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Multiple Sclerosis: An Update for Home Healthcare Clinicians

Capriotti, Teri, DO, MSN, CRNP; Noel, Julia, SN; Brissenden, Simone, SN

doi: 10.1097/NHH.0000000000000666
Feature

Multiple sclerosis (MS) is a chronic neurologic disease and the most common cause of nontraumatic disability in young adults in the United States. It strikes adults in the prime of life and can gradually diminish physical and mental function, affect relationships, employment, financial capacity, and independence. Neurologic symptoms fluctuate in a pattern of remissions and exacerbations for the majority of those with MS. A multidisciplinary treatment approach is essential. There are a wide number of medications that can be used. Treating the disease at an early stage within the first 5 years of clinical symptom onset is optimal. Home healthcare clinicians can use assessment tools to evaluate disease progression, teach the patient and family how to live with the disorder, and monitor the patient for medication side effects.

Teri Capriotti, DO, MSN, CRNP, is a Clinical Associate Professor, College of Nursing, Villanova University, Villanova, Pennsylvania.

Julia Noel, SN, is a Student Nurse, College of Nursing, Villanova University, Villanova, Pennsylvania.

Simone Brissenden, SN, is a Student Nurse, College of Nursing, Villanova University, Villanova, Pennsylvania.

The authors declare no conflicts of interest.

Address for correspondence: Teri Capriotti, DO, MSN, CRNP, Villanova University, 800 Lancaster Avenue, Villanova, PA 19085 (theresa.capriotti@villanova.edu).

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Multiple sclerosis (MS) is a chronic neurologic disorder that affects the brain and spinal cord. It is an autoimmune, demyelinating disorder that results in inflammation and damage to the myelin sheath surrounding neuronal axons. It is the leading cause of nontraumatic disability in young adults in the United States and Europe (Sutliff et al., 2016), striking adults in the prime of their lives. The clinical disease course is variable. It usually starts with reversible episodes of neurologic disability in the third or fourth decade of life. With time, the disease course changes and causes continuous and irreversible neurologic decline by the sixth or seventh decade (Dutta & Trapp, 2011).

The prevalence of MS worldwide is approximately 2.5 million individuals. Prevalence in the United States has been estimated as 450 per 100,000 individuals, affecting women two to three times more often than men and with an average age at diagnosis of 32 years. The disease more commonly affects Caucasians; however, when diagnosed in African Americans, it tends to progress more rapidly (National Multiple Sclerosis Society, 2017).

Although the etiology of MS remains unknown, several risk factors including genetic predisposition, viral or other infective process, trauma, or exposure to heavy metals may trigger the autoimmune response. Curiously, there is a higher prevalence in individuals who live in the northern latitude of the world as opposed to near the equator (National Multiple Sclerosis Society, 2017). Studies of twins indicate that heredity contributes to MS risk; however, no one genetic mutation has been found directly responsible for MS. Some researchers theorize that MS develops because a person is born with a genetic predisposition to react to some environmental agent that, upon exposure, triggers an immune-mediated response. One of the primary genes under study is the HLA-DRB1*15 allele, a gene involved in the surface receptors on cells of the immune system. Another gene under scrutiny is the IL7R gene, which also influences receptor proteins embedded in the cell membranes of immune cells. There are more than 200 genes currently under study with association to MS. Genetic variants in the vitamin D metabolic pathway have also been identified (National Multiple Sclerosis Society, 2017).

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Pathophysiology

It is theorized that activated T cells that have been abnormally sensitized to attack myelin cause the damage of MS. Activated T cells cross the blood–brain barrier and become part of an immune attack on myelin in the brain and spinal cord. The white matter tracts of the central nervous system (CNS) are most commonly affected by the demyelination process; however, gray matter tracts can also be involved. The inflammation of myelin attracts more T cells, B cells, and inflammatory mediators that damage more myelin. In patients with MS, the presence of oligoclonal bands in cerebrospinal fluid (CSF) and brain parenchyma is a consistent finding in over 95% of patients. Ultimately, demyelination of multiple areas of the CNS and disintegration of neural axons occur leaving scarred areas referred to as MS plaques. Oligodendrocytes, the cells that produce myelin, are eventually destroyed (Dargahi et al., 2017).

MS can present as four different patterns: remitting-relapsing MS (RRMS), primary progressive MS (PPMS), progressive-relapsing MS (PRMS), and secondary progressive MS (SPMS) (National Multiple Sclerosis Society, 2017). The most common form is RRMS affecting approximately 85% of individuals; however, with time, this type commonly evolves into the secondary progressive type of MS (Saguil et al., 2014).

