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Care of the patient with Deep Brain Stimulation

Joan Miravite, DNP, RN, FNP-BCDoctor of Nursing PracticeBoard Certified Nurse PractitionerAssistant Professor of NeurologyIcahn School of Medicine at Mount Sinai

Disclosure:

Medtronic Deep Brain Stimulation

(DBS) Advisory Board

Off label use of devices or products

will be not be discussed. No

commercial company or product

names will will be used in this

presentation.

Learning Objectives:

1. To be able to identify features of Parkinson’s

disease, tremor and dystonia

2. To become familiar with medications for

movement disorders

3. To be able to list symptoms treated by Deep Brain

Stimulation (DBS)

4. To become familiar with Multidisciplinary care of

the movement disorder patient

5. To understand the benefits of medical and surgical

treatments for movement disorders

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WHAT CONDITIONS DO WE TREAT WITH DBS?

FDA Approved Indications: Parkinson’s disease (PD) – STN or GPi Essential Tremor (ET) - VIM Dystonia (Cervical or Generalized) - GPi Obsessive Compulsive Disorder (OCD) Epilepsy (Anterior Nucleus of Thalamus)

Shukla & Okun 2016

What is Parkinson’s disease?

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PD Clinical FeaturesPD Clinical Features

• Onset: insidious,

• unilateral progressing to bilateral

• Cardinal signs

• (motor symptoms)

• Bradykinesia*

• Resting tremor

• Rigidity

• Loss of postural reflexes

• 60-80% Dopaminergic

neuronal cell loss in PD

occurs before symptoms

appear

• Non-motor features may

predate the onset of

classic motor symptoms

by years

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Bradykinesia

Slowness of movement. Associated with Parkinson’s Disease.

Video

Rest Tremor

Involuntary rhythmic oscillation of a limb at rest, diminishing with action. A cardinal sign of Parkinson’s disease.

video

Loss of Postural Reflexes

Retropulsion, inability to “right” oneself when force is used to require a stepping response. A cardinal sign of Parkinson’s disease.

Video

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Dyskinesia

Abnormal involuntary movements that occur in response to dopamine therapy. “Choreiform” movements.

Video

Parkinson’s disease MedicationsTherapeutic Class and Medication Daily dose Side Effect Profile

Dopamine precursorCarbidopa/Levodopa (Sinemet)

ODT (orally dissolving tablet)CR or ER (extended release)Rytary (long acting)Duopa (intestinal gel)Carbidopa/Levodopa/Entacapone (Stalevo)Imbrija (inhaled Levodopa)

Individualize dose, starting with tid-qidMax dose: 200/2,000 mg/dayMax dose: 200/2,000 mg/dayCR or ER max dose: 600/2,400 mg/dayRytary max dose: 612.5/2450 mgDuopa max dose: 2,000 mg/day via pegStalevo max dose: 8 tablets/dayImbrija max dose: 2 caps inh up to 5x/day

nausea, dizziness, dyskinesia, orthostatic hypotension, hallucinations,compulsive behavior,vivid dreams

Dopamine AgonistsPramipexole (Mirapex)Pramipexole (Mirapex ER)Ropinirole (Requip)Ropinirole (Requip XL)Apomorphine (Apokyn SC inj)Bromocriptine (Parlodel)Rotigotine (Neupro transdermal)

tid, Max dose: 4.5 mg/dayqd, Max dose: 2.25 mg/daybid-tid, Max dose: 24 mg/dayqd, Max dose: 24 mg/dayMax dose: 0.6 mL/dose, up to 5x/daytid, Max dose: 100 mg/dayqd, Max dose: 8 mg/24h

somnolence, hypotension, dizziness, hallucinations, peripheral edema, compulsive behavior, vivid dreams

NMDA Receptor AntagonistAmantadine (Symmetrel)Amantadine ER

(Gocovri) (Osmolex ER)

bid-qid, Max dose: 400 mg/day

qhs, Max dose: 274 mg qd, Max dose: 322 mg/day

hallucinations, dizziness, peripheral edema, vivid dreams, confusion, fatigue, hypotension, livedo reticularis

MAO-B InhibitorsRasagiline (Azilect)Selegiline (Eldepryl)Selegiline ODT (Zelapar)Safinamide (Xadago)

qd, Max dose: 1 mg/daybid, Max dose: 10 mg qam, Max dose: 2.5 mg/dayqd, Max dose: 100 mg/day

hypotension, headache, compulsive behaviors, dizziness, dyskinesia, hallucinations

COMT InhibitorsTolcapone (Tasmar)Entacapone (Comtan, Stalevo)

Give with each Carbidopa/Levodopa doseMax dose: 600 mg/dayMax dose: 1600 mg/day

(Tolcapone – hepatotoxicity)dyskinesia, nausea, dystonia, vivid dreams, hypotension somnolence, diarrhea, confusion, dizziness, hallucinations, compulsive behaviors

