Friday, June 16, 2017
DEEP BRAIN STIMULATION (DBS) IN PARKINSON’S DISEASE
Major Symptoms of Parkinson’s disease
Parkinson’s disease (PD) is a progressive neurological disease, characterised by tremors, rigidity, slowness of movements and postural imbalance. Though it is more common after the age of 40, people younger than 40 can also get affected (when it is known as young onset PD).
Other symptoms of PD include low volume speech (sometimes totally incomprehensible), expressionless face, reduced blink rate, reduced arm swing while walking, stooped posture, small handwriting (called micrographia), short-shuffling steps, tendency to fall forwards. Many people also have pain and aches in the affected limbs. Sleep disturbance and restless leg syndrome are common comorbid illnesses in people with PD. Severe memory impairment is NOT a feature of PD, however, in advance PD, mild memory impairment may occur in about 10% of patients. Similarly, loss of bladder control or erectile dysfunction is not a feature of PD. When these features are present, one should suspect multiple system atrophy (MSA).
Diagnosis of PD
The diagnosis of PD is still best made on the basis of clinical examination by an experienced neurologist (preferably trained in movement disorders, though not a must). PET and DaT scans are available to help in the diagnosis of PD, but they are not superior to a good clinical examination by an experienced neurologist.
Treatment of PD
Treatment of PD is still primarily medical and DBS is not the first option.
The most effective medicine is levodopa-carbidopa combination. If a patient does not respond to levodopa treatment, we should doubt the diagnosis (it may not be PD). Even though levodopa is the most effective medication, we should delay starting it by 2-3 years, to avoid side effects and lack of efficacy later on. Other medications in use are pramipexole, ropinirole, trihexiphenydyl, selegiline, rasagiline, amantadine, entacapone, safinamide, etc.
Role of Deep Brain Stimulation (DBS) surgery in PD
DBS was approved for PD in 2002. In the past 15 years, about 1,35,000 patients worldwide have undergone DBS for PD.
What does DBS surgery involve?
A neurosurgeon places the leads (thin wires) that carry electrical signals to specific areas of the brain. Then, the surgeon places a battery-run neurostimulator (like a pacemaker) under the skin of the chest.
The surgeon may use a programming device to adjust the settings. You may have a device, similar to a remote control, which allows you to turn the system on and off and check the battery. You may also be able to adjust the stimulation within options programmed by your doctor.
A neurologist initially evaluates a patient to determine whether he or she is the right candidate for DBS surgery. Then, further evaluations include brain imaging (MRI, CT, PET, etc), neuropsychological testing, UPDRS scoring, etc. Once the patient is found to be suitable for DBS, he is referred to the neurosurgeon.
Which patients are likely to benefit from DBS surgery?
1. The diagnosis of PD should be definite.
2. Patient has had PD for five years or more.
3. Patient continues to respond to levodopa, even though the response may or may not be good.
4. There are motor fluctuations, such as on-off phenomena, with or without dyskinesia.
5. Various medical treatments have not had desired benefit.
6. PD symptoms are severe enough to interfere with activities of daily living.
Which patients are NOT likely to benefit from DBS surgery?
1. Patients with atypical Parkinsonian symptoms,
2. Patients with multiple system atrophy (where bladder and sexual dysfunction are prominent symptoms),
3. Patients with progressive supranuclear palsy,
4. Patients with dementia or severe cognitive impairment,
5. Patients with unstable psychiatric illnesses,
6. Patients with advanced PD, who are confined to bed/wheelchair; despite being on medications,
7. Patients with NO response to levodopa therapy,
Who are the best candidates for DBS surgery in PD?
1. Excellent response to levodopa therapy,
2. Younger age,
3. Mild or no cognitive impairment,
4. Few or no axial (affecting neck or trunk) motor symptoms,
5. Absence of or well controlled psychiatric disease.
Are there any complications of DBS surgery?
DBS surgery is generally safe if performed by a trained group of specialists. However, complications may occur in upto 3% of patients, which include:
1. Bleeding (hemorrhage) in the brain,
4. Speech impairment
5. Erosion, migration or fracture of the lead,
What to expect after DBS surgery?
Most patients report a reduction in severity of symptoms after surgery. Tremors, dyskinesia, slowness all respond to the surgery.
PD medications, however, can not be stopped even after DBS. Most patients still need to take medications, however, at much lower doses.
The benefits are seen at five years after surgery, however, the effect tends to wane in later years.
DBS does not alter the disease progerssion, and disease continues to get worse even after DBS.
Is MRI safe after DBS?
Yes, MRI can be safely done after DBS surgery.
What is the cost of DBS surgery ?
The cost of surgery is approximately INR 9,00,000 to 10,00,000.
