Postponing surgical intervention reduces the effectiveness of Parkinson’s treatment, experts say

Summary:
Experts at All India Institute of Medical Sciences highlight that many Parkinson’s patients in India are referred too late for Deep Brain Stimulation (DBS), reducing its effectiveness despite clear guidelines. Although DBS can significantly improve symptoms, lower medication use, and reduce complications, delays often occur because it is mistakenly viewed as a last-resort treatment. Late referrals, rising disease prevalence, high costs, limited awareness, and uneven access to specialised centres further restrict its use, even as technological advancements and expanding availability have improved outcomes. 

Despite well-defined clinical guidelines, numerous patients with Parkinson’s disease in India are referred for Deep Brain Stimulation (DBS) much later than ideal, which limits the procedure’s overall effectiveness, according to experts at AIIMS.

DBS, a widely accepted surgical option for Parkinson’s, is advised for carefully chosen patients who do not respond adequately to levodopa—the most effective medication for the condition—experience significant motor complications such as fluctuations and dyskinesias despite optimised drug therapy, and develop unpredictable “on-off” phases.

“On” phases refer to periods when symptoms are effectively controlled with medication, whereas “off” phases occur when the drug’s effect diminishes, causing symptoms like stiffness, tremors, and slowed movement to return.

In addition to improving symptom control, DBS helps lower medication requirements and reduces complications such as dyskinesias (abnormal movements caused by medication), hallucinations, nausea, and low blood pressure. It can also decrease the need for multiple drugs, said Dr P. Sarat Chandra, Head of Neurosurgery and Gamma Knife at AIIMS Delhi, speaking on World Parkinson’s Day.

However, actual referral practices remain inconsistent.

“Many patients in India are sent for evaluation only at advanced stages, when axial symptoms like freezing of gait and postural instability have already developed—conditions that typically respond poorly to DBS,” Dr Chandra noted.

One major reason for this delay is the common belief that DBS should be used only as a “last resort,” rather than as a treatment introduced during the stage when motor complications first appear but before permanent disability sets in.

Meanwhile, the prevalence of Parkinson’s disease is increasing rapidly, largely due to an ageing population.

“India is likely to witness a significant rise in cases in the coming decades, resulting in a larger number of patients eligible for advanced treatments such as DBS,” he added.

As life expectancy increases, more individuals are living long enough to develop motor complications, highlighting the importance of early detection and timely referral, doctors emphasised.

Over the last ten years, access to DBS has grown considerably across tertiary care centres, including major institutions like AIIMS Delhi.

Technological advancements in imaging, intraoperative monitoring, and devices—such as directional leads and durable rechargeable batteries—have enhanced surgical accuracy and long-term results, said Dr Satish Verma, Additional Professor of Neurosurgery.

Despite this progress, the use of DBS remains far lower than the number of patients who could benefit from it.

“Challenges include the high cost of the procedure, unequal distribution of specialised centres, and insufficient coordination between referring doctors and DBS programmes,” explained Dr Ramesh Doodamani from neurosurgery.

Another significant issue is limited awareness among patients, caregivers, and general practitioners.

Many patients are hesitant about undergoing surgery, while non-specialist doctors may fail to identify early motor fluctuations or continue increasing medication beyond optimal levels without considering surgical options, pointed out Dr Manjari Tripathi, Head of Neurology at AIIMS Delhi.

“This often results in prolonged use of high-dose medications, raising the risk of dyskinesias and neuropsychiatric side effects,” she said.