Management of Medical Complications in a Long-Term Care Patient With Multiple Sclerosis

Multiple sclerosis (MS) is a progressive, autoimmune, demyelinating condition characterized by axonal damage and subsequent delay in nerve conduction. The exact etiology that results in the clinical picture of MS is unknown, although a complex interplay of the immune system, genetics, and the environment has been implicated.¹ MS is more common in women than in men, and the most common age range of presentation is between 25 and 35 years of age.¹ 

MS is comprised of various forms with variable presentations (Table 1). Progressive-relapsing MS is a rapidly progressing, disabling course within 5 years of diagnosis. Alternative courses of MS can be more benign, with patients maintaining neurologic function 15 years after diagnosis. In the relapsing and remitting form of MS (RRMS), patients experience recurrent relapses but tend to be stable in between attacks. These relapses can vary in occurrence and in severity; some patients develop a permanent residual defect.² Benign MS is a subtype of RRMS and is characterized by little disability and high functional status.² In the case of secondary progressive MS, a progressive worsening over time occurs after a minimum of one relapse. It can occur after a clinical isolated incident; however, it can also occur in RRMS.² Finally, primary progressive MS is a less common but slowly progressive form of MS; the highlighting feature of this form is a progressive myelopathy or cerebellar dysfunction.² 

Thirty percent of patients have a progressive form of MS, and this is also the most common form of MS in nursing home (NH) residents.³ Approximately 20% to 25% of people with MS will require long-term care (LTC), whether this is in the form of home care or adult daycare; about 5% will require NH care.⁴ NH care in patients with MS presents unique challenges. MS patients in NHs are generally younger, more likely to be female and physically disabled as well as more socially isolated, with social isolation stemming from being surrounded by the less cognitively alert elderly population.⁴ But MS patients are less likely to have comorbid illnesses such as chronic heart failure, stroke, chronic obstructive pulmonary disease, etc.⁴ The average age of a patient with MS admitted to a NH is 57.8 years, whereas non-MS residents are, on average, 76 years old at the time of admission.⁴ With MS patients being in the minority of NH residents, many NHs may not be equipped with social services and occupational programs tailored to the needs of MS patients.

LTC primary care providers (PCPs) have a major role to play in the management of patients with MS in LTC. They have a primary role in identification and treatment of depression and other comorbid conditions common among patients with MS. In addition, PCPs have a role in recognizing periods of relapse and treatment failure wherein adjustments in primary MS medications are required. These changes can be accomplished in consultation with a neurologist or MS specialist; although, given access issues, these consults are increasingly occurring via telemedicine-facilitated interactions. We report a case of an LTC resident with advanced MS and multiple comorbidities as well as common MS-related conditions. This case demonstrates how PCPs can play a critical role in the identification and management of MS and its complications, resulting in improved outcomes for patients with MS throughout the course of the disease.

Case Report

Ms LH is a 65-year-old, African-American woman with advanced, rapidly progressive malignant MS and an extensive medical history that includes hypertension, anemia, neurogenic bladder, dysphagia, depression, status postradical cystectomy with ileal conduit and urostomy placement, and recurrent urinary tract infection (UTI) with bedbound status. The primary reason for her acute care admission was for sepsis and altered mental status. 

The patient has a history of multiple hospitalizations due to recurring infection and sepsis. She has multiple contractures secondary to MS and is currently being treated with tizanidine and baclofen. She also has chronic, nonhealing ulcers and multiple wounds.

She is under treatment for depression and chronic pain as well. The patient suffered from chronic pain and depression prior to this hospitalization. For her depression, the patient takes venlafaxine; for chronic pain, she takes hydromorphone and acetaminophen.

During her hospitalization, her wounds were found to be infected with methicillin-resistant Staphylococcus aureus and Proteus mirabilis. Additionally, she was found to have a UTI with extended spectrum beta-lactamases and Proteus mirabilis present; she also tested positive for Influenza A and Clostridium difficile colitis. Her blood cultures and chest x-ray were negative. 

She was treated with the appropriate antibiotics for her concurrent infections. Wound care was consulted for her multiple wounds; surgery was also consulted, but the patient did not require debridement of her wounds at that time. Her altered mental status was treated in the hospital. Per available records, it does not appear that her MS treatment was altered during the hospital stay.

