using a non-immersive virtual reality tele-cognitive app, performed remotely in a sample of Italian patients with PD.

METHODS

Non-demented patients with mild PD were included in the study. Patients performed the cognitive rehabilitation in a remote way, at home (three training sessions lasting 20 min/week for 6 weeks) using the NeuroNation app, downloaded for free on the patients' smartphones. The usability and feasibility of the tele-cognitive rehabilitation program were assessed with the System Usability Scale (SUS) and the Goal Attainment Scaling (GAS).

RESULTS

Sixteen patients (9 men and 7 women; mean age 58.4 ± 8.3 years; mean disease duration 4.6 ± 2.1 years) were included in the study. At the end of the study, the mean SUS was 83.4 ± 11.5. The GAS score recorded at the end of the study (65.6 ± 4.2) was significantly higher than at baseline (38.5 ± 2.4; P-value <0.001).

CONCLUSION

In our sample, good feasibility and usability were observed for a 6-week cognitive rehabilitation protocol based on the non-immersive virtual reality tele-cognitive app NeuroNation. Our data support the usefulness of cognitive rehabilitation performed in a remote way in PD patients.

Participants' perspective on a COVID-19 online vocal group stimulation for people with Parkinson's disease

The COVID-19 related confinement and social distancing had negative consequences on the health of individuals living with Parkinson's Disease (PD). In collaboration with a non-profit organization, we developed and implemented a daily online vocal stimulation group named “Musculation de la Voix” (MdlV) in April 2020. To better understand the potential of MdlV to diversify existing services available to people with PD experiencing vocal symptoms, this study aimed to explore participants' experience and perception of MdlV in terms of participation, motivations, feelings, perceived changes, and appreciation. The 45 individuals who registered to the Summer 2020 Semester of MdlV were invited to complete an online ten-question survey. Responses to the four close-ended questions were analyzed using descriptive statistics while statements provided in response to the six open-ended questions were subjected to an inductive qualitative content analysis. Thirty seven participants completed the survey. Results revealed that the sample of respondents was mostly constituted of individuals who were engaged in this activity since its very beginning (62,2%), participated daily (59,5%), intended to keep participating in the activity (97,3%), and had never received speech-language therapy (SLT) services before (72,97%). The qualitative analysis yielded one theme relating to prior services: “Previous SLT services are variable and perceived as beneficial but with limitations,” and three themes pertaining to MdlV: “Seeking improvement and support as initial motivations to engage in MdlV,” “Unanticipated benefits and desired gains catalyzing motivation to participate in MdlV,” and “Perceived limitations of MdlV and persisting needs.” Our study participants' engagement and motivation toward MdlV as well as the benefits they perceived in relation to this activity suggest that an online vocal stimulation group may be a promising complement to currently limited SLT services. As limitations and persisting needs were also identified, future studies are required to elucidate what aspect of MdlV works, for whom and how.

Movement disorders in coronavirus disease 2019 times: impact on care in movement disorders and Parkinson disease

PURPOSE OF REVIEW

The purpose of this review is to outline the impact of the COVID-19 pandemic on movement disorder holistic care, particularly in the care of people with Parkinson disease (PWP).

RECENT FINDINGS

As the pandemic unfolds, a flurry of literature was published regarding the impact of COVID-19 on people with Parkinson disease including the direct impact of infection, availability of ambulatory care, loss of community-based team care, and acceptability of telemedicine.

SUMMARY

COVID-19 has impacted the care of PWP in numerous ways. Recognizing infection in PWP poses challenges. Specific long-term complications, including emerging reports of long COVID syndrome is a growing concern. Caregivers and PWP have also been impacted by COVID-19 social isolation restrictions, with radical changes to the structure of social networks and support systems globally. In a matter of weeks, the global community saw an incredible uptake in telemedicine, which brought with benefits and pitfalls. As PWP adapted to virtual platforms and the changing architecture of care delivery, the pandemic amplified many preexisting inequities amongst populations and countries, exposing a new 'digital divide'.