AnticholinergicsTrihexyphenidyl (Artane)Benztropine (Cogentin)

tid, Max dose: 15 mg/dayPO/IM/IV qhs, bid-tid, Max dose: 6mg/day

dry mouth, blurry vision, dizziness, nausea, confusion, urinary retention, drowsiness, constipation

PD Medication ConsiderationsMedical Purpose Safe Medications Medications to Avoid

Antipsychotics Quetiapine (Seroquel)Clozapine (Clozaril)

Avoid all other atypical and typical antipsychotics

Pain Medication Use narcotics with caution, as these can cause confusion or psychosis

Avoid using Meperidine (Demerol) if patient is taking Selegiline or Rasagiline(Azilect)

Anesthesia Consult Anesthesia If patient is taking Selegiline or Rasagiline (Azilect), avoid using: Meperidine (Demerol)Tramadol (Ultram), Droperidol (Inapsine), Methadone (Dolophine), Propoxyphene (Darvon), Cyclobenzaprine ((Flexeril) Halothane (Fluothane)

Antiemetics Domperidone (Motilium)Trimethobenzamide (Tigan)Ondansetron (Zofran)Dolasetron (Anzemet)Granisetron (Kytril)

Prochlormethazine (Compazine)Metoclopramide (Reglan)Promethazine (Phenergan)Droperidol (Inapsine)

Antidepressants Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Citalopram (Celexa)Escitalopram (Lexapro)Venlafaxine (Effexor)

Amoxapine (Asendin)

(Adapted from Parkinson Foundation, Aware in Care, Hospital Action Plan Booklet)

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PD Considerations

1. Provide PD meds on time, every time.

2. Do not substitute medications.

3. Do not stop Levodopa therapy abruptly.

4. Resume meds when able.

5. If antipsychotic is needed, use Quetiapine or Clozapine.

6. Watch for symptoms of dysphagia and risk for pneumonia.

7. DBS needs to be turned off for surgery, MRI, EKG, EEG or EMG.

(Adapted from Parkinson Foundation, Aware in Care, Hospital Action Plan Booklet)

What is Essential Tremor?

Essential Tremor

Most common movement disorder

Commonly inherited

Primarily kinetic tremor during voluntary movement, may rarely be present at rest, or with holding postures

Tremor frequency of 4-10 Hz with variable amplitude

Can involve head and vocal cords

Increases with stress

Relieved for short periods by Alcohol

Can see a mild ataxic gait

Louis ED. Expert Review or Neurotherapeutics. 2014;14(9): 1057-65

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Postural (Action) Tremor

Involuntary rhythmic oscillation of a Limb being held in a posture against gravity.

Video

Kinetic (Action) Tremor:Simple kinetic tremor, task specific tremor,

intention tremor and isometric tremor

(typically seen in ET)

Videos

Essential Tremor Medications

Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses

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What is Dystonia?

DYSTONIA

Consensus Definition 2013:

• “Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive movements, postures, or both.

• Dystonic movements are typically patterned, twisting, and may be tremulous.

• Dystonia is often initiated or worsened by voluntary action and associated with overflow muscle activation.”

Albanese, Bhatia, Bressman, et al. Movement Disorders.2013;28:863-873

Dystonic Tremor

Dystonic tremor is an action tremor that may be postural, kinetic or both. This tremor is asymmetric, jerky and irregular.

Video

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Dystonia Medications

Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses

What is Deep Brain Stimulation (DBS)?

Video

An implantable system that modulates brain activity to improve some of the motor symptoms movement disorders

AdjustableBilateral

Reversible

Deep Brain Stimulation (DBS)

Shukla & Okun 2016

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PD (DBS ON & OFF)

VIdeo

DBS for Parkinson’s Disease

Good surgical candidate:

idiopathic PD

responsive to Levodopa

at least 4 years of disease

Experiencing motor fluctuations in response to meds

Intact cognition

Shukla & Okun 2016

What does DBS treat in PD?

Tremor

Bradykinesia

Rigidity

Motor Fluctuations (off time)

Dyskinesias

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In PD, DBS does NOT treat

Cognitive problems

Speech

Mood/anxiety

Gait

Postural instability

Surgical Treatment of ET

Good ET DBS candidate:

debilitating tremor

refractory to medication

DBS for Essential Tremor

Video

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ET (BEFORE & AFTER) DBS

Video

ET PRE-DBS

ET POST-DBS

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Good surgical candidate GPi DBS for Dystonia

Primary dystonia Lack of trauma or

damage to the brain Medically refractory Cognitively intact

Bronte-Stewart, et al. Movement Disorders. 2011.26(S1:S5-S16.

