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10/30/2019
1
Care of the patient with Deep Brain Stimulation
Joan Miravite, DNP, RN, FNP-BCDoctor of Nursing PracticeBoard Certified Nurse PractitionerAssistant Professor of NeurologyIcahn School of Medicine at Mount Sinai
Disclosure:
Medtronic Deep Brain Stimulation
(DBS) Advisory Board
Off label use of devices or products
will be not be discussed. No
commercial company or product
names will will be used in this
presentation.
Learning Objectives:
1. To be able to identify features of Parkinson’s
disease, tremor and dystonia
2. To become familiar with medications for
movement disorders
3. To be able to list symptoms treated by Deep Brain
Stimulation (DBS)
4. To become familiar with Multidisciplinary care of
the movement disorder patient
5. To understand the benefits of medical and surgical
treatments for movement disorders
10/30/2019
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WHAT CONDITIONS DO WE TREAT WITH DBS?
FDA Approved Indications: Parkinson’s disease (PD) – STN or GPi Essential Tremor (ET) - VIM Dystonia (Cervical or Generalized) - GPi Obsessive Compulsive Disorder (OCD) Epilepsy (Anterior Nucleus of Thalamus)
Shukla & Okun 2016
What is Parkinson’s disease?
5
PD Clinical FeaturesPD Clinical Features
• Onset: insidious,
• unilateral progressing to bilateral
• Cardinal signs
• (motor symptoms)
• Bradykinesia*
• Resting tremor
• Rigidity
• Loss of postural reflexes
• 60-80% Dopaminergic
neuronal cell loss in PD
occurs before symptoms
appear
• Non-motor features may
predate the onset of
classic motor symptoms
by years
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Bradykinesia
Slowness of movement. Associated with Parkinson’s Disease.
Video
Rest Tremor
Involuntary rhythmic oscillation of a limb at rest, diminishing with action. A cardinal sign of Parkinson’s disease.
video
Loss of Postural Reflexes
Retropulsion, inability to “right” oneself when force is used to require a stepping response. A cardinal sign of Parkinson’s disease.
Video
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Dyskinesia
Abnormal involuntary movements that occur in response to dopamine therapy. “Choreiform” movements.
Video
Parkinson’s disease MedicationsTherapeutic Class and Medication Daily dose Side Effect Profile
Dopamine precursorCarbidopa/Levodopa (Sinemet)
ODT (orally dissolving tablet)CR or ER (extended release)Rytary (long acting)Duopa (intestinal gel)Carbidopa/Levodopa/Entacapone (Stalevo)Imbrija (inhaled Levodopa)
Individualize dose, starting with tid-qidMax dose: 200/2,000 mg/dayMax dose: 200/2,000 mg/dayCR or ER max dose: 600/2,400 mg/dayRytary max dose: 612.5/2450 mgDuopa max dose: 2,000 mg/day via pegStalevo max dose: 8 tablets/dayImbrija max dose: 2 caps inh up to 5x/day
nausea, dizziness, dyskinesia, orthostatic hypotension, hallucinations,compulsive behavior,vivid dreams
Dopamine AgonistsPramipexole (Mirapex)Pramipexole (Mirapex ER)Ropinirole (Requip)Ropinirole (Requip XL)Apomorphine (Apokyn SC inj)Bromocriptine (Parlodel)Rotigotine (Neupro transdermal)
tid, Max dose: 4.5 mg/dayqd, Max dose: 2.25 mg/daybid-tid, Max dose: 24 mg/dayqd, Max dose: 24 mg/dayMax dose: 0.6 mL/dose, up to 5x/daytid, Max dose: 100 mg/dayqd, Max dose: 8 mg/24h
somnolence, hypotension, dizziness, hallucinations, peripheral edema, compulsive behavior, vivid dreams
NMDA Receptor AntagonistAmantadine (Symmetrel)Amantadine ER
(Gocovri) (Osmolex ER)
bid-qid, Max dose: 400 mg/day
qhs, Max dose: 274 mg qd, Max dose: 322 mg/day
hallucinations, dizziness, peripheral edema, vivid dreams, confusion, fatigue, hypotension, livedo reticularis
MAO-B InhibitorsRasagiline (Azilect)Selegiline (Eldepryl)Selegiline ODT (Zelapar)Safinamide (Xadago)
qd, Max dose: 1 mg/daybid, Max dose: 10 mg qam, Max dose: 2.5 mg/dayqd, Max dose: 100 mg/day
hypotension, headache, compulsive behaviors, dizziness, dyskinesia, hallucinations
COMT InhibitorsTolcapone (Tasmar)Entacapone (Comtan, Stalevo)
Give with each Carbidopa/Levodopa doseMax dose: 600 mg/dayMax dose: 1600 mg/day
(Tolcapone – hepatotoxicity)dyskinesia, nausea, dystonia, vivid dreams, hypotension somnolence, diarrhea, confusion, dizziness, hallucinations, compulsive behaviors
AnticholinergicsTrihexyphenidyl (Artane)Benztropine (Cogentin)
tid, Max dose: 15 mg/dayPO/IM/IV qhs, bid-tid, Max dose: 6mg/day
dry mouth, blurry vision, dizziness, nausea, confusion, urinary retention, drowsiness, constipation
PD Medication ConsiderationsMedical Purpose Safe Medications Medications to Avoid
Antipsychotics Quetiapine (Seroquel)Clozapine (Clozaril)
Avoid all other atypical and typical antipsychotics
Pain Medication Use narcotics with caution, as these can cause confusion or psychosis
