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Wednesday, April 23, 2014
Surgery for Older PWP with Dyskinesias
My mother who is PWP for 19 years and is 77 years old has a terrible time with dyskinesias. Her neurologist has reduced Sinemet to four doses of 25/100 and increased Mirapex to 3 doses of .75mg. She is now either rigid, sleepy and sometimes faint/lightheaded during the day with only some good time in the morning and then dyskinesias in the evening or after trying hard to do something (like holding the phone or eating). She does have short term memory loss and trouble learning new things. Nobody has ever suggested palidotomy or STN. Is it because of her age? Her doctor always says she is healthy except for the PD. I would appreciate understanding how a recommendation for surgery is made.
Age in itself is only a relative contraindication for surgery. At the University of Cincinnati, the oldest patient we have done pallidotomy for is 79 years old. The surgery was done primarily because of severe dyskinesias that interfered with her day-to-day care to a considerable extent. She benefited from the surgery tremendously in that respect although her off state symptoms did not improve in such a dramatic way. As a general rule we choose younger patients for STN stimulation as there is a greater risk for cognitive side effects. At our center we have the patients evaluated by a standardized two-day protocol. The first day is spent doing a comprehensive neuropsychological evaluation to rule out dementia or severe depression. From 9 pm on the first day all anti parkinson medications are stopped. The patient is then evaluated according to a standard rating scale (UPDRS) and this examination is videotaped. The patient then gets Sinemet and the on state response is evaluated by the same method. Dyskinesia severity is also noted. The neurosurgeon and myself review these videotapes and neuropsychological evaluation with other members of our team in an effort to decide whether surgery will help and if so the kind of surgery that would be optimal. Even if surgery is not indicated, this detailed evaluation helps us plan medication changes that are often more effective than those suggested during a routine office visit. Your mother may certainly benefit from a similar evaluation at one of the centers performing surgery for PD who use similar protocols in selecting their patients.
Arif Dalvi, MD
College of Medicine
University of Cincinnati