Dr Sudhir Kumar MD (Med) DM (Neuro)
Senior Consultant Neurologist
Apollo hospitals, Hyderabad
Wednesday, July 20, 2016
IMPORTANT INFORMATION ABOUT LEVODOPA USE IN PARKINSON’S DISEASE
Levodopa is one of the most important medicines used for treating Parkinson’s disease (PD). It is sold in combination of levodopa and carbidopa. The commonly used brand names for this medicine are syndopa, sinemet, tidomet and duodopa. Levodopa is very useful in ameliorating the symptoms of PD, especially the tremors and rigidity. However, there are several important points of note regarding its use. The current article highlights a few of them.
1. Try to avoid levodopa use in early PD: Though levodopa is very effective in controlling symptoms of PD even in early stage, it is better to avoid using it in early PD. This is because the risk of dyskinesia (abnormal movements as a side effect of levodopa) and rapid wearing off (reduced efficacy of levodopa) are more common, if levodopa is started early in the course of disease. Also, levodopa loses the efficacy after longer use, so, it makes sense to start it later.
2. Use the lowest effective dose of levodopa: It may be tempting to use levodopa at a higher dose or more frequently, as the symptom control would be better with that. However, for the same reason mentioned above, it is better to use levodopa at the lowest possible dose, and as less frequently as possible.
3. Take levodopa on empty stomach: Presence of food in stomach may interfere with the absorption of levodopa; so, it is better to take levodopa on empty stomach. In the initial days of starting levodopa, there may be nausea or vomiting, so, it may be taken after food or snacks.
4. Reduce or evenly space the amount of protein intake: High protein diet prevents proper absorption of levodopa. So, the protein intake should be evenly spaced out in the day; or better, it can be shifted to dinner time (as most doses of levodopa are taken before dinner time).
5. Avoid pyridoxine (vitamin B6) intake: Pyridoxine can reduce the effects of levodopa, if taken alone. However, pyridoxine does not interfere with the effects, if levodopa is taken along with carbidopa (as in most cases).
6. Hallucinations and psychosis can be a side effect of levodopa: Use of levodopa does increase the risk of visual and auditory hallucinations, and other psychotic reactions (agitation, anger, irritability, etc). However, it is not a simple relationship. The severity & duration of PD, presence of cognitive impairment and daytime somnolence, all increase the risk of psychotic reactions with levodopa use.
7. Avoid using levodopa in late evenings: The risk of hallucinations and other psychotic reactions are higher if levodopa is used in late evenings or nights. So, avoid it at those times, as much as possible.
8. Avoid breaking, crushing or chewing the controlled release (CR) tablets: Those taking medicines such as syndopa CR, tidomet CR, etc should swallow the entire tablet, without breaking or crushing (which would reduce its efficacy).
9. There is a risk of dependence and abuse with levodopa: Levodopa increases the dopamine levels in brain and may cause effects such as euphoria (feeling of extreme happiness) and other positive mental effects. Therefore, a small group of patients with PD may increase the dose of levodopa by self and take upto 1500-2000 mg per day. These patients accept the side effects of high dose levodopa (such as hallucinations, nausea, loss of appetite), in order to experience the positive mental effects. This behavior (of dependence and abuse of levodopa) should be recognised and treated.
10. Other side effects of levodopa to watch for:
a. Dizziness or fainting sensation on standing up (may occur due to fall in BP on standing),
b. Feeling of nausea, vomiting, loss of appetite
c. Sudden sleep episodes: Patients taking levodopa may fall asleep without any drowsiness or warning. It can occur while driving or doing other activities needing full concentration, which can be potentially harmful.
d. Sleep disturbance or insomnia at nights.
DR SUDHIR KUMAR MD (Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Hospitals, Hyderabad, India
Email: firstname.lastname@example.orgOnline consultation: https://www.doctorspring.com/doctors/sudhir-kumar
Tuesday, April 19, 2016
Coffee Breaks Make You Healthier
Coffee drinking is quite popular all across the world. There are many, who have coffee first thing in morning, referred to as bed coffee. Bed coffee is supposed to energize people and get them out of sleepiness. Many others take “coffee breaks” while at work, which relaxes them. Who would have forgotten the student days, when numerous coffee cups kept them awake until late nights just before examinations? Coffee drinking is supposed to increase alertness and concentration. The effects are mainly related to caffeine contained in the coffee.
Health-Related Benefits of Drinking Coffee
1. Lower risk of diabetes: In a Dutch study done on 40,000 people, it was found that drinking at least 3 cups of coffee or tea per day reduced the risk of developing diabetes by 42%. (Diabetologia 2009). The anti-diabetic effects are related to polyphenols found in coffee.