Avoid using Meperidine (Demerol) if patient is taking Selegiline or Rasagiline(Azilect)
Anesthesia Consult Anesthesia If patient is taking Selegiline or Rasagiline (Azilect), avoid using: Meperidine (Demerol)Tramadol (Ultram), Droperidol (Inapsine), Methadone (Dolophine), Propoxyphene (Darvon), Cyclobenzaprine ((Flexeril) Halothane (Fluothane)
Antiemetics Domperidone (Motilium)Trimethobenzamide (Tigan)Ondansetron (Zofran)Dolasetron (Anzemet)Granisetron (Kytril)
Prochlormethazine (Compazine)Metoclopramide (Reglan)Promethazine (Phenergan)Droperidol (Inapsine)
Antidepressants Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Citalopram (Celexa)Escitalopram (Lexapro)Venlafaxine (Effexor)
Amoxapine (Asendin)
(Adapted from Parkinson Foundation, Aware in Care, Hospital Action Plan Booklet)
10/30/2019
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PD Considerations
1. Provide PD meds on time, every time.
2. Do not substitute medications.
3. Do not stop Levodopa therapy abruptly.
4. Resume meds when able.
5. If antipsychotic is needed, use Quetiapine or Clozapine.
6. Watch for symptoms of dysphagia and risk for pneumonia.
7. DBS needs to be turned off for surgery, MRI, EKG, EEG or EMG.
(Adapted from Parkinson Foundation, Aware in Care, Hospital Action Plan Booklet)
What is Essential Tremor?
Essential Tremor
Most common movement disorder
Commonly inherited
Primarily kinetic tremor during voluntary movement, may rarely be present at rest, or with holding postures
Tremor frequency of 4-10 Hz with variable amplitude
Can involve head and vocal cords
Increases with stress
Relieved for short periods by Alcohol
Can see a mild ataxic gait
Louis ED. Expert Review or Neurotherapeutics. 2014;14(9): 1057-65
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Postural (Action) Tremor
Involuntary rhythmic oscillation of a Limb being held in a posture against gravity.
Video
Kinetic (Action) Tremor:Simple kinetic tremor, task specific tremor,
intention tremor and isometric tremor
(typically seen in ET)
Videos
Essential Tremor Medications
Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses
10/30/2019
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What is Dystonia?
DYSTONIA
Consensus Definition 2013:
• “Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive movements, postures, or both.
• Dystonic movements are typically patterned, twisting, and may be tremulous.
• Dystonia is often initiated or worsened by voluntary action and associated with overflow muscle activation.”
Albanese, Bhatia, Bressman, et al. Movement Disorders.2013;28:863-873
Dystonic Tremor
Dystonic tremor is an action tremor that may be postural, kinetic or both. This tremor is asymmetric, jerky and irregular.
Video
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Dystonia Medications
Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses
What is Deep Brain Stimulation (DBS)?
Video
An implantable system that modulates brain activity to improve some of the motor symptoms movement disorders
AdjustableBilateral
Reversible
Deep Brain Stimulation (DBS)
Shukla & Okun 2016
10/30/2019
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PD (DBS ON & OFF)
VIdeo
DBS for Parkinson’s Disease
Good surgical candidate:
idiopathic PD
responsive to Levodopa
at least 4 years of disease
Experiencing motor fluctuations in response to meds
Intact cognition
Shukla & Okun 2016
What does DBS treat in PD?
Tremor
Bradykinesia
Rigidity
Motor Fluctuations (off time)
Dyskinesias
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In PD, DBS does NOT treat
Cognitive problems
Speech
Mood/anxiety
Gait
Postural instability
Surgical Treatment of ET
Good ET DBS candidate:
debilitating tremor
refractory to medication
DBS for Essential Tremor
Video
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Good surgical candidate GPi DBS for Dystonia
Primary dystonia Lack of trauma or
damage to the brain Medically refractory Cognitively intact
Bronte-Stewart, et al. Movement Disorders. 2011.26(S1:S5-S16.
DBS for Generalized Dystonia
Video
DBS for Cervical Dystonia
Video
10/30/2019
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DBS Patient Education
• Remind patient that DBS is not a cure (Shukla 2016)
• Remind patient to continue to take medications
• Inform patient that they might be able to lower dose of medication by 25-50% (Shukla 2016)
• Optimal results can take months and will be different for each patient
• DBS Settings and medications are adjusted concurrently
• DBS is a process (Revell 2015)
• Cognition, speech, gait dysfunction, depression, anxiety and postural instability do not respond to DBS (Martinez-Ramirez 2014)
Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses
• Wash hands frequently & any time before touching surgical incisions while healing.
