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Dementia In Parkinson's Disease Tips

Causes and Symptoms of Dementia

Dr. Sushil Kumar S V 93% (2093 ratings)
MBBS, MD - Psychiatry, MBA (Healthcare)
Psychiatrist, Davanagere
Causes and Symptoms of Dementia

Dementia cannot be singularly regarded as a specific disease, but rather indicates a group of symptoms associated with your memory, cognitive thinking, and social abilities, up to the point where daily functioning gets affected. In most cases, dementia steadily worsens over time (progressive dementias). Dementia is not to be confused with memory loss alone; because it is natural with old people to experience memory loss, but that does not necessarily mean they have dementia. If the reason is dementia, then you may require medical treatment.

Causes:

Dementias are generally caused either by damage to or changes in the nerve cells operating in the brain. The causes can be grouped differently based on the type of dementia experienced and the part of the brain affected. While some causes can be reversed with effective treatment, others, unfortunately, cannot.

The most common causes of dementia which cannot be reversed include:

  1. Alzheimer's disease
  2. Vascular dementia
  3. Parkinson's disease
  4. Frontotemporal dementia
  5. Dementia with Lewy (dementia which is neurodegenerative and progressive in nature) bodies
  6. Severe head injuries

Other irreversible causes which are relatively rarer than usual include:

  1. Huntington's disease (breakage of the brain's nerve cells)
  2. Creutzfeldt-jakob disease (irreversible and fatal brain disease)
  3. Multiple sclerosis or amyotrophic lateral sclerosis
  4. Infections like syphilis
  5. Leukoencephalopathies (diseases affecting the brain's'white' areas)
  6. Brain injuries
  7. Multiple system atrophy

Causes of dementia which can be treated include:

  1. Hypothyroidism
  2. Heavy metal poisoning
  3. Certain brain tumors
  4. Chronic alcoholism
  5. Hiv/aids
  6. Vitamin b12 deficiency
  7. Medicinal side effects or abnormal drug reactions
  8. Normal pressure hydrocephalus
  9. Certain cases of encephalitis

Symptoms

Symptoms of dementia include:

  1. Memory loss
  2. Difficulty finding the right words
  3. Difficulty exercising judgments, especially during emergencies
  4. Inability to recall particular events or to recognize people and places
  5. Depression or other mood disorders, in addition to symptoms like uncontrolled aggression or constant agitation.
Vitamin b1 deficiency
4078 people found this helpful

Parkinson's Disease - What Causes It?

Dr. Sambhaji S Garje 91% (10 ratings)
Bachelor of Ayurveda, Medicine and Surgery (BAMS), Fellowship In Ano-Rectal-Surgery
Ayurveda, Thane
Parkinson's Disease - What Causes It?

Parkinsonism is often mistaken for Parkinson's Disease. Though similar in quite a few aspects, yet Parkinsonism is not the same as Parkinson's Disease. Parkinsonism is a medical condition whereby the affected individual exhibits some symptoms identical to those observed in the case of a Parkinson's disease.

Factors that lead to Parkinsonism
Parkinsonism can result from a host of factors and health condition such as

  1. Increased and repeated exposure to toxic gases and substances, namely organic solvents, cyanide, manganese, or carbon monoxide.
  2. People suffering from the repeated head injury (as in the case of boxing or wrestling).
  3. The medications used in the treatment of psychiatric problems (antipsychotic medicines) or those used in treating nausea (Prochlorperazine or even Metoclopramide). Some of the antipsychotic drugs have the potential to interfere (block) with the activity of the neurotransmitter Dopamine resulting in parkinsonism.
  4. The use of MPTP (1-Methyl-4-Phenyl-1,2,3,6-Tetrahydropyridine), especially the oxidized product MPP+ (1-methyl-4-Phenylpyridinium) can wreck havoc resulting in parkinsonism and the associated symptoms.

Some of the medical conditions that can contribute towards Parkinsonism include

  1. Viral Encephalitis (resulting in acute brain inflammation).
  2. Alzheimer's Disease (a progressive neurodegenerative disorder that triggers cognitive and behavioral problems often accompanied with dementia).
  3. Multiple system atrophy (a progressive neurodegenerative disorder resulting in dysfunctioning of the autonomic nervous system and the voluntary movements).
  4. Progressive supranuclear palsy or Steele-Richardson-Olszewski syndrome (a rare disorder of the brain that interferes with the balancing, walking, and the eye movements of the affected person.
  5. Stroke or a brain tumor.
  6. Lewy body dementia (a condition triggered by the unusual accumulation of alpha-synuclein protein in the brain with the person exhibiting symptoms associated with both Alzheimer's disease and Parkinson's disease).
  7. Wilson Disease (an autosomal recessive condition whereby copper starts accumulating in the vital organs including the liver and the brain).

