A primary goal of DBS surgery is to improve quality of life for people with Parkinson’s. However, notes, Dr. Marjan Jahanshahi, “The aim is to improve the motor symptoms of Parkinson’s without creating negative impacts on the non-motor aspects.” Recognizing that non-motor symptoms such as cognition, mood and behaviour problems can be just as disabling as the motor symptoms, Dr. Jahanshahi, professor of neuropsychology, UCL Institute of Neurology and National Hospital, London, UK offers some suggestions for preventing adverse effects on cognition and mood and maintaining mental well-being after DBS.
Careful selection of DBS candidates. A detailed assessment with a neuropsychologist, including screening for dementia, psychiatric illness such as treatment-resistant major depression and untreated psychosis, and the presence of suicidal ideation – thoughts of suicide. People with these conditions are not recommended for surgery. In general, in carefully selected people with Parkinson’s, surgery does not produce any major adverse effects on cognition.
Pre-surgery counselling of individual and families. Educating individuals and families about what to expect is important. Having brain surgery is a life event and the period around the surgery can be a time of uncertainty and stress for the person with Parkinson’s and the family. Informing them about what to expect can help them mobilize their social support system to get practical and emotional support from family and friends, which can help reduce the stress associated with the surgery.
It is also important to make sure that people have realistic expectations about what surgery will do for their specific motor symptoms, as unrealistic expectations of the surgical outcome can lead to disappointment and influence people’s adjustment after surgery.
Dr. Jahanshahi notes, “Because of the rapid changes in motor function brought on by surgery, someone who was dependent on a caregiver for help with daily activities may have become completely independent again. People may have to re-negotiate roles within the family. They need time to adjust to the changes.”
Extensive monitoring and follow-up. It’s important that doctors monitor non-motor symptoms like changes in cognition or changes in psychiatric status from before to after surgery, to make sure these aspects don’t get worse or emerge following surgery. However, communication with doctors is a two-way process and patients and caregivers also need to report back if there are any new changes that they think are not right. Being alert to problems and managing them early can prevent more problems later on.
Prompt management / treatment of problems. Noting that a minority of people, 15-20%, experience some psychiatric problems after surgery, Dr. Jahanshahi says that some of the changes such as confusion and hypomania (elevated mood and activity), are short-lived. “They are there immediately after the operation, then disappear, in the majority of cases.” Many of the more long-term problems are treatable and can be potentially overcome by adjustment of medication, direct treatment or adjustment of stimulation. For example, apathy and depression could be due to the rapid reduction in medication after surgery, so gradual reduction of medication is the best option. Anti-depressants can be prescribed for depression. When present, cognitive or psychiatric problems could be a result of the electrode contacts not being in the right section of the brain target or they could be due to stimulation spreading beyond the target; so a readjustment of the electrode contacts or stimulation parameters could be a solution.
In addition, Dr. Jahanshahi suggests that some individuals and families may benefit from psychotherapy such as cognitive behavioural therapy to help with adjustment to new roles. “After years of living with Parkinson’s, people fall into daily routines but once mobility and activities of daily living have improved after the surgery, people’s whole outlook may need to be shifted, as well.”