Selecting deep brain stimulation or infusion therapies in advanced Parkinson’s disease: an evidence-based review

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Abstract

Motor complications in Parkinson’s disease (PD) result from the short half-life and irregular plasma fluctuations of oral levodopa. When strategies of providing more continuous dopaminergic stimulation by adjusting oral medication fail, patients may be candidates for one of three device-aided therapies: deep brain stimulation (DBS), continuous subcutaneous apomorphine infusion, or continuous duodenal/jejunal levodopa/carbidopa pump infusion (DLI). These therapies differ in their invasiveness, side-effect profile, and the need for nursing care. So far, very few comparative studies have evaluated the efficacy of the three device-aided therapies for specific motor problems in advanced PD. As a result, neurologists currently lack guidance as to which therapy could be most appropriate for a particular PD patient. A group of experts knowledgeable in all three therapies reviewed the currently available literature for each treatment and identified variables of clinical relevance for choosing one of the three options such as type of motor problems, age, and cognitive and psychiatric status. For each scenario, pragmatic and (if available) evidence-based recommendations are provided as to which patients could be candidates for either DBS, DLI, or subcutaneous apomorphine.

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What are the most important nonmotor symptoms in patients with Parkinson's disease and are we missing them?

David Gallagher, Andrew Lees, Anette Schrag (2010)

Nonmotor symptoms (NMS) are increasingly recognized as important and neglected aspects of Parkinson's disease (PD). We evaluated their relative frequency and comparative impact on health-related quality of life (Hr-QoL) using validated questionnaires. In addition, we assessed the rate of reporting of NMS in neurology clinics compared with their subjective impact on patients. We used a range of validated clinimetric scales of motor and nonmotor symptoms and Hr-QoL to assess consecutive patients with PD. Reporting of NMS was assessed by comparison with case note documentation. A mean of 11 of 30 NMS per patient were elicited on the NMS questionnaire of which on average 4.8 were reported in the clinical notes (44%). The most common NMS were autonomic (particularly urinary). The Hr-QoL scores correlated most strongly with autonomic dysfunction (r = 0.84; particularly urinary and gastrointestinal symptoms), mood (r = 0.74), fatigue (r = 0.74), sleep problems (nocturnal r = 0.55; daytime somnolence r = 0.65), pain (r = 0.56), and psychosis (r = 0.55, all p < 0.0001) followed by UPDRS motor score (r = 0.48, p < 0.0001). Greater motor fluctuations (r = 0.57) and dyskinesia (r = 0.43, both p < 0.0001) were also associated with worse Hr-QoL. In multivariate analysis, depression had the strongest association with Hr-QoL (adjusted R(2) = 0.53, p = 0.005) followed by fatigue, thermoregulatory, gastrointestinal, and cardiovascular autonomic function (especially orthostatic hypotension), daytime somnolence, and urinary problems. This study demonstrates that a autonomic dysfunction, psychiatric complications, pain, fatigue, and sleep problems are major correlates of poor Hr-QoL. However, whilst psychiatric problems are increasingly documented, many symptoms (particularly those possibly perceived as embarrassing or unrelated) remain under-reported. © 2010 Movement Disorder Society.

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Neurosurgery in Parkinson disease: a distressed mind in a repaired body?

M. Gargiulo, D Maltête, J L Houeto … (2006)

To prospectively evaluate the impact of subthalamic nucleus (STN) stimulation on social adjustment in patients with Parkinson disease (PD). Before and 18 to 24 months after bilateral STN stimulation, the authors assessed 29 patients with PD for motor disability, cognition (Mattis dementia rating scale, frontal score), psychiatric morbidity (Mini-5.0.0, MADRS, BAS), quality of life (PDQ-39), social adjustment (Social Adjustment Scale), and psychological status using unstructured in-depth interviews. Despite marked improvement in parkinsonian motor disability, the absence of significant changes in cognitive status, and improvement of activities of daily living and quality of life by the end of the study, social adjustment did not improve. Several kinds of problems with social adjustment were observed, affecting the patients' perception of themselves and their body, marital situation, and professional life. Marital conflicts occurred in 17/24 couples. Only 9 out of 16 patients who had a professional activity before the operation went back to work after surgery. After STN stimulation, patients experienced difficulties in their relations with themselves, their spouses, their families, and their socio-professional environment. The authors suggest a multidisciplinary psychosocial preparation and follow-up to help patients and their entourage cope with the sudden changes in their existence following successful neurosurgery.

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Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease.