Symptoms
In patients with parkinsonism,

  1. The muscles appear stiff. A person experiences a resting tremor (tremor that mainly affects one hand even when the muscles are relaxed), along with difficulty while walking or balancing their body. (These symptoms are also characteristic of a Parkinson's disease).
  2. Further, there may be early signs of dementia (loss of memory or forgetfulness). There may be Agnosia, Aphasia, or Apraxia
  3. Constipation, a dip in the blood pressure, difficulties in eating or swallowing of food.
  4. Hallucinations and loss of judgment (such as failing to locate the kitchen or bathroom at home).
  5. Unusual eye movements.

Ayurvedic Treatment
According to Ayurveda, Parkinsonism is a manifestation of the vitiation of the Vata Dosha (Wind energy) that takes place in the cranial nerves. Thus, corrective measures are followed to restore the balance between the Vata, Kapha, and Pitta Dosha.

  1. Panchakarma can bring about a visible improvement in patients with Parkinsonism. Oil massages using Ashwagandha and Bala can work wonders.
  2. Brahmi is another wonder herb used to treat Parkinsonism.
  3. Meditation, exercise (light to moderate), yoga can be helpful in the case of Parkinsonism.
  4. Try and make the diet as nutritious and healthy as possible.
  5. A Warm Ayurvedic Oil Application is very effective in relieving these kinds of aches and pain if done on regular basis.

In case you have a concern or query you can always consult an expert & get answers to your questions!

4532 people found this helpful

Causes and Symptoms of Parkinson's Disease

Dr. Manish Vaish 86% (77 ratings)
IFAANS, DNB (Neurosurgery), MBBS
Neurosurgeon, Ghaziabad
Causes and Symptoms of Parkinson's Disease

Parkinson's disease is a neurodegenerative condition that affects your brain cells which produce dopamine and thus hampering all kinds of motor functioning and other emotional responses. After the disease is diagnosed, medication and therapy can help to provide relief from the symptoms to a large extent but a permanent cure is not possible.

Causes:

The disorder does not have a definite set of causes. A small percentage of the cases have been related to hereditary factors and others have a range of environmental causes associated with them.

1. Genetic factors:

Specific gene mutations and gene variations have been proved to cause Parkinson's, such as SNCA, PARK2, PARK7, PINK1 and LRRK2. These make or recycle proteins which are linked to the disease.

Research shows that men are at a 1.75 times greater risk of developing the condition than women are. Also, age plays a role with most cases occurring after the age of 60.

2. Environmental factors:

Regular exposure to inorganic insecticides, pesticides, herbicides and heavy metals or other toxins may cause the disorder. In rare cases, Parkinson's disease occurs in the aftermath of a severe head injury or immune disorders.

Symptoms:

The symptoms can be classified into two broad categories-

1. Motor symptoms:

  • The hand tremors when in resting position
  • The grip loosens
  • Walking slows down
  • Facial muscles freeze partially
  • Speech is slurred
  • Balance is disturbed
  • Swallowing is painful
  • Urination is abnormally frequent
  • Dementia-like symptoms are seen
  • There is involuntary twitching of the fingers and toes
  • Repetition of the same movement in quick succession is nearly impossible

2. Non-motor symptoms:

  • Dental problems
  • Vision impairment
  • Skin disorders
  • Panic attacks
  • Excessive secretion of saliva
  • Extreme weight loss or gain
  • Sexual problems
  • Loss of sense of smell
  • Lowering of the pitch of the voice
  • Fatigue
3276 people found this helpful

Few Warning Signs of Parkinson's Disease You Should Know!

Dr. Kodeeswaran Marappan 93% (64 ratings)
MCh, MBBS, MRCS (UK)
Neurosurgeon, Chennai
Few Warning Signs of Parkinson's Disease You Should Know!

Parkinson's disease is a neurodegenerative condition that affects your brain cells which produce dopamine and thus hampering all kinds of motor functioning and other emotional responses. After the disease is diagnosed, medication and therapy can help to provide relief from the symptoms to a large extent but a permanent cure is not possible.

Causes:

The disorder does not have a definite set of causes. A small percentage of the cases have been related to hereditary factors and others have a range of environmental causes associated with them.

1. Genetic factors:

Specific gene mutations and gene variations have been proved to cause Parkinson's, such as SNCA, PARK2, PARK7, PINK1 and LRRK2. These make or recycle proteins which are linked to the disease.

Research shows that men are at a 1.75 times greater risk of developing the condition than women are. Also, age plays a role with most cases occurring after the age of 60.

2. Environmental factors:

Regular exposure to inorganic insecticides, pesticides, herbicides and heavy metals or other toxins may cause the disorder. In rare cases, Parkinson's disease occurs in the aftermath of a severe head injury or immune disorders.

