Collaborative Consultation Interdisciplinary Treatment of Multiple Sclerosis

Transcription

1 Collaborative Consultation Interdisciplinary Treatment of Multiple Sclerosis Multiple sclerosis (MS) is an immune mediated process directed against the central nervous system (CNS) brain, spinal cord and optic nerves Has both inflammatory and neurodegenerative components relapses and progression 1

2 Varies widely in symptoms and severity Motor weakness, spasticity Sensory numbness, paresthesias, pain Bowel/Bladder Vision loss of vision, double vision Brainstem/Cerebellar vertigo, ataxia, dysarthria, dysphagia Fatigue Mood disorders Cognitive dysfunction Diagnosis Modifying the disease course Treating exacerbations Managing symptoms Promoting function through rehabilitation Providing emotional and cognitive support Promoting general health and wellness strategies 2

3 Collaboration from multiple members of health care team PATIENT Neurology Neuropsychology Psychology Primary Care Nursing PT/OT/Speech/PMR Other medical specialties (urology, GI, ophthalmology, psychiatry) Important questions addressed in a neuropsychological evaluation.: 1. The level of brain functioning; A. The areas of dysfunction in the brain B. The areas of normal functioning in the brain 2. How the individual's brain functioning will affect his or her relationships and ADLs at home, in the workplace, and socially. 3

4 Imagining looks at the structure of the brain (bleed, lesion, areas of injury, etc.) Neuropsychological testing looks at the function of the brain (Intellect, memory, executive function, visuospatial skills, etc.) Cognitive impairment occurs in 40-65% of multiple sclerosis (MS) patients, typically involving complex attention, information processing speed, (episodic) memory and executive functions. Clinically significant depression can affect up to 50% of patients with multiple sclerosis over the course of their lifetime. It is associated with an increased morbidity and mortality and is regarded by patients as one of the main determinants of their quality of life. 4

5 Neuropsychological testing is the evaluation of cognitive abilities and psychiatric/personality functioning using a battery of standardized assessment measures A test battery involves tests of a variety of cognitive ability areas, with more than one test per ability area Cognitive ability areas include: general cognitive functioning (IQ), processing speed, achievement, executive functioning, attention, memory, language, visual perception, somatosensory function, motor function, and mood/personality 33 yo female Dx with MS in 2013 in retrospect had episode bilateral hand numbness in 2006 Left optic neuritis Dec 2012 Transverse myelitis with numbness, weakness, balance dysfunction in bilateral lower extremities Jan 2013 Tysabri 5

6 Had clinical relapses and/or MRI disease activity on Tysabri, Tecfidera, Gilenya Enrolled in stem cell clinical trial Placed in control arm on Gilenya Continued relapses/mri disease activity with good return to baseline physically following steroid treatments C/O 6 month progression of deficits in word finding, memory, and attention. (review of record shows actually started in 2013) Denied significant mood challenges. 6

7 Married, no children Works full-time No tobacco, occasional etoh, no rec. drugs Well educated: Bachelor s Degree is in English, she also is a graduate student completing her Master s Degree in Public Administration (she currently has a 4.0) 7

8 Strong Intellectually: Memory: WNL Her Auditory Memory Index Score of 118 places her at the 88 th percentile Visual Memory Index Score of 110 places her at the 75 th percentile Immediate Memory Index of 115 Delayed Memory index scores of 118 8

9 Executive skills: Visuospatial Skills: Processing Speed: Mood: WNL WNL Mild Reduction Mild Anxiety and Depression *Testing established a baseline, started on an SSRI and began individual therapy after more discussion about her affective stability Correlations between mood, cognition and physical function How do assessments generalize to real world function? 9

