Multiple Sclerosis (MS)
Multiple Sclerosis/Nursing assessment
Objective Data General Apathy, inattentiveness Integumentary Pressure ulcers Neurologic Scanning speech, nystagmus, ataxia, tremor, spasticity, hyperreflexia, decreased hearing Musculoskeletal Muscle weakness, paresis, paralysis, spasms, foot dragging, dysarthria Possible Diagnostic Findings ↓ T suppressor cells, demyelinating lesions on MRI or MRS scans, ↑ IgG or oligoclonal banding in cerebrospinal fluid, delayed evoked potential responses IgG, Immunoglobulin G; MRS, magnetic resonance spectroscopy.
Multiple Sclerosis (MS)/Immunomodulators
Teriflunomide (Aubagio) is an immunomodulatory agent with antiinflammatory properties. The exact mechanism of action is unknown but may involve a reduction in the number of activated lymphocytes in the CNS. Fingolimod (Gilenya) reduces MS disease activity by preventing lymphocytes from reaching the CNS and causing damage. Both drugs are specifically indicated for treatment of relapsing forms of MS.
Multiple Sclerosis/Diagnosis
To be diagnosed with MS, the patient must have (1) evidence of at least two inflammatory demyelinating lesions in at least two different locations within the CNS, (2) damage or an attack occurring at different times (usually 1 month or more apart), and (3) all other possible diagnoses ruled out. If evidence exists for only one lesion, or only one clinical attack has occurred, the HCP will monitor the patient for another attack or for an attack at a different site in the CNS.
Multiple Sclerosis/Drug Treatment
Treatment of MS begins with use of immunomodulator drugs to modify the disease progression and prevent relapses. These drugs include (1) interferon β-1a (Rebif, Plegridy [given subcutaneously]) and interferon β-1a (Avonex) (given IM), (2) interferon β-1b (Betaseron, Extavia) (given subcutaneously), and (3) glatiramer acetate (Copaxone) (given subcutaneously).
Multiple Sclerosis/Clinical Manifestations/Cognitive function
About 1/2 of people with MS experience some problems with cognitive function. For most people, the problems are difficulties with short-term memory, attention, information processing, planning, visual perception, and word finding. General intellect remains unchanged and intact, including long-term memory, conversational skills, and reading comprehension. Symptoms can be mild and thus easily overlooked. Cognitive changes are so severe in about 5%-10% they impair the person's ability to perform ADL's. Most of the time, cognitive difficulties occur later in the course of the disease. However, they can occur much earlier in the disease process, and occasionally they are present at the onset of MS. People with MS may also experience emotional changes such as anger, depression, or euphoria. Physical and emotional trauma, fatigue, and infection may aggravate or trigger signs and symptoms. The average life expectancy after the onset of symptoms is more than 25 years. Death usually occurs due to infectious complications of immobility (e.g., pneumonia) or because of an unrelated disease.
Multiple Sclerosis/Drug Therapy
Because no cure currently exists for MS, interprofessional care is aimed at treating the disease process and providing symptomatic relief. Because no two cases of MS are alike, therapy is tailored specifically to the disease pattern and manifestations experienced by each patient (Table 58-13). Disease-modifying therapy has been found to be more effective when initiated early in the course of MS. Delays in treatment have been associated with poor outcomes.
Multiple Sclerosis/Clinical Manifestations
Blurred or double vision, red-green color distortion, or even blindness in one eye may be the first symptom experienced. Muscle weakness in the extremities as well as issues w/ coordination/balance/walking/standing/partial or complete paralysis in the worst cases. Experience paresthesia/numbness/tingling. Lhermitte's sign is a transient sensory symptom described as an electric shock radiating down the spine or into the limbs with flexion of the neck. PT's c/o pain, in the low thoracic/abdominal regions. Other issues speech impediments/tremors/dizziness/hearing loss. Possible cerebellar signs include nystagmus/ataxia/dysarthria/dysphagia. Severe fatigue, sometimes w/ significant disability. The fatigue is aggravated by heat, humidity, deconditioning, and medication side effects.
