How to Receive Your CE Credits Read your selected course Completed the quiz at the end of the course with a 70% or greater. Complete the evaluation for your selected course. Print your Certificate CE s will automatically be reported to the CE Broker Multiple Sclerosis Purpose The purpose of this continuing education course is to educated health care professional about Multiple Sclerosis. In addition to help nursing professional to understand the signs and symptoms, treatment, and resources available for the patient to live a productive life. Objectives 1. Understand the Pathophysiology and etiology of Multiple Sclerosis. 2. List the types of relapsing MS 3. Describe the risk factors for MS 4. Describe Uhthoff's Syndrome 5. Identify the treatment management of MS 6. List nursing consideration for MS 7. Discuss the patient education for MS
Introduction According to Richman, & Schub, (2013) multiple sclerosis (MS) affects an estimated 2.5 million people worldwide, 400,000 in the United States, and 50,000 in Canada. The incidence of MS varies according to one s geographical region. MS can be seem higher in northern locations; per 100,000 population. Common causes of death associated in MS patients includes pneumonia, pulmonary embolism, aspiration, urosepsis, and/or pressure ulcers (Richman, & Schub, (2013); Multiple Sclerosis Association of America (2013). The term Multiple Sclerosis refers to plaques or lesions. These plaques or lesions called MS is an acquired demyelinating disease of the white matter in the brain and spinal cord (Richman, & Schub, 2013). The age of onset of MS is between the ages 20 to 50 however according to Campagnolo (2014) the vast majority of people with MS (approximately 80%) experience their first symptoms by age 40 and is twice as common in women as in men. Campagnolo (2014) further explains that 85% of individuals with MS can present as one of four clinical types: a. Relapsing-remitting (RRMS) b. Primary-progressive (PPMS) c. Secondary-progressive (SPMS) d. Progressive-relapsing (PRMS) RRMS is characterized by acute episodes of exacerbations and remission of neurologic problems that includes: 1. Numbness 2. Loss of voluntary movements in some parts of the body 3. Lack of coordination
4. Dizziness 5. Visual disturbances Patient with RRMS has periods of remission. During these periods of remission, patients often recovers from acute episodes of neurological problems that he or she experienced during the exacerbation phases. PPMS is characterized by steady progression of symptoms experienced in the RR stage of MS until the symptoms progress to the phase called secondary progressive (SPMS). SPMS is characterized by progressive neurological deficits, with or without acute attacks. At this point the disease become chronic and it is in this later phase that the cumulative damage to the central nervous system (CNS) begins to result in permanent disability Campagnolo, (2014); Richman, & Schub, (2013). PRMS involves a steady progression of the disease symptoms combined with acute relapses. Relapses are suggested to be associated with the demyelination and inflammation of the white matter of the central nervous system (CNS). Relapses related to MS can range from mild to significant; to disabling for example: The symptoms of PRMS may include: a. Vision problem for example temporary vision lost, eye pain and double vision. b. Heat sensitivity c. Dizziness d. Severe radiating pain in the neck e. Weakness f. Fatigue g. Urosepsis, and UTI due to a neurogenic bladder h. Depression
i. Difficulty Concentrating j. Aspiration pneumonia due to dysphagia k. Respiratory failure due to cervical myelopathy or severe demyelination in the brainstem l. Deep vein thrombosis (DVT) related to immobility m. Pressure ulcers due to immobility n. Problems with sexual function o. Muscle Weakness p. Muscle stiffness (Campagnolo, (2014); Richman, & Schub, (2013); Ruto, C. (2013). Relapses The Multiple Sclerosis Association of America (2013) indicates that relapses occurs with relapsing-remitting, progressive-relapsing, and sometimes secondary-progressive forms of MS and characterized by inflammation that occurs along the nerves and the myelin resulting in patients having a temporary worsening or recurrence of existing symptoms and/or the appearance of new symptoms. A relapse can last anywhere weeks to months however neurological signs must be present for at least 24 to 48 hours, without any signs of infection or fever, before the treating physician may consider this type of flare-up to be a true relapse. There is also a term called MS pseudo-exacerbation. MS pseudo-exacerbation can be characterized by a temporary worsening of symptoms without actual myelin inflammation or damage. These symptoms can be brought on by: a. Flu or a virus b. An infection c. Excessive exercise d. Exposure to sunlight or a warm environment for a long period of time
