Deep Brain Deep Brain StimulationStimulation
Pricilla PuentePricilla Puente
TGH UDTGH UD
Spring 2013Spring 2013
ObjectivesObjectives
Discuss the pathophysiology of Discuss the pathophysiology of Parkinson’s Disease (PD)Parkinson’s Disease (PD)
Describe ways to know if a Describe ways to know if a patient is a candidate for DBS patient is a candidate for DBS therapy therapy
Describe how DBS therapy works Describe how DBS therapy works Discuss benefits of DBS therapy Discuss benefits of DBS therapy List potential side effects and List potential side effects and
risks of DBS therapyrisks of DBS therapy
PathophysiologyPathophysiology
Parkinson’s Disease (PD) is a Parkinson’s Disease (PD) is a chronic progressive disease chronic progressive disease
Degeneration of dopamine Degeneration of dopamine producing neurons in substantia producing neurons in substantia nigra of midbrain (Osborn, Wraa, nigra of midbrain (Osborn, Wraa, & Watson, 2010, p.798)& Watson, 2010, p.798)
Results in disturbed transmission Results in disturbed transmission of nerve impulsesof nerve impulses
Pathophysiology Pathophysiology
Substantia nigra Substantia nigra (located in midbrain) (located in midbrain) beneath basal ganglia beneath basal ganglia
Neurons in substantia Neurons in substantia nigra produce nigra produce dopamine, a dopamine, a neurotransmitter neurotransmitter necessary for smooth, necessary for smooth, voluntary movement voluntary movement
In PD, neurons of In PD, neurons of substantia nigra begin substantia nigra begin to degenerate and dieto degenerate and die Results in lack of Results in lack of
dopamine productiondopamine production Leads to patient Leads to patient
signs/symptoms of PD signs/symptoms of PD (Osborn, Wraa, & (Osborn, Wraa, & Watson, 2010, p.798)Watson, 2010, p.798)
Patient Signs/SymptomsPatient Signs/Symptoms
Resting tremor Resting tremor RigidityRigidity BradykinesiaBradykinesia Postural inabilityPostural inability Begin to appear when Begin to appear when
approximately 70% of neurons in approximately 70% of neurons in substantia nigra have degenerate substantia nigra have degenerate and/or died (Osborn, Wraa, & and/or died (Osborn, Wraa, & Watson, 2010, p. 798) Watson, 2010, p. 798)
PrevalencePrevalence
Second to Alzheimer’s disease as most Second to Alzheimer’s disease as most common of neurological degenerative common of neurological degenerative disordersdisorders
Most common movement disorder Most common movement disorder Estimated to affect about 1 million Americans Estimated to affect about 1 million Americans
with a lifetime risk of 1 in 40 to 50 with a lifetime risk of 1 in 40 to 50 Incidence increases with age, rising sharply Incidence increases with age, rising sharply
after age 60; about 4% of cases occur before after age 60; about 4% of cases occur before age 50 age 50
More common in relatives of PD patients More common in relatives of PD patients (Osborn, Wraa, & Watson, 2010, p.798) (Osborn, Wraa, & Watson, 2010, p.798)
Patient Scenario Patient Scenario
78 year old male 78 year old male Had PD since 2002 (age of onset was 67 years old) Had PD since 2002 (age of onset was 67 years old) Referred by physician for DBS therapy Referred by physician for DBS therapy S/S: discomfort, trouble manipulating right hand, difficulty brushing S/S: discomfort, trouble manipulating right hand, difficulty brushing
teeth, brushing hair, bathing, writing, tremors, rigidity, teeth, brushing hair, bathing, writing, tremors, rigidity, bradykinesia, postural inability bradykinesia, postural inability
HPI: PD, hypotension, depression HPI: PD, hypotension, depression Objective Findings Pre-op: Objective Findings Pre-op:
HR: 60 bpm HR: 60 bpm BP: 90/70 mmHgBP: 90/70 mmHg Temp: 98.6 FTemp: 98.6 F SpO2: 92%SpO2: 92%
Within a short time, patient noticed effects of medications wearing Within a short time, patient noticed effects of medications wearing off and symptoms were worseningoff and symptoms were worsening
Secondary S/S incl dystonia and dyskinesia became severely Secondary S/S incl dystonia and dyskinesia became severely disabling disabling
Nursing DiagnosisNursing Diagnosis
Impaired physical mobility related to rigidity, bradykinesia, postural instability, altered gait
Impaired verbal communication related to voice and speech changes and decreased facial expression
Disturbed thought processes (confusion, hallucinations, and delusions) related to cognitive changes, medication regimen, and/or infection (Osborn, Wraa, & Watson, 2010, p. 806)