Symptoms:

The symptoms can be classified into two broad categories-

1. Motor symptoms:

  • The hand tremors when in resting position
  • The grip loosens
  • Walking slows down
  • Facial muscles freeze partially
  • Speech is slurred
  • Balance is disturbed
  • Swallowing is painful
  • Urination is abnormally frequent
  • Dementia-like symptoms are seen
  • There is involuntary twitching of the fingers and toes
  • Repetition of the same movement in quick succession is nearly impossible

2. Non-motor symptoms:

  • Dental problems
  • Vision impairment
  • Skin disorders
  • Panic attacks
  • Excessive secretion of saliva
  • Extreme weight loss or gain
  • Sexual problems
  • Loss of sense of smell
  • Lowering of the pitch of the voice
  • Fatigue

If you wish to discuss about any specific problem, you can consult a Neurosurgeon.

3148 people found this helpful

Parkinson's Disease: Few Early Signs You Need To Know!

Dr. Amit Kumar Ghosh 86% (140 ratings)
MBBS, DNB, Fellowship In Neurosurgery
Neurosurgeon, Kolkata
Parkinson's Disease: Few Early Signs You Need To Know!

Parkinson's disease is a neurodegenerative condition that affects your brain cells which produce dopamine and thus hampering all kinds of motor functioning and other emotional responses. After the disease is diagnosed, medication and therapy can help to provide relief from the symptoms to a large extent but a permanent cure is not possible.

Causes:

The disorder does not have a definite set of causes. A small percentage of the cases have been related to hereditary factors and others have a range of environmental causes associated with them.

1. Genetic factors:

Specific gene mutations and gene variations have been proved to cause Parkinson's, such as SNCA, PARK2, PARK7, PINK1 and LRRK2. These make or recycle proteins which are linked to the disease.

Research shows that men are at a 1.75 times greater risk of developing the condition than women are. Also, age plays a role with most cases occurring after the age of 60.

2. Environmental factors:

Regular exposure to inorganic insecticides, pesticides, herbicides and heavy metals or other toxins may cause the disorder. In rare cases, Parkinson's disease occurs in the aftermath of a severe head injury or immune disorders.

Symptoms:

The symptoms can be classified into two broad categories-

1. Motor symptoms:

  • The hand tremors when in resting position
  • The grip loosens
  • Walking slows down
  • Facial muscles freeze partially
  • Speech is slurred
  • Balance is disturbed
  • Swallowing is painful
  • Urination is abnormally frequent
  • Dementia-like symptoms are seen
  • There is involuntary twitching of the fingers and toes
  • Repetition of the same movement in quick succession is nearly impossible

2. Non-motor symptoms:

  • Dental problems
  • Vision impairment
  • Skin disorders
  • Panic attacks
  • Excessive secretion of saliva
  • Extreme weight loss or gain
  • Sexual problems
  • Loss of sense of smell
  • Lowering of the pitch of the voice
  • Fatigue

If you wish to discuss about any specific problem, you can consult a Neurosurgeon.

2945 people found this helpful

Dementia - Quick Facts You Must Know About It!

Dr. Aparna Gupta 89% (35 ratings)
DNB (Neurology), MD/MBBS - General Medicine
Neurologist, Delhi
Dementia - Quick Facts You Must Know About It!

One of the worst neurological disorders to have is dementia. It is a general term used to describe cognitive decline of the brain. It’s not specific disease but denotes several brain disorders and mental illnesses. A person suffering from dementia can have severe impairment in judgment, loss of memory and thinking. Dementia is a very difficult disease not only for the patient but also for their families and caregivers.

Some facts about dementia are as follows:

  • It’s not a mental disorder occurring in old age but it does degenerates with age.
  • An estimation of 47.5 million people worldwide suffers from dementia and 60% of these people live in low and middle-income countries and according to WHO this figure is likely to increase.
  • Every 4 seconds a new case of dementia is reported

Dementia is a collective term to describe the many types of in people, such as 

  • Alzheimer’s Disease: It is one of the most common type of dementia accounting for 60-80% of dementia case. People suffering from Alzheimer’s have fewer nerve cells and the size of the brain shrinks.
  • Vascular Dementia: Another most common form of dementia occurring after a stroke.
  • Lewy Body DementiaIt is neurodegenerative condition that involves a protein called alpha-synuclein which changes the brain. Symptoms may be similar to Parkinson’s disease.

Symptoms of dementia can range from mild to moderate to severe that includes:

  • Memory Loss
  • Disorientation meaning inability to focus or pay attention
  • Changes in visual perception
  • Impairment in reasoning and judgment

Dementia can be caused by damage to brain cells or progressive brain cell death. As a result communication between brain cells become difficult. Other symptoms include:

Reversible Factors

  • There are no definite tests for dementia. Doctors and neurologists have to medical history, blood tests and CT scans to find out whether a person has dementia or not. However, the most potent evaluation comes from a set of questions that are asked to a patient suspected of having dementia. The ability to answer those questions correctly is one of the best diagnoses for dementia.
  • There is no specific treatment for dementia as it is not a curable disease and degenerates with time. However, medicines or drugs given for Alzheimer’s can be given to people suffering from dementia.
  • Although results vary depending upon a person’s lifestyle’s and habits, doctors suggest eating healthy, exercising regularly, and stopping smoking and drinking may prevent some types of dementia.
  • The best treatment for dementia is to treat the person with care and love so that they don’t feel neglected.