e. Depression f. Exhaustion g. Stress. h. Fevers When patients experience MS pseudo-exacerbation symptoms these relapses are usually treated with a high-dose course of powerful corticosteroids over a period of three to five days (Multiple Sclerosis Association of America, 2013). Acthar Gel is another form of treatment. Acthar Gel is a purified form of ACTH. Risk Factors The cause of MS is unknown it is thought to be as result of environmental and genetic factors. There is also thought that that families with first-degree relatives of MS have a 2.5 5% risk of developing the disease, a risk that is 20 40 times the risk in the general population (Richman, & Schub, 2013). According to the Multiple Sclerosis Association of America (2013) risk factors has also been associated vitamin D deficiencies, and exposure to the Epstein-Barr virus. Parasites tend to weaken the immune response. Therefore, individuals with an increased likelihood for parasitic infection, such as those who live in developing countries, are less likely to be diagnosed with MS, which is triggered by a strong immune response. With improved sanitation and decreased exposure to parasites, the diagnosis of MS is on the rise in these countries. Treatment The goal of treatment for MS is early intervention and treatment that reinforces patients remaining on of one of the long-term disease modifying therapies (DMT) to minimize the rate of conversion from RRMS to secondary-progressive MS (SPMS). However clinical trials are in
progress and there are 12 FDA approved long-term treatment medications for early intervention are as follows: Long-Term Disease Modifying Therapy (DMT) Self-injection: Avonex (interferon beta-1a) Betaseron (interferon beta-1b) Copaxone (glatiramer acetate) Extavia (interferon beta-1b) Plegridy (peginterferon beta-1a) Rebif (interferon beta-1a) Intravenous infusion: Lemtrada (alemtuzumab) Novantrone (mitoxantrone) Tysabri (natalizumab) Orally: Aubagio (oral teriflunomide) Gilenya (fingolimod) Tecfidera (dimethyl fumarate or DMF, formerly known as BG-12) When an individual has a more progressive form of MS, interventions are aimed at treating the individual symptoms with the use of medication and improving the quality of life. The following medication are key in treating MS symptoms: Symptoms Treatment Acute pseudoexacerbations dexamethasone, methylprednisolone, adreno- corticotropic hormone (ACTH), prednisone Relapses Fatigue amantadine, fluoxetine, modafinil Spasticity baclofen, dantrolene, diazepam, tizanidine Constipation bisacodyl, docusate, glycerin, magnesium hydroxide Pain carbamazepine, clonazepam, gabapentin, phenytoin Erectile dysfunction alprostadil, sildenafil, tadalafil, vardenafil Depression Urinary tract infection Bladder dysfunction bupropion, citalopram, duloxetine, paroxetine, sertraline ciprofloxacin, methenamine, sulfamethoxazole + trimethoprim imipramine, desmopressin, oxybutynin, prazosin, tamsulosin
Tremor Isoniazid, buspirone, propranolol Walking Dalfampridine Multiple Sclerosis Association of America, (2013); National Multiple Sclerosis Society, (2010) Uhthoff's Syndrome Uhthoff's syndrome is usually one of the first symptoms of experienced by patient when diagnosed with MS. Uhthoff s Syndrome can be described as a dimming or reduction in vision, usually associated with exercise or overheating. However one case study involving a male patient described Uhthoff s Syndrome as temporary vision lost while driving to work at six AM. When partial myelin damage along the optic nerve occurs with the disease vision loss is experienced. In addition when an individual temperature increase the ability to conduct nerve impulses along damaged nerves is reduced (Multiple Sclerosis Association of America, 2013). When the individual body temperature is reduce the vision improves. According to the Multiple Sclerosis Association of America, (2013) the treatment for Uhthoff s Syndrome is to reduce the body temperature, and for individual to avoid overheating. Alternative or Complementary Treatment Complementary and alternative therapy is very popular among patients with MS. Nonetheless these popular alternative therapies are unproven by clinical trials, therefore patients should be cautious when using alternative types of therapies. Individual patients who practice their religious faith, aromatherapy, electromagnetic therapy, massage, acupuncture, and herbal remedies may benefit specific symptoms, such as valerian for insomnia or cranberry for prevention of UTIs, but others may irritate the urinary tract, interact with steroid medications, or stimulate the immune system (Reitman & Kalb, 2012). Naltrexone is an approved medication by