Multiple Sclerosis/Clinical Manifestations/Bowel&Bladder
Bowel/bladder function can be affected if the sclerotic plaque is located in areas of the CNS that control elimination. Usually constipation rather than fecal incontinence. Urinary problems are variable. A common problem is spastic (uninhibited) bladder. As a result, the bladder has a small capacity for urine, and its contractions are unchecked. The result is urinary urgency and frequency, often accompanied by dribbling or incontinence. A flaccid (hypotonic) bladder indicates a lesion in the reflex arc controlling bladder function. A flaccid bladder is large capacity for urine because there is no sensation or desire to void, no pressure, and no pain. Generally, the patient has urinary retention, but urgency and frequency may also occur with this type of lesion. Another urinary problem is a combination of the previous two. Urinary problems cannot be adequately diagnosed and treated without urodynamic studies.
Multiple Sclerosis (MS)
Chronic, progressive, degenerative disorder of the CNS Characterized by disseminated demyelination of nerve fibers of the brain and spinal cord. MS can affect people of any age. Onset usually between 20-50yrs, symptoms first appearing around 30-35yrs. 50yrs and older generally have more progressive disease. Women are affected 2-3x's more than men. An estimated 400,000 people diagnosed in the US, with approximately 10,000 new cases diagnosed annually.
Patterns of Multiple Sclerosis
Category&Characteristics Relapsing-remitting • Clearly defined attacks of worsening neurologic function (relapses) with partial or complete recovery (remission). • Approximately 85% of people are initially diagnosed with this type of MS. Primary-progressive • Steadily worsening neurologic function from the beginning with minor improvements but no distinct relapses or remissions. • About 10% of people are diagnosed with this type of MS. Secondary-progressive • A relapsing-remitting initial course, followed by progression with or without occasional relapses, minor remissions, and plateaus. • New treatments may slow progression. • Most people initially diagnosed with relapsing-remitting MS eventually transition to this type. Progressive-relapsing • Progressive disease from onset, with clear acute relapses, with or without full recovery. Periods between relapses are characterized by continuing progression. • Only 5% of people experience this type of MS.
Multiple Sclerosis/Drugs for Managing Exacerbations
Corticosteroids ACTH prednisone methylprednisolone • Restrict salt intake. • Do not abruptly stop therapy. • Know drug interactions.
Multiple Sclerosis (MS)/Diagnostic Studies
Diagnostic Studies No definitive diagnostic test for MS, factors considered are the history, clinical manifestations, and results of certain diagnostic tests (.An MRI of the brain/spinal cord may show plaques, inflammation, atrophy, and tissue breakdown and destruction. Cerebrospinal fluid (CSF) analysis may show an increase in immunoglobulin G and the presence of oligoclonal banding. Evoked potential responses are often delayed in people with MS because of decreased nerve conduction from the eye and ear to the brain.
Multiple Sclerosis/Disease-Modifying Drugs
Disease Modifying Drugs Immunomodulators β-1a interferon (Rebif, Plegridy, Avonex) β-1b interferon (Betaseron, Extavia) glatiramer acetate (Copaxone) • Perform self-injection techniques. • Report side effects. • Treat flu-like symptoms with an NSAID or acetaminophen. teriflunomide (Aubagio) • Because it may cause serious liver disease, monitor liver tests. • Avoid pregnancy. Immunosuppressant mitoxantrone dimethyl fumarate (Tecfidera) • Report side effects. • Avoid pregnancy. • Avoid contact with large crowds and people who have an infection. Sphingosine 1-Phosphate Receptor Modulator fingolimod (Gilenya) • Report side effects. • Monitor blood pressure regularly. • Avoid pregnancy. Monoclonal Antibody natalizumab (Tysabri) alemtuzumab (Lemtrada) daclizumab (Zinbryta) • Report side effects. • Avoid pregnancy.
Multiple Sclerosis (MS)/Drug Alert
Drug Alert β-Interferon • Rotate injection sites with each dose. • Assess for depression and suicidal ideation. • Instruct patient to wear sunscreen and protective clothing while exposed to sun. • Inform the patient that flu-like symptoms are common after initiation of therapy.
