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Th S t Ch i i MSThe Symptom Chain in MS

The Symptom Chain in MSy p

• Symptom Management Overview• Fatigue• Spasticityp y• Bladder, Bowel, and Sexual Dysfunction• PainPain• Depression

Cognitive Dysfunction• Cognitive Dysfunction• Other Symptoms

Symptom Management Overviewy p g

• Generally motor, sensory, emotional, cognitive• Symptoms may remain, fluctuate, or progress • Symptoms:

– Primary (eg, fatigue, tremor)– Secondary (eg, falls, urinary tract infections)– Tertiary (eg, loss of job, divorce)

• New onset of symptoms may indicate relapse d lor pseudo relapse

Halper J. In: Advanced Concepts in Multiple Sclerosis Nursing Care. 2001:1-25.Schapiro RT, Schneider D. In: Comprehensive Nursing Care in Multiple Sclerosis. 2002.

Neurologic OriginsSymptom presentation depends on lesion location

Neurologic Origins

Cognitive loss

Emotional di i hibiti

Optic neuritisTremor

disinhibition

Sensory symptomsLh itt ’ i

DiplopiaVertigoD sarthria

Ataxia

Lhermitte’s painProprioception

Dysarthria

Bladder dysfunction

Miller AE. In: Handbook of Multiple Sclerosis. 2001:169-177.

Primary Symptoms of MSy y p

• Fatigue• Cognitive problems• Bowel and bladder dysfunctiony• Spasticity• Altered mobilityAltered mobility• Visual disturbance

Altered sensation• Altered sensation• Pain• Depression

Secondary Symptomsy y p

• Infections• Falls• Skin breakdown• Injuries• ContracturesContractures• Decreased ADLs

ADLs=activities of daily living

Tertiary Symptomsy y p

• Job loss• Loss of intimacy• Role changes/family disruptiong y p• Social isolation• DependencyDependency• Loss of self-esteem

Symptoms at Disease Onsety p

Symptoms Percentage of Patients (N=1721)(N=1721)

Sensory symptoms in arms/legs 33

Unilateral vision loss 16Unilateral vision loss 16

Polysymptomatic onset 14

Slowly progressive motor deficit 9Slowly progressive motor deficit 9

Acute motor deficit 5

Diplopia 7p p

Other 16

Paty D. In: Multiple Sclerosis, Diagnosis, Medical Management, and Rehabilitation. 2000:75-80.

Acute vs Chronic Symptoms

Most symptoms were reported as chronic

y p

y p p

PainSexual dysfunction Chronic

Acute

Bladder dysfunctionBowel dysfunction

Paroxysmal symptomsPain

Cognitive dysfunctionDepression

Bladder dysfunction

0 20 40 60 80 100

SpasticityFatigue

Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18. Copyright © 2004 AAN Enterprises, Inc.

% of Patients

Goals of Symptom Management y p g

• Eliminate or reduce symptoms that impair functional abilities

• Improve QOLp• Avoid secondary complications

Targeted and individualized treatment of symptoms is essential in management of MSsymptoms is essential in management of MS

Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

A Multimodal Approach to ppSymptom Management

• Effective communication• Education• Exercise• Professional supportProfessional support• Pharmacologic and non-pharmacologic

interventionintervention


Symptom Managementy p g

• Nurse, PA, and Case Manager roles include:– Listen– Assess– Plan– Make referrals

• Left untreated, symptoms may worsen or , y p yprecipitate other symptoms, producing a cycle of inter-related symptoms.


Cycle of Symptoms

FatigueDepression

y y p

Depression

ExerciseCognitivefunction

Sleep SpasticityConstipation

Bladder problems

Constipation

Bladder problems

Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18. Copyright © 2004 AAN Enterprises, Inc.

Major Mobility and Functional Problems

Halper J. 2007. Unpublished data.

The Symptom Chain in MS y p



Clinical Characteristics of Fatigueg• Overwhelming sense

of sleepinessof sleepiness• Constant sense of

tiredness• Lack of energy• Feeling of exhaustion• Not necessarily related toNot necessarily related to

level of disability• May affect motor function• May affect cognitive

function• Not fully understood

Krupp LB. CNS Drugs. 2003;17(4):225-234.

y

Acute vs Chronic Fatigue

Both forms of fatigue limit functional activities or

g

Both forms of fatigue limit functional activities or affect quality of life

Acute IntermittentNew or a significant increase in feelings of

Chronic PersistentFatigue that is persistent for any amount of time on

fatigue in the previous 6 weeks

50% of the days for more than 6 weeks

Acute fatigue is often associated with the onset of a new lesion

Multiple Sclerosis Council. Clinical Practice Guidelines: Fatigue and Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in Multiple Sclerosis. 1998.

Potential Causes and Effects

Multiple sclerosisPrimary MS fatigue

Secondary MS fatigue pain

Physical healthPsychologic

health yComorbid conditions

Fatigue is identified as

healthAnxietyStress

Depression

Sleep disorders

identified as a significant

problemEnvironment

N l f ti

pPrimary

SecondaryPhysicalSocial

Cultural

Normal fatigueMultiple Sclerosis Council. Fatigue in Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in Multiple Sclerosis. 1998.

