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Year : 2022 | Volume
: 25
| Issue : 6 | Page : 1214-1216
Comparison of pre-deep brain stimulation clinical profiles of patients with young and late-onset parkinson's disease
P Muthukumaran1, Nitish L Kamble1, Tanaya Mishra1, Ravi Yadav1, Dwarakanath Srinivas2, Pramod K Pal1
1 Department of Neurology, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India
2 Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India
Correspondence Address:
Pramod K Pal
Professor, Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore - 560 029, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aian.aian_245_22
How to cite this article:Dear Sir,
Parkinson's disease (PD) is one of the common neurodegenerative disorders in the elderly population. Quinn et al. proposed a criterion to categorize young-onset PD (onset of PD between 21 and 40 years) and juvenile PD (onset below 21 years) based on the age at onset, which is similar to the classification proposed by Golbe et al.[1] Both motor and nonmotor symptoms are observed in young-onset PD (YOPD) and late-onset PD (LOPD). However, several features appear to cluster in YOPD patients, suggesting a phenotypic homogeneity in these patients.
Deep brain stimulation (DBS) is traditionally offered to late-stage PD patients, a mean of 15 years after diagnosis and currently has level I evidence in improving symptoms. However, now DBS is considered even for patients in the early stage of illness.[2]
We aimed to compare the pre-DBS clinical profile of patients with YOPD and LOPD, and understand the regional, socio-cultural, and clinical factors that determine DBS as the choice of therapy in these patients, and the differences in the clinical characteristics and disease course across different populations.
Our study is a retrospective chart review of patients undergoing DBS at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India, a tertiary care referral and teaching hospital. The study included PD patients (diagnosed by the United Kingdom Parkinson's Disease Brain Bank Criteria) who underwent DBS from the year 2007 onwards till March 2018. The genetic diagnosis was not performed in our YOPD patients. However, other secondary causes were ruled out before the patients underwent DBS. The patients were categorized into two groups viz. YOPD (onset of motor symptoms ≤45 years of age) and LOPD (onset of motor symptoms >45 years of age) for comparing the various demographic and clinical profiles. A total of 63 PD patients (18 women and 45 men) were included in the study. At the time of presentation, the age ranged from 27 to 71 years, with a mean of 53.06 ± 9.4 years. The mean age at onset of motor symptoms was 42.59 ± 9.69 years. The duration of illness ranged from 3 to 25 years with a mean duration of 10.56 ± 4.46 years. The mean age at the time of DBS surgery was 53.84 ± 9.24 years (33–71 years). [Table 1] gives a detailed account of various motor and non-motor symptoms.
All patients in the study group had undergone subthalamic DBS except one patient with cervical dystonia and PD who underwent globus pallidus internus (GPi) DBS.
Of the study population, 35 (55.6%) were YOPD and 28 (44.4%) were LOPD patients. Family history of PD was seen in 17.1% of the patients in the YOPD group compared to 10.7% in the LOPD group. The mean age at onset for patients with YOPD was 36.17 ± 6.46 years (mean duration of illness 11.6 ± 4.69 years) and 50.96 ± 4.06 years for patients with LOPD (mean duration of illness 8.7 ± 2.8 years). There was a significant difference in their age, age at onset, duration of illness, and age at DBS [Table 2].
Table 2: Comparison of demographic and clinical characteristics of patients with YOPD and LOPDImpulse control disorders, anosmia, bladder disturbances, rapid eye movement (REM) sleep behavior disorder (RBD), and psychosis were more common in YOPD patients, whereas constipation, depression, and autonomic dysfunction were more common in LOPD patients. Compared to the current literature where RBD and psychosis are more common in LOPD than in YOPD, in our study, it was more common in YOPD. This may be due to the small sample size.
Studies have shown that men carry a greater chance of having PD than women.[3] The age at onset, duration of illness, and age at DBS are almost similar to the three published studies from India. However, the age at DBS is lower in the Indian studies, including ours compared to the majority of the studies from Western countries, Europe, and some parts of Asia.
The overall age standardized incidence of male to female ratio is estimated to be 1.46.[4] PD incidence is higher in postmenopausal women on hormonal therapy than in those who are not on treatment.[5] In addition, men are generally the breadwinners in the family, and their disability was not acceptable. Furthermore, there could also be neglect of women in the family, explaining why very few women had undergone DBS. Many studies have shown this gender bias. In our study, the duration of illness was 10.56 ± 4.46 years, which is less when, compared to the western people that ranges from 12.5 ± 1.3 to 19.2 ± 5.3 years.[6] In addition, the age for DBS surgery is also significantly less when compared to other studies. The age at surgery in our population was 53.8 ± 9.44 years, which is much less when compared with the western population, which ranges from 54 to 60 years.[7] DBS is generally offered not only in advanced PD but also at a younger age. There are studies that have shown good outcomes after DBS in PD patients with a disease duration of fewer than 5 years also.[2]
In studies on patients undergoing DBS in India, patients with YOPD have remained the most prevalent group of PD patients who have undergone DBS. In our study, 55.6% had YOPD. The mean age at onset was comparable to a study by Merola et al.,[7] where the YOPD group had a mean age of onset of 35.5 ± 4.7 years. In another study by Tsai et al.[8] in Taiwanese patients with YOPD, the mean age at onset was 32.3 ± 6.8 years. There is increasing evidence favoring DBS in YOPD patients.[8] The levodopa equivalent daily dose (LEDD) was much less in YOPD than in LOPD patients. This implies that YOPD patients had undergone DBS surgery at lower LEDD. In addition, the duration of medical management was significantly longer in YOPD patients. This suggests that YOPD patients had received adequate medical therapy before undergoing DBS even though the LEDD was less. These patients might have been proactively counseled to undergo DBS earlier when the motor complications started.
It has been observed that YOPD patients have a slower disease progression and lower frequency of falls, freezing of gait, and a lower rate of dementia.[9] The nonmotor symptoms are also more prevalent in YOPD compared to LOPD. Abnormalities in sweating and restless legs syndrome are more common in YOPD. In contrast, the prevalence of impaired taste and smell, dribbling, constipation, nocturia, RBD, dementia, and hallucinations increased with increasing age at onset.[10] YOPD patients underwent DBS at an earlier age when compared to LOPD patients; however, the duration of medical treatment was longer in YOPD patients. Hence, the patients were offered DBS only when they developed motor fluctuations or dyskinesias and had received medical treatment for an adequate duration.
Our study shows that gender, age at onset, duration of illness, tremor as the first symptom, presence of dyskinesias, an adequate trial of dopaminergic treatment, and socio-economic status were the main determinants for performing DBS in patients with Parkinson's Disease.
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Conflicts of interest
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