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Coping with Advanced
MULTIPLE SCLEROSIS
Carol Freeman MSN, RN, CNRN, MSCN
2/6/2008
Disease Courses in MS
Types of MS
Relapsing-Remitting
Disability
Relapsing-Remitting Followed by Secondary-Progressive
Primary-Progressive
Progressive-Relapsing
Time
Lublin et al. Neurology. 1996;46:907-911.
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
Fatigue
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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
Types of Pain in MS
• Acute
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 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
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
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
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
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®
Medications
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Bulk forming agents - Metamucil®, FiberCon®
Stool softeners- Colace®, Surfak®
Laxatives - Pericolace®, Peridum®, Milk of Magnesia®
Suppositories – Glycerin, Dulcolax®
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
Bladder Dysfunction
• Definition of terms: frequency, urgency,
hesitancy, incontinence, and nocturia
• Types: flaccid, spastic and dyssynergic
Flaccid Bladder – failure to empty
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Incidence – 19 – 40%
Symptoms – frequency, urgency, hesitancy, and incontinence
Little voluntary or reflex control of voiding
Bladder overfills with large amounts of urine
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
Dyssynergic Bladder – conflicting or combination
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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
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
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
Lifestyle Changes
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Sexual activity
Employment
Social activities
Complications – skin breakdown, infections
Spasticity
Medication
 Lioresal® (baclofen); oral and intrathecal
 Zanaflex® (tizanidine)
 Klonopin® (clonazepam)
 Neurontin® (gabapentin)
 Dantrium® (dantrolene)
 Valium® (diazepam)
Exercise and MS
• Four elements in prescription
- Type of exercise: aerobic, strengthening,
balance, stretching
- Duration
- Frequency
- Intensity
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
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
Nutrition & MS
• Important to have well-balanced diet
• Over-the-counter multivitamins can be used to supplement dietary
requirements
• Weight loss diets
• Swallowing difficulties
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
Points to Consider
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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
Stress & MS
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Assess concurrent stressors
Identify support systems
Use stress reduction techniques- yoga, tai chi, meditation
Exercise- walking, stretching and toning
Adequate sleep/rest
Cognitive Dysfunction
• Over 50% of MS patients
• Evaluate current medications
• Evaluate psychological factors: anxiety/depression
• Attentional fatigue – longer to process information
Levels of Care
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Newly diagnosed
Functional with adaptations
Functional with assistance from others
Functionally dependent upon caregivers
Assistance Available
• Community Services
 Center for Independent Living
 Area Agency on Aging
• Volunteer Organizations
• NMSS
 Direct Financial Assistance