Dementia is often associated with old age but that is not always true. It is important to gain knowledge and educate others also.

1949 people found this helpful

Treating Dementia - Things You Should Know!

Dr. Jaydeepsinh Gohil 89% (14 ratings)
MBBS, MD - Psychiatry
Psychiatrist, Vadodara
Treating Dementia - Things You Should Know!

Diagnosing dementia can be more difficult than you can imagine. Medically, the patient needs to have at least two areas of mental functionality impaired to an extent where it interferes with their everyday life. However, diagnosis is just the beginning as treating dementia can be even more challenging. Here is a look at some of the treatment options available for dementia patients.

Treatment for Dementia
There is often no cure for most forms of dementia. Treatment relies on the management of the condition, to ensure that the progression can be impeded. With proper treatment, patients can live a relatively normal life for a number of years.

  1. Cholinesterase inhibitors- These medications are used for the treatment of Alzheimer’s disease. They are chemical agents that boost the memory and judgment of the patient. The same is also an effective medication for those suffering from Parkinson’s disease and Lewy body dementia.
  2. Therapy- Making small changes to some aspects of life of the patient can often yield good results. For instance, clearing the clutter and noise in the house can be an effective way of helping dementia patients deal with their condition. Similarly, creating a safe environment at home with little chance of severe accidents, will ensure the safety of the patient.

Stress in caregivers of dementia patients
Dementia patients need to be cared for, ideally by a close family member such as a spouse. However, these caregivers undergo a lot of stress while providing support to the patient. For instance, Alzheimer’s patients often do not recognize their caregiver who may also be their spouse. Here are some burdens that caregivers have to deal with.

  1. Anger- The sense of fury towards the patient can be strong after years of providing care. They may also be frustrated with the fact that the affected person is unable to perform simple everyday jobs, such as brushing their teeth or tying their shoelaces.
  2. Anxiety- A sense of hopelessness regarding the future is common. It is also the fear of what new challenges the next day might bring.
  3. Depression- Seeing their loved one’s mental state deteriorating with each passing day can be difficult to handle and pushes some caregivers into depression.

With such continuous emotional and physical stress, caregivers often fall sick themselves. This is why it is necessary to maintain a bright outlook and remember that a dementia patient can only get well if they have the full support of the caregiver. In case you have a concern or query you can always consult an expert & get answers to your questions!

2749 people found this helpful

Parkinson s Disease

Dr. Amit Kumar Ghosh 86% (140 ratings)
MBBS, DNB, Fellowship In Neurosurgery
Neurosurgeon, Kolkata
Parkinson s Disease

Deep brain stimulation in Parkinson’s disease

Abstract: Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson’s disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients.

Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be discussed.

Key words: deep brain stimulation (DBS); Parkinson’s disease(PD),  stereotaxis

Introduction

Parkinson's disease is a slowly progressive, neurodegenerative disease characterized by tremor, rigidity, bradykinesia and postural instability. It is the most common movement disorder in middle or late life with a prevalence of about 0.3% of the general population, rising to 1% in people over 60 years of age. Approximately 130 000 people suffer from it in the UK and it presents an increasing burden in our ageing population. Pathological findings in Parkinson's disease demonstrate greatly diminished neuromelanin pigmented neurons in the substantia nigra of the basal ganglia with associated gliosis, and Lewy bodies present in many remaining neurons.

James Parkinson, in his original 1817 Essay on The Shaking Palsy, gave an account of six patients in which he noted signs of tremor, festinating gait and flexed posture.  Nearly two centuries from Parkinson's observations, and almost four decades after Cotzias' dramatic demonstration of levodopa's efficacy, the limitations and complications of levodopa treatment for Parkinson's disease have become well documented Five years after initiation of therapy, a majority of patients develop medication related motor complications, namely levodopa induced dyskinesias (LID) and motor fluctuations. Deep brain stimulation (DBS) has been developed primarily to address these treatment related motor complications and therapeutic failures.

Pathophysiology of PD

The loss of dopaminergic neurons in the substantia nigra, the main functional characteristic of PD, affects the circuit described above and leads to the cardinal motor symptoms of PD. While the exact mechanism of this process is unknown, animal research as well as human recordings have provided functional and biochemical evidence that bradykinesia in PD results from excessive activity in the STN and the GPi. This leads to an exaggerated beta (10-30 Hz) synchronization within and between structures in the basal ganglia circuitry  that could also contribute to rigidity and akinesia.

The pathophysiology of rest tremor in PD is less clear and probably more complicated. This symptom most likely results from a dysfunction of both the striato-pallidal-thalamocortical and the cerebellodentato-thalamocortical circuits, with hyperactivity and hypersynchronization between central oscillators.

