Effects of Deep Brain Stimulation on Cognition, Mood, and Behavior in Parkinson’s Disease

Effects of Deep Brain Stimulation on Cognition, Mood, and Behavior in Parkinson’s Disease

Tröster Alexander I
Published: US Neurology - Volume 4 - Issue I
European Neurological Review - Volume 3 - Issue I
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Disappointed by the limitations of pharmacotherapy, emboldened by technological advances in surgery and radiology, and armed with a better understanding of pathophysiology, physicians and scientists in the 1980s charted a renaissance of surgery for movement disorders such as Parkinson’s disease (PD). The desire for a safer alternative to lesional or ablative neurosurgery, coupled with observations that intraoperative electrical stimulation used for target identification could alleviate abnormal movements,1,2 prompted the exploration of fully implantable deep brain stimulation (DBS) systems in movement disorders in the late 1980s.3 Use of similar systems was applied to investigations in epilepsy, psychiatry, and a variety of other neurological conditions in the late 1990s and early 2000s, probably for similar reasons to those that spurred DBS for movement disorders. In addition, experience with DBS in movement disorders, observations about the cognitive and behavioral effects associated with DBS, and the availability of animal models catalyzed the extension of DBS to new indications.4–7 This article focuses on summarizing the neurobehavioral outcomes of DBS in PD.

Neurobehavioral Effects of Deep Brain Stimulation in Parkinson’s Disease

By far the most attention to neurobehavioral outcomes of DBS has been devoted to PD, and the majority of these studies have examined the outcome of subthalamic (STN) rather than thalamic or pallidal (GPi) DBS. Probably greater controversy attends the neurobehavioral outcomes after STN DBS than after GPi or thalamic DBS, and this probably reflects, at least in part, differences among studies in the sample characteristics, selection and exclusion criteria, length of follow-up, surgical technique, postoperative DBS programming and pharmacotherapy protocols, and the thoroughness and timing of the neuropsychological evaluation protocol. In general, studies employing cognitive screening instruments fail to detect neurobehavioral morbidity. While some may argue that the lack of change on screening instruments suggests that neuropsychological changes detected by more extensive evaluations are not of clinical significance, a recent meta-analysis of the empirical data suggests that screening instruments may be insensitive even to clinically meaningful changes after DBS.8 Consequently, cognitive screening measures are probably useful in helping to decide which surgical candidates can be excluded from further evaluation (including full neuropsychological evaluation), but insufficient to adequately document neurobehavioral outcomes of DBS.

Thalamic Deep Brain Stimulation
Four studies9–12 have observed no widespread or significant changes in cognition, mood, or behavior after unilateral thalamic DBS, although one study suggested that statistically (but not necessarily clinically) significant declines in verbal memory are associated with left thalamic DBS. Few studies have examined mood after thalamic DBS, but one study9 found an improvement in depressive symptoms four to 10 days after surgery.

Pallidal Deep Brain Stimulation
Unilateral GPi DBS appears cognitively safe, although this conclusion is tempered by the limited number of small-sample studies published.13–15 Although patients in one study showed statistically significant declines in visuoconstructional ability and verbal fluency, the changes were rarely of clinical significance. Even when using a liberal criterion of impairment (a test score falling one standard deviation below the mean of normative samples), another study13 observed that only six of the 20 patients showed any increase, no matter how small, in the percentage of tests in the impaired range. These patients tended to be older and were taking higher medication dosages prior to surgery. The safety of bilateral GPi DBS has been addressed in a handful of studies, and most found that the procedure is relatively safe from a cognitive standpoint.16–18 Nonetheless, a small minority of patients may develop cognitive morbidity. One case with magnetic resonance imaging (MRI)-confirmed electrode location had significant executive dysfunction ensuing from bilateral GPi DBS; importantly, when the stimulators were turned off, the impairment was partially reversed, thereby suggesting a direct role of stimulation in the neuropsychological deficit.19 Relatively isolated cognitive impairments were reported by the Toronto group in four patients.20

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