Fatigue in MSg• The most common disabling symptom of MS

Ma appear earl in the disease• May appear early in the disease • Occurs without warning

P i it t d/ t t d b h t h idit• Precipitated/accentuated by heat, humidity, cold C t / th t• Can generate/worsen other symptoms (reduces cognition, increases depression, or further limits physical activities)further limits physical activities)

• Prevents sustained physical functioning• Becomes difficult to work productivelyCrayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

• Becomes difficult to work productively

Causes of Fatigueg• Sleep disturbances (deprivation/insomnia) • Sleep apneap p• Restless leg syndrome• Spasms/weakness/ataxia• Urinary problems• Urinary problems• Medications (anticonvulsants, antihistamines,

antihypertensives, sedatives, and some antidepressants)• Heat• Heat• Dietary factors• Deconditioning

D i• Depression• Cognitive dysfunction• Systemic diseases (eg, thyroid disease, anemia, liver/renal

di )Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18. National MS Society. http://www.nationalmssociety.org/download.aspx?id=134. Accessed April 9, 2009.

disease)

Fatigue Management: Collaborative Effort With Rehabilitation TeamCollaborative Effort With Rehabilitation Team• Non-pharmacologic modalities

– Cooling techniques: cooling vest/consumption of coolCooling techniques: cooling vest/consumption of cool beverages

– Aerobic exercise: prevents deconditioning– OT/PT: learn energy conservation techniques/work O / gy q /

simplification– Timed rest periods (appropriate rest-to-activity ratio)– Stress management techniquesg q– Exercise and relaxation

• Address secondary causes• Metabolic: B12, folate, hormonal, ,• Sleeplessness, bladder dysfunction• Medications• Depression

Schapiro RT, Schneider DM. In: Multiple Sclerosis in Clinical Practice. 1999. Multiple Sclerosis Council. Fatigue in Multiple Sclerosis: Evidence-based Management Strategies for Fatigue in Multiple Sclerosis. 1998.

Depression

Pharmacologic Managementg g

• Drugs used:– Amantadine– Modafinil– Methylphenidate– Dextroamphetamine

Pharmacologic Treatment g

Drug Dose Adverse EffectAmantadine 100-200 mg/d Hallucinations

Livido reticularisNausea LightheadednessLightheadedness Insomnia Constipation

Modafinil Up to 400 mg/d HeadacheModafinil Up to 400 mg/d Headache NauseaRhinitisInsomnia

Rosenberg JH, Shafor R. Curr Neurol Neurosci Rep. 2005;5(2):140-146.Rammohan KW, Lynn DJ. Neurology. 2005;65(12):1995-1997.

Pharmacologic Treatment, continued

Drug Dose Adverse EffectM th l h id t 10 60 /d NMethylphenidate 10-60 mg/d Nausea

Lightheadedness Insomnia ConstipationHypertensionTachycardia

Dextroamphetamine 5-40 mg/d Nausea F li f i tFeeling faintInsomnia ConstipationHypertensionTachycardia

Krupp LB, Christodoulou C. Curr Neuro Neurosci Rep. 2001;1(3):294-298. Medline Plus Drug Information: Methylphenidate: http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682188.html; April 9, 2009. Olson LG, et al. Psychosomatics. 2003;44(1):38-43. Medline Plus Drug Information: Dextroamphetamine http://www.nlm.nih.gov/medlineplus/druginfo/meds/a605027.html; April 9, 2009.

Additional Treatments

• Caffeine• SSRIs (eg, fluoxetine, paroxetine)• Bupropionp p• Amphetamines• Fampridine (investigational)Fampridine (investigational)

Crayton H, et al. Neurology. 2004; 63(11 Suppl 5):S12-S18. Romani A, et al. Mult Scler. 2004;10(4):462-468.National MS Society. http://www.nationalmssociety.org/download.aspx?id=134. Accessed April 9, 2009.

Counseling Tips for Patients Dealing With Fatigue• Organize your time to conserve energyg y gy• Pace yourself according to your schedule• Set short-term, realistic goals• Allow for rest periods during the day• Allow for rest periods during the day• Arrange your activities for the time of day you feel your

best• Maintain a fitness program• Obtain a handicapped parking sticker• Don’t stand if you can sitDon t stand if you can sit• Plan activities and assemble everything before you

start• Use a cordless phone• Use a cordless phone• Use walking aids, motorized carts, or other supports

Spasticity in MSp y• Hypertonicity of muscles “tightness, pulling, tugging,

aching”aching• Results from demyelination in descending CNS pathways• Different muscle groups involved depending on lesion

locationlocation• Spasticity may increase over time without new CNS lesions• Results in:

– Increased resistance to stretch– Accentuation of deep tendon reflexes and clonus– Uncontrolled flexor responses and extensor spasmsp p– Limited mobility – Excessive energy expenditure– Pain and discomfort

Crayton H, et al. Neurology. 2004; 63(11 Suppl 5):S12-S18. Johnson J, Porter B. In: Advanced Concepts in Multiple Sclerosis Nursing Care. 2001:117-136.

