Deep Brain Stimulation
Pricilla Puente
TGH UD
Spring 2013
Objectives
Discuss the pathophysiology of
Parkinson’s Disease (PD)
 Describe ways to know if a patient is
a candidate for DBS therapy
 Describe how DBS therapy works
 Discuss benefits of DBS therapy
 List potential side effects and risks of
DBS therapy
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Pathophysiology
Parkinson’s Disease (PD) is a chronic
progressive disease
 Degeneration of dopamine producing
neurons in substantia nigra of
midbrain (Osborn, Wraa, & Watson,
2010, p.798)
 Results in disturbed transmission of
nerve impulses
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Pathophysiology
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Substantia nigra (located
in midbrain) beneath
basal ganglia
Neurons in substantia
nigra produce dopamine,
a neurotransmitter
necessary for smooth,
voluntary movement
In PD, neurons of
substantia nigra begin to
degenerate and die
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Results in lack of
dopamine production
Leads to patient
signs/symptoms of PD
(Osborn, Wraa, &
Watson, 2010, p.798)
Patient Signs/Symptoms
Resting tremor
 Rigidity
 Bradykinesia
 Postural inability
 Begin to appear when approximately
70% of neurons in substantia nigra
have degenerate and/or died (Osborn,
Wraa, & Watson, 2010, p. 798)
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Prevalence
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Second to Alzheimer’s disease as most common
of neurological degenerative disorders
Most common movement disorder
Estimated to affect about 1 million Americans
with a lifetime risk of 1 in 40 to 50
Incidence increases with age, rising sharply
after age 60; about 4% of cases occur before
age 50
More common in relatives of PD patients
(Osborn, Wraa, & Watson, 2010, p.798)
Patient Scenario
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78 year old male
Had PD since 2002 (age of onset was 67 years old)
Referred by physician for DBS therapy
S/S: discomfort, trouble manipulating right hand, difficulty brushing teeth,
brushing hair, bathing, writing, tremors, rigidity, bradykinesia, postural
inability
HPI: PD, hypotension, depression
Objective Findings Pre-op:
 HR: 60 bpm
 BP: 90/70 mmHg
 Temp: 98.6 F
 SpO2: 92%
Within a short time, patient noticed effects of medications wearing off and
symptoms were worsening
Secondary S/S incl dystonia and dyskinesia became severely disabling
Nursing Diagnosis
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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)
Medications
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Carbidopa-Levadopa
Dopamine Agonists
MAOB Inhibitors
COMT Inhibitors
Anticholinergics
Start low, go slow
Fall prevention
Hydration important to counteract low BP,
constipation, general health (Osborn, Wraa, &
Watson, 2010, p.800)
Current Treatment: DBS
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Alternative treatment for PD and
essential tremor that can improve
motor function
Surgical approach
Placing electrodes in targeted areas of
the brain
 Subthalmic nucleus
 Globus Pallidus
Does not cure the disease, but may
help lessen symptoms (Osborn, Wraa,
& Watson, 2010, p. 804)
In some cases, medications may still
be needed, at lower doses, for certain
conditions
Does not damage nerve cells
Can be reversed if needed (Jasmin,
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. DBS
Medications Alone
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0 hours of additional “on”
time
Unpredictable motor
fluctuations
Dyskinesias and
nonmotor side effects
DBS Therapy & Medications
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Average 5.1 hours
additional “on” time
without troubling
dyskinesias
More predictable motor
fluctuations
Medication reduction may
lead to fewer druginduced side effects
(Medtronic, 2013)
Target Areas
(Jasmin, 2012)
Potential DBS Sites
DBS Site
*Subthalamic Nucleus
(STN)
Globus Pallidus internus
(GPi)
Ventralis intermediate
nucleus of the thalamus
(Vim)
Therapeutic Effect(s)
Reduction in tremor,
rigidity, bradykinesia,
and dyskinesia
Same as above
Reduction in tremor
*STN DBS is currently most common target in PD
(Jasmin, 2012)
Candidates for DBS
Diagnosis
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Advanced PD complicated by motor fluctuation, dyskinesia, or tremor despite optimized drug
therapy
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Atypical parkinsonism and are not considered good candidates
Age
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No cut-off point based on age
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Concerns with older age include increased comorbidities, cognitive decline, higher incidence
of levadopa-resistant symptoms, and greater risk of complications
Disease Duration
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Concern about operating on individual earlier than 5 years following diagnosis increases risk
of operating on patients with atypical parkinsonism
Levodopa Response
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Response to levadopa considered single best outcome predictor for response to DBS in
parkinsonism
Cognitive Impairment
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Dementia is most frequent exclusion criteria
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Advanced age may be associated with higher risk of frontal and related detioration following
DBS of STN
Psychiatric Issues
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Unstable psychiatric conditions