Multiple Sclerosis/Drugs for symptom management
Drugs for Symptom Management Cholinergics bethanechol (Urecholine) neostigmine • Consult with HCP before using other drugs, including over-the-counter drugs. Anticholinergics propantheline oxybutynin (Ditropan XL) • Consult HCP before using other drugs, especially sleeping aids, antihistamines (possibly leading to potentiated effect). Muscle Relaxants diazepam (Valium) baclofen (Lioresal) dantrolene (Dantrium) tizanidine (Zanaflex) • Avoid driving and similar activities because of sedative effects. • Do not abruptly stop therapy. • Avoid use with tranquilizers and alcohol. Nerve Conduction Enhancer dalfampridine (Ampyra) • Be aware that it may cause seizures, especially at higher doses. • Take the tablet whole. Do not take more than 2 in 24 hr.
Multiple Sclerosis (MS)/ Patho
Etiology and Pathophysiology Cause: unknown, it is unlikely to be related to a single cause. The disease develops in a genetically susceptible person as a result of environmental exposure, such as an infection. Multiple genes are believed to be involved in the inherited susceptibility to MS. Having a first-degree relative with MS increases a person's risk of developing the disease. Common genetic factors have also been found in families with more than one affected member. Possible precipitating factors include infection, smoking, physical injury, emotional stress, excessive fatigue, pregnancy, and a poor state of health. The role of precipitating factors such as exposure to pathogenic agents is controversial. More than a dozen viruses and bacteria have been investigated, but none has definitely been proven to cause MS. Three pathologic processes characterize MS: chronic inflammation, demyelination, and gliosis in the CNS. The primary neuropathologic condition is an autoimmune process orchestrated by activated T cells. An unknown trigger in genetically susceptible individuals may initiate this process. The activated T cells in the systemic circulation migrate to the CNS, disrupting the blood-brain barrier. This is likely the initial event in the development of MS. Subsequent antigen-antibody reaction within the CNS activates the inflammatory response and leads to the demyelination of axons. Initially, attacks on the myelin sheaths of the neurons in the brain and spinal cord result in damage to the myelin sheath. However, the nerve fiber is not affected. Transmission of nerve impulses still occurs, but it is slowed. PY may c/o noticeable impairment of function (e.g., weakness). Myelin can regenerate. When it does, symptoms disappear. At that point, the patient experiences a remission. As ongoing inflammation occurs, nearby oligodendrocytes are affected, and myelin loses the ability to regenerate. Eventually damage occurs to the underlying axon. Nerve impulse transmission is disrupted, resulting in permanent loss of nerve function. As inflammation subsides, glial scar tissue replaces damaged tissue, leading to formation of hard, sclerotic plaques. These plaques are found throughout the white matter of the CNS.
Multiple Sclerosis/Nursing Imp
Focus patient teaching on building general resistance to illness, including avoiding fatigue, extremes of heat and cold, and exposure to infection. Encourage vigorous and early treatment of infection when it occurs. Teach the patient to achieve a good balance of exercise and rest; minimize caffeine intake; and eat nutritious, well-balanced meals. A diet high in fiber may help relieve constipation. The patient should know the treatment regimens, drug side effects, how to identify and manage side effects, and drug interactions with over-the-counter medications. The patient should consult an HCP before taking nonprescription drugs. Bladder control is a major problem for many patients with MS. Although anticholinergics may be beneficial for some patients to decrease spasticity, you may need to teach others self-catheterization. Bowel problems, particularly constipation, frequently occur in patients with MS. Increasing dietary fiber intake may help some patients achieve regularity in bowel elimination. The patient with MS and the caregiver need to make many emotional adjustments because of the unpredictability of the disease, need for lifestyle changes, and challenge of avoiding or decreasing precipitating factors. The National Multiple Sclerosis Society and its local chapters can offer a variety of services to meet the needs of patients with MS.
Multiple Sclerosis (MS)/Active and aggressive MS/Drug
For more active and aggressive forms of MS, natalizumab (Tysabri), alemtuzumab (Lemtrada), mitoxantrone, and dimethyl fumarate (Tecfidera) may be used. Natalizumab is given when patients have had an inadequate response to other drugs. An adverse effect of natalizumab is the increased risk of progressive multifocal leukoencephalopathy, a potentially fatal viral infection of the brain. Because of its safety profile, alemtuzumab is generally reserved for patients who have an inadequate response to two or more drugs indicated for the treatment of MS.
