When should a Parkinsons Patient Consider DBS

When Should You Consider DBS for a Parkinson’s Patient?

In the early stages, Parkinson’s disease, a progressive neurological disorder, can often be well controlled with medication. However, as the disease advances, some patients will experience shorter periods of symptom control, unpredictable “ON-OFF” fluctuations, troublesome dyskinesia or tremor that continue to be difficult to control despite appropriately titrated medication.

Then Deep Brain Stimulation (DBS) can be an important treatment option The decision to consider DBS should not be based on how long someone has had Parkinson’s disease. More importantly it relies on the patient’s symptoms, response to medication, motor fluctuations, cognitive health and impact of Parkinson’s on day-to-day life. 

What is Deep Brain Stimulation (DBS) for Parkinson’s Disease?

Deep brain stimulation (DBS) is a neurosurgical procedure where electrodes are implanted in specific areas of the brain that control movement. These electrodes are connected to an implanted neurostimulator that delivers controlled electrical stimulation to help control abnormal brain circuits.

DBS does not cure Parkinson’s disease or stop it from progressing. Instead, it can be useful in controlling motor symptoms such as tremor, rigidity, bradykinesia, dyskinesia and medication related motor fluctuations in carefully selected patients.

5 Signs It Might Be Time to Talk About DBS:

1. Parkinson’s drugs still work, but not all the time

One of the most important indicators is a good response to levodopa in conjunction with increasingly unpredictable symptom control. A patient may feel relatively mobile during a “ON” period, but when the medication wears off they can become slow, stiff or unable to move comfortably.

If these fluctuations begin to significantly interfere with daily life, despite optimized medication, then discussion of DBS evaluation may be appropriate.

2. Increasing length or frequency of “OFF” periods

As Parkinson’s progresses, the benefit from each dose of medication may get shorter. Patients may experience increased “OFF” time, when tremor, stiffness, slowness or difficulty walking returns.

Transitions between good and poor mobility are frequent and unpredictable and can impact on independence, work, social activities and daily routines.

3. Dyskinesia is becoming a problem

Long-term treatment with dopamine agonists can cause dyskinesia, uncontrolled involuntary movements that can occur when the medication is working.

In suitably selected patients, DBS may be considered when either dyskinesia itself is disabling or when adjustment of medication produces a difficult balance between Parkinson’s symptom control and excessive involuntary movements.

4. Tremor is difficult to control

Some patients remain with disabling tremor despite appropriate medication. Another reason for specialist DBS assessment may be when tremor affects eating, writing, dressing or other daily activities.

5. The effect of medication side effects on quality of life

As the patient’s medication requirements grow, treatment-related complications can sometimes occur. A movement-disorder neurologist and functional neurosurgeon can determine if one should add DBS to the treatment plan (instead of just increasing doses).

Should patients wait until Parkinson's is at an advanced stage?

If you are waiting until your Parkinson’s is quite advanced before considering DBS, this may not be the best strategy, as DBS is mainly based on targeting specific motor symptoms and may not work for all aspects of advanced Parkinson’s disease.

DBS may not respond well to some symptoms such as major cognitive decline and some speech or balance issues. This makes the timing of the assessment important.

A DBS consultation does not mean the patient will undergo surgery. It provides an opportunity to determine if the patient is a good candidate now, may be a candidate later, or would be better served by another treatment approach.

Who Could Be a right Candidate for DBS?

There is no checklist that defines the right candidate. However, evaluation typically considers whether the patient:

• Has been diagnosed with Parkinson’s disease
• Has motor symptoms responsive to levodopa.
• Has troublesome motor fluctuations or “OFF” periods
• Has problematic dyskinesia
• Has a disabling tremor despite medication
• No gross cognitive disorder
• Is healthy enough for surgery
• Has realistic expectations of what DBS can and cannot improve

Dr. Sawhney’s guidance for patients specifically highlights levodopa responsiveness and no significant cognitive decline as important factors in selection of DBS candidates.

Pre-DBS Testing?

Symptoms alone do not justify a recommendation for DBS. Patients usually receive a structured multidisciplinary assessment.

Depending on the case, evaluation may include detailed neurological examination, medication history, levodopa-response testing, brain imaging, cognitive or neuropsychological assessment, evaluation of speech and balance, and general medical fitness for surgery.

The team also needs to know WHICH symptoms are most bothersome to the patient. This is important because DBS can be quite effective for some motor symptoms but may have limited benefit for others.

DBS Assessment at Fortis Hospital Mulund, Mumbai

Patients are evaluated for advanced functional neurosurgical procedures, such as DBS. Under Dr. Gurneet Singh Sawhney Director – Stereotactic & Functional Neurosciences and Senior Consultant, Department of Neurosurgery & Spinal Surgery, Fortis Hospital, Mulund, Mumbai 

Dr. Sawhney has done 80+ DBS surgeries and advanced international fellowship training in Functional Neurosurgery from Tokyo Women’s Medical University, Japan. His clinical interests include DBS, Parkinson’s disease and movement disorder surgery, essential tremor, dystonia, stereotactic neurosurgery and neuromodulation.

The aim of a DBS evaluation for patients from Mumbai, Navi Mumbai and the rest of India is to help to answer three important questions. Is the patient an appropriate candidate? Is this the right time to think about DBS? And realistically what symptoms should be expected to improve?

The Right Time to Inquire About DBS

The right time to talk about DBS is often when Parkinson's is not yet very advanced, especially when medication still helps with symptoms, but no longer gives predictable, sustained control.

Patients with increasing “OFF” time, troublesome dyskinesia, medication-resistant tremor or significant motor fluctuations should consider discussing DBS with their neurologist and a functional neurosurgeon.

The aim is not to substitute for drugs unwarrantably or to rush into surgery. It's about getting the right treatment at the right stage and making sure that patients who could benefit from DBS are assessed before the therapeutic window closes.