In RRMS, myelin destruction is episodic and healing of the myelin occurs. The patient endures remissions when the disease is quiescent, and exacerbations when the disease is active. Alternatively, areas of myelin undergo damage and progressively deteriorate with eventual development of irreversible fibrotic scar tissue; this is referred to as PPMS. In SPMS, the patient's disorder begins as RRMS and with time evolves into a steadier decline in neuron function. PRMS is the rarest form, where there is steady neurologic decline with exacerbations when disease activity is intensified and remissions may or may not occur. In all types of MS, myelin deterioration disrupts the conduction of impulses traveling throughout the nervous system, and this causes various sensory and motor symptoms (Saguil et al., 2014).

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Clinical Presentation

MS has a predilection for the optic nerves and cerebellum. It often initially presents as an isolated symptom, such as unilateral optic neuritis, or unilateral motor or sensory symptoms (Tintoré, 2016 ; Tur & Thompson, 2015). Patients often present with symptoms of weakness, numbness, tingling, balance problems, or blurred vision. Excessive fatigue is commonly experienced. Lhermitte sign consists of paresthesia in the limbs or an electric-like jolt down the spine with neck flexion. Uhthoff sign consists of transient worsening of symptoms with increases in core body temperature, such as after a hot bath or heavy exercise (Miller et al., 2012). See Table 1 for classic MS signs and symptoms.

Table 1

Table 1

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Figure

In the most common form, RRMS, brief episodes of sensory or motor deficits last anywhere between several weeks to 3 months, occurring approximately every 1 to 3 years. These are followed by a complete or almost complete return to normal function. The most common and early symptoms involve the eyes. Because the optic nerves are heavily covered with myelin, when those nerves are attacked, patients may experience a temporary distortion or loss of vision in one eye, impairment in color perception, abnormal extraocular movement, or pain (Kale, 2016). Damage to cerebellar nerves commonly presents initially with symptoms of ataxia, tremor, and difficulty with speech (Newsome et al., 2017).

Severe motor nerve damage typically occurs late in the disease. Individuals may have difficulty walking or performing tasks that require coordination. Motor deficits can include hemiparesis, paraparesis, and quadriparesis. Spinal cord involvement may also lead to urinary and fecal incontinence and sexual dysfunction because these spinal tracts are heavily covered with myelin. Depression and cognitive impairment commonly occur in late stages (Newsome et al., 2017). After several decades, approximately 50% of individuals with RRMS go on to develop SPMS, in which they have continually progressive deterioration and consequent disability (Smith et al., 2017).

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Diagnosis

MS cannot be diagnosed after a single symptomatic episode. There is no single clinical feature or diagnostic test that is sufficient to diagnose MS, so the diagnosis is based on clinical presentation. When MS is suspected early due to a single neurologic sign or symptom, the term clinically isolated syndrome (CIS) is often used (Miller et al., 2012). CIS is a temporary diagnosis due to insufficient magnetic resonance imaging (MRI) evidence of MS. It implies a high risk for future confirmed diagnosis of MS (Wingerchuk & Carter, 2014). Diagnosis is usually made after two neurologic deficits or two objective attacks separated by time (Saguil et al., 2014). Diagnosis is also based on the appearance of lesions of demyelination detected on imaging studies, known as sclerotic (demyelinating) plaques (Milo & Miller, 2014).

The McDonald criteria that includes specific neurologic examination findings, MRI evidence of areas of deterioration, and patient symptoms are used to diagnose MS (Preziosa et al., 2017). The clinician should perform blood work to help exclude conditions such as other autoimmune disorders, Lyme disease, thyroid disease, and vitamin B12 deficiency. For supportive evidence of a diagnosis, CSF may be evaluated for oligoclonal bands (OCBs) and immunoglobulin G (IgG). OCBs are found in 90% to 95% of patients with MS, and IgG is found in 70% to 90% of MS patients (Dobson et al., 2013). Evoked potentials, which are recordings of the timing of CNS responses to specific stimuli, can be useful neurophysiological studies that can support a diagnosis of MS (Brownlee et al., 2017).

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Common Assessment Tools Used in MS

There are many assessment tools available for evaluating the patient's abilities and limitations in MS. The following tools can be used to assess extent of disability. A baseline evaluation can be established initially and followed by periodic assessments in the course of the disease.

