MULTIPLE SCLEROSIS (MS)

MULTIPLE SCLEROSIS (MS) – Etiology and Risk Factors, Pathophysiology, Signs and Symptoms, Complications, Diagnostic Evaluation and Management

DEFINITION

Multiple sclerosis (MS) is a disease in which immune system attacks the protective sheath (myelin) that covers nerves. Myelin damage disrupts communication between brain and the rest of body. Ultimately, the nerves themselves may deteriorate a process that is currently irreversible.

ETIOLOGY AND RISK FACTORS

These factors may increase risk of developing multiple sclerosis

• Age: Multiple sclerosis can occur at any age, but most commonly affects people between the ages of 15 and 60
• Sex: Women are about twice as likely as men are to develop MS
• Family History: If one of parents or siblings has had MS, you are at higher risk of developing the disease
• Certain Infections: a variety of viruses have been linked to MS, including Epstein-Barr, the virus that causes infectious mononucleosis
• Race: white people are at highest risk of developing MS
• Climate: MS is far more common in countries with temperate climates
• Certain autoimmune diseases: like thyroid diseases, type 1 diabetes or inflammatory bowel disease
• Smoking: smokers who experience an initial event of symptoms that may signal MS are more likely that nonsmokers to develop a second event that confirms relapsing-remitting MS

PATHOPHYSIOLOGY

Early in the diseases course, MS involves recurrent bouts of CNS inflammation —- results in damage to both the myelin sheath surrounding axons as well as the axons themselves —- severe demyelination, decreased axonal and oligodendrocyte numbers, and gliotic scarring —- an autoimmune response directed against CNS antigens is suspected —- activation of T-cell mediated or T-cell-plus-antibody-mediated autoimmune responses — significant axonal injury is occurs in cortical demyelinating lesions.

SIGNS AND SYMPTOMS

Signs and symptoms of multiple sclerosis vary, depending on the location of affected nerve fibers. Multiple sclerosis signs and symptoms may include:

• Numbness or weakness in one or more limbs that typically occurs on one side of body at a time, or the legs and trunk
• Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement
• Double vision or blurring of vision
• Tingling or pain in parts of body
• Electric-shock sensations that occur with certain neck movements, especially bending the neck forward
• Tremor, lack of coordination or unsteady gait
• Slurred speech
• Fatigue
• Dizziness
• Problems with bowel and bladder function

COMPLICATIONS

People with multiple sclerosis also may develop:

• Muscle stiffness or spasms
• Paralysis, typically in the legs
• Problems with bladder, bowel or sexual function
• Mental changes, such as forgetfulness or mood swings
• Depression
• Epilepsy

DIAGNOSTIC EVALUATION

• Blood tests: it helps to rule out infectious or inflammatory diseases with  symptoms similar to MS
• Spinal tap (lumbar puncture): in which a small sample of fluid is removed from spinal canal for laboratory analysis. This sample can show abnormalities in white blood cells or antibodies that are associated with MS. Spinal tap can also rule out viral infections and other conditions with symptoms similar to MS
• MRI: which can reveal areas of MS (lesions) on brain and spinal cord

MANAGEMENT

• Corticosteroids: such as oral prednisone and intravenous methylprednisolone, are prescribed to reduce nerve inflammation. Side effects may include insomnia, increased blood pressure, mood swings, and fluid retention
• Plasma exchange (plasmapheresis): the liquid portion of part of blood (plasma) is removed and separated from blood cells. The blood cells are then mixed with a protein solution (albumin) and put back into body
• Beta interferons: these medications, which are injected under the skin or into muscle, can reduce the frequency and severity of relapses. Beta interferons can cause side effects such as flu-like symptoms and injection-site reactions.
• Glatiramer acetate: this medication may help block immune system’s attack on myelin. The medication must be injected beneath the skin. Side effects may include skin irritation at the injection site
• Dimethyl fumarate: this twice-daily oral medication can reduce relapses. Side effects may include flushing, diarrhea, nausea and lowered white blood cell count
• Fingolimod: this once-daily oral medication reduces relapse rate. Heart rate must be monitored for six hours after the first dose because heartbeat may be slowed. Other side effects include high blood pressure and blurred vision
• Teriflunomide: this once-daily medication can reduce relapse rate. Teriflunomide can cause liver damage, hair loss and other side effects. It is also known to be harmful to a developing fetus
• Natalixumab: this medication is designed to block the movement of potentially damaging immune cells from bloodstream to brain and spinal cord. The medication increases the risk of a viral infection of the brain called progressive multifocal leukoencephalopathy. It is generally given to people who have more severe or active MS, or who do not respond to or cannot tolerate other treatments
• Mitoxantrone: this immunosuppressant drug can be harmful to the heart and is associated with development of blood cancers. Mitoxantrone is usually used only to treat severe, advanced M.
• Physical therapy: a physical or occupational therapist can teach like stretching and strengthening exercises
• Muscle relaxants: muscle relaxants such as baclofen and tizanidine may help
• Medications to reduce fatigue
• Other medications: medications may also be prescribed for depression, pain and bladder or bowel control problems that are associated with MS