Jacques Favre, J Hammerstad, Penelope Hogarth … (2005)

Deep brain stimulation (DBS) of the globus pallidus interna (GPi) and subthalamic nucleus (STN) has been reported to relieve motor symptoms and levodopa-induced dyskinesia in patients with advanced Parkinson disease (PD). Although it has been suggested that stimulation of the STN may be superior to stimulation of the GPi, comparative trials are limited. To extend our randomized, blinded pilot comparison of the safety and efficacy of STN and GPi stimulation in patients with advanced PD. This study represents the combined results from our previously published, randomized, blinded, parallel-group pilot study and additional patients enrolled in our single-center extension study. Oregon Health and Science University in Portland.Patients Twenty-three patients with idiopathic PD, levodopa-induced dyskinesia, and response fluctuations were randomized to implantation of bilateral GPi or STN stimulators. Patients and evaluating clinicians were blinded to stimulation site. All patients were tested preoperatively while taking and not taking medications and after 3, 6, and 12 months of DBS. Postoperatively, response of symptoms to DBS, medication, and combined medication and DBS was evaluated. Twenty patients (10 in the GPi group and 10 in the STN group) completed 12-month follow-up. Off-medication Unified Parkinson's Disease Rating Scale motor scores were improved after 12 months of both GPi and STN stimulation (39% vs 48%). Bradykinesia tended to improve more with STN than GPi stimulation. No improvement in on-medication function was observed in either group. Levodopa dose was reduced by 38% in STN stimulation patients compared with 3% in GPi stimulation patients (P = .08). Dyskinesia was reduced by stimulation at both GPi and STN (89% vs 62%). Cognitive and behavioral complications were observed only in combination with STN stimulation. Stimulation of either the GPi or STN improves many features of advanced PD. It is premature to exclude GPi as an appropriate target for DBS in patients with advanced disease.

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Author and article information

Contributors

Jens Volkmann: +49-931-20123751 , volkmann_j@klinik.uni-wuerzburg.de

Journal

Journal ID (nlm-ta): J Neurol

Journal ID (iso-abbrev): J. Neurol

Title: Journal of Neurology

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0340-5354

ISSN (Electronic): 1432-1459

Publication date (Electronic): 5 January 2013

Publication date PMC-release: 5 January 2013

Publication date (Print): 2013

Volume: 260

Pages: 2701-2714

Affiliations

[ ]Department of Neurology, University Clinic of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany

[ ]Dipartimento di Neuroscienze Cliniche, Istituto Nazionale Neurologico Carlo Besta, Università Cattolica del Sacro Cuore, Milan, Italy

[ ]IRCCS San Camillo, Venice, Italy

[ ]Department of Neurology, King’s College Hospital, London, UK

[ ]Medical and Dental School, University of Birmingham, Birmingham, UK

[ ]Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands

[ ]Department of Neurology, Christian-Albrechts-University, Kiel, Germany

[ ]Department of Neurology, Philipps-University Marburg, Marburg, Germany

[ ]Service de Neurologie, CIC 802, CHU de Poitiers, Poitiers, France

[ ]Movement Disorders Unit, Neurology Department, Sant Pau Hospital, Universitat Autònoma de Barcelona and CIBERNED, Barcelona, Spain

[ ]Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden

[ ]Department of Neurology, Klinikum-Bremerhaven, Bremerhaven, Germany

[ ]Department of Neurology, Aarhus University Hospital, Aarhus, Denmark

[ ]Clinical Department of Neurology, Innsbruck Medical University, Innsbruck, Austria

[ ]Service de Neurologie, Hòpitaux Universitaires de Genève, Genève, Switzerland

[ ]Department of Neurology, Assaf Harofeh Medical Center, Tel Aviv University, Zerifin, Israel

[ ]Departments of Clinical Pharmacology and Neurology, INSERM CIC9302 and UMR 825, University Hospital and University of Toulouse III, Toulouse, France

[ ]Department of Neurology, 1st Medical Faculty, Charles University, Prague, Czech Republic

[ ]Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands

[ ]Department of Neurology, Karolinska University Hospital, Stockholm, Sweden

[ ]Neurology Services, Movement Disorders Unit, Hospital Clinic i Provincial, Barcelona, Spain

[ ]Department of Neurology, AZ Sint Lucas, Ghent, Belgium

Article

Publisher ID: 6798

DOI: 10.1007/s00415-012-6798-6

PMC ID: 3825542

PubMed ID: 23287972

SO-VID: 3635ab9b-a7ef-4abf-91f1-7a962c6081de

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

History

Date received : 18 October 2012

Date accepted : 10 December 2012

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ScienceOpen disciplines: Neurology

Keywords: apomorphine,deep brain stimulation,duodenal levodopa infusion,parkinson’s disease

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ScienceOpen disciplines: Neurology

Keywords: apomorphine, deep brain stimulation, duodenal levodopa infusion, parkinson’s disease

Selecting deep brain stimulation or infusion therapies in advanced Parkinson’s disease: an evidence-based review

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Most cited references 67

What are the most important nonmotor symptoms in patients with Parkinson's disease and are we missing them?

Neurosurgery in Parkinson disease: a distressed mind in a repaired body?

Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease.

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