Adult failure to thrive r/t depression associated withchronic progressive disease
Imbalanced nutrition less than body requirements r/t tremor, slowness in eating, difficulty in chewing and swallowing
Risk for injury r/t tremors, slow reactions, altered gait (Ackley & Laddwig, 2011, p.85)
MedicationsMedications
Carbidopa-Levadopa Carbidopa-Levadopa Dopamine Agonists Dopamine Agonists MAOB InhibitorsMAOB Inhibitors COMT Inhibitors COMT Inhibitors AnticholinergicsAnticholinergics Start low, go slow Start low, go slow Fall prevention Fall prevention Hydration important to counteract low BP, Hydration important to counteract low BP,
constipation, general health constipation, general health (Osborn, (Osborn, Wraa, & Watson, 2010, p.800)Wraa, & Watson, 2010, p.800)
Current Treatment: DBSCurrent Treatment: DBS
Alternative treatment for PD and Alternative treatment for PD and essential tremor that can improve essential tremor that can improve motor function motor function
Surgical approachSurgical approach Placing electrodes in targeted Placing electrodes in targeted
areas of the brain areas of the brain Subthalmic nucleus Subthalmic nucleus Globus Pallidus Globus Pallidus
Does not cure the disease, but Does not cure the disease, but may help lessen symptoms may help lessen symptoms (Osborn, Wraa, & Watson, 2010, p. (Osborn, Wraa, & Watson, 2010, p. 804) 804)
In some cases, medications may In some cases, medications may still be needed, at lower doses, for still be needed, at lower doses, for certain conditions certain conditions
Does not damage nerve cells Does not damage nerve cells Can be reversed if needed (Jasmin, Can be reversed if needed (Jasmin,
2012)2012) Health-related quality of life seems
to improve to a greater extent in women (Hariz, Limousin, Zrino, Tripoliti, Aviles-Olmos, Jahanshahi, Hamberg, & Foltynie, 2013)
Medications vs. DBSMedications vs. DBS
Medications AloneMedications Alone 0 hours of additional 0 hours of additional
“on” time“on” time Unpredictable motor Unpredictable motor
fluctuations fluctuations Dyskinesias and Dyskinesias and
nonmotor side effects nonmotor side effects
DBS Therapy & MedicationsDBS Therapy & Medications
Average 5.1 hours Average 5.1 hours additional “on” time additional “on” time without troubling without troubling dyskinesias dyskinesias
More predictable More predictable motor fluctuations motor fluctuations
Medication reduction Medication reduction may lead to fewer may lead to fewer drug-induced side drug-induced side effects effects
(Medtronic, 2013)
Target AreasTarget Areas
(Jasmin, 2012)
Potential DBS SitesPotential DBS Sites
*STN DBS is currently most common target *STN DBS is currently most common target in PD (Jasmin, 2012)in PD (Jasmin, 2012)
DBS Site Therapeutic Effect(s)
*Subthalamic Nucleus (STN)
Reduction in tremor, rigidity, bradykinesia, and dyskinesia
Globus Pallidus internus (GPi)
Same as above
Ventralis intermediate nucleus of the thalamus (Vim)
Reduction in tremor
Candidates for DBS Candidates for DBS
DiagnosisDiagnosisAdvanced PD complicated by motor fluctuation, dyskinesia, or tremor despite optimized Advanced PD complicated by motor fluctuation, dyskinesia, or tremor despite optimized drug therapy drug therapy Atypical parkinsonism and are not considered good candidates Atypical parkinsonism and are not considered good candidates
AgeAgeNo cut-off point based on ageNo cut-off point based on ageConcerns with older age include increased comorbidities, cognitive decline, higher Concerns with older age include increased comorbidities, cognitive decline, higher incidence of levadopa-resistant symptoms, and greater risk of complications incidence of levadopa-resistant symptoms, and greater risk of complications
Disease DurationDisease DurationConcern about operating on individual earlier than 5 years following diagnosis increases Concern about operating on individual earlier than 5 years following diagnosis increases risk of operating on patients with atypical parkinsonism risk of operating on patients with atypical parkinsonism
Levodopa Response Levodopa Response Response to levadopa considered single best outcome predictor for response to DBS in Response to levadopa considered single best outcome predictor for response to DBS in parkinsonism parkinsonism