NURSING MANAGEMENT

Nursing Diagnosis

1. Fatigue related to decreased energy production, increased energy requirements to perform activities

Interventions

• Note and accept presence of fatigue
• Indentify and review factors affecting ability to be active: temperature extremes, inadequate food intake, insomnia, use of medications, time of day
• Schedule ADLs in the morning if appropriate
• Determine need for walking aids. Provide braces, walkers, or wheelchairs. Review safety considerations
• Accept when patient is unable to do activities
• Plan care consistent rest periods between activities. Encourage afternoon nap
• Assist with physical therapy. Increase patient comfort with massages and relaxing baths
• Stress need for stopping exercise or activity just short of fatigue
• Investigate appropriateness of obtaining a service dog
• Recommend participation in groups involved in fitness or exercise

• Self-care deficit related to neuromuscular, perceptual impairment

Interventions

• Determine current activity level and physical condition. Assess degree of functional impairment using 0-4 scale
• Encourage patient to perform self-care to the maximum of ability as defined by patients. Do not rush patient
• Assist according to degree of disability allow as much autonomy as possible
• Encourage patient input in planning schedule
• Allot sufficient time to perform tasks, and display patience when movements are slow
• Encourage scheduling activities early in the day or during the time when energy level is best
• Note presence of fatigue
• Anticipate hygienic needs and calmly assist as necessary with care of nails, skin, and hair; mouth care; shaving
• Provide assistive devices and aids as indicated: shower  chair, elevated toilet seat with arm supports
• Provide massage and active or passive ROM exercises on a regular schedule. Encourage use of splints or footboards as indicated
• Reposition frequently when patient is immobile. Provide skin care to pressure points, such as sacrum, ankles and elbows. Position properly and encourage to sleep prone as tolerated
• Consult with physical and occupational therapist
• Problem-solve ways to meet nutritional and fluid needs
• Encourage stretching and toning exercises and use of medications, cold packs, and splints and maintenance of proper body alignment, when indicated

• Low self-esteem related to change in structure and function

Interventions

• Establish and maintain a therapeutic nurse-patient relationship, discussing fears and concerns
• Acknowledge reality of grieving process related to actual or perceived changes. Help patient deal realistically with feelings of anger and sadness
• Support use of defense mechanisms, allowing patient to deal with information in own time and way
• Note withdrawn behaviors and use of denial or over concern with body and disease process
• Review information about course of disease, possibility of remissions, prognosis.
• Provide accurate verbal and written information about what is happening and discuss with patient
• Explain that labile emotions are not unusual. Problem-solve ways to deal with these feelings
• Assess interaction between patients. Note changes in relationship
• Note presence of depression and impaired thought processes, expressions of suicidal ideation
• Discuss use of medications and adjuncts to improve sexual function
• Provide open environment for patient to discuss concerns about sexuality, including management of fatigue, spasticity, arousal and changes in sensation

• Powerlessness and hopelessness related to illness-related regimen, unpredictability of disease

Intervention

• Note behaviors indicative of powerlessness or hopelessness. Patient may say statements of despair
• Discuss plans for the future. Suggest visiting alternative care facilities, taking a look at the possibilities for care as condition changes
• Encourage and assist patient to identify activities he or she would like to be involved in within the limits of his or her abilities
• Acknowledge reality of situation, at the same time expressing hope for patient
• Assist patient to identify factors that are under own control. List things that can or cannot be controlled
• Encourage patient to assume control over as much of own care as possible
• Discuss needs openly with patient, setting up agreed-on routines for meeting identified needs
• Incorporative patient’s daily routine into home care schedule or hospital stay, as possible.
• Refer to vocational rehabilitation as indicated.

• Risk for ineffective coping related to physiological changes, psychological conflict and impaired judgment

Intervention

• Assist current functional capacity and limitations; note presence of distorted thinking processes, labile emotions, cognitive dissonance
• Determine patient’s understanding of current  situation and previous methods of dealing with life’s problems
• Discuss ability to make decisions, care for children or dependent adults, handle finances
• Maintain an honest, reality-oriented relationship
• Encourage verbalization of feelings and fears, accepting what patient says in a nonjudgmental manner
• Encourage patient to tape-record important information and listen to the recording periodically
• Provide clues for orientation: calendars, clocks, notecard, and organizers
• Observe nonverbal communication: posture, eye contact, movements, gestures and use of touch. Compare with verbal content and verify meaning with patient as appropriate