Due to the patient’s history and worsening of dysphagia, she suffers from suboptimal nutrition; in the hospital, the patient requested a percutaneous endoscopic gastrostomy (PEG) tube, because she felt that she was unable to eat enough to fulfill her requirement. Subsequently, a PEG tube was placed during her admission without complications.

Upon resolution of sepsis, the patient was transferred back to her LTC facility where her multiple comorbidities are managed. She is currently a hospice patient secondary to the progressive and now terminal status of her chronic comorbid conditions. Although her wounds are no longer acutely infected, they are difficult to treat; she is managed with daily dressing changes and is regularly seen by wound care. The patient is completely dependent on caregivers for all activities of daily living. The combination of the progressive nature of her illness and the above-described comorbidities place her life expectancy at less than 6 months. 

Depression in Patients With MS

Depression is qute prevalent in the NH population, with an estimated prevalence of 15.5%.³ Patients with MS have an even higher risk.³ Not surprisingly, the patient discussed in this case report was under treatment for depression; she had multiple risk factors, as discussed above: female sex, unmarried, NH resident, and chronic illness (in this case, MS). It is incumbent upon providers taking care of patients in the NH setting to recognize and appropriately treat depression.

Depression may be underdiagnosed in patients with MS and often leads to a decline in the quality of life.⁵ The lifetime risk of depression in patients with MS is estimated to range between 22.8% and 54%; comparatively, lifetime prevalence of depression is 13% in those with chronic illnesses other than MS and 8% in the general population.⁶ MS disease progression inevitably leads to increased disability, the resultant loss of independence, decreased socialization, and increased reliance on caregivers. Therefore, social support, disability, and employment status correlate with depression in patients with MS.⁴ Unemployment is associated with a negative change in standard of living; additionally, unemployment was found to have a strong positive correlation with depression.^5,7

Moreover, patients with MS tend to have more severe depressive symptoms. For example, patients who were more physically disabled tended to have higher levels of depression.³ Females, unmarried/uncoupled persons, and those with health insurance were more likely to be on antidepressants.⁷ Additionally, patients receiving interferon therapy were found to have higher rates of depression.⁷ It is not established whether the depression stemmed as a side effect of the medication or as a result of MS.

Depression in patients with MS is thought to have a multifactorial etiology. In addition to the psychosocial effects of disability resulting from MS, the effect of demyelinating lesions on the regulation and maintenance of mood and immune dysfunction are contributing factors as well. magnetic resonance imaging has been utilized in order to study the location of MS lesions and resultant depressive symptoms. Lesions in the arcuate fasiculus and superior frontal and superior parietal areas are positively associated with depression.⁵ Depressed patients were also found to have increased numbers of activated T cells and acute phase proteins as well as higher production of proinflammatory cytokines.⁵

Health care providers treating MS should screen and treat patients with MS for depression. Similar to the general population, if left untreated, depression in patients with MS is likely to worsen. Risk factors of suicide include diagnosis before age 30, male gender, and hopelessness.⁸ Cognitive behavioral therapy has been consistently demonstrated as an effective method of treating depression. In terms of medications, tricyclic antidepressants with their anticholinergic properties are beneficial in patients with neurogenic bladder symptoms. Selective serotonin reuptake inhibitors are also a safe and effective treatment choice.

Contractures, Spasticity, and Fatigue in MS

Contractures in the ankle joints are quite common in the MS population, which severely limit mobility. Often occurring in conjunction with contractures is weakness, though no causal relationship has been established. An Australian study looked at the prevalence of contractures in patients MS. It found a 60% prevalence rate of contractures affecting at least one joint and a positive correlation between disability and contractures.⁹ MS invariably progresses, and patients with the disease require LTC in some form or another.⁴ The patient in the case report had both upper and lower extremity contractures as well as spasticity for which she was being treated with baclofen and tizanidine. Assesment of motor activity and performance status for functional decline is imperative in these patience in order to optimize medical management. In comparison to NH residents without MS, patients with a diagnosis of MS tend to lose voluntary movement at higher rates.⁴

