Clinical and neuropsychological follow up at 12 months in patients with complicated Parkinson's disease treated with subcutaneous apomorphine infusion or deep brain stimulation of the subthalamic nucleus

Background: The clinical condition of advanced Parkinson's disease ( PD) patients is often complicated by motor fluctuations and dyskinesias which are difficult to control with available oral medications. Objective: To compare clinical and neuropsychological 12 month outcome following subcutaneous apomorphine infusion (APO) and chronic deep brain stimulation of the subthalamic nucleus (STN-DBS) in advanced PD patients. Methods: Patients with advanced PD and medically untreatable fluctuations underwent either APO (13 patients) or STN-DBS (12 patients). All patients were clinically (UPDRS-III, AIMS, 12 h on-off daily) and neuropsychologically (MMSE, Hamilton-17 depression, NPI) evaluated at baseline and at 12 months. APO was discontinued at night. Results: At 12 months APO treatment (74.78 +/- 24.42 mg/day) resulted in significant reduction in off time ( 251%) and no change in AIMS. Levodopa equivalent medication doses were reduced from 665.98 +/- 215 mg/ day at baseline to 470 +/- 229 mg/ day. MMSE, NPI, and Hamilton depression scores were unchanged. At 12 months STN-DBS resulted in significant clinical improvement in terms of reduction in daily off time (276%) and AIMS (281%) as well as levodopa equivalent medication doses (980 +/- 835 to 374 +/- 284 mg/ day). Four out of 12 patients had stopped oral medications. MMSE was unchanged (from 28.6 +/- 0.3 to 28.4 +/- 0.6). Hamilton depression was also unchanged, but NPI showed significant worsening (from 6.58 +/- 9.8 to 18.16 +/- 10.2; p < 0.02). Category fluency also declined. Conclusions: Both APO and STN- DBS resulted in significant clinical improvement in complicated PD. STNDBS resulted in greater reduction in dopaminergic medications and provided 24 h motor benefit. However, STN-DBS, unlike APO, appears to be associated with significant worsening on NPI resulting from long term behavioral problems in some patients.