AAN 2026 | Advances in DBS for Parkinson’s disease and updated recommendations for referral

So the new updates on deep brain stimulation for management of Parkinson’s disease are a few. One would be adaptive DBS that allows for an adaptive amount of stimulation based on following Parkinson’s frequencies in the brain. The other one would be image-guided programming that allows for programming of the brain stimulation based on patient-specific anatomy. And also we have telemedicine or remote programming available. And these are all different ways that have improved our care for patients who have Parkinson’s disease and also essential tremor that we can use image-guided programming, remote programming for patients with essential tremor as well.

There has been a recent publication that a group of us from the Parkinson’s study group came together and worked on updating the recommendations for referral for deep brain stimulation for Parkinson’s disease. The reason for that is that the previous guidelines have been outdated and we have had many new advancements in deep brain stimulation. And we think about it way earlier into the disease these days, as opposed to many years ago, where we would say that you only refer for surgery when this is the last resort and there’s nothing else to be done. These days, we think that we could improve quality of life if we think about this surgery earlier in the course of the disease. Still, we don’t have any evidence that the surgery will slow progression of the disease. So this is only for management of motor and some non-motor symptoms, but we start thinking about it much earlier than before.

And the updates in referral recommendations that came from this consensus paper were mostly focused on indications for surgery, which are tremor that is not optimally managed with medication, presence of fluctuation or troublesome dyskinesia. And we emphasize the fact that the patients don’t have to meet a certain cutoff for a stage or UPDRS, which is a way of scoring motor symptoms of Parkinson’s disease. UPDRS 3, Unified Parkinson’s Disease Rating Scale, which is a scale that we use in clinic very often for assessment of motor and has other sections that also assess non-motor symptoms. The Part 3 of this scale has been traditionally used, and we use it for “on” when medications are working and “of”f when medications are not working. Testing of on, off, and the difference between the two will usually tell us what a difference medication makes for each individual patient. But the truth is some of these patients have a lot of troublesome dyskinesia that even if they don’t have a robust response to improvement of UPDRS in on state, they still will benefit from surgery for management of that troublesome dyskinesia that could potentially put them at risk of falls or would be painful and cause troubles for them. Also, patients who have a lot of tremor that is refractory to levodopa treatment may not necessarily see a whole lot of change on the UPDRS testing in “on” state compared to “off”. And we emphasize that these patients are still good surgical candidates and you should consider referring them earlier. Another important point that came from this paper was that earlier counseling and education of patients and their caregivers are exceptionally important because they need to hear about surgery earlier in the course of the disease to be able to consider surgical considerations when they become the next step in treatment, as opposed to break it to them that this is the next step and they haven’t heard about surgery before and this could be really scary for the patients and their caregivers. So that was the main point of this paper to make sure that we eliminate these possible blocks in the road to surgical treatments that could certainly improve quality of life for these patients.

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