Possible mechanism of action of DBS

DBS acts through delivering an electrical current in a specific target area of the brain. This current can be modulated through modification of voltage, frequency and duration of each electrical pulse delivered. The delivered energy creates an electrical field of variable size and shape according to the parameters used for stimulation. Although initially believed to stimulate the target, thus the name of the whole process, it seems that

DBS actually excites the neuronal fibers, but inhibits the neural cells. In fact, GPi DBS decreases the GPi mean firing rate back to a normal range in animal models as well as PD patients, and high frequency DBS has a similar effect as dopamine replacement therapies, and promotes faster (about 70 Hz) nonhypersynchronous activity in the basal ganglia, correlated with clinical improvement. This might be achieved through stimulation of bypassing inhibitory pathways, synaptic inhibition, depolarizing blockade, synaptic depression, and simulation-induced disruption of pathological network activity. Overall, this leads to modifications of the firing rate and pattern of neurons in the basal ganglia, as well as local release of neurotransmitters such as glutamate and adenosine. In addition, it seems that DBS also increases blood flow and stimulates neurogenesis. Over the last few years, functional imaging, specifically functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single-photon emission computed tomography (SPECT), has been used in an attempt to clarify the mechanism of action of DBS. In fMRI, blood-oxygen-level-dependent (BOLD) signals are acquired, and oxygenated blood marks areas of neural stimulation or inhibition. On the other hand, PET and SPECT allow for imaging of multiple activity markers, such as blood flow, glucose and oxygen metabolism. While fMRI is less powerful than nuclear medicine techniques, it provides a much better spatial and temporal resolution. Because of the suspected inhibitory DBS effects in electrophysiological studies, reduced STN blood flow or glucose metabolism would have been expected on functional imaging. However, the opposite has been found to be true in an overwhelming majority of imaging studies to date. In addition, BOLD activation in the area surrounding the electrode has been reported, despite the electrode imaging artifact preventing direct observation of the STN around the electrode. This discrepancy between apparent STN inhibition in single-cell studies and activation in imaging studies might be explained by a few hypotheses. First, electrophysiological recordings identify short neuronal modulation (in the order of milliseconds) while neuroimaging methods may reflect the summed activity changes over seconds to minutes. Second, non-neuronal contributions to the change in blood flow and/or glucose metabolism cannot be excluded, and could confound the results of neuroimaging.

Finally, it is possible that PET and fMRI actually detect the increased activity in the axons, rather than in the cell bodies. Complicating matters further, some imaging studies after STN DBS have showed increased

activity in the GPi while others reported decreased activity in that nucleus. In summary, it is still unclear how exactly DBS affects the firing rate and pattern of neurons and how these changes actually modify the symptoms of Parkinson’s disease. DBS is presently more of an empirically proven treatment in search of physiological explanation.

The effect of DBS on the cardinal symptoms of PD have been established in three randomized controlled clinical trials --- 

TABLE 1

Author, year

 

No of patients

Follow up

Target

Results

Deuschl et al., 2006

156

6 months

BL STN

QOL better with DBS, motor symptom better with DBS

 

Weaver et al., 2009

255

6 months

BL STN or GPi

Dyskinesia free ON time better with DBS

 

Williams et al., 2010

366

12 months

BL STN  or GPi

QOL better with DBS

 

 

PATIENT SELECTION for DBS in PD

Patient selection is a critical first step as poorly chosen candidates may not have optimal benefits and have increased morbidity. Several factors must be considered before determining if a patient is an appropriate candidate for DBS surgery. A multidisciplinary approach involving the neurosurgeon, neurologist, and neuropsychologist is important to determine the appropriate surgical candidate. It is also important that the diagnosis of idiopathic PD be confirmed prior to proceeding with DBS surgery. Key to this assessment is evaluating the surgical candidate in both the on and off medication states with a corroborating levodopa challenge. Perhaps the best prognostic indicator of a patient’s suitability for DBS surgery is their response to levodopa.In general, a levodopa challenge following a 12-hour medication withdrawal should provide at least a 33% improvement in the motor section of the Unified Parkinson’s Disease Rating Scale (UPDRS).

                     In our institute, we follow a simple chart(below) for screening of patients for DBS in PD.

 

 

  1.  

Age<75 years

 

  •  

No

  1.  

Idiopathic PD ( No PSP/MSA/NSD etc)

 

  •  

No

  1.  

Levodopa responsive  

                      

  •  

No

  1.  

Poor/adverse response to drug          

 

  1.  Increased off period                                                              

 

  1. Disabling dyskinesia                                                              

 

 

  1. Disabling motor fluctuations                 

 

 

Yes

 

Yes

 

 

Yes

 

 

No

 

No

 

 

No

  1.  

Degree of disability(UPDRS part III score)>25

 

  •  

No

  1.  

Neuropsychology, MMSE>24

 

  •  

No

  1.  