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Increased risk of suicide following DBS  need for accurate preoperative psychiatric
assessments, treatment of depression, and careful postoperative follow-op (Jasmin, 2012)
Candidates for DBS
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Undergo a complete multidisciplinary
screening with a neurologist, psychiatrist,
neuropsychologist, neurosurgeon
PD patients should undergo a “off/on”
levadopa medication challenge to determine
which symptoms responds best to
medication—these usually are the ones that
respond best to stimulation (Olanow, &
Schapira, 2009)
Medtronic 3-day “On” Time Diary
How DBS Works
(National Institutes of Health, 2012)
How DBS Works
(National Institutes of Health, 2012)
DBS: Pre-Op
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Fit with sterotactic
head frame
MRI to map brain
and identify area(s)
in brain where
electrodes will be
placed
NPO 6-12 hours
prior to surgery
(Jasmin, 2012)
DBS: Intra-Op
Part I:
Brain Surgery
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Local anesthetic—don’t
need an anesthetic in brain
itself b/c brain has no pain
receptors
Patient awake and alert
during procedure
Surgeon implant thin wire
lead with four electrodes at
tips into specific area of
brain
Neurologist and surgeon
monitor brain to ensure
correct electrode placement
Part II:
Chest Wall Surgery
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General anesthesia used
Surgeon implans
pacemaker-like device that
contains the batteries under
skin in chest, near
collarbone
Wires from brain electrodes
placed under skin and
guided down to pulse
generator –programmed to
send continuous electrical
pulses to brain
(Massachusetts General Hospital, 2008)
DBS: Post-Op
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Patient takes antibiotics to
lower risk of infection
Pulse generator in chest is
activated in doctor’s office
Doctor can program pulse
generator from outside body
using special remote control –
amount of stimulation
customized to patient’s
condition
Battery life varies with usage
and setting—may last
between 3-5 years and can be
replaced during an outpatient
procedure
Once connected, the tiny
pulses interfere with/block
electrical signals that cause
movement disorder symptoms
(Jasmin, 2012)
Patient Teaching
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DBS is not a cure for PD, but helps control
symptoms
DBS is not a substitute for medication use; drugs
may still be needed to control symptoms
Generally, symptoms that improve with levadopa
administration will be improved with DBS
The DBS system is composed of the lead wire,
extension (connecting) wire, implanted
neurostimulator, programmer, and patient
controller and/or magnet (Massachusetts General
Hospital, 2008)
Batteries must be replaces every 3-5 years
Complications
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Surgical procedure
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DBS system
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Infection, lead break, lead displacement, skin
ulceration, misplacement/migration of the lead
Stimulation
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Intracerebral hemorrhage, infarction, infection,
seizures, pulmonary embolism
Ocular and speech abnormalities, muscle
twitches, paresthesias, depression, suicide,
confusion, death (Olanow, & Schapira, 2009)
Riskier in people over age 70 and those with
comorbities like HTN and diseases that affect
blood vessels in brain
Research vs. Practice
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DBS is not for idiopathic parkinonism
Examining additional targets that might
benefit gait dysfunction, depression,
cognitive impairment in PD
More DBS and device-related studies are
needed to know all adverse effects
(Olanow, & Schapira, 2009)
Changes in clinical symptoms can be
associated with battery drain (Fakhar,
Hastings, Butson, Foote, Zeilman, &
Okhun, 2013)
Prognosis
Research being done:
 To determine its safety, reliability, and
effectiveness as a treatment for PD
 To determine the site(s) in the brain where
DBS surgery will be most effective in
reducing PD symptoms
 To compare DBS to other PD therapies to
find out which is more effective
 To study DBS as a treatment for epilepsy,
cluster headaches, Tourette syndrome,
chronic pain, major depressio (National
Institutes of Health, 2012)
Patient Outcome
Decided to treat patient with DBP to
left subthalmic nuclei on 3/1/2013
with a pulse generator placement 2
weeks later
 After treatment patient’s gait became
normal, increased agility in upper
extremities, dyskinesia and dystonia
had disappeared
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Conclusion
STN stimulation from DBS alone
significantly improves smooth pursuit in
patients with PD (Nilsson, Patel,
Rehncrona, Magnusson, & Fransson,
2013)
NCLEX 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 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 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 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 Sources
Medtronic FAQs
 DBS Journey (short version)
 DBS Journey (long version)
 Medline Plus Long Video
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References
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 from
http://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 from
http://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=978-0-323-047432&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.
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.