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IDIOPATHIC PARKINSON’S DISEASE
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Continue oral drug therapy, no advanced treatment option
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Yes
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Pronounced dementia?
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Severe tremor with insufficient effect of medication?
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Yes
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DBS
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Continue oral drug therapy, no advanced treatment option
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No
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Levodopa effect?
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Continue oral drug therapy, no advanced treatment option
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No
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Motor fluctuations?
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Slight-moderate dementia?
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Yes
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Pump
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Biological age >70-75 years?
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Yes
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Pump
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Disabling dyskinesias?
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Yes
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DBS
Levodopa/carbidopa infusion
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Significant depression?
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Yes
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Pump
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Surgical contraindication for brain surgery?
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Yes
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Pump
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Surgical contraindication for abdominal surgery? |
Yes
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DBS
Apomorphine
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Discuss individual risk/benefit of DBS and pump
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As seen from the list of indications overleaf, the patients suitable for apomorphine infusion, levodopa/carbidopa infusion and DBS can have similar characteristics. Regarding contraindications there are, however, clear differences. Pump treatments can be applicable for a relatively large population of Parkinson’s patients with advanced motor fluctuations. DBS is suitable for a subgroup of such patients who are not too old and do not have any dementia or psychiatric vulnerability (depression, anxiety). The simplified algorithm above, might be helpful when choosing between the most advanced Parkinson’s therapies below:
- Patients with advanced dementia are excluded from all these therapies
- Patients with severe tremor as their main problem, should be selected for DBS
- Patients with only limited levodopa effect are excluded from all these therapies
- Patients without troublesome motor fluctuations are excluded from all these therapies
- Patients with a biological age higher than 70-75 years should primarily be selected for pump therapies
- Patients with disabling dyskinesias should be selected for DBS or levodopa/carbidopa infusion
- Patients with slight to moderate dementia should primarily be selected for pump therapies
- Patients with depression or anxiety that cannot be adequately controlled with medication should primarily be selected for pump therapies
- Patients with contraindications for brain surgery should be selected for pump therapies
- Patients with contraindications for abdominal surgery should be selected for DBS or apomorphine pump treatment
- For the remaining patients all therapy options are available. These patients should be well informed about all three treatment options and the choice of therapy should be discussed between the treating doctor, patient and carer. Pump treatment should at least be considered before DBS is performed
- Patients that already have had apomorphine treatment but start to have troublesome side effects, or the effects of treatment start to deteriorate, can still be canidates for either levodopa/carbidopa or DBS.
Further considerations that could be relevant:
- people who are not capable of handling medical equipment themselves and who do not have sufficient social support should first hand consider DBS, since this therapy demands little intervention from the patient
- for people who want to live a very independent life, DBS can offer advantages relative to pump therapies
- if the reversibility – the possibility to stop the treatment – is of importance, the pump therapies (and first hand apomorphine pumps) are preferable to DBS
- in people with tendency to hallucinations and dopaminergic psychosis, levodopa/carbidopa infusion and DBS are preferable to apomorphine pumps.
Summary
Each individual case of Parkinson’s is unique and the decision to pursue advanced Parkinson’s therapy should only be made after thorough consultation with specialists in all four therapies. These decisions should therefore be centralised to centres with extensive experience in movement disorders and Parkinson’s.