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Multiple Sclerosis Functional Composite

The Multiple Sclerosis Functional Composite consists of three components that measure leg function/ambulation, arm/hand function, and cognitive function (Fischer et al., 1999):

  • Nine-hole peg test (9HPT)—upper extremity assessment
  • Timed 25-foot walk test (T25W)—lower extremity assessment.
  • Paced auditory serial addition test (PASAT)—cognitive assessment

The directions for these assessment tools can be found at: https://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/10-2-3-31-MSFC_Manual_and_Forms.pdf.

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Multiple Sclerosis Symptom Checklist

The Multiple Sclerosis Symptom Checklist is a 26-item self-report measure designed to assess for the presence of 26 disease symptoms common in MS patients (Gulick, 1989). The tool consists of five subscales assessing motor function, sensory disturbance, mental and emotional concerns, bowel and bladder elimination, and brain stem symptoms. Scores are determined using a six-point scale with responses ranging from never to always. A baseline functional assessment can be used to compare with future neurologic examinations. An initial assessment of function should be completed and monitoring should take place on an ongoing basis for changes in condition.

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Modified Fatigue Impact Scale

The Modified Fatigue Impact Scale is based on items derived from interviews with MS patients concerning how fatigue impacts their lives. This instrument provides an assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning. The full-length scale consists of 21 items, whereas the abbreviated version has 5 items. Instructions can be found at: https://www.sralab.org/rehabilitation-measures/modified-fatigue-impact-scale.

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Modified Ashworth Scale for Spasticity

The Modified Ashworth Scale (Ability Lab, 2013) is used to grade spasticity. This scale measures the presence of velocity-dependent resistance on a 0 to 4 scale, with zero representing normal muscle tone and four representing a limb that is fixed in flexion or extension. Screening for spasticity involves assessing range of motion of upper and lower extremities across joints. Instructions can be found at: http://www.rehabmeasures.org/PDF%20Library/Modified%20Ashworth%20Scale%20Instructions.pdf

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Treating MS With Disease-Modifying Therapies

The Consortium of Multiple Sclerosis Centers (2015) recently published A Practical Guide to Rehabilitation in Multiple Sclerosis (http://www.cmeaims.org/rehab-primer-cme.php) that provides detailed information and strategies about assessments and interventions by rehabilitation specialists. Topics covered include mobility assessments and therapeutic strategies, adaptive/assistive devices, cognitive impairment, speech/swallowing/oral health, health and wellness in MS, and complementary/alternative medicine.

Because MS is suspected to be an autoimmune disease directed against the CNS, many drugs used are immunomodulators. The immunomodulators used in MS, called disease-modifying therapies (DMTs), aim to reduce attacks caused by new MS lesions and delay disability progression, particularly in RRMS. Studies show that DMTs have been effective in RRMS; however, they have not been as effective in progressive types of MS (Thompson, 2015). In progressive MS, symptom management is the focus of clinicians.

There are a wide variety of agents currently approved for use (Table 2). Medications work better when treatment is started early during the course of MS; however, it is often difficult to make a diagnosis during the first episodes of MS. A variety of studies have shown that inflammatory activity is most robust early in the disease and that early treatment with DMTs is most effective (Newsome et al., 2016 ; Noyes & Weinstock-Guttman, 2013).

Table 2

Table 2

Tintoré (2016) identified early factors that are associated with long-term disability. These include the presence of OCBs in the CSF, new lesions on MRI, and incomplete recovery from relapses are independent predictors of disability. The baseline lesion load, development of new lesions during the first year, and not starting a disease-modifying treatment before a second attack are independent predictors of further relapses. Evaluating people with MS for these parameters early on can help determine how aggressive to be with DMTs.

There are a wide variety of agents available for MS, but patients respond to drugs differently and all are not effective in every patient. There are first-line drugs that are recommended for initial use and second-line drugs are used if first-line drugs are ineffective. Interferon preparations are among the older agents used. Many of the newer drugs are monoclonal antibody preparations that are administered parenterally (Ingwersen et al., 2016 ; Newsome et al., 2016).

Patients often experience side effects that cause nonadherence to medication. Infusion reactions can present as flu-like symptoms. Injection site reactions can also occur. A rare, fatal disorder, progressive multifocal leukoencephalopathy, is a serious adverse reaction that has been seen with monoclonal antibody treatment. It is caused by activation of the polyomavirus JC that destroys the white matter of the brain. Monoclonal antibody type medications can also trigger the patient's own immune system to form antibodies that attack healthy tissue (Ingwersen et al., 2016). Therefore, the MS patient needs to be closely monitored for side effects and adverse reactions.