Cognitive Impairment Cognitive Impairment Dementia is most frequent exclusion criteriaDementia is most frequent exclusion criteriaAdvanced age may be associated with higher risk of frontal and related detioration Advanced age may be associated with higher risk of frontal and related detioration following DBS of STNfollowing DBS of STN
Psychiatric IssuesPsychiatric IssuesUnstable psychiatric conditions Unstable psychiatric conditions Increased risk of suicide following DBS Increased risk of suicide following DBS need for accurate preoperative psychiatric need for accurate preoperative psychiatric assessments, treatment of depression, and careful postoperative follow-op (Jasmin, 2012)assessments, treatment of depression, and careful postoperative follow-op (Jasmin, 2012)
Candidates for DBSCandidates for DBS
Undergo a complete multidisciplinary Undergo a complete multidisciplinary screening with a neurologist, psychiatrist, screening with a neurologist, psychiatrist, neuropsychologist, neurosurgeon neuropsychologist, neurosurgeon
PD patients should undergo a “off/on” PD patients should undergo a “off/on” levadopa medication challenge to levadopa medication challenge to determine which symptoms responds determine which symptoms responds best to medication—these usually are the best to medication—these usually are the ones that respond best to stimulation ones that respond best to stimulation (Olanow, & Schapira, 2009)(Olanow, & Schapira, 2009)
Medtronic 3-day “On” Time DiaryMedtronic 3-day “On” Time Diary
How DBS WorksHow DBS Works
(National Institutes of Health, 2012)
How DBS WorksHow DBS Works
(National Institutes of Health, 2012)
DBS: Pre-OpDBS: Pre-Op
Fit with Fit with sterotactic head sterotactic head frame frame
MRI to map brain MRI to map brain and identify and identify area(s) in brain area(s) in brain where electrodes where electrodes will be placed will be placed
NPO 6-12 hours NPO 6-12 hours prior to surgeryprior to surgery
(Jasmin, 2012)
DBS: Intra-OpDBS: Intra-Op
Part I: Part I:
Brain SurgeryBrain Surgery Local anesthetic—don’t Local anesthetic—don’t
need an anesthetic in need an anesthetic in brain itself b/c brain has brain itself b/c brain has no pain receptors no pain receptors
Patient awake and alert Patient awake and alert during procedure during procedure
Surgeon implant thin Surgeon implant thin wire lead with four wire lead with four electrodes at tips into electrodes at tips into specific area of brainspecific area of brain
Neurologist and surgeon Neurologist and surgeon monitor brain to ensure monitor brain to ensure correct electrode correct electrode placementplacement
Part II: Part II:
Chest Wall SurgeryChest Wall Surgery General anesthesia usedGeneral anesthesia used Surgeon implans Surgeon implans
pacemaker-like device pacemaker-like device that contains the that contains the batteries under skin in batteries under skin in chest, near collarbone chest, near collarbone
Wires from brain Wires from brain electrodes placed under electrodes placed under skin and guided down to skin and guided down to pulse generator –pulse generator –programmed to send programmed to send continuous electrical continuous electrical pulses to brain pulses to brain
(Massachusetts General Hospital, 2008)
DBS: Post-OpDBS: Post-Op
Patient takes antibiotics to Patient takes antibiotics to lower risk of infectionlower risk of infection
Pulse generator in chest is Pulse generator in chest is activated in doctor’s officeactivated in doctor’s office
Doctor can program pulse Doctor can program pulse generator from outside generator from outside body using special remote body using special remote control –amount of control –amount of stimulation customized to stimulation customized to patient’s condition patient’s condition
Battery life varies with Battery life varies with usage and setting—may usage and setting—may last between 3-5 years last between 3-5 years and can be replaced and can be replaced during an outpatient during an outpatient procedure procedure
Once connected, the tiny Once connected, the tiny pulses interfere with/block pulses interfere with/block electrical signals that electrical signals that cause movement disorder cause movement disorder symptoms (Jasmin, 2012)symptoms (Jasmin, 2012)
Patient TeachingPatient Teaching
DBS is not a cure for PD, but helps control DBS is not a cure for PD, but helps control symptoms symptoms
DBS is not a substitute for medication use; DBS is not a substitute for medication use; drugs may still be needed to control symptoms drugs may still be needed to control symptoms
