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BRIEF COMMUNICATIONS: H. Russmann, J. Ghika, J.-G. Villemure, B. Robert, J. Bogousslavsky, P. R. Burkhard, and F. J.G. Vingerhoets Subthalamic nucleus deep brain stimulation in Parkinson disease patients over age 70 years Neurology 2004; 63: 1952-1954 [Abstract] [Full text] [PDF]

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Subthalamic nucleus deep brain stimulation in Parkinson disease patients over age 70 years

Michele Tagliati, Michel H. Pourfar, Ron L. Alterman   (1 March 2005)

Reply to Tagliati et al

Francois JG Vingerhoets, Heike Russmann, Jean-Guy, Villemure, Pierre R Burkhard   (1 March 2005)

Subthalamic nucleus deep brain stimulation in Parkinson disease patients over age 70 years 1 March 2005
Michele Tagliati, Department of Neurology, Mount Sinai School of Medicine One Gustave L. Levy Place, Box 1052, New York, NY 10029, Michel H. Pourfar, Ron L. Alterman Send Correspondence to journal: Re: Subthalamic nucleus deep brain stimulation in Parkinson disease patients over age 70 years michele.tagliati{at}mssm.edu Michele Tagliati, et al.	We read with interest the article by Russmann et al on STN DBS in PD patients older than 70. [1] The authors conclude that age itself is likely an independent risk factor in predicting DBS outcomes. Patients over 70 did not comprise a uniform group in terms of response to DBS, as five of thirteen (38%) did well after surgery. In our experience [2], the average OFF medication motor improvement of 18 patients older than 70 did not statistically differ from that observed in younger patients. As in Russmann et al’s study, some of our elderly patients had a satisfactory post-operative improvement while others achieved a less than optimal response. It appears that using strict age criteria in determining who is a DBS candidate is thus insufficient, potentially including poor candidates and excluding good ones. Given that PD patients older than 70 are potentially the largest population in need of DBS, further studies are needed to clarify what features best predict sub-optimal outcomes. Russmann et al’s suggestion that axial scores are predictive is a potentially important contribution that requires further validation. Looking retrospectively at our older patients who did not do well post-DBS, pre-operative axial scores in the ON state slightly deteriorated after DBS (from 5.8 ± 2.6 to 6.4 ± 2.4). While less dramatic a decline, it offers some corroboration on the potential predictive value of axial scores. To further research predictors of outcome, we recently looked retrospectively at the brain MRI’s burden of pre-operative white matter disease using the Manolio grading system. [3] Our initial review does not seem to indicate any correlation between extent of white matter disease and post-operative course of elderly patients. There are patients over 70 who do well. Identifying this subset pre-operatively will be beneficial to elderly patients suffering from the motor complications of advanced PD. Observing a 25% institutionalized rate of those over 70, Russmann et al also point out the hazards of not identifying these patients. Whether DBS will stave off or hasten the need for nursing home placement in an elderly patient is one of the most important determinations facing the DBS community. References 1. Russmann H, Ghika J, Villemure J-G, Robert B, Bougousslavsky J, Burkhardt PR, Vongerhoets FJG. Subthalamic nucleus deep brain stimulation in Parkinson’s disease patients over age 70 years. Neurology 2004 Nov 23; 63:1952-4 2. Tagliati M, Miravite J, Koss A, Shils J, Alterman RL. Is Advanced Age A Poor Predictor Of Motor Outcome For Subthalamic DBS In Parkinson’s Disease? Neurology 2004; 69: A345. 3. Longstreth WT Jr, Manolio TA, Arnold A, et al. Clinical Correlates of White Matter Findings on Cranial Magnetic Resonance Imaging of 3301 Elderly People: The Cardiovascular Health Study. Stroke 1996; 27:1274-1282
Reply to Tagliati et al 1 March 2005
Francois JG Vingerhoets, CHUV, Lausanne Service de Neurologie, BH13, CHUV, CH-1011-Lausanne, Switzerland, Heike Russmann, Jean-Guy, Villemure, Pierre R Burkhard Send Correspondence to journal: Re: Reply to Tagliati et al francois.vingerhoets{at}chuv.hospvd.ch Francois JG Vingerhoets, et al.	We thank Tagliati et al for their comments. We reiterate that a strict age-based limit (70 years in our study) for STN-DBS might be too drastic. More accurate delineation of inclusion and exclusion criteria for DBS in PD is still needed. In addition, the impact of DBS on partially levodopa-responsive motor aspects, non-motor symptoms, and co-morbidities is still unclear. Frank dementia or significant cognitive decline contraindicate surgery. STN DBS is a heavy surgical procedure [2] and may precipitate dementia in at-risk PD patients. It is still unclear which neuropsychological parameters, clinical signs or symptoms (e.g., hallucinations), or dementia scales are the best predictors of poor postoperative outcome. We recently reported increased risk of suicide in DBS-treated patients, most of whom exhibited varying degrees of depression prior to surgery. [3] Inclusion and exclusion psychiatric criteria for DBS and standardizing specific psychiatric tools for the preoperative assessment of DBS patients are needed. Other non-motor, levodopa- unresponsive features may also emerge as major determinants of DBS outcome including orthostatic hypotension, incontinence and other dysautonomic features of PD. The impact of one or, in old patients, many neurological comorbidities at the time of DBS needs further research but appears a priori critical in view of the length, complexity and invasive nature of the procedure. Tagliati et al failed to identify vascular lesions on T2- weighted MRI scan images as negative outcome parameters. We also looked for such changes in our aged patients but did not find any correlation with outcome. We have also noticed that some rheumatic conditions, such as arthritis, vertebral discopathy and lumbar canal stenosis may exacerbate after DBS and result in orthopedic surgery. [4] Non-neurological comorbidities needing prospective evaluations may alter DBS prognosis. All potential contraindications for STN-DBS mentioned are more frequent in aged patients and may prove to increase the risk of a poor DBS postsurgical outcome. We concur with Tagliati et al that the negative effect of age on STN DBS outcome is indisputable and warrants further examination. References 1. Russmann H, Ghika J, Villemure J-G, Robert B, Bougousslavsky J, Burkhardt PR, Vingerhoets FJG. Subthalamic nucleus deep brain stimulation in Parkinson's disease patients over age 70 years. Neurology 2004 Nov 23;63:1952-4 2. Moller JT, Cluitmans P, Rasmussen LS et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet 1998 ; 351: 857-861 3. Burkhard PR, Vingerhoets FJG, Berney A, Bogousslavsky J, Villemurre JG, Ghika J. Suicide after successful DBS for movement disorders. Neurology 2004; 63: 2170-2172. 4. Wider C, Ghika J, Villemure JG, Burkhard P, Bogousslavsky J, Vingerhoets F. High incidence of osteo-articular complications after STN-DBS in Parkinson’s disease. Mov Disord 2004; 19 (Suppl 9): S298.