LEVODOPA CHALLENGE RESPONSE POSITIVE                                                   

 

(30% improvement in UPDRS after 12-hours off medication)

 

  •  

No

  1.  

Advanced  co-morbidity

 

Yes

  •  
  1.  

long term anticoagulation

 

Yes

  •  
  1.  

Willing for surgery and programming

 

  •  

No

 

 

PREOPERATIVE MANAGEMENT

A full medical assessment is a necessary part of the preoperative evaluation, as advanced PD patients tend to be elderly with significant comorbidities. Major issues are---

 

Anticoagulation/antiplatelets--- The risk of discontinuing medications that affect anticoagulation and

platelet aggregation should be weighed against the potential benefits in the quality of life offered by DBS surgery. However, timely discontinuation of these latter medications is mandatory for stereotactic surgery since intracerebral hematomas are the most serious of all potential complications from DBS. Any anticlotting medications, including aspirin, ticlopidine, clopidogrel, and all nonsteroidal anti-inflammatory drugs should be discontinued at least 7 to 10 days preoperatively to ensure the return of normal blood clotting function.

Arterial hypertension can also increase the risk of intracranial bleeding during stereotactic procedures and must be controlled in the weeks prior to surgery.

A prolonged discussion on the short- and long-term effects of DBS on Parkinson’s disease should be carried out with the patient, family, and caregivers.

The night prior to DBS surgery, the antiparkinsonian medications are typically held to pronounce the Parkinson’s symptoms at the time of surgery to see the clinical effects on symptoms during surgery and the families must be counselled regarding their role in facilitating the patient.

Target selection

The two main targets considered for DBS in PD are the STN and the GPi. current tendency is to prefer targeting the STN because of a greater improvement in the OFF phase motor symptoms as well as a higher chance to decrease the medication dosage and a lower battery consumption linked to the use of lower voltage in the STN compared to the GPi DBS. GPi can be the preferred target if LID is the main complaint. GPi DBS might be preferred for patients with mild cognitive impairment and psychiatric symptoms. Because STN DBS might have a higher rate of cognitive decline and/or depression and worsening of verbal fluency in some studies.

Surgical technique

The basic components of DBS implantation surgery involve frame placement, anatomical targeting, physiological mapping, evaluation of macrostimulation thresholds for improvement in motor symptoms or induction of side effects, implantation of the DBS electrode and implantable pulse generator (IPG).

Head-frame placement

The CRW frame is the most commonly used followed by the Leksell frame. Placement of the frame is done under local anesthesia unless anxiety or uncontrollable movements necessitate the use of sedation or general anesthesia.

Leksell stereotactic frame  placed over the head of a patient showing the correct method for placement of the Leksell head-frame. The frame should be placed parallel to orbito-meatal line in order to approximate the AC-PC plane. It is attached to the patient’s head using four pins under local anesthesia.

Imaging and anatomic targeting

Computerized Tomography (CT) scans and MRI are the two main imaging modalities used for targeting when performing DBS implantations. A thin cut stereotactic CT (_2 mm slices with no gap and no gantry tilt) is obtained after frame placement and is then fused with the stereotactic MRI on a planning station (Stealth station). The advantage of fusing the CT with MRI is the ability to avoid image-distortions inherent to MR imaging adding to the stereotactic accuracy. To better define the STN, T2-weighted images (TR 2800, TE 90, flip angle 90˚, slice thickness 2.0 mm) were obtained.

The AC and the PC were marked and the centre of the AC–PC line determined. The next step is planning the entry point and trajectory. The strategy here is to avoid surface and sub-cortical vessels. After trajectory planning, the patient is placed supine on the operating table and the frame attached to the table using an adaptor. Prophylactic antibiotics are given at least 30 min prior to incision. The head is prepped and draped in a sterile fashion. Under local anesthesia, a burr-hole is placed on the calculated entry point marked on the skull. The entry point is determined by the calculated arc and ring angles. Hemostasis is achieved with bone wax and bipolar cautery.

A Medronic Stim-Loc anchoring device (Medtronic, Minneapolis, MN) burr-hole base ring is then placed on the burr-hole and secured with two screws which are used at the end of the procedure to anchor the DBS electrode.

The dura is then cauterized and opened exposing the underlying surface of the brain. The microdrive is then assembled and cannulae inserted 10 mm above the target to avoid lenticulostriate vessels found deeper. Gel- foam and fibrin glue is applied on dural hole to minimize cerebrospinal fluid (CSF) loss and air entry into the skull. Subsequently, microelectrode recording and stimulation is undertaken.

Microelectrode recording/ Mapping

Microelectrode mapping is used to precisely define the target STN and its boundaries as well as nearby critical structures. We believe microelectrode mapping is crucial in order to give one the best chance for optimal placement of the DBS lead given anatomical inaccuracies due to image distortion and intraoperative brain shifts secondary to CSF loss, and pneumocephalus that can lead to inaccuracies in defining the initial target coordinates and shifts in the target itself once the skull is opened. Microelectrode mapping is performed using platinum-iridium glass coated microelectrodes dipped in platinum black with an impedance of around 0.3–0.5 Mo. These platinum-iridium microelectrodes are capable of recording single unit activity and can also be used for micro-stimulation up to 100 mAwithout significant breakdown in their recording qualities.