the United States Food and Drug Administration (FDA) for the treatment of addictions to opioids and alcohol. At the full recommended dose, Naltrexone blocks opioid docking sites on cells (National Multiple Sclerosis Society, 2010). However Naltrexone at significantly lower doses has also been suggested as an alternative therapy, and studies indicate that it improves the client s quality of life but has no impact on physical symptoms (Cree, Kornyeyeva, & Goodin, 2010). Nursing Considerations When Caring for the MS Patients Nursing care for aging clients with MS should focus on helping the client meet needs that allow them to have a productive life, have access to continuum health care, function independently, and social interaction. The nursing care should be focused around a holistic approach in helping the patient to achieve activities of daily living for example: a. Mobility b. Assistive Devices c. Social Activities (Horseback riding, skiing, and daily walking) d. Maintaining Independence e. Referring Home Health Care f. Referring to Adult Living Facilities g. Range of Motion Exercises h. Watching for depression i. The nurse should also assist older clients with MS by teaching them: 1. Coping skills 2. Monitoring their disease progression
3. Planning and prioritizing activities 4. Participating in the community activities (DiLorenzo, 2011). j. The nurse should keep the patient informed about appropriate healthcare services such as: 1. Physical therapy 2. Ophthalmology care 3. Support groups 4. Physical and wellness promotion programs Patient Education Patients with early onset of MS has the potential to live a productive life with this disease for many years. Therefore, the nurse should educate the patient to understand the essential of MS, and its implications. Teaching topics for the patient should include the following: a. The overall pathophysiology of the disease b. Classifications of clinical type c. Pseudo-exacerbation and causes d. Symptoms commonly experienced by clients with MS e. Medications and treatment options f. Medications and side effects g. Medication schedule h. Medication Dosages i. Common medication and drug interactions j. How to prevent exacerbations of MS k. Getting plenty of rest during activities l. Avoiding prolong exposure to heat of cold temperatures
m. Managing fatigue and stress n. Avoiding physical overexertion o. Avoiding infections p. Explain the precautions for women of childbearing ages and desires to become pregnant q. Available resources such as the National Multiple Sclerosis Society. Conclusion Living with a chronic illness can be very difficult. Intervention should be aim at early treatment to stop the progression of MS and to live a productive life. According to the Multiple Sclerosis Association of America, (2013) early treatment and staying on one of the long-term DMTs for MS may also delay the rate of conversion from RRMS to secondary-progressive MS (SPMS). Nursing intervention should continue to focus on referring the patient that will include a multidisciplinary approach, and educating the patient about resources that are available for them to live a productive life.
References Cree, B., Goodin, D., Kornyeyeva. (2010). Low Dose Naltrexone. Annals of Neurology, 68(2), 145-150. DiLorenzo, T. (2011) Aging with Multiple Sclerosis. Clinical Bulletin. Information for heath Professionals. Retrieved from http://www.nationalmssociety.org/nationalmssociety/media/msnationalfiles/brochures/ Clinical_Bulletin_Aging_with_MS.pdf Mayo Clinic. (2012). Multiple sclerosis: Treatments and drugs. Retrieved from Multiple Sclerosis Association of America. (2013a). What are the Symptoms of MS. Retrieved from http://mymsaa.org/about-ms/symptoms/. Multiple Sclerosis Association of America. (2013b). Uhthoffs Syndrome. Retrieved from http://mymsaa.org/about-ms/symptoms/uhthoffs-syndrome/. Multiple Sclerosis Association of America. (2013c). Treatments for MS. Retrieved from http://mymsaa.org/about-ms/treatments/. National Institute of Neurological Disorders and Stroke. (2012). Multiple sclerosis: Hope through research. Retrieved from http://www.ninds.nih.gov/disorders/multiple_sclerosis /detail_ multiple_sclerosis.htm#210833215. National Multiple Sclerosis Society (2010). Low Dose Naltrexone. Retrieved from http://www.mayoclinic.com/health/multiple-sclerosis/ DS00188/DSECTION=treatmentsand-drugs. http://www.nationalmssociety.org/treating-ms/complementary-alternative- Medicines/Low-Dose-Naltrexone.
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