Spasticity occurs most commonly in the lower extremities, impairing walking, maintenance of posture, and activities of daily living. Central nervous system lesions result in impairment of signal transmission in spinal pathways, resulting in the loss of inhibitory control over spinal pathways; this results in spasticity seen in MS and is closely related to decrease in quality of life. Spasticity results in changes in gait in terms of speed of walking as well as stride and range of motion. These patients are also at a higher fall risk, with about half of the falls requiring medical evaluation.¹⁰ Clinicians can utilize the Modified Ashworth Scale (MAS), which measures resistance during the passive range of motion of a joint, to assess spasticity; a score between 0 (normal) to 4 is given. Motor diseases are associated with higher MAS scores as compared to healthy individuals.¹⁰  There are various classes of medications to help treat spasticity: gamma-aminobutyric acid agonists, a2 agonists, and botulinum toxin, although the efficacy of antispastic medications in the setting of MS is not well established, often resulting in suboptimal management of these symtoms.¹⁰ Common side effects of these medications include weakness, dizziness, and nausea. Exercise has also shown to have a beneficial effect on spasticity. 

Fatigue and weakness are common in patients with chronic illness. This patient also suffered from fatigue; however, it is difficult to separate fatigue associated with a chronic progressive illness from fatigue associated with depression. In the case of this patient, recognition of decline from baseline mental status resulted in her hospitalization and subsequent treatment for sepsis. Impaired conduction of motor impulses secondary to demyelination is thought to play a role in fatigue.¹¹ It is considered by patients to be one of the most taxing aspects of their condition. An estimated one-third of patients with MS experience fatigue impacting their daily lives.¹¹ Fatigue can be present with or without concurrent depression or weakness and can sometimes signal an oncoming relapse; it is more prevalent later in the day. Fatigue in patients with MS is significant enough that patients will decrease their activity. Patients also complain of mental fatigue, which is characterized by inability to concentrate or detriment in decision-making capability.¹² Exercise programs helps with preventing deconditioning, but providers should be wary of overexertion. Comorbidities that could be contributing to or worsening fatigue should be addressed. For example, antidepressants may help in those with coexisting depression; sleep aids can help patients with insomnia. 

Bladder Dysfunction in Patients With MS

Bladder dysfunction tends to be one of the most bothersome symptoms of MS.¹³ Although UTIs are common in the NH population, MS patients have higher rates of infection, 30% vs 13% in MS and non-MS patients, respectively.⁴ MS patients are also more likely to use incontinence products compared with non-MS patients. This particular patient most likely became incontinent as a part of the natural progression of her disease, eventually requiring radical cystectomy and ileal conduit.

The prevalence of bladder dysfunction in patients with MS is estimated to be around 92%.¹⁴ Bowel, bladder, and sexual dysfunction are commonly associated with MS and can occur at anytime during the disease course, resulting in considerable disability as well as decreased quality of  life; a study found that bladder dysfunction is associated with impaired physical functioning in both early and late stages of MS.¹⁵ The most common type of bladder dysfunction in patients with MS is neurogenic overactive bladder; common symptoms include frequency, urgency, incontinence and nocturia.¹³ These symptoms are often overlooked in patients with MS, as patients are not questioned about them and consequently they are not referred to urologists. On the other hand, some patient’s symptoms are inadequately treated, as they are unable to tolerate medication. There are newer treatments that seem promising, such as sacral neuromodulation and posterior tibial nerve stimulation, but their role in treatment specifically for patients with MS requires further research. Onabotulinum toxin A became US Food and Drug Administration approved in 2011 for treatment of neurogenic detrusor overactivity and appears to be beneficial in patients with MS. Two large trials in patients with MS have shown considerable reduction in incontinence symptoms.¹³

Conclusion

MS is an autoimmune, demyelinating condition of uncertain etiology with many associated medical complications, including but not limited to depression, contractures, spasicty, and fatigue. Depression is exceedingly common as are fatigue, bladder dysfunction, and contractures; these conditions should be appropriately treated to prevent worsening of disability. Providers in LTC settings should be cognizant of the numerous concurrent health problems associated with this condition in addition to the added potential of complications that NH residents may have. 

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