As the recording electrode was advanced, entry into the STN was identified by a sudden increase in the density of cellular discharge, with the characteristic irregular pattern of discharge—spikes of different sizes, occurring at random intervals. On coming out of the STN a quiet period (background noise) was seen followed by recording from the substantia nigra if the recording was continued far enough, described as high frequency (50–60 spikes/s) discharge pattern.11 Characteristic STN recordings (visual and audio) were identified and the depth of the STN activity was noted. Identification of STN activity was only based on the visual identification. The centre of the point of best electrical activity was selected as the final target. The microelectrode was replaced with a permanent quadripolar macroelectrode (Medtronic electrode no. 3389) to target the centre of the STN electrical activity. The proximal part of this electrode consists of four nickel conductor wires insulated with a polytetrafluoroethylene jacket tubing. The distal part has four metallic noninsulated contacts of 1.5 mm spaced at 0.5 mm intervals. The diameter of the distal electrode is 1.27 mm. Based on the clinical response any of the four contacts can be used for stimulation. Macrostimulation using the DBS electrode itself is then used to determine benefits and side effects. In most cases lateral skull x rays were obtained at this point with image intensifier carefully positioned to locate the target point in the centre of the Leksell-G frame rings.

Initial programming is always refined by using intra-operative macrostimulation data and a mono-polar review to identify the thresholds of stimulation for improvement in parkinsonian motor signs as well as the thresholds for inducing side effects at the level of each contact. The four variables that are used in programming are choice of contacts (0, 1, 2 or 3 used either as the cathode or anode), frequency of stimulation (hertz), pulse-width (ms) and amplitude (voltage).

POSTOPERATIVE MANAGEMENT

In the immediate hours after surgery, it is important to keep arterial blood pressure in the normal range. In addition, the patient’s preoperative drug regimen should be restarted immediately after surgery to avoid problems with dopaminergic withdrawal. Patients should undergo postoperative CT scans and/or MRI scans to assess the electrode location and intracranial status. In addition, plain X-rays are obtained to assess the location and geometry of the leads and hardware. Parkinson’s medications may need to be adjusted depending on the patient’s status. Cognitive and behavioral changes may occur in the postoperative period, particularly in older patients. Patients can be discharged as early as 24 hours after surgery, depending on their neurological and cognitive status.

Conclusion

For the last 50 years, levodopa has been the cornerstone of PD management. However, a majority of patients develop motor fluctuations and/or LID about 5 years after the initiation of therapy. DBS of the STN or the GPI grant to patients with PD improved quality of life and decreased motor complications, and has been approved as such by the Food and Drug Administration in the US in 2002. We reviewed the experience and available literature on DBS for Parkinson’s disease over the last decade and arrive at the following understandings.

The success of DBS surgery depends on the accurate placement of the leads and meticulous programming of the stimulation. Therefore, it is best accomplished by an experienced team of neurosurgeon, neurologist, and support staff dedicated to the treatment.

Reports of surgical complication rates and long-term side-effects of DBS are very variable, so benefits and potential adverse results should not be under- or over-emphasized.

While essentially equal in improving the motor symptoms of PD, STN and GPi might have their own benefits and risks, and the choice of the target should be individualized and adapted to the patient’s situation.

Knowledge to further improve DBS treatment for Parkinson’s disease, such as a more scientific and reliable protocol on programming, strategies to minimize cognitive and psychiatric complications, and the better

long-term maintenance of the implanted device, are still lacking.

Data on the impact of DBS on non-motor symptoms affecting the quality of life of PD patients, such as pain, speech or gastro-intestinal complaints, are still scarce. Further research in these areas will help make this useful treatment even more beneficial.

4 people found this helpful

Parkinsonism - Factors That Can Lead To It!

Dr. Harshita Sethi 92% (192 ratings)
MD - Ayurveda, CIY, Guru Shishya parampara, BAMS
Ayurveda, Gurgaon
Parkinsonism - Factors That Can Lead To It!

Parkinsonism is often mistaken for Parkinson's Disease. Though similar in quite a few aspects, yet Parkinsonism is not the same as Parkinson's Disease. Parkinsonism is a medical condition whereby the affected individual exhibits some symptoms identical to those observed in the case of a Parkinson's disease.