10 49 yo female Dx with RRMS 2007 Multiple symptoms dating back to 1990 s variable numbness and tingling, arthralgias, chronic constipation possible Sjogren s vs. other connective tissue 1997 MRI brain with peri-atrial white matter changes with enhancement negative LP 2005 sensory loss from waist down -? Sjogrens Imuran hemolytic anemia Multiple rheum evals no definite Sjogrens or other specific connective tissue disease Further relapses Avonex, Copaxone, Gilenya 10

11 Chronic pain in back, extremities, and joints, diarrhea, lymphadenopathy, elevated alk phos, weight fluctuations (loss), fatigue, generalized weakness, memory loss, mood changes, tachycardia, chest pain Multiple specialists ortho, GI, heme/onc, cardiology, pain management Medications Gilenya (fingolimod) Neurontin Antivert Naproxyn Atenolol Diltiazem Fentanyl Xanax Unable to tolerate multiple SSRIs, SNRIs, Wellbutrin 11

12 Referred to NP in 2009 secondary to c/o cognitive deficits HS graduate, no hx of LD, ADD, etc. Works part-time for family business in their accounting department 12

13 Recently divorced, 2 adult children Lives alone Independent with all ADL/IADL Repeat NP batteries have been utilized She participates in monthly NP sessions Intellect: Drop in fund of information Drop in perceptual reasoning subtests Visuospatial Mild-Moderate decline in Judgment of Line Mood Minimizes on self-report but recognizes adjustment challenges, personality changes and impulse control issues 13

14 Testing remain variable?influence of exacerbation?influence of mood/stress R/O malingering Case collaboration is frequent to tease etiology of increased symptoms: Neuro vs psych Mood stability influences functional stability. Even when doing well, benefits from maintenance work! Neuropsych+Psych+Psychiatry 14

15 49-year-old diagnosed in 2005 with Relapsing Remitting MS Currently classified as secondary progressive Uses manual wheelchair and scooter Bilateral lower extremity weakness Bladder incontinence Prior disease modifying therapies (DMT) At baseline (2007) relatively asymptomatic Off all DMT for several years I just don t want any more medications Presented 1 month ago wishing to start DMT to improve symptoms Refused NP referral, until recently 15

16 She currently lives with her boyfriend and 23- year-old son She has an attendant care via Voices for Independence (45.5 hours/week) Unable to ambulate and uses a sliding board with supervision for transfers. *most physically and cognitively challenged of the 3 both progressive 16

17 Frequent falls, though denies ever hitting her head History of optic neuritis and has ongoing difficulty with blurred vision C/O word finding Avoiding reading because of poor attention word substitutions, that is she will substitute one word for another word that is written on the paper. Limited leisure pursuits She can watch television, however, if there is a commercial she will forget what she is watching once the commercial is done Has a BA in Social Work. No LD/ADD but school was a challenge Hx of anxiety and depression Treated with Effexor and Wellbutrin 17

18 Intellect: Memory: Auditory Memory Index Score of 67 is at the 1 st percentile Visual Memory Scores of 73 or 4 th percentile. Immediate Memory Score of 58 Delayed Memory Index score of 74 18

19 Personality Testing: Significant degree of anxiety and depression present She is having difficulty mustering up any positive emotions She has very little in the way of positive coping strategies Significant degree of social discomfort. Her depression appears to be more vegetative in nature Unfortunately her self-esteem is certainly suffering from her decline Severe limitations with visual scanning, sequencing and switching Her motor speed is also very low Measures of attention and concentration utilizing the CPT-3 revealed significant disruption in attention and concentration Wisconsin Card Sorting Test which evaluates her mental flexibility and parallel processing, she demonstrates severe deficits as well 19

20 Highlights disease progression not only physical, but also cognitive Neurodegenerative Psychological support critical Address issues that influence her treatment decisions How do we, as providers, handle pt s who decline treatment options? Noncompliant vs. Nonadherence Why is an interdisciplinary approach critical for MS? Clinically wise MS Comprehensive Care Center mandate Includes all disciplines (SLP, OT, PT, NSG, CM/SW) QUESTIONS??? 20