Pain and discomfort

Exacerbations

Exacerbations may be caused by:• Very cold temperatures• Infection (skin or bladder)( )• Relapse of MS• ConstipationConstipation• Temperature changes

Crayton H, et al. Neurology. 2004; 63(11 Suppl 5):S12-S18.

Modified Ashworth ScaleScore Criteria

0 No increased tone

1 Slight increased tone (catch and release at end of ROM)

1+ Slight increase in tone manifested by a catch followed by min. resistance throughout the remainder of the ROM (less than half the ROM)

2 Marked increase in tone through most of ROM but affected part(s) move easily

3 Considerable increased tone, passive movement difficult

ROM=range of motion

4 Affected part(s) rigid in flexion or extension

ROM=range of motion

Spasm Frequency Scalep q y0 No spasms

1 No spontaneous spasms except with vigorous stimulation

2 Occasional spontaneous spasms and easily induced spasms

3 More than 1 but less than 10 spontaneous spasms per hour

4 More than 10 spontaneous spasms per hour

Effects of Spasticityp y

• Gross motor activity • Energy levelneeded for ambulation

• GaitS ti

• Sexual function• Activities of daily

li i• Seating• Hygiene

C f t

living• Skin

Bl dd f ti• Comfort• Sleep

• Bladder function• Bowel function


Spasticity Managementp y g

Surgicalinterventions

Technologicalinterventions

Pharmacologic interventions

Regional and local agents

Non-pharmacologic interventions

g

Schapiro RT. Neurorehabil Neural Repair. 2002;16(3):223-231.Schapiro RT, Schneider DM. In: Comprehensive Nursing Care in Multiple Sclerosis. 2002:31-52.

Spasticity Management

Non-pharmacologic Pharmacologic

p y g

• Stretching• Positioning• Seating

• Baclofen • Tizanidine• Gabapentin g

• Range of motion• Orthotics• Physical therapy

• Levetiracetam • Diazepam • Botulinum toxin

Surgical

• Baclofen pump

Data from Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

Pharmacologic Interventions for Spasticity• Baclofen

– Stimulates gamma-aminobutyric acid (GABA) receptorsI iti t d t 5 bid tid d tit t d d– Initiated at 5 mg bid-tid and titrated upward

– Typical effective dose 30-90 mg/day– Adverse events (AEs): drowsiness, dry mouth, and

li hth d dlightheadedness– Do not discontinue abruptly (seizures, hallucinations,

agitation)Ti idi• Tizanidine– Centrally acting α2-adrenergic receptor agonist– Initiate at bedtime (sedation) 1-4 mg if possible; if initiate at

d ti 1 2 QID th tit t t 4 8 QID ( 32daytime 1-2 mg QID, then titrate up to 4-8 mg QID (max 32 mg/day)

– AE: sedation, hypotension, weakness, constipation, dry mouthC l ti t b t ti iti i i l t (d i i


– Counsel patient about activities requiring alertness (driving, etc.) and use of alcohol

– Liver function test and CBC should be performed

Pharmacologic Interventions for gSpasticity, continued• Benzodiazepines (diazepam, clonazepam, etc.)e od a ep es (d a epa , c o a epa , etc )

– May cause daytime sedation; therefore, take at bedtime

• Dantrolene (rarely) – Monitor liver enzymes due to hepatotoxicity

G b ti• Gabapentin• Combination of baclofen, tizanidine, and

benzodiazpines may help those patients who are p y p punresponsive to monotherapy

• For combination therapy, lower doses are used, hi h i i i d t (AE )


which may minimize adverse events (AEs).

Clinical Case: Carl• A 45-year-old man diagnosed with MS 2 years ago.

Key findings: weakness in both lower extremities• Key findings: weakness in both lower extremities, diminished truncal sensation, mild clumsiness both hands, ataxic gait.

• He states he was told 2 years ago he had primary progressive disease and was not offered any treatment.

• He calls your office complaining of severe fatigue; he is y p g g ;sure he has the flu.

• Neurologic examination is without change; timed walking (20 feet) is 20 seconds (normal 4-4 5 seconds)(20 feet) is 20 seconds (normal 4-4.5 seconds)

• Lab work within normal limits. • Patient’s affect was flat; he made poor eye contact. • He states that he is going to continue to get worse and

wants treatment for the flu.

What is your impression of this patient?

a. He has the flu.b. He requires more education about his MS.c. He probably is depressed.c. He probably is depressed.d. He probably is malingering.