DBS for Generalized Dystonia

Video

DBS for Cervical Dystonia

Video

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DBS Components

DBS Components

DBS Components

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DBS for PD

Video

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DBS Patient Education

• Remind patient that DBS is not a cure (Shukla 2016)

• Remind patient to continue to take medications

• Inform patient that they might be able to lower dose of medication by 25-50% (Shukla 2016)

• Optimal results can take months and will be different for each patient

• DBS Settings and medications are adjusted concurrently

• DBS is a process (Revell 2015)

• Cognition, speech, gait dysfunction, depression, anxiety and postural instability do not respond to DBS (Martinez-Ramirez 2014)

Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses

• Wash hands frequently & any time before touching surgical incisions while healing.

• Look for signs and symptoms of wound infection or skin erosion.

• Change dressings as instructed.

• Refrain from picking, scratching, or unnecessarily touching incisions.

• Call the neurology or neurosurgery office for any erythema, bleeding, purulent discharge or drainage, edema, tenderness, warmth, delayed healing, discoloration, or fever greater than 101°F.

Post DBS Wound Care

Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses

There are several reasons to call the office.

Ensure that the patient has reviewed the following:

• Signs and symptoms of infection

• Signs and symptoms of a stroke:

• BE-FAST (balance, eyes, face, arm, speech, time)

• Headache, weakness, and change in speech or gait

• Abrupt return of symptoms

• Worsening of symptoms

• Burning sensation along the DBS hardwareBautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019)

Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses

DBS Post-Operative Patient & Caregiver Education

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Non-pharmacologic Considerations in Movement Disorders

Physical therapy

Goals:• Improve motor function• Increase range of motion• Build endurance

Techniques: counting steps, marching, visual fixation, balance training

Can be helpful for symptoms such as stooped posture, shuffling and other gait disturbances, difficulty rising from chairs

Occupational therapy

Concentrates on fine finger and hand movements Techniques: adaptive equipment, energy conservation,

range of motion

Speech therapy

Concentrates on speech impairments and swallowing difficulties

Techniques: voice projection and vocal exercises

Diet Patients should maintain a well-balanced diet Meals rich in protein may reduce absorption of levodopa

Multi-disciplinary Team

Movement Disorder SpecialistNurse, Nurse Practitioner, PA

PsychiatristNeuropsychologistPhysical Therapist

Occupational TherapistSpeech TherapistGenetic Counselor

NeurosurgeonSocial WorkerResearchers

Movement Therapists

Conclusions:

1. To be able to identify features of Parkinson’s

disease, tremor and dystonia

2. To become familiar with medications for

movement disorders

3. To be able to list symptoms treated by Deep Brain

Stimulation (DBS)

4. To become familiar with Multidisciplinary care of

the movement disorder patient

5. To understand the benefits of medical and surgical

treatments for movement disorders

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Resources for Patients with Movement Disorders

Parkinson’s disease:

• Michael J. Fox Foundation

• www. michaeljfox.org

• The Parkinson Foundation

• www.parkinson.org

• Parkinson Alliance• www.parkinsonalliance.net

• American Parkinson Disease Association (APDA)

• www.apdaparkinson.org

Essential Tremor

• International Essential Tremor Foundation

• www.essentialtremor.org

Dystonia

• Dystonia Medical Research Foundation

• www.dystonia-foundation.org

References

Albanese, A., Bhatia, K., Bressman, S. B., DeLong, M. R., Fahn, S., Fung, V. S. C., . . . Teller, J. K. (2013).

Phenomenology and classification of dystonia: A consensus update: Dystonia: Phenomenology and

classification. Movement Disorders, 28(7), 863–873. doi:10.1002/mds.25475

Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the

Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of

Neuroscience Nurses

Bronte-Stewart, H., Taira, T., Valldeoriola, F., Merello, M., Marks, W. J., Albanese, A., & . . . Moro, A. E. (2011).

Inclusion and exclusion criteria for DBS in dystonia. Movement Disorders, 26S5. doi:10.1002/mds.23482

Louis, E. D., Rohl, B., & Rice, C. (2015). Defining the treatment gap: What essential tremor patients want that they

are not getting. Tremor and Other Hyperkinetic Movements, 5, 331. doi:10.7916/D87080M9

Martinez-Ramirez, D., & Okun, M. S. (2014). Rationale and clinical pearls for primary care doctors referring

patients for deep brain stimulation. Gerontology, 60(1), 38–48. doi:10.1159/000354880

Parkinson Foundation (n.d.). Aware in Care Hospital Action Plan. Retrieved from:

https://www.parkinson.org/sites/default/files/HospitalActionGuide.pdf

Revell, M. A. (2015). Deep brain stimulation for movement dis- orders. Nurses Clinics of North America, 50(2015),

691–701. doi:10.1016/j.cnur.2015.07.014

Shukla, W. A., & Okun, M. S. (2016). State of the art for deep brain stimulation therapy in movement disorders: A

clinical and technological perspective. IEEE Reviews in Biomedical Engineering, 9, 219–233.

doi:10.1109/RBME.2016.2588399