Multiple Sclerosis: An Overview

• Multiple Sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the Central Nervous System (CNS).

Demyelination

• Demyelination is the destruction of myelin in the brain and spinal cord, which impairs nerve impulse transmission.

Statistics and Demographics

• MS affects nearly 400,000 people in the United States.
• Peak onset is between 20 and 50 years old.
• Women are affected three times more often than men.

Etiology and Risk Factors

• The cause of MS is unknown, but it involves autoimmune activity leading to demyelination.
• Genetic variations, numbering around 200, are related to MS but it is not genetically transmitted.
• Environmental risks include obesity, vitamin D deficiency, and high salt intake during teenage years.

Prevalence

• Geographic prevalence of MS is highest in Europe, New Zealand, southern Australia, the northern United States, and southern Canada.
• MS is less prevalent in Asians.
• There is a greater frequency in northern colder latitudes.

Acute and Subacute Forms

• Radiologically Isolated Syndrome (RIS) involves MS-like lesions on MRI without clinical signs; about one-third develop MS within 5 years of incidental lesion identification.
• Clinically Isolated Syndrome (CIS) presents acute or subacute clinical findings lasting at least 24 hours.

Clinical Forms

• The four main clinical forms of MS are:
  • Remitting-Relapsing (RRMS)
  • Secondary Progressive
  • Primary Progressive (PPMS)
  • Progressive-Relapsing

Pathophysiology

• Sensitized T and B lymphocytes cross the blood-brain barrier and remain in the CNS, promoting immune system damage.
• The immune system attacks the white matter of the CNS myelin and oligodendroglial cells.
• Demyelination disrupts nerve impulse flow, with plaques forming on demyelinated axons.
• Frequently affected areas include the optic nerves, cerebrum, brainstem, cerebellum, and spinal cord.
• Axon degeneration leads to permanent damage.

Clinical Manifestations

• MS has varied patterns, with some patients experiencing a benign course.
• RIS patients are asymptomatic, while CIS typically includes unilateral optic neuritis, focal symptoms, or partial myelopathy.
• Approximately 85% of patients have RRMS.
  • Recovery is usually complete after each relapse.
  • Residual deficits may accumulate over time.
• Most RRMS patients transition to the secondary progressive form, with disease progression occurring with or without relapses.
• About 15% of patients have PPMS.
  • Disabling symptoms steadily increase with rare plateaus.
  • PPMS may result in quadriparesis, cognitive dysfunction, visual loss, and brainstem syndromes.
• The least common presentation (about 5% of cases) is progressive-relapsing.
  • Relapses occur with continuous disabling progression between exacerbations.

Symptoms

• Signs and symptoms vary, reflecting lesion locations, and include physical, emotional, and cognitive impacts on quality of life.
• Common symptoms are fatigue, depression, weakness, numbness, incoordination, balance loss, spasticity, and pain.
• Visual disturbances include blurred vision, diplopia, scotoma, and total blindness.
• Fatigue affects most people with MS and is often the most disabling symptom.
• Heat, depression, anemia, deconditioning, and medications may contribute to fatigue.
• Pain results from lesions on sensory pathways, with sensory manifestations including paresthesias, dysesthesias, and proprioception loss.
• Spasticity, characterized by muscle hypertonicity with increased resistance to stretch, occurs in 90% of patients, mainly in the lower extremities.
• Cognitive changes, such as memory loss and decreased concentration, occur in about half of patients.
• Ataxia and tremor can result from involvement of the cerebellum or basal ganglia.
• Emotional lability and euphoria may occur due to loss of control connections between the cortex and basal ganglia.
• Bladder, bowel, and sexual dysfunctions are common.
• Additional complications include UTIs, constipation, pressure injuries, contracture deformities, dependent pedal edema, pneumonia, and osteoporosis.
• Emotional, social, marital, economic, and vocational problems may also occur.
• Exacerbations involve new or worsening symptoms; remissions involve symptom decrease or disappearance.
• Relapses may be associated with emotional and physical stress.

Gerontologic Considerations

• Life expectancy for patients with MS is 7 to 14 years shorter.
• Those diagnosed with secondary progressive disease live an average of 38 years after onset.
• Older adult patients face challenges like chronic health problems, medication interactions, and age-related changes affecting medication processing.
• Older adults must be monitored closely for adverse effects of MS medications and for osteoporosis, especially with frequent corticosteroid use.
• Cost of medications may lead to poor adherence.
• Concerns include increasing disability, family burden, marital issues, and potential need for nursing home care.
• Immobility leads to loneliness and depression.
• Physical challenges include spasticity, pain, bladder dysfunction, impaired sleep, and increased need for assistance with self-care.

Assessment and Diagnostic Findings

• Diagnosis is based on clinical, imaging, and laboratory findings.
• The presence of plaques in the CNS disseminated in space and over time observed on MRI scans with no better explanation for the clinical presentation.
• Electrophoresis of CSF identifies oligoclonal banding (immunoglobulin G bands indicating immune abnormality).
• Evoked potential studies help define disease extent and monitor changes.
• Urodynamic studies diagnose underlying bladder dysfunction.
• Neuropsychological testing assesses cognitive impairment.
• A sexual history identifies changes in sexual function.