What would be your first intervention?

a. Request the patient be given modafinilb. Suggest physical therapyc. Begin educating the patient about MSg gd. Try to ascertain the patient’s understanding

of his disease

Fatigue can be managed with:

a. Scheduled rest periods

g g

b. Rehabilitation servicesc. Assessing sleep patternsc. Assessing sleep patternsd. All of the above

Bladder Dysfunctiony• Approximately 80% of patients have bladder

symptoms at the time of MS diagnosissymptoms at the time of MS diagnosis • After 10 years, up to 96% of patients have

experienced bladder symptoms during course of y gdisease

• Three categories: – Hyperactive or spastic bladder (failure to store

due to detrusor hyperreflexia) ~60%Hypoactive or flaccid bladder (failure to empty– Hypoactive or flaccid bladder (failure to empty due to detrusor areflexia) ~20%

– Detrusor sphincter dyssynergia (combination)


p y y g ( )~25%

Bladder Dysfunction: Assessmenty• Post-voiding residual urine

D t i th t t i d i th– Determines the amount retained in the bladder after voluntary emptyingE l t d b th t i ti OR bl dd– Evaluated by catheterization OR bladder ultrasound

Other causes of bladder dysfunction:• Other causes of bladder dysfunction: – Urinary tract infections (UTIs)

P l i fl l ti i– Pelvic floor relaxation in women– Benign prostatic hyperplasia (BPH) in men


Bladder DysfunctionBladder DysfunctionInability to Store Inability to Empty CombinationSymptoms• Urgency/frequency• Incontinence• Nocturia

Symptoms• Urgency, hesitancy• Double voiding• Frequency

Symptoms• Urgency, hesitancy• Double voiding• IncompleteNocturia

• PVR <100 mLNon-pharmacologic• Dietary changes

Ti d idi

Frequency• Incomplete emptying• PVR >100 mLN h l i

Incomplete emptying• Dribbling incontinenceN h l i• Timed voiding Non-pharmacologic

• Intermittent caths• Indwelling catheter

Non-pharmacologic• Intermittent caths• Indwelling catheter

PVR=post-voiding residualData from Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

Management of Bladder Dysfunction

Treatment Goals

g y

• Maintain renal function• Establish normal voiding patterns• Reduce symptoms and improve QOL

Non-pharmacologic Approaches• Bladder training and behavior

Pharmacologic Treatment•Antimuscarinics/anticholinergics

modification• Intermittent or continuous catheterization•Dietary modification

•Alpha blockers• Anti-spasticity agents/nerve blocks

Prevention of Secondary Symptoms •Avoid urinary tract infection and reflux

by effective bladder emptying

Pharmacologic Management of g gBladder DysfunctionDrug Dose Adverse Effect

Oxybutynin (Ditropan/XL) 5-30 mg/day Dry mouth, constipation, headache, blurred vision

Oxybutynin transdermal 3.9 mg/72 hours Dry mouth, site reaction

Tolterodine (Detrol/LA) 2-4 mg/day Dry mouth, headache, dyspepsia( ) g y y , , y p p

Solifenacin (VESIcare) 5-10 mg/day Dry mouth, constipation, blurred vision

Darifenacin (Enablex) 7.5-15 mg/day Dry mouth, constipation, blurred visionvision

Flavoxate (Urispas) 300-800 mg/day Dry mouth, headache, GI upset, dizziness

Hyoscyamine (Levsinex) 1-2 mg/day Dry mouth, difficulty swallowing

Desmopressin (DDAVP) 100-200 mcg/bedtime Headache, nausea

Tamsulosin (Flomax) 0.4-0.8 mg/day Hypotension, dizziness, somnolence

Schapiro R, Schneider D. In: Comprehensive Nursing Care in Multiple Sclerosis. 2002:41-44.Frenette J. In: Advanced Concepts in Multiple Sclerosis Nursing Care. 2001:175-212.

Management g

• Detrusor sphincter dyssynergia (lack of coordination between the bladder and the external urethral sphincter causing urine t b t d)to be trapped)– Combination of anticholinergics and self-

catheri ation is recommendedcatherization is recommended


General Bladder Management Adviceg

• Drink 1½-2 quarts of fluid a day• Caffeine, NutraSweet, and alcohol are

bladder irritants—avoid• The urge to void occurs about 1½-2 hours

after your drink something• Quick access to bathroom• Pads or protectionPads or protection

Bowel Dysfunction in MSy

• Constipation: develops in ~35%-55% of patients• Fecal incontinence: occurs in ~30%-50% of

patients• Causes vary including:• Causes vary, including:

– Visceral neuropathy and muscular atrophyFibrosis associated w/ constipation and low– Fibrosis associated w/ constipation and low anal sphincter pressure

– Poor rectal sensationPoor rectal sensation• Symptoms may be intermittent or constant• Symptoms can occur at any time in the disease


y p y

Bowel Symptoms in MSy p

• Constipation—slow bowel, medications, impaired motility

• Diarrhea—infection, fecal impaction, medications, food intolerance, malabsorption

• Involuntary bowel—diminished sphincter control, hyperreflexic bowel

Bowel Dysfunction ManagementBowel training/dietary modification recommendedBowel training/dietary modification recommended for all bowel dysfunction

Constipation• Fluids 1½ quarts/d• Daily fiber 20-30 grams/d• Bulk forming agents

Diarrhea• Monitor labs, weight, diet• Monitor skin/skin care

• Bulk forming agents• Stool softeners/stimulants• Laxatives/enemas• Suppositories

