Coping with Advanced MULTIPLE SCLEROSIS

Coping with Advanced MULTIPLE SCLEROSIS

Carol Freeman MSN, RN, CNRN, MSCN

2/6/2008

Carol Freeman MSN, RN, CNRN, MSCN

2/6/2008

Disease Courses in MSTypes of MS

Lublin et al. Neurology. 1996;46:907-911.Lublin et al. Neurology. 1996;46:907-911.

Disability

Disability

TimeTime

Relapsing-Remitting

Relapsing-Remitting Followed by Secondary-Progressive

Progressive-Relapsing

Primary-Progressive

Symptom ManagementSymptom Management

Types of SymptomsTypes of Symptoms• Primary

Caused by actual demyelination within the CNS

• Secondary Caused by failure to manage the primary

•Contractures, UTIs, decubiti, fractures, muscle atrophy

• Tertiary Psychological, social, marital, vocational,

personal

Fatigue

• Reduce fatigue-producing medications• Evaluate for medical condition• Treat depression• Treat asymptomatic UTIs• Medications

Symmetrel® (amantadine) Provigil® (modafinil) Cylert® (pemoline) Prozac® (fluoxetine)

• Energy conservation counseling

Types of Pain in MS

• Acute Brief paroxysmal attacks Results from abnormal axon

conduction- electrical discharges spread or jump to adjacent fibers, if sensory pathway may result in a painful sensation

• i.e.: Trigeminal neuralgia

Types of Pain in MS

• Subacute Lasts for days or weeks Caused by demyelination (optic

neuritis) Secondary source- painful bladder

spasm associated with neurogenic bladder

Types of Pain in MS

• Chronic Neuropathic or dysesthetic pain

occurs in approximately one-third of MS patients

Related to demyelination of sensory pathways- spinothalamic tracts, posterior columns

Constipation

• Contributing factors include: medications, muscle weakness, decreased activity, diet and reduced fluid intake

• Establish an elimination schedule, 15-30 minutes

• Drink a cup of warm liquid – this may facilitate the process

Bowel Incontinence and Diarrhea

• Bulk formers should be taken once a day and should not be followed by any extra fluid

• Medications that slow the bowel muscles, Kaopectate®, Imodium®, or Lomotil®

Medications

• Bulk forming agents - Metamucil®, FiberCon®

• Stool softeners- Colace®, Surfak®• Laxatives - Pericolace®, Peridum®,

Milk of Magnesia®• Suppositories – Glycerin, Dulcolax®

Dietary Management

• Drink 8-12 cups of fluid a day• High fiber diet• Regular meal times – gastrocolic

reflex occurs 20-30 minutes after a meal

Bladder Dysfunction

• Definition of terms: frequency, urgency, hesitancy, incontinence, and nocturia

• Types: flaccid, spastic and dyssynergic

Flaccid Bladder – failure to empty

• Incidence – 19 – 40%• Symptoms – frequency, urgency,

hesitancy, and incontinence• Little voluntary or reflex control of

voiding• Bladder overfills with large

amounts of urine

Spastic Bladder – failure to store

• Most common type incidence ranging from 26-50%

• Symptoms – increased frequency, urgency, and incontinence

• Small amounts of urine causing spontaneous contractions

Dyssynergic Bladder – conflicting or combination

• Incidence – 24 – 46%• Symptoms – urgency followed by

hesitation or incontinence• Bladder wall contracts when the

sphincter is closed –OR -• Bladder wall relaxes when

sphincter is open

Treatment of Bladder Dysfunction• Small, hypertonic, failure to store

Pharmacologic—oxybutynin (Ditropan®), tolterodine (Detrol®)

• Large, hypotonic, failure to empty Mechanical—intermittent self-catheterization,

Foley catheter• Dyssynergic

Alpha adrenergic agonists—dibenzyline, terazosin (Hytrin®)

Intermittent self-catheterization • Nocturia

Desmopressin

Management of Bladder Dysfunction

• Develop a drinking and voiding schedule

• Caffeine, Aspartame, Alcohol, Infection, Constipation may create symptoms

• Modification of home/office to improve access

• Intermittent catheterization• Indwelling catheter

Lifestyle Changes

• Sexual activity• Employment• Social activities• Complications – skin breakdown,

infections

SpasticityMedication

Lioresal® (baclofen); oral and intrathecal

Zanaflex® (tizanidine)

Klonopin® (clonazepam)

Neurontin® (gabapentin)

Dantrium® (dantrolene)

Valium® (diazepam)

Exercise and MS

• Four elements in prescription - Type of exercise: aerobic,

strengthening, balance, stretching - Duration - Frequency - Intensity

Appropriate Exercise

• Stretching and toning: maintains range of motion, combats weakness by reducing stiffness

• Balancing: helpful in ambulation by increasing the amount of stimulation received by centers in the brainstem

• Relaxation: helpful to reduce stress which can increase weakness and fatigue

Major Concepts

• Tailor an exercise program for individual – one type of program does not work for all

• Choose type: moderate (rowing, bicycling, treadmill)

• Do not raise core body temperature• Rigorous exercise to the point of pain

can cause fatigue and weakness• Slow but steady increase in exercise

should increase endurance

Nutrition & MS

• Important to have well-balanced diet

• Over-the-counter multivitamins can be used to supplement dietary requirements

• Weight loss diets • Swallowing difficulties

Complementary and Alternative Therapies• Common reason for use is to

improve health• Nutritional therapies include:

vitamins, megavitamins, macrobiotics, dietary modifications

• Information can be found through the internet- NIH and patient support agencies

Points to Consider

• Consider possible side effects and drug interactions

• No regulation of content of supplements

• Fat soluble vitamins (DAKE) are stored in the body’s fat stores

• Notify healthcare providers about all supplements and vitamins

Stress & MS

• Assess concurrent stressors• Identify support systems• Use stress reduction techniques-

yoga, tai chi, meditation• Exercise- walking, stretching and

toning• Adequate sleep/rest

Cognitive Dysfunction

• Over 50% of MS patients

• Evaluate current medications

• Evaluate psychological factors: anxiety/depression

• Attentional fatigue – longer to process information

Levels of Care

• Newly diagnosed• Functional with adaptations• Functional with assistance from

others• Functionally dependent upon

caregivers

Assistance Available

• Community Services Center for Independent Living Area Agency on Aging

• Volunteer Organizations• NMSS

Direct Financial Assistance