CLINICAL CLIPS
Deep Brain Stimulation for Parkinson’s Disease Barbara Godden, MHS, RN, CPAN, CAPA PARKINSON’S DISEASE IS a chronic progressive neurologic disorder that exhibits both motor and nonmotor symptoms. Motor symptoms include tremors, rigidity, impaired balance, and bradykinesia. Nonmotor symptoms can include mood disorders including depression and anxiety, restlessness, cognitive decline and dementia, and compromised bowel and bladder functions.1,2 Currently, 500,000 Americans are diagnosed with Parkinson’s disease each year, and as the population ages, many more people will be diagnosed over time.1,2 In Parkinson’s disease, there is a degeneration of dopamine-containing neurons.3 Levodopa, which works primarily in controlling the motor symptoms, is the primary drug used to treat the disease. Other drugs are used in combination with Levodopa to enhance its effectiveness. The exact cause of Parkinson’s disease is not known, although genetic and environmental factors are suggested risk factors.
tionships with friends and family, and abandonment are common among participants.1 These support groups have been found to be very beneficial for patients and caregivers to share similar feelings and receive support from members of the group.1
There is no cure for Parkinson’s disease. In addition, the progression of Parkinson’s disease is unpredictable in terms of severity and timing of symptoms. The uncertainty of the disease course causes stress and anxiety for patients and their caregivers. In many cases, the disease progresses fairly rapidly to a point where the patient is no longer independent in activities of daily living. Research suggests that Parkinson’s disease can have a very negative impact on the health of the caregiver when the disease progresses to the level of the patient needing assistance with most activities.1 In support groups for patients with Parkinson’s disease and their caregivers, themes of fear, uncertainty of illness progression, broken rela-
DBS was first developed in France in 1987. The procedure was approved by the United States Food and Drug Administration for use in treating essential tremor in 1997, approved for use in Parkinson’s disease in 2002, and approved for use in dystonia in 2003.4,5 The procedure does not cure these diseases, but can reduce the severity of symptoms and decrease the amount of medication that patients require. After DBS, many patients demonstrate a dramatic improvement in quality of life and ability to perform activities of daily living. Also, the DBS procedure is reversible, unlike a pallidotomy or pallidectomy, both lesioning techniques, done for very severe dyskinesia.2 The exact mechanism of DBS is unclear, but studies suggest that there is a complex interaction between the basal ganglia, thalamus, and layers of the motor cortex.3 Further studies continue to better understand the role that DBS may play in Parkinson’s disease in the future.
Barbara Godden, MHS, RN, CPAN, CAPA, PACU Clinical Nurse Coordinator, Sky Ridge Medical Center, Lone Tree, CO. Conflict of Interest: None to report. Address correspondence to Barbara Godden, 9320 Erminedale Drive, Lone Tree, CO 80124; e-mail address: bagodden@ comcast.net. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.03.006
230
Care for patients with Parkinson’s disease is centered on delaying progression of the disease, managing symptoms, and optimizing functional abilities related to activities of daily living and quality of life.2 Additionally, a multidisciplinary approach is most effective in managing patients with Parkinson’s disease, to include nursing, occupational therapy, physical therapy, and speech therapy.2 As symptoms progress, deep brain stimulation (DBS) may be an option to explore to preserve quality of life.