Virtual Reality Fitness (VRF) for Behavior Management During the COVID-19 Pandemic: A Mediation Analysis Approach

Background

During the COVID-19 pandemic, cellphone health apps and virtual reality fitness for treating neurological disorders such as Parkinson’s were beneficial. Virtual reality has been used to treat PTSD, depression, anxieties, dementia, ADHD, dyslexia, and pain control in various settings. Virtual reality exercise has been studied for its effects on biological, mental, rehabilitation, behavior, and attitude management.

Purpose

This research aimed to find out the role of virtual reality fitness (VRF) for behavior management during the COVID-19 pandemic concerning the demographic characteristics of the study participants and the use of fitness and health apps.

Methods

The population for the current study was Chinese residents across China who were in home isolation during the early pandemic in China. According to the study objective, a convenience sampling method was used to collect the primary data through an online survey. SPSS-25 statistical software was used to analyze the demographic information and clean and prepare the data to test all proposed hypotheses. The proposed research framework was examined using the structural equation modeling (SEM) approach through SmartPLS 3.0 software.

Results

The structural equation model analysis shows that all the proposed hypotheses (H1: β = 0.137, t = 10.454, p = <0.000; H2: β = 0.256, t = 16.824, p = <0.000; H3: β = 0.418, t = 27.827, p = <0.000; H4: β = 0.133, t = 8.913, p = <0.000; H5: β = 0.076, t = 4.717, p = <0.000; H6: β = 0.162, t = 10.532, p = <0.000; H7: β = 0.384, t = 26.645, p = <0.000) are confirmed.

Conclusion

Fitness and health apps with virtual reality fitness play a substantial role in improving the overall quality of life and positively influencing behavior and attitude.

Covid-19 and Parkinson's disease: an overview

In March 2020, WHO declared Covid-19 outbreak pandemic. There has been increasing evidence that frail, old, multi-pathological patients are at greater risk of developing severe Covid-19 infection than younger, healthy ones. Covid-19's impact on Parkinson's Disease (PD) patients could be analysed through both the influence on PD patients' health and their risk of developing severe Covid-19, and the consequences of lockdown and restrictive measures on mental and cognitive health on both patients and caregivers. Moreover, there are critical issues to be considered about patients' care and management through an unprecedented time like this. One important issue to consider is physiotherapy, as most patients cannot keep exercising because of restrictive measures which has profoundly impacted on their health. Lastly, the relationship between PD and Sars-Cov2 may be even more complicated than it seems as some studies have hypothesized a possible Covid-19-induced parkinsonism. Hereby, we review the state of the art about the relationship between Covid-19 and Parkinson's Disease, focusing on each of these five points.

Tele-Rehabilitation with Virtual Reality: A Case Report on the Simultaneous, Remote Training of Two Patients with Parkinson Disease

ABSTRACT

Physical training in Parkinson disease improves motor performance, alleviates nonmotor symptoms, and enhances cognition and quality of life. Nonetheless, adherence to exercise is low and travel costs and time may limit participation and compliance. Training at home can help avoid these burdens and, as needed during the recent global pandemic (COVID-19), reinforce social distancing and reduce the risk of infection. However, training at home requires motivation and self-control and telerehabilitation is time-consuming for both patient and therapist. In recent years, there is growing use of virtual reality and exergaming to increase motivation and adherence for exercising with evidence of improvements in mobility and balance after using virtual reality in the clinic. Here, a novel telerehabilitation training program using a treadmill-virtual reality system for simultaneous training of two patients with Parkinson disease in their homes is described. Remote monitoring software enabled visual and auditory communication with the two patients, allowing the trainer to adapt the settings remotely and provide feedback. Participants received weekly training sessions over 1 yr. The findings show high adherence to training, increased walking duration throughout the sessions, and increased patient confidence, gait speed, and mobility. Training multiple participants simultaneously was feasible, enabling an individualized treatment approach while conserving therapist time.

Review: How Can Intelligent Robots and Smart Mechatronic Modules Facilitate Remote Assessment, Assistance, and Rehabilitation for Isolated Adults With Neuro-Musculoskeletal Conditions?