• Medications to decrease GI motility (anticholinergics, opiates)• Bulk forming supplementpp

• Exerciseg pp

Involuntary BowelInvoluntary Bowel• Medications/suppositories • Bowel training/timed evacuations

Namey MA. In: Comprehensive Nursing Care in Multiple Sclerosis. 2002. Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

Sexual Dysfunction in MSSexual Dysfunction in MS• Approximately 50% of women with MS• Approximately 75% of men with MS• A significant impact on QOLg p• Often an overlooked symptom of MS

Demirkiran M, et al. Mult Scler. 2006;12(2):209-214. Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

Primary Sexual Dysfunction in MSy y

• Men and women can experience difficulties↓ Libido↓ Erectile dysfunction/ejaculation↓ Altered genital sensation↓ Frequency/intensity of orgasms↓ Vaginal lubrication/clitoral engorgement↑ Bladder spasticity↑ Depression

Costello K, et al. Nursing Practice in Multiple Sclerosis: A Core Curriculum. 2003.Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18.

p

Sexual Dysfunction Managementy g• Exclude metabolic causes (eg, diabetes)• Management strategies include• Management strategies include

– Pharmacologic management– Treat underlying symptoms/secondary eat u de y g sy pto s/seco da y

dysfunction• Spasticity, fatigue, paresthesias, bladder/bowel

Adj t di ti– Adjust medications– Positioning

Lifestyle changes– Lifestyle changes• Key to successful management is open

communication

Costello K, et al. Nursing Practice in Multiple Sclerosis: A Core Curriculum. 2003.

• Counseling and culturally sensitive support

Pharmacologic Management of g gSexual Dysfunction

Drug Dose Indicationg

Bupropion 150–300 mg/day Decreased libidoDecreased orgasm

Sildenafil 50–100 mg/day Erectile dysfunction

Vardenafil 5–20 mg/day Erectile dysfunctiong y y

Tadalafil 5–20 mg/72 hours Erectile dysfunction

E t V i l ti V i l dEstrogens Vaginal preparationsTopical creams

Vaginal dryness Clitoral sensitivity

Tullman M. Continuum. 2004;10:Chapter 7. Fowler CJ, et al. J Neurol Neurosurg Psychiatry. 2005;76(5):700-705. Crayton H, et al. Neurology. 2004;63(11 Suppl 5):S12-S18. Costello K, et al. Nursing Practice in Multiple Sclerosis: A Core Curriculum. 2003.

Pain in Multiple Sclerosisp

• A complex sensory phenomenon, multifactorial

• Reported in up to 80% of MS patients1-3

• Common cause of disability in MS4

• Under-recognized and inadequately g q ymanaged5, 6

• Most MS-related pain is treatableMost MS related pain is treatable

1. Benrud-Larson LM, Wegener ST. NeuroRehabilitation. 2000;14(3):127-137. 2. Solaro C, et al. Neurology. 2004;63(5):919-921. 3. Svendsen KB, et al. Arch Neurol. 2003;60(8):1089-1094. 4. Archibald CJ, et al. Pain. 1994;58(1):89-93. 5. Thompson AJ. Curr Opin Neurol. 1998;11(4):305-309. 6. Stenager E, et al. Acta Neurol Scand. 1991;84(3):197-200.

Acute vs Chronic Pain

• Acute syndromes– Neuralgic pain (eg, trigeminal neuralgia)– Painful optic neuritis– Lhermitte’s syndrome

• Chronic syndromesy– Neurogenic pain (eg, dysesthesia)– Musculoskeletal pain (eg, low back pain)Musculoskeletal pain (eg, low back pain)– Spasticity/spasms

Indaco A, et al. Acta Neurol (Napoli). 1994;16(3):97-102.Kerns RD, et al. J Rehab Res Dev. 2002;39(2):225-232.Stenager E, et al. Acta Neurol Scand. 1991;84(3):197-200.

Pain in Multiple Sclerosis:Clinical Characteristics• Most common pain is a p

burning dysesthesia– Sharp, shooting,

tingling pins andtingling, pins and needles, tightness

• In TGN, a lightning-like electrical pain is typical– 400 times more

common in MS thancommon in MS than general population

TGN=trigeminal neuralgiaSchapiro RT. Curr Neurol Neurosci Rep. 2001;1(3):299-302.

Anatomic Distribution

Extremities(not muscles(not muscles

or joints)JointsBack

**

HeadMuscles

Neck*

Patients with MSReference subjects

EyesAbdomen

Chest*

*

0 10 20 30 40 50 60

N=1540

Face

% of Patients

*

N=1540*P<0.001Svendsen KB, et al. Arch Neurol. 2003;60(8):1089-1094. Copyright © 2003 American Medical Association.

Non-pharmacologic Managementp g g

• Adaptation to stress• Relaxation techniques• Acupressure and acupuncturep p• Physical and occupational therapy• CoolingCooling• Soft collars may help diminish symptoms

of Lhermitte’s syndromeof Lhermitte s syndrome • Stretching for spasticity

Archibald CJ, et al. Pain. 1994;58(1):89-93.Bashir K, Whitaker JN. Handbook of Multiple Sclerosis. 2002.

