Neuroscience nursing

MND Resource

Introduction

Motor Neurone Disease (MND) is a rare but devastating neurological condition which leads to progressive paralysis and ultimately death. An average GP can expect to see 1 or 2 cases in their career. Although it is rare many patients and doctors are both aware and fearful of it. You can access an infographic from the MND Association, which contains key messages here.

After using this resource you should have:

  • an improved understanding of what MND is, and the red flags for its diagnosis
  • increased awareness of symptom management and available treatments
  • appreciate the importance of coordination and a multi-disciplinary approach to achieving good care for people living with MND
  • recognise the importance of keeping and sharing accurate records with your colleagues in the multidisciplinary team
  • explored the importance of advance planning and timely support for changing symptoms
  • considered the impact of a diagnosis of MND on a person and their family and carers and know where to go for further information

Motor neurone disease (MND) or Amyotrophic Lateral Sclerosis (ALS) describes a group of related diseases affecting the motor neurones in the brain and spinal cord. Messages stop reaching the muscles, leading to weakness and wasting. It affects how a person walks, talks, eats and breathes. Not all symptoms necessarily happen to everyone and it is unlikely they will all develop at the same time, or in any specific order.

We know four main types of MND, but it’s not always possible to determine which an individual has.

Amyotrophic lateral sclerosis (ALS)

The most common form, it involves both upper and lower motor neurones. It is characterized by limb weakness and wasting. An individual may notice they are dropping things or tripping when they walk. Life expectancy: 2-5 years from the onset of symptoms.

Progressive bulbar palsy (PBP)

Affects about a quarter of people with MND. It involves upper and lower motor neurones. Symptoms may include slurred speech or difficulty swallowing. Life expectancy: 6 months – 3 years from the onset of symptoms.

Progressive muscular atrophy (PMA)

Affects only a small proportion of people and causes damage to the lower motor neurones. Early symptoms may be noticed as weakness or clumsiness of the hands or feet. On average, people usually live for more than five years.

Primary lateral sclerosis (PLS)

A rare form: people experience stiffness and clumsiness in the hands or legs, or speech problems. Average life expectancy is 10 years+ although it may be life-limiting.

There is currently no cure for MND, but symptoms can be managed to achieve the best possible quality of life for people living with the disease. Click here for some key statistics about MND.

Motor neurone disease can be difficult to diagnose as:

  • it is classified as a rare disease and not seen regularly by practitioners
  • early symptoms may be mild and hard to detect
  • an individual may wait sometime before seeing their GP
  • there may be an element of waiting for symptom progression to indicate MND
  • it is a clinical diagnosis requiring the elimination of other possible conditions.

Red Flags tool

The MND Association worked with the Royal College of General Practitioners (RCGP) to create a Red Flag Tool, to support timely referrals to neurology and speed up the time to accurate diagnosis.

Diagnostic tests may include:

  • Blood tests to screen for inflammatory conditions mimicking the symptoms of MND
  • Electromyography (EMG) – detects muscular electrical activity. When muscles lose their nerve supply, as in MND, their electrical activity is different – this test highlights abnormalities
  • Nerve Conduction Tests: measure the speed at which nerves carry electrical signals
  • Magnetic Resonance Imagery (MRI) scans: used to eliminate other conditions. Damage caused by MND is not shown on this scan.

Genetics

5 – 10% of people with MND will have a strong family history of the disease. These rare inherited forms of MND are caused by a mistake in the genetic code passed down from one generation to the next.

You can access the slides from Jan's webinar here.

Limb symptoms

Movement and mobility are likely to be affected by MND and symptoms will progress over time, sometimes rapidly. This can impact on how people living with MND carry out activities of daily life and get around. Adaptations to the home may be required, and equipment needed to enable the person to maintain their independence for as long as possible. Thoughtful forward planning is essential.

  • Planning ahead is imperative
  • Timely support and coordinated care provides best practice
  • Put the person at the centre of care

Respiratory symptoms

As MND progresses, the muscles between the ribs, and the diaphragm itself weaken, this leads to respiratory problems. Breathing issues in turn cause other symptoms, such as fatigue and breathlessness. Respiratory failure is the most common cause of death in MND. Techniques and equipment are available to help with breathing.

You can access the slides from Charlotte's webinar here.

  • Non refreshing sleep can be an early indicator of respiratory failure
  • O2 should only be given under guidance from the person’s specialist team
  • When discussing NIV as a therapy its eventual withdrawal should form part of the conversation

Bulbar symptoms

‘Bulbar’ refers to an area at the base of the brainstem, the motor neurones from here control muscles in the tongue, pharynx and larynx. When affected by MND issues with swallowing (dysphagia) occur making it harder to eat and drink. Weakness in the tongue, lips, vocal cords and chest, can cause speech to become faint, slurred or unclear (dysarthria). Communication can become increasingly difficult as symptoms progress.

 

You can access the slides from Gabrielle's webinar here.

 

You can access the slides from Jodi's webinar here.

  • Voice banking is time critical – people need to complete the process while their voice is good. See if the patient is interested in discussing and if they are, make a referral to Speech and Language Therapy
  • Tube feeding is time critical – it is best carried out whilst breathing is not too compromised. See if the patient is interested in discussing and if they are, make a referral to the nutrition team.

Cognition

Some people with MND will experience changes to their thinking and behaviour. This may affect the way they take in information, process language, express emotion and react to others. Changes can be mild or barely noticeable, for others they are more pronounced and obvious.

  • Carers or family may be the first to notice changes
  • Understand the effects on the individual so that strategies and plans can be put in place for appropriate care.
  • Support family members and carers to understand what is happening and why, this empowers them to help the person they care for.
  • The MDT is crucial to ensure broad discussion and awareness from different professional perspectives.

Planning Ahead

MND is a life-shortening disease. Making plans for adjustment in the future include end of life decisions – so planning ahead with MND can be emotionally challenging. Conversations with your patient on these matters may be difficult but they do ensure that the wishes of the person in your care are respected.

  • Timeliness is key to planning as MND can progress very rapidly
  • Advance Care Planning is the responsibility of the whole multidisciplinary team
  • Acknowledging and recording the person’s wishes gives them control of their care