Deep Brain Stimulation
DBS is a neurosurgical procedure that involves stereotactic mapping performed by a neurosurgeon. Electrodes are implanted in the brain, which are
Journal of PeriAnesthesia Nursing, Vol 29, No 3 (June), 2014: pp 230-233
CLINICAL CLIPS
then attached to an extension and connected to an internal pulse generator (IPG). This generator is battery operated and is similar to a pacemaker/internal cardio defibrillator unit. The pulse generator is most often placed in the upper chest but can also be placed in the abdomen. The stimulator delivers small high-frequency electrical stimulation to the areas of the brain that control symptoms related to Parkinson’s disease, which include the subthalamic nucleus and globus pallidus interna, the areas where the electrodes are placed.3,4,6,7 DBS is safe and effective, but as with any surgery, there are risks and complications. The major complications of DBS are hemorrhage and infection, both less than 2%. Other less frequent complications include leakage of cerebrospinal fluid, erosion, lead fractures, hardware breakage, and battery failure in the generator.4 DBS was first done as an awake procedure. There are now a few centers in the United States that perform DBS asleep. Awake DBS requires three procedures, and asleep DBS requires two procedures. Both approaches are safe and effective.4,6
Awake Procedure Awake DBS requires an accurate brain image, obtained through computed tomography (CT) or a magnetic resonance imaging (MRI) scan, to locate the exact targets for the placement of the electrodes. This CT or MRI can be done up to 1 month out from placement of the electrodes. During this procedure, bone markers are placed onto the surface of the skull. A platform is created at this time that will be used during the electrode placement in part two. The bone markers remain in place until after the electrode placement. Intravenous sedation can be provided to allow the patient to be comfortable during the procedure. Imaging is done at this time and provides information to a company that will create the platform to be used during the second procedure. The patient can be discharged home after this procedure. The second part of the awake procedure involves the placement of the electrodes. The patient is placed in a ‘‘beach chair’’ position in the operating room. A local anesthetic is used to numb the scalp. However, the patient receives little or no sedation for the procedure, allowing the surgeon to stimulate parts of the brain and have
231
the patient participate in this process. The custom platform from the first procedure is placed on the patient and fitted onto the bone markers with small screws. Following this, small holes are placed into the skull and test electrodes are placed. The surgeon will test precise areas of the brain and will ask the patient to perform simple tasks to assess placement. Once the test areas have been confirmed, the permanent leads will be placed. This entire procedure can take about 5 to 6 hours. The patient will spend one to two nights in the hospital. The third part of the awake procedure is placement of the IPG. The patient is asleep for this procedure, and it takes about 2 hours. The IPG is most often implanted in the upper chest under the collarbone, similar to a pacemaker/internal cardio defibrillator, but can also be implanted in the abdominal area. An extension wire connects the IPG with the electrodes. It is threaded under the skull and behind the ear. The patient can be discharged home after this procedure but may also stay overnight in the hospital. Programming of the generator will occur in the physician’s office a few weeks after the IPG placement. Immediate programming is not done as there is often some immediate improvement because of the stimulation during the procedure. A break in time allows the patient to ‘‘settle’’ back into a normal pattern, and programming as well as medication adjustments can be done at the time of the office visit.4,6
Asleep Procedure With the asleep procedure, only two procedures are needed. The first part of the asleep procedure starts with an MRI with the patient asleep under anesthesia. After the MRI, the patient is taken to surgery, and a portable CT machine is used to overlay the MRI that was done earlier. This allows for precise placement of the electrodes, usually within 1 mm of the targeted area in the brain. This entire procedure, including the MRI, takes approximately 4 to 5 hours. The patient comes to the postanesthesia care unit (PACU) for postanesthesia recovery, in which routine PACU care is provided, along with neurologic checks. It is important to receive a thorough handoff from the anesthesia provider, the circulator, and the surgeon related to the patient’s preoperative neurologic status. The patient will require a 1- to 2-day
BARBARA GODDEN
232
hospital stay, often spending the first night in an intensive care unit.