Worldwide, at the time this article was written, there are over 127 million cases of patients with a confirmed link to COVID-19 and about 2.78 million deaths reported. With limited access to vaccine or strong antiviral treatment for the novel coronavirus, actions in terms of prevention and containment of the virus transmission rely mostly on social distancing among susceptible and high-risk populations. Aside from the direct challenges posed by the novel coronavirus pandemic, there are serious and growing secondary consequences caused by the physical distancing and isolation guidelines, among vulnerable populations. Moreover, the healthcare system's resources and capacity have been focused on addressing the COVID-19 pandemic, causing less urgent care, such as physical neurorehabilitation and assessment, to be paused, canceled, or delayed. Overall, this has left elderly adults, in particular those with neuromusculoskeletal (NMSK) conditions, without the required service support. However, in many cases, such as stroke, the available time window of recovery through rehabilitation is limited since neural plasticity decays quickly with time. Given that future waves of the outbreak are expected in the coming months worldwide, it is important to discuss the possibility of using available technologies to address this issue, as societies have a duty to protect the most vulnerable populations. In this perspective review article, we argue that intelligent robotics and wearable technologies can help with remote delivery of assessment, assistance, and rehabilitation services while physical distancing and isolation measures are in place to curtail the spread of the virus. By supporting patients and medical professionals during this pandemic, robots, and smart digital mechatronic systems can reduce the non-COVID-19 burden on healthcare systems. Digital health and cloud telehealth solutions that can complement remote delivery of assessment and physical rehabilitation services will be the subject of discussion in this article due to their potential in enabling more effective and safer NMSDK rehabilitation, assistance, and assessment service delivery. This article will hopefully lead to an interdisciplinary dialogue between the medical and engineering sectors, stake holders, and policy makers for a better delivery of care for those with NMSK conditions during a global health crisis including future pandemics.

How COVID-19 will boost remote exercise-based treatment in Parkinson's disease: a narrative review

The lack of physical exercise during the COVID-19 pandemic-related quarantine measures is challenging, especially for patients with Parkinson's disease (PD). Without regular exercise not only patients, but also nursing staff and physicians soon noticed a deterioration of motor and non-motor symptoms. Reduced functional mobility, increased falls, increased frailty, and decreased quality of life were identified as consequences of increased sedentary behavior. This work overviews the current literature on problems of supplying conventional physiotherapy and the potential of telerehabilitation, allied health services, and patient-initiated exercise for PD patients during the COVID-19 period. We discuss recent studies on approaches that can improve remote provision of exercise to patients, including telerehabilitation, motivational tools, apps, exergaming, and virtual reality (VR) exercise. Additionally, we provide a case report about a 69-year-old PD patient who took part in a 12-week guided climbing course for PD patients prior to the pandemic and found a solution to continue her climbing training independently with an outdoor rope ladder. This case can serve as a best practice example for non-instructed, creative, and patient-initiated exercise in the domestic environment in difficult times, as are the current. Overall, many recent studies on telemedicine, telerehabilitation, and patient-initiated exercises have been published, giving rise to optimism that facilitating remote exercise can help PD patients maintain physical mobility and emotional well-being, even in phases such as the COVID-19 pandemic. The pandemic itself may even boost the need to establish comprehensive and easy-to-do telerehabilitation programs.

Mobile-Based Health Apps to Promote Physical Activity During COVID-19 Lockdowns

Objective

Periods of lockdown due to coronavirus disease 2019 (COVID-19) have a negative effect on individuals’ physical health and quality of life, and may result in a weakened immune response, leading to enhanced risk of infection. Due to lack of access to public resources during periods of lockdown many individuals cannot perform their usual daily physical activities. The aim of this short report is to discuss the use of mobile-based health applications and virtual reality systems for promoting physical activity at home through an interactive and motivating digital environment.

Methods and results

Information on tele-health, available from the US Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), and data on physical activity during lockdowns were reviewed. A list of mobile-based health applications suitable for use in promoting physical activity at home was compiled.