2. Lower risk of coronary heart disease: Moderate habitual coffee consumption (3-4 cups per day) lowers the risk of coronary heart disease, especially in women. (International Journal of Cardiology)
3. Coffee improves headaches and migraine, if taken alone or along with other painkillers.
4. Lower risk of brain stroke: Middle aged people in Japan, who drank 3 or more cups of coffee per day had lower rates of silent brain infarctions (strokes without symptoms, picked up on MRI scan of brain). Lesser brain infarctions would also lead to lesser incidence of dementia. (Journal of Stroke and Cerebrovascular Diseases, 2016)
3 or more cups of coffee intake per day reduced the risk of brain stroke (despite smoking tendency in coffee drinkers). A lower incidence of heart failure, diabetes and hypertension was also observed. (Nutritional Neuroscience, 2015)
5. Reduced risk of Alzheimer’s disease: Alzheimer’s disease is the commonest cause of dementia (memory loss and loss of other higher mental functions) in the world. Based on the meta-analysis of 11 research studies, it was found that higher coffee consumption reduced the risk of Alzheimer’s disease. (Nutrition, 2015)
6. Reduced risk of Parkinson’s disease: Parkinson’s disease is the commonest cause of movement disorder, characterized by tremors, rigidity and slowness of movements. Based on meta-analysis of 26 studies, increased caffeine/coffee consumption was associated with reduced risk of Parkinson’s disease. (Journal of Alzheimer’s Disease, 2010)
7. Reduced risk of multiple sclerosis: Researchers in USA and Sweden have found that drinking at least 900 ml (six cups) of coffee per day has protective effects against multiple sclerosis. Caffeine has neuroprotective properties and suppresses inflammation. (JNNP, 2016)
8. Reduced risk of depression and suicide: A meta-analysis of 11 studies showed a protective effect of coffee against depression. The relationship between coffee intake and depression was linear; for each cup/day increase in coffee intake, the risk of depression reduced by 8%. (Australia NZ Journal of Psychiatry 2016)
In addition, increased coffee consumption was also associated with reduction in incidence of completed suicides. (World Journal of Biol Psychiatry, 2014)
9. Reduced risk of cancer: Various studies have shown that regular coffee consumption is associated with lower risk of cancers. 5 or more cups per day reduced the risk of colorectal cancer (Oncotarget, 2016). Other studies have shown reduced risk of cancers of oral cavity, pancreas, urinary bladder, breast, uterus, and liver among regular coffee drinkers.
10. Lesser incidence of erectile dysfunction: Coffee can provide a boost to sexual health too. Men with coffee intakes of 2-3 cups of coffee/ day reported significantly lesser incidence of erectile dysfunction, as compared to those with no coffee intake or only 1 cup/day. (PLos One, 2015)
11. Lower death rates: Regular intake of coffee can increase longevity and prevent deaths too. Recent research has shown that people drinking 2-5 cups of coffee/day had significantly lower deaths from heart disease, chronic lung diseases, diabetes, pneumonia and influenza, and intentional self-harm. Coffee may reduce mortality risk by favorably affecting inflammation, lung function, insulin sensitivity, and depression. (American Journal of Epidemiology,
Possible Health Hazards of Coffee Drinking
1. Poor control of BP in patients with hypertension: A recent study showed that older people with hypertension, who consumed 3 or more cups of coffee per day, had higher BP (systolic and diastolic). Coffee drinking, however, does not lead to an increased risk of developing hypertension (in people with normal BP).
2. Increased cholesterol levels: Drinking unfiltered or boiled coffee may cause an increase in the levels of LDL cholesterol and triglycerides.
3. Increased risk of coronary heart disease: Drinking 3 or more cups of Italian-style coffee (espresso or mocha) is associated with increased risk of coronary heart disease. (PLoS One, 2015). This effect was independent of cholesterol levels, as the cholesterol levels did not increase in this study.
4. Sleep problems: Caffeine is a brain stimulant and after consuming it, people feel alert. People sensitive to the stimulant effects of caffeine may not get proper sleep, if they drink coffee close to bedtime. Since, the effect of coffee may last for 5-6 hours, people sensitive to it should avoid coffee after 6 PM.
5. Not recommended for children: Coffee suppresses appetite, and may cause children to eat less. Also, after having coffee, children feel full, and avoid nutritious foods such as milk.
6. Pregnant and nursing women should have coffee in moderation: There is no restriction of coffee in pregnant or nursing mothers. However, they should restrict the coffee intake to 2-3 cups per day.
So, what is the final take home message?
1. Coffee is good for health, and can be safely consumed by adults.
2. For optimum benefits, it should be restricted to 2-5 cups per day.
3. The maximum safe limits for caffeine/coffee intake is 200 mg in one sitting (around 2½ cups of coffee) or 400 mg daily (around 5 cups of coffee).
4. Coffee (without sugar and milk) has zero calories; and hence, people on strict diet too can freely have coffee.
DR SUDHIR KUMAR MD (Internal Medicine) DM (Neurology)
Senior Consultant Neurologist
Apollo Health City, Jubilee Hills, Hyderabad
Online Consultation: http://bit.ly/Dr-Sudhir-kumar