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Coping with Advanced MULTIPLE SCLEROSIS

Coping with Advanced MULTIPLE SCLEROSIS. Carol Freeman MSN, RN, CNRN, MSCN 2/6/2008. Relapsing-Remitting. Relapsing-Remitting Followed by Secondary-Progressive. Primary-Progressive. Progressive-Relapsing. Disease Courses in MS Types of MS. Disability. Time.

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Coping with Advanced MULTIPLE SCLEROSIS

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  1. Coping with Advanced MULTIPLE SCLEROSIS Carol Freeman MSN, RN, CNRN, MSCN 2/6/2008

  2. Relapsing-Remitting Relapsing-Remitting Followed by Secondary-Progressive Primary-Progressive Progressive-Relapsing Disease Courses in MSTypes of MS Disability Time Lublin et al. Neurology. 1996;46:907-911.

  3. Symptom Management Types 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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®

  10. Medications • Bulk forming agents - Metamucil®, FiberCon® • Stool softeners- Colace®, Surfak® • Laxatives - Pericolace®, Peridum®, Milk of Magnesia® • Suppositories – Glycerin, Dulcolax®

  11. 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

  12. Bladder Dysfunction • Definition of terms: frequency, urgency, hesitancy, incontinence, and nocturia • Types: flaccid, spastic and dyssynergic

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. Lifestyle Changes • Sexual activity • Employment • Social activities • Complications – skin breakdown, infections

  19. Spasticity Medication • Lioresal® (baclofen); oral and intrathecal • Zanaflex® (tizanidine) • Klonopin® (clonazepam) • Neurontin® (gabapentin) • Dantrium® (dantrolene) • Valium® (diazepam)

  20. Exercise and MS • Four elements in prescription - Type of exercise: aerobic, strengthening, balance, stretching - Duration - Frequency - Intensity

  21. 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

  22. 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

  23. Nutrition & MS • Important to have well-balanced diet • Over-the-counter multivitamins can be used to supplement dietary requirements • Weight loss diets • Swallowing difficulties

  24. 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

  25. 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

  26. Stress & MS • Assess concurrent stressors • Identify support systems • Use stress reduction techniques- yoga, tai chi, meditation • Exercise- walking, stretching and toning • Adequate sleep/rest

  27. Cognitive Dysfunction • Over 50% of MS patients • Evaluate current medications • Evaluate psychological factors: anxiety/depression • Attentional fatigue – longer to process information

  28. Levels of Care • Newly diagnosed • Functional with adaptations • Functional with assistance from others • Functionally dependent upon caregivers

  29. Assistance Available • Community Services • Center for Independent Living • Area Agency on Aging • Volunteer Organizations • NMSS • Direct Financial Assistance

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