Pharmacologic Treatmentg

Drug Dose Adverse EffectG b ti 100 3600 /d F tiGabapentin 100-3600 mg/d Fatigue

SomnolenceDizzinessAtaxiata a

Carbamazepine 400-1000 mg/d DizzinessDrowsinessNauseaUnsteadiness

Amitriptyline 10-150 mg/d DrowsinessDry mouthyFatigueConstipation

Schapiro RT. Neurorehabil Neural Repair. 2002;16(3):223-231.

Pharmacologic Treatment, continuedg

Drug Dose Adverse EffectMi t l 100 200 / id Di hMisoprostol 100-200 mg/qid Diarrhea

Abdominal painNauseaDyspepsiayspeps a

Tiagabine 32-56 mg/d DizzinessLack of energySomnolenceTremor

Topiramate 25-400 mg/d FatigueSomnolenceCognitive dysfunctionWeight loss

Schapiro RT. Neurorehabil Neural Repair. 2002;16(3):223-231.

New Treatments

Drug Dose Adverse EffectPregabalin 150-600 mg/d Dry mouth

ConstipationUnsteadinessSomnolenceSomnolence

Duloxetine 60-120 mg/d Upset stomachVomitingC ti tiConstipationDizziness

MedlinePlus. Pregabalin http://www.nlm.nih.gov/medlineplus/druginfo/meds/a605045.html; April 9, 2009.MedlinePlus. Duloxetine http://www.nlm.nih.gov/medlineplus/druginfo/meds/a604030.html; April 9, 2009.

Additional Treatments

Drug Dose Adverse EffectLid i t h 5% 3 t h t B iLidocaine patch 5% 3 patches max at a

time up to 12 hrs/dBurningRednessSwellingSkin rashS as

Baclofen pump(spasticity)

100-800 mcg/d SeizuresConstipationDizzinessNausea

Botulinum toxin(spasticity)

50-120 units FeverDiarrhea( p y)NauseaInjection site pain

MedlinePlus. Drug information: http://www.nlm.nih.gov/medlineplus/druginformation.html; April 9, 2009.

SynchroMed® Infusion System ComponentsComponents• Pump• Infuses drug at

programmed rate• CatheterCatheter• Delivers drug to the

intrathecal ( b h id)(subarachnoid) space of the spinal cord

• Programmerg• Allows for precise dosing• Easily adjustable dosing


Depression in Multiple Sclerosisp p

• High rates of depression – 50% of patients have major depression1,2

• Depression may lead to altered quality of life 3and loss of self-esteem3

• Increased incidence of suicide – 7.5 times higher in MS than general

population4

• Assessment of depression in critical cases

1. Sadovnick AD, et al. Neurology. 1996;46(3):628-632.2. Feinstein A. Can J Psychiatry. 2004;49(3):157-163.3. Bashir K, Whitaker JN. Handbook of Multiple Sclerosis. 2002.4. Sadovnick AD, et al. Neurology. 1991;41(8):1193-1196.

Clinical Characteristics

• Feeling sad or empty• Irritable or crying

most of the day• Loss of energygy• Loss of interest or

pleasure in most activities• Significant change in• Significant change in

appetite and weight • Unusual sleep behavior• Decreased sex drive • Suicidal thoughts

Siegert RJ, Abernethy DA. J Neurol Neurosurg Psychiatry. 2005;76(4):469-475.The National Multiple Sclerosis Society. http://www.nationalmssociety.org/download.aspx?id=53. Accessed April 9, 2009.

Depression in Multiple Sclerosis by Type: B k D i I t (BDI) A t

NoneMild depression

Beck Depression Inventory (BDI) Assessment

60 Mild depressionModerate depressionSevere depression50

4250

60

2933

2924

2729

37

2630

40

erce

ntag

e

13 1217

12

19

10

20Pe

00

Mild RRMS RRMS PRMS SPMSMS Type

n=260; Mild RRMS=little or no impact on daily function; BDI=Beck Depression Inventory.Data from Somerset M, et al. Health Expect. 2001;4(1):29-37.

Depression in MSp

• The most common mood disorder in patients with MS: lifetime occurrence approx 50% of patients

• Etiology is unknown (related to MS pathophysiology, meds used to treat MS,

th h ll f li i ith MS)or the challenges of living with MS)• Weak association may exist between

fdepression and disease-modifying therapies


Comprehensive Managementp g

• Provide a supportive, therapeutic environment

• Identify risk factors (screening, self-report, environmental factors, family history)

• Use psychotherapy plus antidepressants• Be alert for suicidal ideation/plan• Assess and reassess continuallyAssess and reassess continually• Adjust medications appropriately

Bashir K, et al. Handbook of Multiple Sclerosis. 2002.