Medical Management

• There is no cure for MS.
• Treatment aims to relieve symptoms and provide continuing support.
• Goals include delaying disease progression, managing chronic symptoms, and treating acute exacerbations.
• Common symptoms requiring intervention include ataxia, bladder dysfunction, depression, fatigue, and spasticity.
• Management includes pharmacologic and nonpharmacologic strategies.

Pharmacologic Therapy

• Medications include those for disease modification and symptom management.
• Disease-modifying therapies delay disease progression in many forms of MS.

Disease-Modifying Therapies

• Reduce the frequency of relapse, the duration of relapse, and the number and size of plaques observed on MRI in RRMS.
• Not effective in PPMS
• Interferon beta-1a and interferon beta-1b are administered subcutaneously every other day.
  • Side effects include flulike symptoms, increased liver function tests, leukopenia, headache, depression, and skin necrosis.
• Glatiramer acetate reduces the rate of relapse in RRMS and is administered subcutaneously daily.
  • Adverse effects: injection-site reactions and flushing.
• Teriflunomide, fingolimod, and dimethyl fumarate are oral disease-modifying therapies with significantly reduced relapse rates.
• Ocrelizumab has a 6% annual relapse reduction rate in patients with PPMS.
• IV methylprednisolone, used to treat acute exacerbations, shortens the duration of relapse.
  • Side effects: mood swings, weight gain, and electrolyte imbalances.
• Mitoxantrone is given via IV infusion every 3 months and can reduce the frequency of clinical relapses in patients with secondary progressive or worsening RRMS.
  • Patients must be closely monitored for cardiac toxicity, and there is a maximum lifetime dose.

Symptom Management

• Baclofen is the medication of choice for treating spasticity, given orally or by intrathecal injection.
• Benzodiazepines, tizanidine, and dantrolene may also be used to treat spasticity and improve motor function.
• Fatigue may be treated with amantadine, pemoline, or dalfampridine.
• Ataxia medications include beta-adrenergic blockers, anticonvulsant agents, and benzodiazepines.
• Bladder and bowel problems are managed with anticholinergic agents, alpha-adrenergic blockers, and antispasmodic agents, along with nonpharmacologic strategies.
• UTIs are managed with increased fluid intake, good perineal care, and antibiotics when appropriate.

Nursing Assessment

• Addresses neurologic deficits and the impact of the disease on the patient and family.
• Assesses mobility and balance to determine fall risk.
• Evaluates function when the patient is well-rested and fatigued.
• Assesses for weakness, spasticity, visual impairment, incontinence, and disorders of swallowing and speech.
• Additional assessments include the impact on quality of life, coping mechanisms, medication adherence, and desired improvements.

Nursing Diagnosis

• Impaired mobility related to weakness, muscle paresis, spasticity, and increased weight
• Risk for falls related to sensory and visual impairment and lower extremity weakness
• Fatigue related to insufficient energy
• Difficulty coping related to uncertainty of MS course

Collaborative Problems/Potential Complications

• Constipation or fecal incontinence
• Communication issues and potential for aspiration related to cranial nerve involvement
• Cognitive changes
• Managing therapies at home related to physical, psychological, and social limits imposed by MS
• Changes in sexuality
• Urinary incontinence

Planning and Goals

• Major goals include promotion of physical mobility, fall avoidance, fatigue reduction, coping strategy development, and absence of complications.

Nursing Interventions

• Combines physical, occupational, and speech-language therapy, rehabilitation, education, and emotional support.
• Develops an educational plan of care to address physiological, social, and psychological problems.
• Addresses depression, pain, fatigue, and walking difficulty to increase physical activity.

Promoting Physical Mobility

• Relaxation and coordination exercises improve muscle efficiency.
• Progressive resistive exercises strengthen weak muscles.
• Walking improves gait, especially for loss of position sense.
• Assistive devices may be needed, requiring instruction on their safe use.

Minimizing Spasticity and Contractures

• Warm packs may be beneficial, but avoid hot baths.
• Avoid extreme cold exposure.
• Daily muscle stretching exercises are prescribed, focusing on hamstrings, gastrocnemius, hip adductors, biceps, and wrist/finger flexors.
• Orthotics help maintain functional position and reduce contractures.
• Stretch–hold–relax routines help treat muscle spasticity.
• Swimming and stationary bicycling are useful, along with progressive weight bearing.

Activity and Rest

• Encourage work and exercise to a point just short of fatigue.
• Avoid strenuous physical exercise.
• Take frequent short rest periods.
• Use air conditioning to avoid heat exposure.

Nutrition

• Promote healthy eating and weight reduction, addressing fatigue and mobility impairments.
• Include family members in nutrition education.
• Avoid alcohol and cigarette smoking.

Preventing Falls

• Instruct patients to walk with feet apart to widen the base of support.
• Instruct patients to watch their feet while walking if loss of position sense occurs.
• Gait training may require assistive devices.
• Consider a wheelchair or motorized scooter for inefficient gait.
• Provide training in transfer and ADLs.
• Address sensory loss to prevent pressure injuries.

Managing Fatigue

• Identify and ameliorate factors contributing to fatigue.
• Decreasing the use of electronic devices prior to sleep can improve sleep quality and lessen fatigue.

Strengthening Coping Mechanisms

• Educate that no two patients with MS have identical symptoms or courses of illness.
• Some patients experience significant disability, while others have minimal disability.
• Address family conflict, disintegration, separation, and divorce.
• Provide counseling and support referrals to minimize the adverse effects of dealing with chronic illness.