Multiple Sclerosis/Test 3

Question 1

Pathophysiology of MS:

Answer 1

• Chronic, progressive, degenerative CNS disorder
• Starts as inflammation then disseminated demyelination and gliosis (scarring) of nerve fibers in the brain and spinal cord
• Random distribution: brainstem, optic nerves, spinal cord, cerebrum
• Formation of plaque

Question 2

MS is initially triggered by:

Answer 2

a virus in genetically susceptible individuals

• activated T cells migrate to CNS causing blood brain disruption.
• Subsequent antigen-antibody reaction leads to demyelination of axons

Question 3

Considered a disease of

Answer 3

the young to middle age adults. Onset 15-50. Women are affected more often than men.

Question 4

Manifestations-

Answer 4

Motor weakness/paralysis of the limbs, trunk or head; diplopia; scanning speech; spasticity of muscles that are chronically affected. Sensory-numbness/tingling, parasthesias, patchy blindness (scotomas), blurred vision, vertigo, tinnitus, decreased hearing, chronic neuropathic pain. Cerebellar signs: nystagmus, ataxia, dysarthria, dysphagia. Bowel and bladder dysfunctions- flaccid bladder

Question 5

Baclofen:

Answer 5

Acts on the CNS to relieve spasms, cramping and tightness of muscles caused by spasticity in MS

Question 6

Proper use of Baclofen:

Answer 6

people with MS are usually started on an initial dose of 5 mg every six to eight hours. If necessary, the amount is increased by 5 mg per dose every 5 days until symptoms improve. The goal of treatment is to find a dosage level that relieves spasticity without causing excessive weakness or fatigue. The effective dose may vary from 15 mg to 160 mg per day or more.

Question 7

Precautions of Baclofen use:

Answer 7

If you are taking more than 30 mg daily, do not stop taking this medication abruptly. Stopping high doses of this medication can cause convulsions, hallucinations, increase in muscle spasms or cramping, mental changes, or unusual nervousness or restlessness. Consult your physician about how to reduce the dosage gradually before stopping the medication completely.

Question 8

Possible side effects of Baclofen:

Answer 8

Expected: drowsiness or unusual tiredness, increased weakness, dizziness or lightheadedness, confusion, unusual constipation, new or unusual bladder symptoms, trouble sleeping, unusual unsteadiness or clumsiness
-unusual side effects: (immediate medical attention) fainting, hallucinations, severe mood changes, skin rash or itching, symptoms of overdose, sudden onset of blurred or double vision, convulsions, SOB, vomiting.

Question 9

Etiology of MS:

Answer 9

*Cause in unknown
-possibly autoimmune
Research suggests- Infectious (viral), immunologic, genetic factors
**Higher incident in colder, northern latitude

Question 10

Clinical manifestations of MS:

Answer 10

• *Remember to correlate symptoms where lesions are:
• Motor symptoms- weakness or a feeling of heaviness in the lower extremities, paralysis, spasticity and hyperrelexia, diplopia, bowel and bladder dysfunction.
• retention, frequency, urgency, incontinences, bladder common symptom
• Neurobehavioral symptoms- emotional lability, euphoria and depression common. Irritability, apathy, poor judgement, inability to problem solve, loss of short term memory r/t demyelination of the white matter in the frontal lobe.
• Optic neuritis
• Impotence
• Sexual dysfunction
• Fatigue (ranges from mild to severe)

Question 11

MS diagnostic studies:

Answer 11

• *No definitive diagnostic test
• history and physical esp: neuro
• visual, auditory, somatosensory response
• -assess nerve conduction to these areas
• Usually diagnosed by ruling out other neurological causes
• MRI- extremely sensitive to white matter lesions- locating sites of demyelination. Presence of multiple lesions seen over time on MRI (2nd lesion)
• CSF analysis- higher white count, 90% MS patient have a specific protein present. Increase in oligoclonal immunoglobulin G, myelin basic protein. Higher number of lymphocytes and monocytes.
• Evoked responses- decreased nerve conduction from the eye and ear to the brain.

