Don't Wait For The 'Last Resort': AIIMS Experts Urge Earlier Deep Brain Stimulation Referral For Parkinson's

Despite clear clinical guidelines, many Parkinson's disease patients in India are being referred too late for Deep Brain Stimulation (DBS), reducing the potential benefits of the procedure, AIIMS experts said.

DBS, a well-established surgical therapy for Parkinson's, is recommended for carefully selected patients who respond poorly to levodopa, the most effective medicine for managing the disease, develop disabling motor complications such as fluctuations and dyskinesias despite optimised medical therapy, and also develop unpredictable "on-off" periods.

"On" periods are when Parkinson's symptoms are well controlled with medication, while "off" periods are when the medication effect wears off, and symptoms (like rigidity, tremor, and slowness) reappear.

DBS also reduces medication dose, prevents complications like dyskinesias (medicine-induced abnormal movements), hallucinations, nausea and hypotension. It also helps to reduce multiple medicines, said Dr P Sarat Chandra, Head of Department of Neurosurgery and Gamma Knife at AIIMS, Delhi, on World Parkinson's Day.

However, in real-world practice, referral patterns remain inconsistent.

"Many patients in India are referred only in advanced stages of the disease, when axial symptoms such as gait freezing and postural instability have already set in, features known to respond poorly to DBS, " Dr Chandra said.

A key contributor to this delay is the widespread perception of DBS as a "last resort" therapy, rather than an intervention best introduced during the window when motor complications begin but before irreversible disability occurs, he said.

At the same time, the burden of Parkinson's disease is rising rapidly, driven by an ageing population.

" India is expected to see a substantial increase in prevalence in the coming decades, leading to a larger pool of patients eligible for advanced therapies like DBS," he said.

As longevity improves, more patients are living long enough to develop motor complications, underscoring the need for timely identification and referral, doctors stated.

Over the past decade, access to DBS has expanded significantly across tertiary care centres, including leading institutions such as AIIMS Delhi.

Advances in imaging, intraoperative monitoring and device technologies, such as directional leads and long-lasting rechargeable batteries, have improved surgical precision and long-term outcomes, said Dr Satish Verma, additional professor of Neurosurgery.

Yet, utilisation remains disproportionately low compared to the number of eligible patients.

"Barriers include high costs, uneven geographic distribution of specialised centres, and limited coordination between referring physicians and DBS programmes," Dr Ramesh Doodamani from neurosurgery stated.

Another major challenge is the lack of awareness among patients, caregivers, and general physicians.

Many patients remain apprehensive about surgery, while non-specialist doctors may not recognise early signs of motor fluctuations or may continue escalating medication beyond optimal limits without considering surgical evaluation, Dr Manjari Tripathi, head of Neurology at AIIMS, Delhi, highlighted.

"This often leads to prolonged high-dose drug therapy, increasing the risk of dyskinesias and neuropsychiatric complications," she said.

Experts stressed the need for structured referral pathways and wider awareness campaigns targeting both the public and healthcare providers.

"Identifying early referral triggers, such as wearing-off symptoms, dyskinesias, and medication intolerance, can significantly improve outcomes," said Dr Tripathi.

The doctors emphasised that timely intervention with DBS, in appropriately selected patients, can substantially improve quality of life and functional independence.

They also warned that early-onset Parkinson's disease, increasingly seen in people in their 30s and 40s in India, is emerging as a serious but often overlooked health concern that cannot be ignored.

While Parkinson's has traditionally been associated with older age, specialists say a growing number of younger patients are being diagnosed, raising alarm about long-term disability and quality of life, added Dr Elavarasi, Professor of Neurology and main coordinator for the event at AIIMS.

Neurologists attribute this shift partly to genetic factors, along with environmental triggers and improved diagnosis.

"Genetics plays a significant role in early-onset cases, making timely recognition crucial," said Dr Elavarasi, stressing the need for greater awareness and early intervention strategies.

Dr Chandra also informed that AIIMS will soon introduce focused ultrasound (FUS) therapy and is in the process of procuring technology for performing the non-invasive MRI-guided targeted procedure on such patients.

The FUS therapy uses targeted ultrasound waves to create small, precise lesions in specific parts of the brain, such as the thalamus or globus pallidus, Dr Chandra explained.

In Parkinson's disease, it helps control tremor and dyskinesia that do not respond well to medicines, and provides quick relief without the need for surgery.

However, the FUS has some limitations compared to the DBS.

It is usually done only on one side of the brain, so it may not be suitable for patients with symptoms on both sides, Dr Chandra pointed out.

It has not been recommended by the Food and Drug Administration (FDA) as a first-line treatment for Parkinson's disease, he said.

Also, unlike DBS, doctors cannot assess improvement during the procedure.

In DBS, patients are often awake, allowing doctors to check symptom relief in real time and adjust the electrode placement for better results.

The FUS therapy is mainly recommended for patients with symptoms largely on one side, especially tremor and for those who may not be fit for surgery due to old age or conditions such as heart disease, Dr Chandra added.

He said AIIMS may start doing FUS by August 2026 at a reasonable cost. 

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