which is often one of the first things that these patients lose after symptoms become severe.5,9
The second part of the asleep procedure occurs about 1 to 2 weeks later. During this procedure, the generator is implanted, and the electrodes are connected to the generator via an extension wire. The patient may stay overnight or go home from the PACU after this procedure. Programming of the generator takes place about 30 days after the procedure and can be done in the surgeon’s office.4,6
Care of Patients/Meeting Their Needs
Benefits of DBS The literature discusses how many patients with Parkinson’s disease have experienced dramatically improved lives with DBS. They are often able to immediately resume many activities in which they previously required assistance, such as dressing and feeding themselves.4 In a study using a driving simulator, patients who had DBS performed better in the driving simulation than patients without DBS. This study also suggests that because driving requires cognitive and decision-making skills that DBS improves these functions as well.8 DBS is generally considered as an intervention 11 to 13 years after Parkinson’s disease is diagnosed.5 But there is new evidence that supports that early DBS intervention at 7 to 8 years of the disease can provide significant improvement in these patients early in the disease course. In a study of 251 patients conducted in Germany and France, a 26% improvement was shown in the Parkinson’s Disease Questionnaire 39 summary index score, which was a clinically relevant finding.9 It is unknown whether DBS can delay symptoms, but early intervention may allow patients to have a better quality of life for a longer period of time, including continuing with their employment,
Patients who have the asleep procedure under general anesthesia for lead placement will come to the PACU like any other patient from surgery. Priorities with these patients are the same as other patients in the PACU, including airway management, hemodynamic stability, and other routine PACU care. In addition, it is important during handoff from the anesthesiologist, the circulator, and the surgeon to obtain the patient’s baseline neurologic status. Thorough neurologic checks should be performed at regular intervals during the patient’s PACU stay. Patients having DBS surgery generally stay in the hospital 1 to 2 days, either in an intensive care unit, a step-down unit, or in a designated neurologic nursing unit.
New Research and Future Uses of DBS One advantage of DBS is that it is reversible, and this is important as new therapies are discovered and trialed, such as stem cell transplants and gene therapy.2,4 DBS is also demonstrating potential to treat a number of other disorders. Clinical trials are being done in patients with epilepsy, chronic pain, Tourette syndrome, cluster headaches, major depression, and obsessive-compulsive disorder.7,10 These studies are being done in patients who have developed resistance to traditional therapies, and the trials may show promise to treat additional disorders, in addition to Parkinson’s disease. Additional large studies need to be completed to further refine appropriate indications for DBS in the field of neuropsychiatry.10 Currently, patients with Parkinson’s disease have DBS as a clear option to improve quality of life.
References 1. Abendroth M, Greenblum CA, Gray JA. The value of peer-led support groups among caregivers of persons with Parkinson’s disease. Holist Nurs Pract. 2014;28: 48-54. 2. Shin JU, Hendrix CC. Management of patients with Parkinson disease. Nurse Pract. 2013;38:35-43. 3. Li Q, Qian ZM, Arbuthnott GW, Ke Y, Yung WH. Cortical effects of deep brain stimulation: Implications for pathogenesis and treatment of Parkinson disease. JAMA Neurol. 2014;71: 100-103.
4. Oregon Health & Science University. Deep Brain Stimulation Surgery. Available at: http://www.ohsu.edu/xd/health/ services/brain/getting-treatment/diagnosis/parkinsons/treatment-options/surgery/index.cfm. Accessed February 9, 2014. 5. Kalia SK, Sankar T, Lozano AM. Deep brain stimulation for Parkinson’s disease and other movement disorders. Curr Opin Neurol. 2013;26:374-380. 6. Denver DBS Center. Asleep DBS. Available at: www.southdenverneurosurgery.org/denver-dbs-center. Accessed February 9, 2014.
CLINICAL CLIPS 7. Mayo Clinic. Deep brain stimulation. Available at: http:// www.mayoclinic.org/tests-procedures/deep-brain-stimulation/ basics/definition/PRC-20019122. Accessed February 9, 2014. 8. Buhmann C, Maintz L, Hierling J, et al. Effect of subthalamic nucleus deep brain stimulation on driving in Parkinson disease. Neurology. 2014;82:32-40.
233
9. Schuepbach WMM, Rau J, Knudsen K, et al. Neurostimulation for Parkinson’s disease with early motor complications. N Engl J Med. 2013;368:610-622. 10. Williams NR, Okun MS. Deep brain stimulation (DBS) at the interface of neurology and psychiatry. J Clin Invest. 2013; 123:4546-4556.
