Parkinson’s Disease: Advantages and Disadvantages of Deep Brain Stimulation Treatment
Guest: Vicky Salak – Neurology, MUSC
Host: Dr. Linda Austin – Psychiatry, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Vicky Salak, who is a family nurse practitioner and Program Coordinator for the Deep Brain Stimulation Program for Parkinson’s disease. We talked in an earlier podcast about just what deep brain stimulation is. This podcast is for folks who are really getting seriously interested in pursuing this and what they might expect. Vicky, let’s talk a little bit about some of the advantages and disadvantages of deep brain stimulation. What do you think patients need to understand about that?
Vicky Salak: Most importantly, deep brain stimulation is not a cure. It is a treatment for the disease, for the motor symptoms of Parkinson’s disease. One of the main advantages is that it does not destroy any part of the brain, such as the pallidotomies that were done in years past. Therefore, if new treatment is available that they’d like to participate in, we can turn off the devices or have them removed.
The other thing is that we can treat both sides. Generally, people are more affected on one side than the other. However, we have found that, taking into account both sides, we’re able to significantly reduce their medications and manage their symptoms with the deep brain stimulation settings. With programming changes, we’re able to keep up with the changes in their Parkinson’s symptoms; with the progression of the disease.
Dr. Linda Austin: That’s a great advantage. Who is a good candidate for deep brain stimulation?
Vicky Salak: Potential candidates for DBS, for Parkinson’s disease, are patients that clearly have a diagnosis of Parkinson’s disease. Sometimes, there are atypical types of Parkinson’s which will not be helped significantly by the surgery.
Dr. Linda Austin: Such as?
Vicky Salak: Diffusely body dementia, progressive supranuclear palsy, or multiple system atrophy. Once we’re sure that a patient has the diagnosis of Parkinson’s disease, they must also have a good response to their medications. Basically, we tell patients that whatever their best on time is will, accordingly, be how they’ll be with the stimulation, about 90 percent of the time. And this is significant to patients. As the disease progresses, they have fluctuations. On time refers to periods when they can function. In some cases, they can barely move. So, to be on for 90 percent of their day is very significant to patients. They’re not living their life around their medication schedule, so they have a better quality of life.
We can also significantly reduce their medications to, maybe, one pill four times a day, whereas, prior to surgery, they may have been taking 20 pills a day. So, this is very significant, cost wise and in managing their day, as well as the side effects of the medications.
So, someone needs to have good on time, a good response to their medications, and have exhausted all pharmacological treatment. Because this is a very invasive surgery, you want to make sure you’ve exhausted that option, and, basically, to have had Parkinson’s for at least five years. At that point, we can pretty much rule out that this is an atypical type of Parkinson’s.
Dr. Linda Austin: Now, you mentioned the cost of medications. How about the cost of DBS? Is it covered by insurance?
Vicky Salak: Medicare has covered DBS surgery. And, private insurance, in all cases that I’ve come into contact with, has covered it.
Dr. Linda Austin: Vicky, what are some of the potential side effects, or adverse consequences, of deep brain stimulation?
Vicky Salak: After surgery, patients can have some brain swelling, which is normal and can take 6 to 12 weeks to resolve. During that time, their balance may be affected, and their thinking may be affected, so we just need to be aware of that during that time. But, that will resolve. Patients can also become emotionally labile; more emotional. They cry over commercials; they cry more easily. That can happen after surgery, and sometimes needs to be treated.
What becomes apparent in a lot of patients is that the Parkinson’s medications are actually mood elevators. As we take them off the medications, patients with Parkinson’s disease can be prone to depression because they [the medications] do affect the same area of the brain. When we take them off the medications, their depression becomes more apparent, and we need to treat that with antidepressants.
Dr. Linda Austin: And, does that depression usually then respond to antidepressants?
Vicky Salak: Yes.
Dr. Linda Austin: It does?
Vicky Salak: We’ve had a few cases where patients have had some high energy levels during their lifetime. They haven’t really been diagnosed as bipolar or obsessive compulsive. When we start putting an electrical field in the brain, sometimes we’re close to the limbic system and can activate some of that behavior. We do take a careful history to understand whether that could be problem later on; we’re aware of that. We can address that if that should come up and need treatment.
Dr. Linda Austin: Vicky, let’s talk, now, about the adjustment of the stimulation. I know you’re responsible for that part. How often does that occur? And, how do you make the decision about when it’s time for that to happen?
Vicky Salak: Generally, the first programming visit, when we adjust the stimulation, occurs about two weeks after the generators are implanted. At that time, we need to start reducing medications, as the stimulation is like taking medication. So, we need to bring the medication level down and bring the stimulation level up. Generally, this takes about six months to get it to an acceptable level, where patients are stable on minimal medications and stimulation. Visits are generally every month and can take up to an hour to several hours, depending on the presence of side effects. Sometimes, with stimulation, we can cause other side effects, such as speech changes, dyskinesias; the type of movement that Michael J. Fox has, some ballistic movement, in some patients. So, sometimes, patients need to sit and allow the stimulation, at whatever settings I’ve chosen, to take place for about an hour or so to see if any adverse events occur that need to be addressed before going home. This is particularly important in patients that live several hours away and cannot come back very easily.
Dr. Linda Austin: So, in other words, their regular doctor could not do this, if they live several hours away; they always need to come back?
Vicky Salak: Correct.
Dr. Linda Austin: Now, what happens if, let’s say, next year, or in three years, a cure for Parkinson’s disease is found?
Vicky Salak: That’s the great thing about deep brain stimulation. We can turn it off if we need to remove the hardware; we can do that, and the patient can participate in whatever future treatment available that they feel would be better for them.
Dr. Linda Austin: Some people listening to this, no doubt, will want to be evaluated for deep brain stimulation. What would be their next step?
Vicky Salak: The next step would be for their primary care physician, or their neurologist, to refer them to the MUSC, to one of our movement disorder specialists; Dr. Kenneth Bergmann or Dr. Vanessa Hinson. They will evaluate them to ensure that they’re appropriate candidates for the surgery. Once that’s determined, we then refer them to the neurosurgeon, so they can meet with him, so he can address the risks and benefits of surgery. We also like to have them contact patients that have had the surgery, so they can get their input as to what they feel the benefit has been to them.
Dr. Linda Austin: Is there a telephone number here, at MUSC, for patients to call?
Vicky Salak: First of all, they can go to www.muschealth.com/movementdisorders. There’s information there about our program. They can also contact our scheduling department: (843) 792-3223.
Dr. Linda Austin: And, just ask for?
Vicky Salak: Just let them know that they need a referral for Dr. Kenneth Bergmann or Dr. Vanessa Hinson, for DBS evaluation, and they’ll direct you as to whatever information is needed in order to schedule an appointment.
Dr. Linda Austin: Would a person need a referral from their own physician?
Vicky Salak: Yes. We’ll need to see what their treatment has been so far. This is not a treatment that’s used in newly diagnosed Parkinson’s patients. This is for someone who, as I said, has exhausted pharmacologic treatment and was diagnosed at least five years ago. We need to be sure that theirs is not an atypical type of Parkinson’s.
Dr. Linda Austin: Vicky, thank you so much for talking with us.
Vicky Salak: Thank you.
If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you’d like to schedule an appointment with one of our physicians, please call MUSC Health Connection at: (843) 792-1414.