Factors that lead to Parkinsonism
Parkinsonism can result from a host of factors and health condition such as

  1. Increased and repeated exposure to toxic gases and substances, namely organic solvents, cyanide, manganese, or carbon monoxide.
  2. People suffering from the repeated head injury (as in the case of boxing or wrestling).
  3. The medications used in the treatment of psychiatric problems (antipsychotic medicines) or those used in treating nausea (Prochlorperazine or even Metoclopramide). Some of the antipsychotic drugs have the potential to interfere (block) with the activity of the neurotransmitter Dopamine resulting in parkinsonism.
  4. The use of MPTP (1-Methyl-4-Phenyl-1,2,3,6-Tetrahydropyridine), especially the oxidized product MPP+ (1-methyl-4-Phenylpyridinium) can wreck havoc resulting in parkinsonism and the associated symptoms.

Some of the medical conditions that can contribute towards Parkinsonism include

  1. Viral Encephalitis (resulting in acute brain inflammation).
  2. Alzheimer's Disease (a progressive neurodegenerative disorder that triggers cognitive and behavioral problems often accompanied with dementia).
  3. Multiple system atrophy (a progressive neurodegenerative disorder resulting in dysfunctioning of the autonomic nervous system and the voluntary movements).
  4. Progressive supranuclear palsy or Steele-Richardson-Olszewski syndrome (a rare disorder of the brain that interferes with the balancing, walking, and the eye movements of the affected person.
  5. Stroke or a brain tumor.
  6. Lewy body dementia (a condition triggered by the unusual accumulation of alpha-synuclein protein in the brain with the person exhibiting symptoms associated with both Alzheimer's disease and Parkinson's disease).
  7. Wilson Disease (an autosomal recessive condition whereby copper starts accumulating in the vital organs including the liver and the brain).


Symptoms
In patients with parkinsonism,

  1. The muscles appear stiff. A person experiences a resting tremor (tremor that mainly affects one hand even when the muscles are relaxed), along with difficulty while walking or balancing their body. (These symptoms are also characteristic of a Parkinson's disease).
  2. Further, there may be early signs of dementia (loss of memory or forgetfulness). There may be Agnosia, Aphasia, or Apraxia
  3. Constipation, a dip in the blood pressure, difficulties in eating or swallowing of food.
  4. Hallucinations and loss of judgment (such as failing to locate the kitchen or bathroom at home).
  5. Unusual eye movements.

Ayurvedic Treatment
According to Ayurveda, Parkinsonism is a manifestation of the vitiation of the Vata Dosha (Wind energy) that takes place in the cranial nerves. Thus, corrective measures are followed to restore the balance between the Vata, Kapha, and Pitta Dosha.

  1. Panchakarma can bring about a visible improvement in patients with Parkinsonism. Oil massages using Ashwagandha and Bala can work wonders.
  2. Brahmi is another wonder herb used to treat Parkinsonism.
  3. Meditation, exercise (light to moderate), yoga can be helpful in the case of Parkinsonism.
  4. Try and make the diet as nutritious and healthy as possible.
  5. A Warm Ayurvedic Oil Application is very effective in relieving these kinds of aches and pain if done on regular basis.

In case you have a concern or query you can always consult an expert & get answers to your questions!

4443 people found this helpful

Understanding The Motor & Non-Motor Symptoms Of Parkinson's Disease!

Dr. Devesh K Singh 89% (18 ratings)
MBBS Bachelor of Medicine and Bachelor of Surgery, MS - General Surgery, Mch - Neurosurgery, FLCS
Neurologist, Ghaziabad
Understanding The Motor & Non-Motor Symptoms Of Parkinson's Disease!

What is Parkinson’s disease?
Parkinson’s disease is a progressive and degenerative disorder of the Central Nervous System that mostly affects older people. It is a chronic disease and the symptoms develop over a period of time. The characteristic symptoms of Parkinson’s are rigidity, shaking, bradykinesia (slowness in movement) and shuffled gait. Anxiety and depression also seem to be common in advanced stages of Parkinson’s disease. In addition to the motor symptoms, the cognitive function of the brain is also compromised.

Degeneration of the nerve cells in the substantia nigra of the brain results in the reduction in production of dopamine which is a neurotransmitter in the brain. Neurotransmitters relay impulses from one nerve to the other. This is what is mainly responsible for the motor symptoms in Parkinson’s. Although, Parkinson’s is not a curable disease, it can be controlled and the progress of the disease can be kept in check with certain medications.

What causes Parkinson’s disease?
The cause of Parkinson’s is mostly idiopathic, i.e. the cause is unknown and is not specific. However, there have been cases which show that it can be attributed to factors such as genetic and environmental factors.

What are the symptoms of Parkinson’s?

The symptoms of Parkinson’s can be classified as Motor symptoms and Non-motor symptoms:

Motor Symptoms 

  • Bradykinesia: Slow movement
  • Tremor of limbs
  • Rigidity or stiffness of trunk and limbs
  • Impaired balance and difficulty in coordination or postural instability

Non-motor Symptoms 

Parkinson’s disease is not curable, but when detected early, medicines are prescribed to give symptomatic relief. Dopamine substitutes are prescribed to the patient to relieve the motor symptoms.

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