Although none of the medications can cure the disorder, they can reduce the number of days a person suffers symptoms. Most importantly, they appear to reduce the accumulation of lesions within the CNS as seen on MRI. In times of acute exacerbation, short courses of corticosteroids are commonly used to reduce inflammation and expedite recovery (Saguil et al., 2014).

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Treating Exacerbations

Exacerbations affect 85% of patients with MS; infections and stress may play a role in triggering a relapse (National Multiple Sclerosis Society, 2017). For those with significant, acute symptoms, corticosteroids are the treatment of choice (Repovic & Lublin, 2011). Although parenteral steroids build up to peak concentrations faster than oral preparations, a Cochrane review indicates no difference in effectiveness (as measured by clinical or radiologic markers) or safety between oral and parenteral preparations (Burton et al., 2012). In people who do not respond to corticosteroids in relapsing forms of MS, plasma exchange may be effective as a secondary therapy. Plasma exchange may also be useful for severe, rapidly progressive MS; however, the treatment has not been effective for secondary-progressive MS or primary-progressive MS (Ehler et al., 2015). Plasma exchanges are relatively well tolerated and are usually performed every other day for 14 days.

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Symptom Management

MS causes symptoms that are specifically related to demyelination and secondary symptoms that are indirectly related to the disease process (Table 3). Symptom management commonly requires a multidisciplinary approach, including pharmacologic, rehabilitative, and psychosocial interventions (Newsome et al., 2016). Rehabilitative therapies utilize the principle that the brain has neuroplasticity and new neural connections can be created (Flachenecker, 2015). All caregivers should be included in the treatment plan. The aim is to obtain optimal function and quality of life.

Table 3

Table 3

Table 3

Table 3

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Fatigue

Overwhelming fatigue is one of the most common symptoms affecting persons with MS. The clinician should rule out other conditions that can cause fatigue such as medication effects, metabolic imbalances, infection, anemia, hypothyroidism, vitamin B12 deficiency, or depression (Saguil et al., 2014). The extra energy required to overcome spasticity, deconditioning of muscles, and weakness can cause fatigue. Nocturia, pain, and sleep apnea may cause inadequate sleep and daytime fatigue. Occupational therapists can teach the patient how to conserve energy when performing tasks. Altering medication schedules to allow for an uninterrupted sleep regimen is important. Exercise therapy can also counteract fatigue. According to a meta-analysis by Heine et al. (2015), of 2,250 patients, prescribed exercise interventions including endurance training and muscle strengthening effectively counteracted fatigue. Exercise was not found to do harm nor trigger relapse in the subjects with MS. To counteract fatigue, stimulant medications such as amantadine, modafinil, and methylphenidate can be used (Newsome et al., 2016).

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Sensory Loss

Sensory disturbances that consist of feelings of numbness, tingling, burning, and heaviness in the extremities are common in patients with MS. Sensory losses can hinder independent activities and affect the safety of the individual. Occupational therapists can demonstrate ways for the patient to carry on activities of daily living with the sensory losses with assistive devices and task modification strategies. According to Newsome et al. (2017), burning and numbness sensations may be treated with gabapentin, pregabalin, carbamazepine, topiramate, or oxcarbazepine. Serotonin-norepinephrine receptor inhibitors and tricyclic antidepressants have also been effective.

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Spasticity

Spasticity and stiffness are common problems for patients, particularly during MS exacerbations. These commonly affect the hamstrings, quadriceps, and gastrocnemius muscles (Frohman et al., 2011). Stretching exercises, relaxation techniques, orthotic devices, and pain management can be helpful. Also the clinician should understand that individuals with MS suffer from heat sensitivity. This heat sensitivity is known as Uhthoff sign, which is demonstrated as a worsening of symptoms when the patient is overheated. Cooling methods such as cool showers, ice packs, cold towels, cold beverages, fans, and air conditioning of the environment can counteract this phenomenon (Frohman et al., 2013).

Medications such as baclofen, tizanidine, and gabapentin are often prescribed, but may not be effective (Newsome et al., 2017). Adding cannabidiol oromucosal spray to the regimen has been effective for moderate-to-severely resistant MS spasticity (Vermersch & Trojano, 2016). Intramuscular botulinum toxin has also been effective in reducing spasticity (Safarpour et al., 2017).