• Look for signs and symptoms of wound infection or skin erosion.
• Change dressings as instructed.
• Refrain from picking, scratching, or unnecessarily touching incisions.
• Call the neurology or neurosurgery office for any erythema, bleeding, purulent discharge or drainage, edema, tenderness, warmth, delayed healing, discoloration, or fever greater than 101°F.
Post DBS Wound Care
Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses
There are several reasons to call the office.
Ensure that the patient has reviewed the following:
• Signs and symptoms of infection
• Signs and symptoms of a stroke:
• BE-FAST (balance, eyes, face, arm, speech, time)
• Headache, weakness, and change in speech or gait
• Abrupt return of symptoms
• Worsening of symptoms
• Burning sensation along the DBS hardwareBautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019)
Evidence-Based Strategies for Care of the Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of Neuroscience Nurses
DBS Post-Operative Patient & Caregiver Education
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Non-pharmacologic Considerations in Movement Disorders
Physical therapy
Goals:• Improve motor function• Increase range of motion• Build endurance
Techniques: counting steps, marching, visual fixation, balance training
Can be helpful for symptoms such as stooped posture, shuffling and other gait disturbances, difficulty rising from chairs
Occupational therapy
Concentrates on fine finger and hand movements Techniques: adaptive equipment, energy conservation,
range of motion
Speech therapy
Concentrates on speech impairments and swallowing difficulties
Techniques: voice projection and vocal exercises
Diet Patients should maintain a well-balanced diet Meals rich in protein may reduce absorption of levodopa
Multi-disciplinary Team
Movement Disorder SpecialistNurse, Nurse Practitioner, PA
PsychiatristNeuropsychologistPhysical Therapist
Occupational TherapistSpeech TherapistGenetic Counselor
NeurosurgeonSocial WorkerResearchers
Movement Therapists
Conclusions:
1. To be able to identify features of Parkinson’s
disease, tremor and dystonia
2. To become familiar with medications for
movement disorders
3. To be able to list symptoms treated by Deep Brain
Stimulation (DBS)
4. To become familiar with Multidisciplinary care of
the movement disorder patient
5. To understand the benefits of medical and surgical
treatments for movement disorders
10/30/2019
17
Resources for Patients with Movement Disorders
Parkinson’s disease:
• Michael J. Fox Foundation
• www. michaeljfox.org
• The Parkinson Foundation
• www.parkinson.org
• Parkinson Alliance• www.parkinsonalliance.net
• American Parkinson Disease Association (APDA)
• www.apdaparkinson.org
Essential Tremor
• International Essential Tremor Foundation
• www.essentialtremor.org
Dystonia
• Dystonia Medical Research Foundation
• www.dystonia-foundation.org
References
Albanese, A., Bhatia, K., Bressman, S. B., DeLong, M. R., Fahn, S., Fung, V. S. C., . . . Teller, J. K. (2013).
Phenomenology and classification of dystonia: A consensus update: Dystonia: Phenomenology and
classification. Movement Disorders, 28(7), 863–873. doi:10.1002/mds.25475
Bautista C*, Miravite J*, Coronel H, Hunt D, and Dallow E. (2019) Evidence-Based Strategies for Care of the
Patient with Movement Disorders and Deep Brain Stimulation. Chicago: American Association of
Neuroscience Nurses
Bronte-Stewart, H., Taira, T., Valldeoriola, F., Merello, M., Marks, W. J., Albanese, A., & . . . Moro, A. E. (2011).
Inclusion and exclusion criteria for DBS in dystonia. Movement Disorders, 26S5. doi:10.1002/mds.23482
Louis, E. D., Rohl, B., & Rice, C. (2015). Defining the treatment gap: What essential tremor patients want that they
are not getting. Tremor and Other Hyperkinetic Movements, 5, 331. doi:10.7916/D87080M9
Martinez-Ramirez, D., & Okun, M. S. (2014). Rationale and clinical pearls for primary care doctors referring
patients for deep brain stimulation. Gerontology, 60(1), 38–48. doi:10.1159/000354880
Parkinson Foundation (n.d.). Aware in Care Hospital Action Plan. Retrieved from:
https://www.parkinson.org/sites/default/files/HospitalActionGuide.pdf
Revell, M. A. (2015). Deep brain stimulation for movement dis- orders. Nurses Clinics of North America, 50(2015),
691–701. doi:10.1016/j.cnur.2015.07.014
Shukla, W. A., & Okun, M. S. (2016). State of the art for deep brain stimulation therapy in movement disorders: A
clinical and technological perspective. IEEE Reviews in Biomedical Engineering, 9, 219–233.
doi:10.1109/RBME.2016.2588399
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