Generally, symptoms that improve with Generally, symptoms that improve with levadopa administration will be improved with levadopa administration will be improved with DBS DBS
The DBS system is composed of the lead wire, The DBS system is composed of the lead wire, extension (connecting) wire, implanted extension (connecting) wire, implanted neurostimulator, programmer, and patient neurostimulator, programmer, and patient controller and/or magnet (Massachusetts controller and/or magnet (Massachusetts General Hospital, 2008)General Hospital, 2008)
Batteries must be replaces every 3-5 years Batteries must be replaces every 3-5 years
Complications Complications
Surgical procedureSurgical procedure Intracerebral hemorrhage, infarction, Intracerebral hemorrhage, infarction,
infection, seizures, pulmonary embolism infection, seizures, pulmonary embolism DBS systemDBS system
Infection, lead break, lead displacement, Infection, lead break, lead displacement, skin ulceration, misplacement/migration of skin ulceration, misplacement/migration of the lead the lead
StimulationStimulation Ocular and speech abnormalities, muscle Ocular and speech abnormalities, muscle
twitches, paresthesias, depression, suicide, twitches, paresthesias, depression, suicide, confusion, death (Olanow, & Schapira, 2009)confusion, death (Olanow, & Schapira, 2009)
Riskier in people over age 70 and those Riskier in people over age 70 and those with comorbities like HTN and diseases with comorbities like HTN and diseases that affect blood vessels in brain that affect blood vessels in brain
Research vs. PracticeResearch vs. Practice
DBS is not for idiopathic parkinonismDBS is not for idiopathic parkinonism Examining additional targets that Examining additional targets that
might benefit gait dysfunction, might benefit gait dysfunction, depression, cognitive impairment in depression, cognitive impairment in PD PD
More DBS and device-related studies More DBS and device-related studies are needed to know all adverse are needed to know all adverse effects (Olanow, & Schapira, 2009)effects (Olanow, & Schapira, 2009)
Changes in clinical symptoms can be Changes in clinical symptoms can be associated with battery drain associated with battery drain ((Fakhar, Hastings, Butson, Foote, Zeilman, & Okhun, 2013)
PrognosisPrognosis
Research being done: To determine its safety, reliability, and effectiveness as a treatment for PDTo determine the site(s) in the brain where DBS surgery will be most effective in reducing PD symptomsTo compare DBS to other PD therapies to find out which is more effectiveTo study DBS as a treatment for epilepsy, cluster headaches, Tourette syndrome, chronic pain, major depressio (National Institutes of Health, 2012)
Patient OutcomePatient Outcome
Decided to treat patient with DBP Decided to treat patient with DBP to left subthalmic nuclei on to left subthalmic nuclei on 3/1/2013 with a pulse generator 3/1/2013 with a pulse generator placement 2 weeks laterplacement 2 weeks later
After treatment patient’s gait After treatment patient’s gait became normal, increased agility became normal, increased agility in upper extremities, dyskinesia in upper extremities, dyskinesia and dystonia had disappeared and dystonia had disappeared
ConclusionConclusion
STN stimulation from DBS alone significantly improves smooth pursuit in patients with PD (Nilsson, Patel, Rehncrona, Magnusson, & Fransson, 2013)
NCLEX QuestionsNCLEX Questions
A patient asks what can be expected from DBS therapy for treatment of parkinsonism. The best response by the nurse would be:
a. That a cure can be expected within 6 months
b. That symptoms can be reduced, and the ability to perform ADLs can be improved
c. That disease progression will be stopped
d. That EPS will be prevented
NCLEX QuestionsNCLEX Questions
A patient asks what can be expected from DBS therapy for treatment of parkinsonism. The best response by the nurse would be:
a. That a cure can be expected within 6 months
b. That symptoms can be reduced, and the ability to perform ADLs can be improved
c. That disease progression will be stopped
d. That EPS will be prevented
NCLEX QuestionsNCLEX Questions
A client is scheduled to receive DBS therapy for relief of parkinsonian symptoms on 4/29/2013. Which of the following statements made by the client best indicates that the client needs further teaching?
