Objective: To describe clinical outcomes after DBS in patients with PD and moderate cognitive impairment (CI).

Background: DBS is generally contraindicated in PD patients with dementia, however no guidelines (whether to proceed, choice of target and staging) exist for those with moderate CI. Furthermore, the published clinical outcomes are mostly based on cohorts with mild CI or normal cognition, leaving clinicians and patients with unclear expectations in routine clinical practice.

Method: We did retrospective chart review to identify PD patients with moderate CI (having at least 2 test scores from neurocognitive battery at >=2 SD below the norm) who underwent DBS at Emory University between 2008-2018. Clinical outcomes included postoperative complications (inpatient, within first 30 days and within 1 year) and changes in UPDRS subscores at ~1 year post-surgery. Repeat neurocognitive testing was not routinely performed so gross changes in cognition were obtained from postoperative clinical notes (no reported change, transient worsening and permanent worsening).

Results: We identified 44 patients with PD and moderate CI who underwent DBS. The mean age was 66±8 years, disease duration 11±5 years, 82% were males, and 84% were impaired in multiple cognitive domains. Surgery was unilateral (59%), staged (25%) or bilateral (16%); targets were GPi (55%), STN (34%) and ViM (11%). Inpatient complications were present in 43% (N=44), prolonging the hospital stay in 30%, mostly due to delirium, hemorrhage and pain. Additionally, 50% and 36% (N=42) patients had complications within the first 30 days and 1 year after surgery respectively; including hallucinations, mood changes, confusion and device infection. Motor score(UPDRS 3) improved by 36% (N=35) and motor complications(UPDRS 4) improved by 19% (N=20), however mood/behavior score(UPDRS 1) worsened by 25% (N=21) and ADLs score(UPDRS 2) improved by 2% (N=20). Upon reviewing clinical notes (N=42), 7% had transient and 33% had permanent worsening of cognition.

Conclusion: Patients with moderate CI who underwent DBS surgery at our center had motor improvements within the range of previously published studies. However, non-motor outcomes and complication rates may be worse than expected. Future analysis should apply the same methodology on less cognitively impaired patients. Nonetheless, cognitively impaired patients should undergo rigorous testing and discussion of expectations before DBS surgery.

References: 1. Witt K et al. J Neurol Sci. 2011 Nov 15;310(1-2):261-6. 2. Floden D et al. Mov Disord. 2015 Aug;30(9):1279-83. 3. Goetz CG et al. Mov Disord. 2008 Nov 15;23(15):2129-70. 4. Abboud et al. Parkinsonism and Related Disorders 21 (2015) 249-253

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