Deep Brain Stimulation for Parkinson’s Disease Barbara Godden, MHS, RN, CPAN, CAPA PARKINSON’S DISEASE IS a chronic progressive neurologic disorder that exhibits both motor and nonmotor symptoms. Motor symptoms include tremors, rigidity, impaired balance, and bradykinesia. Nonmotor symptoms can include mood disorders including depression and anxiety, restlessness, cognitive decline and dementia, and compromised bowel and bladder functions.1,2 Currently, 500,000 Americans are diagnosed with Parkinson’s disease each year, and as the population ages, many more people will be diagnosed over time.1,2 In Parkinson’s disease, there is a degeneration of dopamine-containing neurons.3 Levodopa, which works primarily in controlling the motor symptoms, is the primary drug used to treat the disease. Other drugs are used in combination with Levodopa to enhance its effectiveness. The exact cause of Parkinson’s disease is not known, although genetic and environmental factors are suggested risk factors.
tionships with friends and family, and abandonment are common among participants.1 These support groups have been found to be very beneficial for patients and caregivers to share similar feelings and receive support from members of the group.1
There is no cure for Parkinson’s disease. In addition, the progression of Parkinson’s disease is unpredictable in terms of severity and timing of symptoms. The uncertainty of the disease course causes stress and anxiety for patients and their caregivers. In many cases, the disease progresses fairly rapidly to a point where the patient is no longer independent in activities of daily living. Research suggests that Parkinson’s disease can have a very negative impact on the health of the caregiver when the disease progresses to the level of the patient needing assistance with most activities.1 In support groups for patients with Parkinson’s disease and their caregivers, themes of fear, uncertainty of illness progression, broken rela-
DBS was first developed in France in 1987. The procedure was approved by the United States Food and Drug Administration for use in treating essential tremor in 1997, approved for use in Parkinson’s disease in 2002, and approved for use in dystonia in 2003.4,5 The procedure does not cure these diseases, but can reduce the severity of symptoms and decrease the amount of medication that patients require. After DBS, many patients demonstrate a dramatic improvement in quality of life and ability to perform activities of daily living. Also, the DBS procedure is reversible, unlike a pallidotomy or pallidectomy, both lesioning techniques, done for very severe dyskinesia.2 The exact mechanism of DBS is unclear, but studies suggest that there is a complex interaction between the basal ganglia, thalamus, and layers of the motor cortex.3 Further studies continue to better understand the role that DBS may play in Parkinson’s disease in the future.
Barbara Godden, MHS, RN, CPAN, CAPA, PACU Clinical Nurse Coordinator, Sky Ridge Medical Center, Lone Tree, CO. Conflict of Interest: None to report. Address correspondence to Barbara Godden, 9320 Erminedale Drive, Lone Tree, CO 80124; e-mail address: bagodden@ comcast.net. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.03.006
230
Care for patients with Parkinson’s disease is centered on delaying progression of the disease, managing symptoms, and optimizing functional abilities related to activities of daily living and quality of life.2 Additionally, a multidisciplinary approach is most effective in managing patients with Parkinson’s disease, to include nursing, occupational therapy, physical therapy, and speech therapy.2 As symptoms progress, deep brain stimulation (DBS) may be an option to explore to preserve quality of life.
