Treatment of advanced Parkinson's diseaseKeywords:
When even the best medication no longer sufficiently helps in the motor fluctuations caused by advanced Parkinson's disease, invasive treatment options may be considered: deep-brain stimulation, and levodopa or apomorphine infusions.
We are a pioneer in the treatment of advanced Parkinson's disease. Our movement disorder unit is the largest in volume in Finland.
You need a referral for treatment at our unit, and a neurologist specialized in movement disorders will evaluate the referral at our Neurology Outpatient Clinic. Our treatment team implementing the treatments also includes a neurosurgeon, abdominal surgeon, radiologist, and neuropsychologist. Invasive treatments cannot be used if you suffer from severe dementia or severe psychosis. At least a short-term response to levodopa is a requirement for the treatment. The only exception to this rule is drug-resistant tremor, which usually responds well to deep-brain stimulation.
You will have an appointment at our unit with a neurologist specialized in movement disorders to discuss your symptoms and current status of health. Your wishes will be 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 treatment decision; for example, a levodopa challenge test can be taken to evaluate the treatment response.
Currently, deep-brain stimulation is the most commonly used invasive treatment method in the world. In 2017, we were the first hospital in Finland to implement the directional electrode, which reduces the DBS-related adverse effects, such as speech difficulties, even better than before. In deep-brain stimulation, the electrodes, wires, and the generator are placed under your skin. When necessary, you can adjust the stimulator with your own programmer device. However, with the stimulator optimally programmed, there is no need for you to perform any daily adjustments. Deep-brain stimulation reduces tremor, motor fluctuations, and involuntary movements significantly better than optimized medicinal therapy. At best, the response lasts for over 10 years. In our unit, the stimulators are currently installed under general anesthesia.
In levodopa infusion therapy, an external pump is used to administer levodopa gel to the small intestine. You can adjust the infusion speed according to the response. Levodopa infusion has been shown to significantly reduce daily off-phases and increase 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 our experience, the response to this therapy optimally lasts at least 10 years.
Apomorphine injections and infusions
Apomorphine is a dopamine agonist, and despite its name, 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 have been shown to significantly reduce daily off-phases. It is especially suited for patients for whom apomorphine pens are verifiably suitable and who require more than five injections a day. However, 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 deep-brain stimulation, such as balance or speech difficulty that does not respond to levodopa, or the patient is afraid of the risks related to brain surgery.
The invasive treatments of advanced Parkinson's disease in our unit 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 new directional electrode
- 2017 Apomorphine infusion therapy