Pharmacologic TreatmentgSSRIs Dose Adverse Effect

Fluoxetine 20-80 mg/d Nausea, insomnia, diminished libido

Sertraline 25-200 mg/d Nausea, fatigue, diminished libido

Paroxetine 20-50 mg/d Nausea, insomnia, diminished libido

Citalopram 20-40 mg/d Nausea, somnolence, diminished libido

Escitalopram 10 20 mg/d Nausea insomnia diminished libidoEscitalopram 10-20 mg/d Nausea, insomnia, diminished libido

SNRIs

Venlafaxine 75-225 mg/d Nausea, dizzinessVenlafaxine 75 225 mg/d Nausea, dizziness

Duloxetine 40-60 mg/d Nausea, insomnia

SNRI=serotonin/norepinephrine reuptake inhibitor; SSRI=selective serotonin reuptake inhibitorSchapiro RT. Neurorehabil Neural Repair. 2002;16(3):223-231.Medline Plus Drug Information. http://www.nlm.nih.gov/medlineplus/druginformation.html. Accessed April 9, 2009.

Pharmacologic Treatment, continuedg

Tricyclics Dose Adverse Effect

Amitriptyline 10-150 mg/d Neuropathy, fatigue

Imipramine 75-150 mg/d Tremors, hypotension

Nortriptyline 10-175 mg/d Blurred vision, drowsiness

Unique Antidepressants

Bupropion 200-450 mg/d Nausea, insomnia, seizures

Schapiro RT. Neurorehabil Neural Repair. 2002;16(3):223-231.Medline Plus Drug Information. http://www.nlm.nih.gov/medlineplus/druginformation.html. Accessed April 9, 2009.

Cognitive Dysfunction in MS Cognition: The Mind’s Ability to Store Organize andThe Mind s Ability to Store, Organize, and Recall Information • Each patient’s experience with cognitive• Each patient s experience with cognitive

dysfunction is unique and evolving• Most symptoms are mild y p• The cause is not always clear

– Damage to brain tissue caused by lesions in g ythe cerebral hemisphere (the “thinking” part of the brain)

• MS can affect cognition indirectly (eg, due to pain, depression)

LaRocca N. In: Multiple Sclerosis Diagnosis Medical Management and Rehabilitation. 2000:405-409.

Cognitive Dysfunctiong y

• Can occur early in the disease• Does not correlate with physical disability• May be subtleMay be subtle• May be under-recognized or denied by

patient, family, friends, or employerspatient, family, friends, or employers• Deficits are not diffuse or global


Prevalence by Cognitive Domainy gDomains

Memory 30%• Memory 30%• Information processing 25%• Problem solving 20%• Problem solving 20%• Visuospatial abilities 20%• Attention/concentration 10%• Attention/concentration 10%• Verbal fluency 10%

One domain: 50% Multiple domains: 22%


Cognitive Impairment in MS Patient g pPopulation

Invisible Symptom of MS

None50%40%

NoneModerate to SevereMild

10%


Cognitive Evaluationg

• Neuropsychological testing:– Practical applications– Supports employment, legal cases

Cl ifi th t bl d d t i t– Clarifies that problems do or do not exist• Performed by a neuropsychologist, occupational

therapist or speech/language pathologisttherapist, or speech/language pathologist• Physical therapist for safety strategies• These health care providers retrain previously• These health care providers retrain previously

learned skills


Managing Cognitive Impairmentg g g pNon-pharmacologic:

Discuss the problem openly; include family or significant• Discuss the problem openly; include family or significant other

• Counseling or psychotherapy• Neuropsychological evaluation identifies extent of

problem • Cognitive rehabilitation for coping and “compensatoryCognitive rehabilitation for coping and compensatory

strategies”• Environmental modifications to enhance cognitive

f nctionfunctionPharmacologic: • Disease-modifying therapies to slow disease progressiony g p p g• Agents to slow cognitive dysfunction, or help prevent

progression (eg, donepizil)

Pharmacologic Treatmentg

• A recent onset of cognitive deficits may signify ti di fi t t h ld b t d lactive disease; first step should be to delay

progression with disease-modifying therapy• Treatment may contain the development of newTreatment may contain the development of new

cerebral lesions • IFN beta-1a: 30 mcg IM week vs placebo g p

decreased:– Memory loss– Information-processing deficits and increased

time to sustained cognitive deteriorationDi bilit i


– Disability progression

Treatments Under Research

• Cholinesterase inhibitors – Donepezil, galantamine, and rivastigmine

under investigation for managing cognitive d f ti i MS ti tdysfunction in MS patients

– Initial pilot studies suggest that cholinesterase inhibitors improvedcholinesterase inhibitors improved learning and memory in MS patients with initial cognitive difficultiesinitial cognitive difficulties

Christodoulou C, et al. J Neurol Sci. 2006; 245(1-2):127-136. Amato MP, et al. J Neurol Sci. 2006;245(1-2):183-186. Parry AM, et al. Brain. 2003;126(Pt 12):2750-2760.