Deep Brain Stimulation
DBS is a neurosurgical procedure that involves stereotactic mapping performed by a neurosurgeon. Electrodes are implanted in the brain, which are
Journal of PeriAnesthesia Nursing, Vol 29, No 3 (June), 2014: pp 230-233
CLINICAL CLIPS
then attached to an extension and connected to an internal pulse generator (IPG). This generator is battery operated and is similar to a pacemaker/internal cardio defibrillator unit. The pulse generator is most often placed in the upper chest but can also be placed in the abdomen. The stimulator delivers small high-frequency electrical stimulation to the areas of the brain that control symptoms related to Parkinson’s disease, which include the subthalamic nucleus and globus pallidus interna, the areas where the electrodes are placed.3,4,6,7 DBS is safe and effective, but as with any surgery, there are risks and complications. The major complications of DBS are hemorrhage and infection, both less than 2%. Other less frequent complications include leakage of cerebrospinal fluid, erosion, lead fractures, hardware breakage, and battery failure in the generator.4 DBS was first done as an awake procedure. There are now a few centers in the United States that perform DBS asleep. Awake DBS requires three procedures, and asleep DBS requires two procedures. Both approaches are safe and effective.4,6
Awake Procedure Awake DBS requires an accurate brain image, obtained through computed tomography (CT) or a magnetic resonance imaging (MRI) scan, to locate the exact targets for the placement of the electrodes. This CT or MRI can be done up to 1 month out from placement of the electrodes. During this procedure, bone markers are placed onto the surface of the skull. A platform is created at this time that will be used during the electrode placement in part two. The bone markers remain in place until after the electrode placement. Intravenous sedation can be provided to allow the patient to be comfortable during the procedure. Imaging is done at this time and provides information to a company that will create the platform to be used during the second procedure. The patient can be discharged home after this procedure. The second part of the awake procedure involves the placement of the electrodes. The patient is placed in a ‘‘beach chair’’ position in the operating room. A local anesthetic is used to numb the scalp. However, the patient receives little or no sedation for the procedure, allowing the surgeon to stimulate parts of the brain and have
231
the patient participate in this process. The custom platform from the first procedure is placed on the patient and fitted onto the bone markers with small screws. Following this, small holes are placed into the skull and test electrodes are placed. The surgeon will test precise areas of the brain and will ask the patient to perform simple tasks to assess placement. Once the test areas have been confirmed, the permanent leads will be placed. This entire procedure can take about 5 to 6 hours. The patient will spend one to two nights in the hospital. The third part of the awake procedure is placement of the IPG. The patient is asleep for this procedure, and it takes about 2 hours. The IPG is most often implanted in the upper chest under the collarbone, similar to a pacemaker/internal cardio defibrillator, but can also be implanted in the abdominal area. An extension wire connects the IPG with the electrodes. It is threaded under the skull and behind the ear. The patient can be discharged home after this procedure but may also stay overnight in the hospital. Programming of the generator will occur in the physician’s office a few weeks after the IPG placement. Immediate programming is not done as there is often some immediate improvement because of the stimulation during the procedure. A break in time allows the patient to ‘‘settle’’ back into a normal pattern, and programming as well as medication adjustments can be done at the time of the office visit.4,6
Asleep Procedure With the asleep procedure, only two procedures are needed. The first part of the asleep procedure starts with an MRI with the patient asleep under anesthesia. After the MRI, the patient is taken to surgery, and a portable CT machine is used to overlay the MRI that was done earlier. This allows for precise placement of the electrodes, usually within 1 mm of the targeted area in the brain. This entire procedure, including the MRI, takes approximately 4 to 5 hours. The patient comes to the postanesthesia care unit (PACU) for postanesthesia recovery, in which routine PACU care is provided, along with neurologic checks. It is important to receive a thorough handoff from the anesthesia provider, the circulator, and the surgeon related to the patient’s preoperative neurologic status. The patient will require a 1- to 2-day
BARBARA GODDEN
232
hospital stay, often spending the first night in an intensive care unit.