Question 12

MS is based primarily on

Answer 12

history, clinical manifestations- “DX of exlusion”

• 2 attacks at least 1 month apart
• more than 1 area of damage

Question 13

Lab tests for MS:

Answer 13

• T4 and immune globulin G (IgG) are increased.
• CSF electrophoresis shows presence of IgG oligoclonal bands, myelin basic protein, higher number of lymphocytes and monocytes.
• Radioimmunoassay: measures the myelin basic protein that is released during the acute attack.

Question 14

No cure: Goals are: Drug therapy

Answer 14

• Treat the disease process
• Providing symptomatic relief
• Adjust to illness
• Maximize neuromuscular function
• Maintain independence- leading cause of unemployment for MS pt is cognitive impairment, not weakness
• Optimize psychosocial well-being
• Decrease factors that precipitate exacerbations.

Question 15

For Acute exacerbation: MS

Answer 15

• Steroid use to treat/alleviate the major symptoms of MS
• Short course of high-dose corticosteroids
• Methylprednisolone
• Oral predisone
• Corticotropin (ACTH) IV or IM

Question 16

For decreasing relapse-

Answer 16

• Immune response modifiers-Maintenance drugs that modify the disease process and slows progression. Inhibits the # of lymphocytes migrating to the CNS and suppresses production of macrophages.
• fingolimod (Gilenya)
• teriflunomide (Aubagio)- immunosuppressive, anti-inflammatory drug

Question 17

For halting disease progression

Answer 17

• Immunosuppressive agents have shown some positive benefit in progressive disease
• Cyclophosphamide, cyclosporine, total lymphoid radiation, oral myelin (Clinical trials)

Question 18

Collaborative interventions: MS

Answer 18

Medications:

• goal is to decrease inflammation and destruction of the myelin sheaths
• most drugs are effective for just one or two types of MS

Question 19

Drug therapy for managing symptoms:

Answer 19

• Baclofen- S.E. withdraw symptoms can occur if stopped abruptly.
• Dantrolene- direct acting skeletal muscle relaxant
• Diazepam
• Intrathecal phenol

Question 20

Meds for tremors:

Answer 20

• Hydroxyzine (Vistaril)
• Isoniazid (INH)
• Trihexyphenidyl (Artane)
• Primidone (Mysoline)

Question 21

Spasticity Management:

Answer 21

*Aantispasmodic drugs (primary tx)
*Dorsal-column electrical stimulation
*Intrathecal Baclofen Pump- decreased risk for abrupt stoppage of drug.l
*Orthosis, Occupational Therapy Interventions
*Physical therapy
*Botolinum Toxin injection
*Surgery
Plasma exchange

Question 22

Drug therapy for Spastic bladder and urge incontinence:

Answer 22

• Oxybutynin (Ditropan)
• Imipramine (Tofranil)
• Propantheline (Pro-Banthine)

Question 23

Drug therapy for urinary retention-

Answer 23

Bethanechol Chloride (urecholine)
-A cholinergic agent for atonic bladder

Question 24

Antidepressants Drugs:

Answer 24

• Amitriptyline (Elavil)
• Imipramine (Trofanil)
• Trazodone (Desyrel)
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

Question 25

Fatigue Drugs:

Answer 25

*Amanadine hydrochloride (Symmetrel) *Pemoline (Cylert) Others: stool softeners and laxatives

Question 26

Collaborative management MS:

Answer 26

* Avoid hot baths-may increase weakness * Safety precautions * Well balanced diet * Balanced between activity and rest- avoid fatigue and stres * Physical therapy * Positioning to prevent contractures- don't use pillows under the knees support the whole leg * Eye patches for diplopia * Bowel and bladder training * Environmental safety control if sensory losses are present * Psychosocial therapy * Patient education