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.