Deep brain stimulation may be safe for older Parkinson patients
1. Deep brain stimulation (DBS) has established effectiveness in the treatment of medication-refractory Parkinson disease, and in patients with significant motor fluctuations and dyskinesia.
2. The rate of complications from DBS did not correlate with increased age, suggesting that older patients, who are typically not considered to be candidates for DBS, may benefit from this treatment.
Evidence Rating Level: 2 (Good)
Study Rundown: Deep brain stimulation (DBS) is a treatment in which electrodes are introduced into the brain and provide electrical stimulation. It is valuable in the treatment of many disease states, most notably advanced Parkinson disease (PD) that has become refractory to medical treatment. However, the procedure is associated with potential side effects and complications, which have been thought to increase with advanced age. Most studies performed thus far have excluded patients older than the age of 75, and some previous studies had a mean age at surgery of 57 years old. Because the average age of onset of PD is approximately 60 years old, and DBS is done a mean of 14 years after diagnosis, most patients that may potentially benefit from DBS are in an older age group. This study found that the rate of complications from DBS was not significantly correlated with increasing age.
A limitation of this study is that complication rates past 90 days were not accounted for, and that only a certain complications (PE, hemorrhage, pneumonia, and wound infection) were identified using ICD-9 codes. However, this study analyzed a large and diverse group of patients for major complications after surgery, avoiding selection bias that might have been caused by only examining patients from certain centers. This suggests that age should not be a deciding factor in determining candidacy for DBS treatment. Older patients are likely to suffer from postural instability, gait difficulty, and other complications of PD that may affect morbidity and mortality, making them a particularly interesting target population for benefiting from DBS.
Click to read the study, published today in JAMA Neurology
Relevant Reading: Risks of common complications in deep brain stimulation surgery: management and avoidance
In-Depth [retrospective cohort]: This study retrospectively analyzed cases of DBS procedures and the rates of adverse effects by age group to assess if DBS would be a safe, effective therapy for patients of advanced age. Cases were found using the Thomson Reuters MarketScan national database, based on ICD-9 codes. A total 1757 patients were included in analysis, with dates of treatment ranging from 2000 to 2009. The average age of the patients was 61.2 years. 582 patients were older than 65 years of age and 123 were older than 75 years of age.
Of all patients included in the study, 7.5% of these patients had one or more complications within 90 days. The complications recorded includedpneumonia (2.3%), hemorrhage/hematoma (1.4%), wound infections (3.6%), and pulmonary embolism (0.6%). Complications such as revision surgery, death, or removal were not included as they were presumed to be quite rare. 7.3% of patients older than 75 years of age had a complication within 90 days, compared to 7.5% of patients younger than 75 years of age (p=0.93). Increasing age (in patients grouped by 5 year epochs) was not a significant predictor of having a complication in 90 days postoperatively (OR: 1.10, 95% CI 0.96-1.25), nor was it associated with increased length of hospital stay (OR: 0.93, CI: 0.73-1.2, p=0.57).
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Image: PD
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