a. “My hands won’t be as shaky as they are now.”
b. “The pulse generator battery re-charges itself, therefore it lasts a lifetime.”
c. “I will be awake and alert during the brain surgery procedure.”
d. “I cannot eat or drink for 6-12 hours before my surgery.”
NCLEX QuestionsNCLEX Questions
A client is scheduled to receive DBS therapy for relief of parkinsonian symptoms on 4/29/2013. Which of the following statements made by the client best indicates that the client needs further teaching?
a. “My hands won’t be as shaky as they are now.”
b. “The pulse generator battery re-charges itself, therefore it lasts a lifetime.”
c. “I will be awake and alert during the brain surgery procedure.”
d. “I cannot eat or drink for 6-12 hours before my surgery.”
Helpful SourcesHelpful Sources
Medtronic FAQs DBS Journey (short version) DBS Journey (long version) Medline Plus Long Video
ReferencesReferences
Ackley, B.J., & Laddwig, G. B. (2011). Nursing Diagnosis Handbook. St. Louis, MO: Mosby, Inc. Fakhar, K., Hastings, E., Butson, C.R., Foote, K.D., Zeilman, P., & Okun, M.S. (2013). Management of deep brain stimulator battery failure: battery estimators, charge density, and importance of clinical symptoms. PLoS One, 8. Retrieved fromhttp://www-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/pubmed/23536810 Hariz, G.M., Limousin, P., Zrino, L., Tripoliti, E., Aviles-Olmos, I., Jahanshahi, M., Hamberg, K., & Foltynie, T. (2013). Gender differences in quality of life following subthalmic stimulation for Parkinson’s disease. Acta Neurologica Scandinavica. Retrieved fromhttp://www-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/pubmed/23550919 Jasmin, Luc. (2012). Deep Brain Stimulation. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007453.htm Massachusets General Hospital. (2008). Deep Brain Stimulation. In Comprehensive Clinical Psychiatry (Chapter 46: Neurotherapeutics). Retrieved from http://www.mdconsult.com.ezproxy.hsc.usf.edu/books/page.do?eid=4-u1.0-B978-0-323-04743-2..50048-2--cesec6&isbn=978-0-323-04743-2&sid=1426293494&uniqId=407266391-3#4-u1.0-B978-0-323-04743-2..50048-2--cesec6
Medtronic. (2013). DBS Therapy for Parkinson’s Disease. Retrieved from http://www.medtronicdbs.com/parkinsons/index.htm. Medtronic. (2013). DBS Therapy for Parkinson’s Disease. Retrieved from http://www.medtronicdbs.com/parkinsons/index.htm. National Institutes of Health. (2012). NINDS Deep Brain Stimulation for Parkinson’s Disease Information Page. Retrieved from http://www.ninds.nih.gov/disorders/deep_brain_stimulation/deep_brain_stimulation.htm Nilsson, M.H., Patel, M., Rehncrona, S., Magnusson, M., & Fransson, P.A. (2013). Subthalamic deep brain stimulation improves smooth pursuit and saccade performance in patients with Parkinson’s disease. Journal of Neuroengineering and Rehabilitation, 10. Retrieved from http://www-ncbi-nlm-nih-gov.ezproxy.hsc.usf.edu/pubmed/23551890 Olanow, C. W., & Schapira, A. H. (2009). Parkinson’s Disease and Related Disorders. In Harrison’s Online. (Section 2. Diseases of the CNS). Retrieved from http://www.accessmedicine.com.ezproxy.hsc.usf.edu/content.aspx?aID=9146572&searchStr=deep+brain+stimulation#9146572 Osborn, K.S., Wraa, C.E., & Watson A.B. (2010). Medical Surgical Nursing: Preparation for Practice. Upper Saddle River, NJ: Pearson.