General Advice for Patients With Cognitive Dysfunction• Keep distractions to a minimum when attempting toKeep distractions to a minimum when attempting to

remember• Unclutter your schedule• Do the most important things first• Do the most important things first• Focus your attention on one task at a time• Repeat information to make sure you have heard it

correctlycorrectly• Write it down!• Practical intervention tools

– Notebook– Day planner– Electronic organizerElectronic organizer

• Counseling families about dysfunction may help to better understand these deficits

Tremor in MS

• Caused by MS lesions in cerebellum and its pathways

• Can affect head, limbs, trunk, eye movements, and speech

• Titubation• Difficult to treat

Frenette J, et al. In: Symptom Management in Advanced Concepts in Multiple Sclerosis Nursing Care. 2001:200-204.

Tremor Management

Non pharmacologic Pharmacologic

g

Non-pharmacologic

• Proximal stability• Self-care strategies• Weight bearing activities

Pharmacologic• Clonazepam• Gabapentin• Primidone• Weight-bearing activities

• Weighting (utensils, assistive devices)• Coordination exercises

• Primidone • Propranolol

SurgicalSurgical• Deep brain stimulation

Frenette J, et al. In: Symptom Management in Advanced Concepts in Multiple Sclerosis Nursing Care. 2001:200-204.

Altered Mobility in MSy• Possible causes:

– SpasticitySpast c ty– Weakness– Imbalance– Sensory loss– Sensory loss– Vision changes– Peripheral neurological changesRi k• Risks: – Decreased safety (eg, increased risk of falls)– Impaired biomechanics – Pain– Immobility– Isolation

Schapiro R, Schneider D. In: Comprehensive Nursing Care in Multiple Sclerosis. 2002:41-44.

– Reduced quality of life

Management g

• Early recognition• Physical therapy/occupational therapy

assessment/care• Use of aids (plate guard, molded utensils,

ankle-foot orthotic, cane, rollator, wheelchair, scooter)

• Environmental adaptations

Schapiro R, Schneider D. In: Comprehensive Nursing Care in Multiple Sclerosis. 2002:41-44.

C l t d Alt tiComplementary and Alternative Medicine (CAM)

Popular CAM Therapies p p• Acupuncture

Meditation• Meditation• Hypnotherapy• Massageg• Chiropractic medicine• Herbs

C ff i F ti– Caffeine: Fatigue– Cranberry: Prevention of urinary infection– Ginkgo Biloba: Memory

M ij S i ti it– Marijuana: Sensory pain, spasticity– Senna: Constipation– St. John’s Wart: Mild depression

V l i I i

Alcock G, et al. In: Advanced Concepts in Multiple Sclerosis Nursing. 2001:239-265.

– Valerian: Insomnia

CAM Statistics• 42% of individuals in the US use some form of

CAMCAM• 629 million visits were made to practitioners of

alternative medicines a te at e ed c es• 20% of people were taking some type of herb or

vitamin with prescription medicine • 50% of people using CAM do so without the

knowledge of their physician• CAM use higher in women than men • 60% of individuals with MS use one or more CAM

therapiesAlcock G, et al. In: Advanced Concepts in Multiple Sclerosis Nursing. 2001:239-265.

therapies

CAM: The Role of Nurses and Physician Assistants• Ask about over the counter and CAM use each visit• Ask about over the counter and CAM use each visit• Encourage patients to discuss use openly• Encourage patients to use conventional therapy firstg p py

– Use CAM as “complementary therapy”• Educate about most CAM therapies:

– Not FDA approved– Side effects of many compounds unknown

99% f h b i ti l ti– 99% of herbs are immune stimulating• Try to have a general understanding of CAM

therapies; keep resources available


therapies; keep resources available

Symptom Management: Conclusionsy p g

Multidisciplinary approach can maximize outcomes for

Optimal symptom

Pharmacologic and non-pharmacologic interventions are necessary for manyoutcomes for

patients with MSsymptom

managementnecessary for many symptoms

Reassessment and adjustment

M i i i QOL i ti l t f ti l t t tM i i i QOL i ti l t f ti l t t t


Maximizing QOL is an essential component of an optimal management strategy.Maximizing QOL is an essential component of an optimal management strategy.

Clinical Case: Phyllis y

• A 35-year-old married woman diagnosed with MS 1515 years ago.

• She and her husband opted not to have children due to concern about her MS worseningdue to concern about her MS worsening.

• She is on an injectable medication and is very adherent to her treatment schedule.

• She works full time, exercises regularly, has a busy social life, and feels she has overcome the anxiety related to MS.

• Over the weekend, her husband informed her that he wants a divorcethat he wants a divorce.

Phyllis, continuedy

• Phyllis asks her husband “Why? I thought we were very happy.”

• Her husband tells her that he is unhappy. MS has ruled their lives. Their sexual life is non-existent. She is focused on herself

d h d h i ti d f th i it dand her needs; he is tired of the uninvited guest, MS.

• The couple calls their nurse and asks to see her. They want help.

What should the nurse do?

a. Refer them for counselingb. Review Phyllis’ case historyc. Do a review of systemsc. Do a review of systemsd. Assess the couple’s history of intimacy

and their goals for their meeting with theand their goals for their meeting with the nurse

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