Neurosurgery in Parkinson disease - A distressed mind in a repaired body?
ABSTRACT To prospectively evaluate the impact of subthalamic nucleus (STN) stimulation on social adjustment in patients with Parkinson disease (PD).
Before and 18 to 24 months after bilateral STN stimulation, the authors assessed 29 patients with PD for motor disability, cognition (Mattis dementia rating scale, frontal score), psychiatric morbidity (Mini-5.0.0, MADRS, BAS), quality of life (PDQ-39), social adjustment (Social Adjustment Scale), and psychological status using unstructured in-depth interviews.
Despite marked improvement in parkinsonian motor disability, the absence of significant changes in cognitive status, and improvement of activities of daily living and quality of life by the end of the study, social adjustment did not improve. Several kinds of problems with social adjustment were observed, affecting the patients' perception of themselves and their body, marital situation, and professional life. Marital conflicts occurred in 17/24 couples. Only 9 out of 16 patients who had a professional activity before the operation went back to work after surgery.
After STN stimulation, patients experienced difficulties in their relations with themselves, their spouses, their families, and their socio-professional environment. The authors suggest a multidisciplinary psychosocial preparation and follow-up to help patients and their entourage cope with the sudden changes in their existence following successful neurosurgery.
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ABSTRACT: One of the reasons why moral enhancement may be controversial, is because the advantages of moral enhancement may fall upon society rather than on those who are enhanced. If directed at individuals with certain counter-moral traits it may have direct societal benefits by lowering immoral behavior and increasing public safety, but it is not directly clear if this also benefits the individual in question. In this paper, we will discuss what we consider to be moral enhancement, how different means may be used to achieve it and whether the means we employ to reach moral enhancement matter morally. Are certain means to achieve moral enhancement wrong in themselves? Are certain means to achieve moral enhancement better than others, and if so, why? More specifically, we will investigate whether the difference between direct and indirect moral enhancement matters morally. Is it the case that indirect means are morally preferable to direct means of moral enhancement and can we indeed pinpoint relevant intrinsic, moral differences between both? We argue that the distinction between direct and indirect means is indeed morally relevant, but only insofar as it tracks an underlying distinction between active and passive interventions. Although passive interventions can be ethical provided specific safeguards are put in place, these interventions exhibit a greater potential to compromise autonomy and disrupt identity.Neuroethics 02/2015; DOI:10.1007/s12152-015-9230-y · 1.04 Impact Factor
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ABSTRACT: Unlike dementia, the effect of mild cognitive impairment (MCI) on outcomes after deep brain stimulation (DBS) in Parkinson's disease (PD) is less clear. We aimed to examine the effect of MCI on short- and long-term DBS outcomes. To study the effect of MCI type, cognitive domains (attention, language, visuospatial, memory, executive function), and Dementia Rating Scale (DRS) score on immediate postoperative outcomes (postoperative confusion, hospitalization days), PD patients who underwent DBS at our Center from 2006 to 2011 were analyzed. To determine cognitive predictors of intermediate (6-month) and long-term (1-year) post-operative outcomes, the changes in functional and quality-of-life (QOL) scores were analyzed in a smaller group with available preoperative health status measures. We identified 130 patients [71% male, mean age: 63 ± 9.1, mean PD duration: 10.7 ± 5.1]. At preoperative assessment, 60% of patients had multiple-domain MCI, 21% had single-domain MCI, and 19% had normal cognition. MCI presence and type as well as DRS performance did not affect immediate outcomes. Attention impairment predicted longer postoperative hospitalization (P = 0.0015) and showed a trend towards occurrence of postoperative confusion (P = 0.089). For intermediate and long-term outcomes we identified 56 patients [73.2% male, mean age: 61.3 ± 9.6, mean PD duration: 10.6 ± 4.7]. Visuospatial impairment showed a trend towards less improvement in 6-month functional score (P = 0.0652), and 1-year QOL score (P = 0.0517). The presence of MCI did not affect DBS outcomes. However, the types of impaired domains were more detrimental. Detailed cognitive testing can help stratify low- and high-risk patients based on their pattern of cognitive dysfunction. Copyright © 2014 Elsevier Ltd. All rights reserved.Parkinsonism & Related Disorders 12/2014; DOI:10.1016/j.parkreldis.2014.12.018 · 4.13 Impact Factor
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ABSTRACT: To study the caregivers' perception of their own well-being 1 year after subthalamic deep brain stimulation (STN-DBS) surgery in Parkinson's disease (PD) patients, using a qualitative and quantitative approach. 25 patients and caregivers, living together in partnerships, were examined before and at 3-month and 1-year follow-up (FU) after STN-DBS surgery. Semi-structured FU interviews concerning caregivers' own well-being under STN-DBS were conducted and analyzed: caregivers were accordingly assigned to positive or negative outcome groups. Quality of life (QoL), depression, apathy and anxiety of caregivers and patients were measured. These quantitative data were compared to the 1-year FU interview outcomes. Multiple comparisons analyzed caregiver group assignments based on these measurements. Logistic regression was used to find predictors. Additionally, patients' mood ratings were used in multiple comparisons with caregivers' subjective outcome, to analyze the interaction of patient and caregiver ratings. At 3-month FU, caregivers were more indecisive concerning their own well-being than at 1-year FU. At 1-year FU, caregivers from the negative group had greater depression, anxiety and lower QoL ratings. They were significantly older compared to the positive group. Patients' depression showed significantly stronger improvement in the positive outcome group. Patients' apathy and depression ratings were significant covariates of caregivers' QoL. Our results show that at 1-year FU over 50 % of the caregivers rated their subjective well-being as negative. Especially older and more depressed caregivers are at risk. These caregivers and their partners should be monitored more closely to identify possible problems and help them adapt following surgery.Journal of Neurology 11/2014; 262(2). DOI:10.1007/s00415-014-7571-9 · 3.84 Impact Factor