which is often one of the first things that these patients lose after symptoms become severe.5,9
The second part of the asleep procedure occurs about 1 to 2 weeks later. During this procedure, the generator is implanted, and the electrodes are connected to the generator via an extension wire. The patient may stay overnight or go home from the PACU after this procedure. Programming of the generator takes place about 30 days after the procedure and can be done in the surgeon’s office.4,6
Care of Patients/Meeting Their Needs
Benefits of DBS The literature discusses how many patients with Parkinson’s disease have experienced dramatically improved lives with DBS. They are often able to immediately resume many activities in which they previously required assistance, such as dressing and feeding themselves.4 In a study using a driving simulator, patients who had DBS performed better in the driving simulation than patients without DBS. This study also suggests that because driving requires cognitive and decision-making skills that DBS improves these functions as well.8 DBS is generally considered as an intervention 11 to 13 years after Parkinson’s disease is diagnosed.5 But there is new evidence that supports that early DBS intervention at 7 to 8 years of the disease can provide significant improvement in these patients early in the disease course. In a study of 251 patients conducted in Germany and France, a 26% improvement was shown in the Parkinson’s Disease Questionnaire 39 summary index score, which was a clinically relevant finding.9 It is unknown whether DBS can delay symptoms, but early intervention may allow patients to have a better quality of life for a longer period of time, including continuing with their employment,
Patients who have the asleep procedure under general anesthesia for lead placement will come to the PACU like any other patient from surgery. Priorities with these patients are the same as other patients in the PACU, including airway management, hemodynamic stability, and other routine PACU care. In addition, it is important during handoff from the anesthesiologist, the circulator, and the surgeon to obtain the patient’s baseline neurologic status. Thorough neurologic checks should be performed at regular intervals during the patient’s PACU stay. Patients having DBS surgery generally stay in the hospital 1 to 2 days, either in an intensive care unit, a step-down unit, or in a designated neurologic nursing unit.
New Research and Future Uses of DBS One advantage of DBS is that it is reversible, and this is important as new therapies are discovered and trialed, such as stem cell transplants and gene therapy.2,4 DBS is also demonstrating potential to treat a number of other disorders. Clinical trials are being done in patients with epilepsy, chronic pain, Tourette syndrome, cluster headaches, major depression, and obsessive-compulsive disorder.7,10 These studies are being done in patients who have developed resistance to traditional therapies, and the trials may show promise to treat additional disorders, in addition to Parkinson’s disease. Additional large studies need to be completed to further refine appropriate indications for DBS in the field of neuropsychiatry.10 Currently, patients with Parkinson’s disease have DBS as a clear option to improve quality of life.
References 1. Abendroth M, Greenblum CA, Gray JA. The value of peer-led support groups among caregivers of persons with Parkinson’s disease. Holist Nurs Pract. 2014;28: 48-54. 2. Shin JU, Hendrix CC. Management of patients with Parkinson disease. Nurse Pract. 2013;38:35-43. 3. Li Q, Qian ZM, Arbuthnott GW, Ke Y, Yung WH. Cortical effects of deep brain stimulation: Implications for pathogenesis and treatment of Parkinson disease. JAMA Neurol. 2014;71: 100-103.
4. Oregon Health & Science University. Deep Brain Stimulation Surgery. Available at: http://www.ohsu.edu/xd/health/ services/brain/getting-treatment/diagnosis/parkinsons/treatment-options/surgery/index.cfm. Accessed February 9, 2014. 5. Kalia SK, Sankar T, Lozano AM. Deep brain stimulation for Parkinson’s disease and other movement disorders. Curr Opin Neurol. 2013;26:374-380. 6. Denver DBS Center. Asleep DBS. Available at: www.southdenverneurosurgery.org/denver-dbs-center. Accessed February 9, 2014.
CLINICAL CLIPS 7. Mayo Clinic. Deep brain stimulation. Available at: http:// www.mayoclinic.org/tests-procedures/deep-brain-stimulation/ basics/definition/PRC-20019122. Accessed February 9, 2014. 8. Buhmann C, Maintz L, Hierling J, et al. Effect of subthalamic nucleus deep brain stimulation on driving in Parkinson disease. Neurology. 2014;82:32-40.
233
9. Schuepbach WMM, Rau J, Knudsen K, et al. Neurostimulation for Parkinson’s disease with early motor complications. N Engl J Med. 2013;368:610-622. 10. Williams NR, Okun MS. Deep brain stimulation (DBS) at the interface of neurology and psychiatry. J Clin Invest. 2013; 123:4546-4556.