Conclusion

This report makes recommendations for mobile-based health applications to promote physical health, which can be used at home during periods of lockdown.

Virtual Reality as a Technological-Aided Solution to Support Communication in Persons With Neurodegenerative Diseases and Acquired Brain Injury During COVID-19 Pandemic

The COVID-19 poses an ongoing threat to lives around the world and challenges the existing public health and medical service delivery. The lockdown or quarantine measures adopted to prevent the spread of COVID-19 has caused the interruption in ongoing care and access to medical care including to patients with existing neurological conditions. Besides the passivity, isolation, and withdrawal, patients with neurodegenerative diseases experience difficulties in communication due to a limited access to leisure opportunities and interaction with friends and relatives. The communication difficulties may exacerbate the burden on the caregivers. Therefore, assistive-technologies may be a useful strategy in mitigating challenges associated with remote communication. The current paper presents an overview of the use of assistive technologies using virtual reality and virtual body ownership in providing communication opportunities to isolated patients, during COVID-19, with neurological diseases and moderate-to-severe communication difficulties. We postulate that the assistive technologies-based intervention may improve social interactions in patients with neurodegenerative diseases and acquired brain injury-thereby reducing isolation and improving their quality of life and mental well-being.

Telehealth in Neurodegenerative Diseases: Opportunities and Challenges for Patients and Physicians

Telehealth, by definition, is distributing health-related services while using electronic technologies. This narrative Review describes the technological health services (telemedicine and telemonitoring) for delivering care in neurodegenerative diseases, Alzheimer's disease, Parkinson's Disease, and amyotrophic lateral Sclerosis, among others. This paper aims to illustrate this approach's primary experience and application, highlighting the strengths and weaknesses, with the goal of understanding which could be the most useful application for each one, in order to facilitate telehealth improvement and use in standard clinical practice. We also described the potential role of the COVID-19 pandemic to speed up this service's use, avoiding a sudden interruption of medical care.

Impact of Coronavirus Disease 2019 Pandemic on Parkinson's Disease: A Cross-Sectional Survey of 568 Spanish Patients

Background

The aim of this study was to know the impact of the coronavirus disease 2019 (COVID‐19) pandemic on Spanish patients with Parkinson's disease (PD).

Methods

This is a descriptive, observational, cross‐sectional study. An anonymous online survey with 95 questions was distributed among patients. Responses were collected from 11 May 2020 to 20 July 2020.

Results

Of a total of 570 questionnaires received, 568 (99.6%) were considered valid for the analysis (mean age, 63.5 ± 12.5 years; 53% females). A total of 553 patients (97.4%) were aware of the COVID‐19 pandemic and 68.8% were concerned about it; 95.6% took preventive measures. A total of 484 patients (85.2%) had no contact with cases of COVID‐19, and only 15 (2.6%) had confirmed COVID‐19. Although up to 72.7% remained active during confinement, 65.7% perceived a worsening of their symptoms.

Conclusions

Spanish patients with PD perceived the COVID‐19 pandemic with concern and responsibility. More than half experienced worsening of their symptoms during confinement. © 2020 International Parkinson and Movement Disorder Society

COVID-19 and neurological disorders: are neurodegenerative or neuroimmunological diseases more vulnerable?

Neurological disorders and coronavirus 2019 (COVID-19) pandemic are two conditions with a recent well-documented association. Intriguing evidences showed that COVID-19 infection can modify clinical spectrum of manifested neurological disorders but also it plays a crucial role in the development of future diseases as long-tem consequences. In this viewpoint review, we aimed to assess the vulnerability to SARS-CoV-2 infection and development of COVID-19 among neurological disorders. With this in mind, we tested the hypothesis that age rather than neuropathology itself could be decisive in neurodegenerative diseases such as Parkinson’s disease, whereas neuropathology rather than age may be critical in neuroimmunological diseases such as Multiple Sclerosis. Highlighting the role of potential susceptibility or protection factors from this disastrous infection, we also stratify the risk for future neurodegeneration.