Treatment of advanced Parkinson’s disease

When even the best medication no longer sufficiently help the motor fluctuations caused by Parkinson's disease, invasive treatment options may be considered: deep brain stimulation, and levodopa or apomorphine infusions. These treatments are proven to significantly reduce the motor fluctuations, tremor, and involuntary movements. The aim of invasive treatment is to improve the patient’s quality of life.
The patient needs a referral for invasive treatment, and a neurologist specialized in movement disorders will evaluate the referral at HUS Neurology Outpatient Clinic. The team that implements the treatments also includes a neurosurgeon and an abdominal surgeon, a radiologist, and a neuropsychologist. Invasive treatments cannot be used if the patient suffers from difficult dementia or a difficult psychosis. A short-term response to levodopa is required in all three treatment options. The only exception to this rule is drug-resistant tremor, which usually responds well to deep brain stimulation.
The patient will have an appointment with a neurologist specialized in movement disorders to discuss the Parkinson's symptoms and their current condition. The patient's wishes are taken into consideration when choosing the type of treatment, but the neurologist will make the final decision. Further examinations are always performed to confirm the decision; for example, a levodopa challenge test can be taken to evaluate the levodopa response. 
Deep brain stimulation (DBS)
Currently, deep brain stimulation is the most commonly used invasive treatment method in the world. In 2017, HUS was the first hospital in Finland to implement the  directional electrode, which reduces the  DBS related adverse effects, such as speech difficulties, better than conventional stimulation. In DBS treatment, the electrodes, wires, and the generator are placed under the patient's skin. When necessary, the patient can adjust the stimulator with their own programmer device. However, with the stimulator optimally programmed, the patient does not need to perform any daily adjustments. DBS reduces tremor, motor fluctuations and involuntary movements significantly better than optimized medicinal therapy. At best, the response lasts for over 10 years. In HUS, the stimulators are currently installed under general anesthesia.  
Levodopa infusions
In levodopa infusion therapy, an external pump is used to administer levodopa gel to the small intestine. The patient can adjust the infusion speed according to their response. Levodopa infusion significantly reduces daily off-phases and  increases on-phases when compared to regular medication. This treatment is useful for patients with motor fluctuations or involuntary movements who still clearly respond to levodopa treatment. According to experiences in HUS, the response for this therapy optimally lasts at least 10 years.
Apomorphine injections and infusions
Apomorphine is a dopamine agonist, and despite its name, it has no opiate effects. Apomorphine alleviates motor symptoms about as much as levodopa does. An apomorphine injection has a rapid onset time, even as quick as 10 minutes. Apomorphine infusions significantly reduce off-phases. It is best suited for patients for whom apomorphine pens are verifiably suitable and who require more than five injections a day. It is also possible to proceed directly to the infusion without using the pen first. 
Both levodopa and apomorphine infusions may be suitable options if the patient has some contraindications for DBS, such as balance or speech difficulty that does not respond to levodopa, or the patient is afraid of the risks related to brain surgery.

HUS is a Finnish forerunner in the treatment of advanced Parkinson's disease
HUS's movement disorder unit is the largest in volume in Finland. The invasive treatments of advanced Parkinson's disease are implemented according to international criteria and our clinical pathways score well in international comparison.  
First in Finland milestones of HUS's unit for motor disorders:

  • 1995 Deep brain stimulation surgery
  • 2005 Levodopa infusion test
  • 2006 Modern clinical pathway for deep brain stimulation
  • 2017 Use of the new directional electrode in advanced Parkinson's disease
  • 2017 Apomorphine infusion therapy in advanced Parkinson's disease