Surgical Management of Parkinson's Disease in the Elderly

Abstract

BackgroundBackground: Deep Brain Stimulation (DBS) is an increasingly popular therapy for Parkinson's Disease (PD). Despite the experience gained over time with DBS of either the subthalamus or the globus pallidus pars interna, there is still no consensus regarding the age limit for DBS indication. Objectives Objectives: This narrative review of the literature discusses the issues of age and DBS, emphasizing the critical need for good quality evidence to support the surgical management of elderly patients with PD. Methods Methods: We searched PubMed using the terms Parkinson's Disease; Parkinson's Disease therapy; deep brain stimulation; antiparkinsonian agents therapeutic use; age factors; aged; aged, 80 and over; middle aged; treatment outcome; and risk assessments. ResultsResults: We identified several limitations of the available evidence, such as under-representation of older patients in DBS studies, small sample sizes in studies with older participants, heterogeneity of outcomes, and conflicting results. Conclusions Conclusions: Despite preliminary suggestions that age might affect the outcomes of DBS, the evidence to support the hypothesis of age as an independent predictor of DBS outcomes is limited and results are controversial. Ultimately, finding an age-independent biomarker predicting DBS outcome is the final goal to expand this powerful treatment to all patients age in an effective and safe manner.

Deep Brain Stimulation of the Globus Pallidus Internus and Externus in Multiple System Atrophy

“…GPi DBS has been considered the target of choice for patients with PD with frailty, including axial issues. 23 There are only four reported cases of GPi DBS in MSA. [7][8][9]19 A very recent study of 12 patients with MSA undergoing DBS (9 STN and 3 GPi) reported transient improvement of at least one symptom, although 7 had overall worsening while undergoing GPi stimulation.…”

“…GPi DBS has been considered the target of choice for patients with PD with frailty, including axial issues 23 . There are only four reported cases of GPi DBS in MSA 7‐9,19 .…”

Short- and Long-Term Efficacy and Safety of Deep-Brain Stimulation in Parkinson’s Disease Patients aged 75 Years and Older

“…The same applies to clinical trial limits; some studies considered 75 years old as the cutoff [ 8 , 10 ], others considered 80 years [ 11 ], and others had no specified maximum age [ 1 , 2 , 4 ]. In recent years, although there have been reports of DBS in PD patients over 70 years old [ 12 ], even in those aged 75 years and over [ 13 , 14 ], there are still relatively few such reports. With age, many brain functions decline, including working and episodic memory, cognitive and emotional function, decision making, and executive function [ 15 ].…”

“…All patients voluntarily participated in this study and signed an informed consent form. For the inclusion and exclusion criteria for surgery, we referred to the previous literature [ 13 , 27 , 28 , 29 , 30 ]. The following inclusion criteria were used for eligible participants: (1) a 4 year diagnosis of idiopathic PD [ 28 ]; (2) a levodopa/apomorphine challenge test demonstrating >30% improvement in UPDRS-III score [ 29 ]; (3) motor fluctuations and/or severe dyskinesia; (4) QoL and social functioning influenced by levodopa-responsive signs; (5) clinical manifestations in off periods (unpredictable off periods, severe off periods (pain, dystonia, or panic attack), and off time more than 25% in the daytime) [ 13 ].…”

“…Because patients were relatively old, we used strict exclusion criteria to minimize complications, as follows: (1) high surgical risk (e.g., severe atrophy or diffuse vascular white-matter changes in brain magnetic resonance imaging (MRI)) [ 13 ]; (2) severe levodopa-resistant axial impairment (balance, speech, or gait problems) [ 30 ]; (3) suicide risk, moderate or severe depression (HAMD ≥ 17), or severe anxiety (HAMA ≥ 24); (4) moderate or severe cognitive impairment or mild cognitive impairment with progressive features (MMSE < 27 or MoCA < 26); (5) a levodopa/apomorphine challenge test demonstrating ≤30% improvement in UPDRS-III score.…”