Referrals for Movement Disorder Surgery: Under-Representation of Females and Reasons for Refusal

Abstract

Although deep brain stimulation (DBS) for movement disorders (MD) is an accepted option for selected patients who have failed maximal medical management, 1,2 only a small number are referred and only a proportion of those proceed to the operating room. Furthermore, a gender imbalance in operated patients was suggested previously. 3,4 Therefore, we sought to determine (i) if disproportionate numbers of males are referred compared to females, and (ii) why the patients referred for surgery failed to reach the operating room. METHODSIn March 2004, the University of Calgary Movement Disorders Clinic (MDC) patient database included 1598 patients ABSTRACT: Objective: Referral of movement disorder patients for deep brain stimulation surgery was examined to determine whether referred patients were representative of gender proportions in our population, and reasons why patients do not proceed to surgery. Methods: Demographic information on referrals to the surgical program was retrospectively reviewed from our database and from a detailed chart review. Results: Although almost equal numbers of movement disorder patients are male and female, of the 91 patients referred for surgery, only 31% were female. Sixty-one percent of referred patients did not undergo surgery. Of these, the majority were denied for medical reasons, including cognitive decline (21%), psychiatric concerns (5%) and neurological reasons (42%). Conclusions: Almost one-third of patients referred for movement disorder surgery were denied for medical reasons. This underscores the importance of evaluation of all potential patients by a multidisiplinary team to fully assess suitablity for stereotactic surgery. Interestingly, women were under-represented in those referred. In order that all appropriate patients have the opportunity to consider surgery, education of both physicians and patients, and different strategies to approach females regarding surgery may allow more patients to benefit from this treatment. RÉSUMÉ: L'orientation des patients vers la chirurgie dans les troubles du mouvement: sous-représentation des femmes et raisons d'exclusion.Objectif: L'orientation des patients atteints de troubles du mouvement vers la neurochirurgie pour stimulation cérébrale profonde a été examinée afin de déterminer si la proportion de ces patients par sexe était représentative de cette proportion dans notre population et pourquoi un certain nombre de ces patients ne subissent pas l'intervention. Méthodes: Il s'agit d'une analyse rétrospective de l'information démographique sur les patients orientés en chirurgie contenue dans notre base de données et obtenue également d'une revue détaillée de dossiers. Résultats: Bien qu'un nombre presque égal d'hommes et de femmes soient atteints de troubles du mouvement, seulement 31% des 91 patients orientés en chirurgie étaient des femmes. La chirurgie n'a pas été effectuée chez soixante et un pour cent d'entre eux, la plupart du temps pour des raisons médicales, soit un déclin cognitif chez 21%, des problèmes de nature psychiatriq...

Are Patients Ready for “EARLYSTIM”? Attitudes towards Deep Brain Stimulation among Female and Male Patients with Moderately Advanced Parkinson’s Disease

“…Earlier studies have shown that, in relation to the gender prevalence of PD, women are underrepresented among those treated with DBS [12, 14, 15, 31]. The reason for this is unknown but it has been suggested that women might be more “afraid” of (and hesitant towards) neurosurgery compared to men [32].…”

“…However, non-operated upon patients' own thoughts, considerations, and apprehensions concerning advanced therapy for PD have received scarce attention in the literature [10, 11]. This issue is all the more interesting in light of existing gender differences, with more men than women undergoing DBS for PD [12–15] and given the current trend of suggesting DBS earlier in the disease progress [16–18]. …”

Ethical Focal Points in the International Practice of Deep Brain Stimulation

“…Early estimations range from 1.6% to 4.5% (Morgante et al 2007), but have been criticized to underrate the ratio of eligible PD patients (Cacciola 2008). Several factors contribute to this underrating: Referring clinicians may underestimate the number of suitable patients (Oyama et al 2012), women are under-represented in those referred (Setiawan et al 2006), and the amount of suitable candidates could increase, if patients would be referred earlier to DBS (Charles et al 2012;Schüpbach et al 2013). Therefore, a more reasonable guess is that 10-20 % of PD patients may qualify for DBS (Christen and Müller 2012).…”

Criteria for deep-brain stimulation in Parkinson’s disease: review and analysis

“…Cognitive impairment has been reported as the most frequent cause of exclusion for STN DBS surgery [26,29,34,64,68,69]. This strict criterion has been supported by cognitive changes observed after STN DBS in elderly patients without cognitive impairment before surgery [70] and further cognitive worsening in patients with pre-existing impairment [71,72].…”