Multiple Sclerosis (MS)
More prevalent in temperate climates (between 45-65 degrees of latitude), such as those found in the northern United States, Canada, and Europe, as compared with tropical regions. People who are born in an area of high risk but migrate to an area of low risk before age 15 assume the risk of their new home. Researchers thus suspect that exposure to some environmental agent before puberty may predispose a person to develop MS later in life. MS is less common in Hispanics, Asians, and people of African descent. It rarely occurs in some ethnic groups, including Alaskan Natives and Aborigines.
Multiple Sclerosis (MS)/Interprofessional Care
Multiple Sclerosis Diagnostic Assessment • History and physical examination • CSF analysis • CT scan • MRI, MRS • Evoked potential testing • Somatosensory evoked potential (SSEP) • Auditory evoked potential (AEP) • Visual evoked potential (VEP) Management • Drug therapy (Table 58-13) • Surgical therapy • Thalamotomy (unmanageable tremor) • Neurectomy, rhizotomy, cordotomy (unmanageable spasticity) • Physical therapy • Occupational therapy MRS, Magnetic resonance spectroscopy.
Multiple Sclerosis (MS)/Other Therapy's
Other Therapies. Spasticity is treated primarily with muscle relaxants. Surgery (e.g., neurectomy, rhizotomy, cordotomy), dorsal-column electrical stimulation, or intrathecal baclofen (Lioresal) delivered by pump may be required. Tremors that become unmanageable with drugs are sometimes treated by thalamotomy or deep brain stimulation. Neurologic dysfunction sometimes improves with physical and speech therapies. Exercise improves the daily functioning for patients with MS not experiencing an exacerbation. Exercise decreases spasticity, increases coordination, and retrains unaffected muscles to substitute for impaired ones. An especially beneficial type of physical therapy is water exercise. Water, which gives buoyancy to the body, allows the patient to have more control over the body and perform activities that would normally be impossible.
Multiple Sclerosis/Clinical Manifestations/Sexual dysfunction
Sexual dysfunction occurs in many people with MS. Physiologic erectile dysfunction may result from spinal cord involvement in men. Women may experience decreased libido, difficulty with orgasmic response, painful intercourse, and decreased vaginal lubrication. Diminished sensation can prevent a normal sexual response in both men and women. The emotional effects of chronic illness and the loss of self-esteem also contribute to loss of sexual response. Some women with MS who become pregnant experience remission or an improvement in their symptoms during the gestation period. Hormonal changes associated with pregnancy appear to affect the immune system. However, during the postpartum period, women are at greater risk for exacerbation of the disease.
Multiple Sclerosis/Nursing assessment
Subjective Data Important Health Information Past health history: Recent or past viral infections or vaccinations, other recent infections, residence in cold or temperate climates, recent physical or emotional stress, pregnancy, exposure to extremes of heat and cold Medications: Adherence to regimen of corticosteroids, immunomodulators, immunosuppressants, cholinergics, anticholinergics, antispasmodics Functional Health Patterns Health perception-health management: Positive family history; malaise Nutritional-metabolic: Weight loss; difficulty in chewing, dysphagia Elimination: Urinary frequency, urgency, dribbling or incontinence, retention; constipation Activity-exercise: Generalized muscle weakness, muscle fatigue; tingling and numbness; ataxia (clumsiness) Cognitive-perceptual: Eye, back, leg, joint pain; painful muscle spasms; vertigo; blurred or lost vision; diplopia; tinnitus Sexuality-reproductive: Impotence, decreased libido Coping-stress tolerance: Anger, depression, euphoria, social isolation
Multiple Sclerosis/Nursing Imp
The patient with MS should be aware of triggers that may cause exacerbations or worsening of the disease. Exacerbations of MS are triggered by infection (especially upper respiratory and urinary tract infections), trauma, immunization, childbirth, stress, and change in climate. Each person responds differently to these triggers. Assist the patient in identifying triggers and developing ways to avoid them or minimize their effects. During the diagnostic phase, the patient needs reassurance that certain diagnostic studies must be done to rule out other neurologic disorders, even though a tentative diagnosis of MS has been made. Assist the patient in dealing with anxiety caused by a diagnosis of a disabling illness. The patient with recently diagnosed MS may need assistance with the grieving process. During an acute exacerbation, the patient may be immobile and confined to bed. The focus of nursing interventions at this phase is to prevent major complications of immobility, such as respiratory and urinary tract infections and pressure ulcers.