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Gait and Balance Difficulty

Aerobic exercises, stretching, and core strengthening are important for the individual with MS. Physical therapists can assess the patient's limitations and ability to develop an exercise regimen that enhances balance and coordination. Additionally, there are numerous ambulation assistive devices that can be used. Physical therapy should include ambulation on uneven surfaces and inclines, ambulation up and down curbs, the ability to cross the street with head scanning and gait velocity, ambulation in the community with an assistive device, and community mobility with a wheelchair or scooter (Ontaneda et al., 2015).

Studies show that dalfampridine, an orally administered potassium channel blocker, can help patients with walking impairment. Filli et al. (2017) found that patients with MS demonstrated improvements in walking speed, endurance, and self-perceived ambulatory function after long-term use (2 years) of the drug (Goodman et al., 2009). Hippotherapy (horseback riding) was also found to be a beneficial physical therapy treatment strategy in MS patients to improve balance, functional gait, and enhance sensory processing cues for postural control (Lindroth et al., 2015).

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Bladder Dysfunction

Patients with MS may have symptoms of neurogenic bladder that include urgency, frequency, incomplete emptying, hesitancy, nocturia, incontinence, urinary tract infection, and dysuria. The patient may have inability to retain urine or to void. The patient should avoid bladder irritants such as caffeine, aspartame, and smoking. Fluids should be discontinued 2 to 3 hours before bedtime. Kegel exercises to increase pelvic floor muscle strength can be taught. Protective pads, panty liners, and insertion of a vaginal pessary device can be used. Botox injections into the bladder detrusor muscle and a surgical sling procedure that can support the urethra and enhance the integrity of the bladder are also possible (Frohman et al., 2011 ; Safarpour et al., 2017). There are numerous medications available that can enhance bladder retention (Table 3). Anticholinergics/antimuscarinic medications such as oxybutynin, tolterodine, solifenacin succinate, and darifenacin can be used to enhance retention of urine. Alpha-adrenergic blockers tamsulosin and doxazosin can be used to enhance urinary flow. Timed voiding to empty bladder every 2 hours during the day can be helpful. Intermittent catheterization, indwelling catheterization, and external bladder stimulators can also be used (Newsome et al., 2017).

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Bowel Dysfunction

The clinician should assess the patient's bowel function, stool frequency and consistency, straining or pain with defecation, fiber in the diet, fluid intake, and activities. Although MS causes neurologic impairment of the bowel, medication side effects can also cause bowel dysfunction. Common symptoms of bowel dysfunction in MS include constipation, fecal incontinence, and irritable bowel syndrome (Dibley et al., 2017 ; Frohman et al., 2011). Constipation, the most common complaint, can be treated with fiber supplements, stool softeners, or increased fluid intake. Osmotic laxatives such as polyethylene glycol (Miralax) are preferred over stimulant laxatives. Suppositories and digital manual stimulation can be used. Regular exercise, if possible, is recommended. Medications such as lubiprostone can be used off label (National Multiple Sclerosis Society, 2011).

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Pain

Pain occurs in more than half of people with MS (O'Connor et al., 2008). Primary pain is directly related to MS pathology (i.e., neuropathic pain) and includes dysesthesia and paresthesia, trigeminal neuralgia, and paroxysmal cord phenomena. This pain can be treated with certain anticonvulsant or antidepressant medications; however, narcotics have a limited effect. According to Newsome et al. (2017), commonly used medications include gabapentin, pregabalin, tricyclic antidepressants such as amitriptyline, and serotonin-norepinephrine receptor inhibitors such as venlafaxine and duloxetine. Other medications that can decrease pain in some patients include carbamazepine, clonazepam, baclofen, misoprostol, tramadol, topiramate, tizanidine, and phenytoin. Physical therapy, exercise, transcutaneous electrical neurostimulation (TENS), hydrotherapy, and cooling are recommended. Additionally, studies show cannabinoids are effective as adjunctive treatment to control pain in MS (Andreae et al., 2015). Patients also use alternative medicine therapies such as yoga, meditation, massage, acupuncture, guided imagery, breathing, and relaxation techniques (Claflin et al., 2018).

