New Delhi: Despite clear clinical guidelines, many Parkinson’s disease patients in India are referred too late for deep brain stimulation, diminishing the potential benefits of the procedure, AIIMS experts said.
Deep brain stimulation, an established surgical treatment for Parkinson’s disease, is recommended for carefully selected patients who respond poorly to levodopa, the most effective drug for managing the disease, develop disabling motor complications such as fluctuations and dyskinesia despite optimal medical treatment, and experience unpredictable “off” periods.
“On” periods are when Parkinson’s symptoms are well controlled with medication, while “off” periods are when the drug’s effect wears off and symptoms return.
DBS also reduces the dose of medication and prevents complications such as dyskinesia, hallucinations, nausea, and low blood pressure. It also helps in reducing polypharmacy, said Dr P Sarat Chandra, head, 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 at advanced stages of the disease, when pivotal symptoms such as freezing of gait and postural instability, features known to respond poorly to DBS, are already present,” said Dr Chandra.
A major contributor to this delay is the widespread perception of DBS as a “last resort” treatment, rather than an intervention best delivered 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 increasing rapidly, due to the aging of the population.
“India is expected to witness a significant increase in the prevalence of the disease in the coming decades, resulting in a larger pool of patients eligible for advanced treatments such as deep brain stimulation,” he said.
As longevity improves, more patients live long enough to develop motor complications, underscoring the need for timely identification and referral, doctors said.
Over the past decade, access to DBS has expanded significantly across tertiary care centres, including leading institutions such as AIIMS Delhi.
Dr Satish Verma, additional professor of neurosurgery, said advances in imaging techniques, intraoperative monitoring and devices, such as directional sutures and long-lasting rechargeable batteries, have improved surgical precision and long-term outcomes.
However, the utilization rate remains disproportionately low compared to the number of eligible patients.
“Barriers include high costs, uneven geographic distribution of specialty centers, and limited coordination between referring physicians and DBS programs,” said Dr. Ramesh Doddamani of Neurosurgery.
Another major challenge is a lack of awareness among patients, carers and GPs.
Many patients remain apprehensive about surgery, while lay doctors may not recognize early signs of motor fluctuations or may continue to escalate medication beyond optimal limits without considering surgical evaluation, explains Dr Manjari Tripathi, head, department of neurology, AIIMS, Delhi.
“This often leads to long-term treatment with high doses of medications, which increases the risk of dyskinesia and neuropsychiatric complications,” she said.
Experts stressed the need for structured referral pathways and broader awareness campaigns targeting both the public and healthcare providers.
“Identifying triggers for early referral, such as wear symptoms, dyskinesia, and drug intolerance, can significantly improve outcomes,” Dr. Tripathi said.
Doctors emphasized that timely intervention using DBS technology, in appropriately selected patients, can significantly improve quality of life and functional independence.
They also warned that early-onset Parkinson’s disease, which is increasingly seen in people in their 30s and 40s in India, has become a serious health concern but is often overlooked and cannot be ignored.
While Parkinson’s disease is traditionally associated with aging, specialists say an increasing number of younger patients are being diagnosed, raising concerns about long-term disability and quality of life, added Dr Ilavarasi, professor of neurology and chief coordinator of the event at AIIMS.
Neurologists attribute this shift in part to genetic factors, along with environmental triggers and improved diagnosis.
“Genetics plays an important role in early cases, which makes timely recognition of it crucial,” Dr. Ilavarasi said, stressing the need for increased awareness and early intervention strategies.
Dr. Chandra also informed that AIIMS will soon offer focused ultrasound therapy and is in the process of procuring technology to perform the non-surgical MRI-guided targeted procedure on these patients.
Dr. Chandra explained that FUS treatment uses targeted ultrasound waves to create small, precise lesions in specific parts of the brain, such as the thalamus or globus pallidus.
In Parkinson’s disease, it helps control tremors and dyskinesia that do not respond well to medications, and provides quick relief without the need for surgery.
However, FUS has some limitations compared to DBS.
It’s usually performed on only one side of the brain, so it may not be appropriate for patients with symptoms on both sides, Dr. Chandra noted.
The Food and Drug Administration has not recommended it as a first-line treatment for Parkinson’s disease, he said.
Also, unlike deep brain stimulation (DBS), doctors cannot evaluate improvement during the procedure.
In deep brain stimulation, patients are often awake, allowing doctors to check symptom relief in real time and adjust the electrode position for better results.
FUS treatment is primarily recommended for patients with symptoms largely on one side, especially tremor and for those who may not be a candidate for surgery due to aging or conditions such as heart disease, Dr. Chandra added.
AIIMS may start conducting FUS by August 2026 at a reasonable cost, he said.
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