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Visual Impairment

Optic neuritis is one of the most common manifestations of MS (Kale, 2016). This may cause visual acuity loss, a “blind spot” in the center of vision, decreased color distinction, reduced light perception, and pain. Diplopia, nystagmus, and eye movement abnormalities due to cranial nerve palsies are also common in MS. The primary strategy for treatment of acute-onset oculomotor syndromes is high-dose corticosteroids. For diplopia, an ophthalmologist should be consulted and lenses containing prisms can be prescribed (Costello, 2016).

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Dysphagia

In MS, dysphagia occurs because of weakened esophageal muscles that can lead to choking and aspiration pneumonia. Aspiration pneumonia is a leading cause of death in MS (Tassorelli et al., 2008). Clinicians should always assess the gag reflex before feeding a patient with MS. Individuals with liquid dysphagia may complain of coughing or choking while eating, whereas those with solid food dysphagia may complain of food “sticking” in the throat or chest. Other features include dysphonia, “wet” voice/phonation, coughing, or gastroesophageal reflux (GERD) (Poorjavad et al., 2010). Patients with hypersalivation may benefit from anticholinergic medications and/or botulinum toxin injections. Proton pump inhibitors are used to treat symptoms of GERD. A speech pathologist should be consulted for a swallowing assessment and rehabilitative recommendations. In some cases, a nasogastric or percutaneous endoscopic gastrostomy tube may be temporarily or permanently required to maintain optimal nutritional and fluid intake, decrease the risk of choking, and increase survival (Bell & Brammer, 2017).

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Dysarthria and Dysphonia

Dysarthria and dysphonia are the most commonly observed speech-related disorders in the MS population (Renauld et al., 2016). Dysarthria is a collection of motor speech disorders caused by weakness, slowness, and/or lack of coordination of the muscles utilized for speech. Dysphonia is a disorder of voice, often seen with dysarthria, and affects respiration, phonation, articulation, pitch, speech rate, stress, prosody, intelligibility, loudness, and vocal quality. Consultation with a speech pathologist for evaluation and rehabilitative strategies is necessary. Speech techniques can be taught that augment voice and voice amplifiers can be used. Although not usually needed, augmentative strategies with communication boards and computerized devices may be used.

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Depression

Depression is the most common mood disorder for people with MS; it is underdiagnosed and undertreated. It affects over half of all patients with MS and is a contributor to diminished quality of life (Mohr et al., 2007). Depression affects motivation, limits physical abilities, and decreases overall health. Treatment with selective serotonin receptor inhibitors and venlafaxine ER have been shown to work for treatment of depression in older adults with MS (National Multiple Sclerosis Society, 2011). Improvement in depressive symptoms may take up to 12 weeks and patients should be advised to remain on the medication for at least 3 months to experience a benefit. Follow-up telephone calls can encourage the patient to give the medication time to take effect and increase adherence.

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Cognitive Impairment

Problems with memory and cognition affect 40% to 70% of persons with MS and are more common as patients age (National Multiple Sclerosis Society, 2011). Word retrieval difficulties, delayed verbal recall, and impaired executive functioning are most common. Executive functioning include such activities as balancing a check book, paying bills, and understanding complex directions. Cognitive impairment can cause loss of ability to engage in social activities and maintain relationships. Patients should be encouraged to remain as physically and mentally active as possible to maintain cognitive health. According to Newsome et al. (2017), attention-enhancing medications (modafinil, armodafinil, and amphetamine stimulants) may be effective in improving cognition. All other patient medications should be evaluated for possible cognitive side effects and changed if they are a source. Comorbid illnesses other than MS should be assessed for and treated. Pain, depression, and fatigue should be particularly treated because these disorders can cause or mimic cognitive difficulties.

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Conclusion

MS is a chronic neurologic disease and the most common cause of nontraumatic disability in young adults in the United States. It strikes adults in the prime of life and gradually affects neurologic function. It can diminish physical and mental function, affect relationships, employment, financial capacity, and independence. MS patients live with a variety of symptoms such as fatigue, spasticity, pain, visual impairment, dysphagia, cognitive dysfunction, depression, bowel and bladder dysfunction. Neurologic symptoms fluctuate in a pattern of remissions and exacerbations for the majority of those with MS. A multidisciplinary treatment approach is essential. There are a wide number of medications that can be used for disease exacerbation, disease modification, and symptom management. Treating the disease at an early stage within the first 5 years of clinical symptom onset is optimal. Monitoring lesion progression on MRI is essential throughout the disease. Home healthcare providers can use a variety of assessment tools to evaluate disease progression, teach the patient and family how to live with the disorder, and monitor the patient for medication effectiveness and side effects.

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