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Reflections On Observing Caregivers Of People With MS

10/24/2014

This week has been very busy, beginning with an NMSS society sponsored program in Boston to introduce MS Fellows (those being formally trained to become MS specialists) to the unique issues and concerns of people with advanced MS. Following my opening remarks and those of David Rintell, a wonderful psychologist in Boston at the Partner’s MS program, we were treated to a panel discussion with 4 caregivers of people with advanced MS. Three of the caregivers were spouses of a person with MS and the remaining person with MS was cared for by her mother and sister-in–law.

The challenges and stresses of their day-to-day existence was palpable in their demeanors and their frequent pauses to fight back tears and collect themselves before proceeding with their monologues. Each described the immense difficulty of accomplishing what to us is considered the most mundane of tasks; rolling their loved one over in bed, sitting them up, transferring them to a chair, standing them at the toilet, balancing them upright while pulling down their pants to sit on the toilet, cleaning and dressing them. Each described in vivid detail how dressing and toileting alone consumed a minimum of 2 hours every morning of their lives.

Some of these caregivers did not qualify for personal care assistance because of their income level and never received any respite from their responsibilities; those that did qualify rarely experienced any significant respite or relief from their burden since they knew that no one could or would do as good a job as they are able to do. All of the caregivers acknowledged that their relationship with their loved one was no longer the same; as the disease advanced their loved one became dependent on them entirely and their prior partnership was no longer equal; changes in cognition and behavior often strained relationships further. Yet they persisted years on end caring for them, because they loved them. None could conceive of placing their loved one in a nursing home but all knew that a day could come when a nursing home was inevitable.

I myself found it difficult to fight back tears while listening to their descriptions of daily life. At the end of the session, I asked each of them what would make their lives better. All of them felt that they needed more skilled caregiver assistance and support. So let me throw out an idea that may help us reach this goal; besides lobbying state governments for broader qualification criteria for personal care assistants (PCAs), I think caregivers should use a website like ours to develop requirements for PCAs, create a pool of PCAs in your region meeting these requirements (MS certified PCAs) that can be shared for MS care and use this site to communicate with each other to provide support and advice. We already have a caregiver blog but I think the MS HealthAllies site that will launch in the near future will also help with this endeavor. (if you haven't already signed up for the MS HealthAllies beta test please do so here...Click Here To Sign Up For MS HealthAllies Beta Test

If you have any thoughts or ideas on this issue please share them with us.

Lastly, the next time you meet someone who cares day in and day out for a loved one in the home, regardless of whether they have MS, give them a big hug. This little bit of support and affection does really help.

-Rip Kinkel, MD

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Folic Acid Supplementation In Pregancy Age Women With MS

10/12/2014

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I was reminded today at our weekly department grand rounds of an extremely important topic that MS specialists often forget; the benefits of folic acid supplementation in pregnancy age women. We spend so much time discussing the use of disease modifying therapies in pregnancy that we often forget about other equally common and well-known risks. It has been known for decades that folic acid supplementation in doses above 0.4 mg per day reduces the risk of neural tube defects such as spina bifida. What women often do not know is that by the time their pregnancy is confirmed, it is often too late to start this supplementation, since neural tube closure is an early event in embryogenesis (first 25 days). More importantly, at least 40 % of pregnancies are not planned in advance.

Why is this topic so important in woman of childbearing ages with MS? Well, one of the most common class of medications used to treat MS related symptoms are the anti-epileptic drugs (AEDs) such as gabapentin, valproic acid, carbamazepine, lamotrigine, phenytoin, primidone and topiramate. We use these drugs to treat MS related pain syndromes, migraine headaches, mood disorders and even the main disorder for which they were developed, seizures. This class of medication, particularly valproic acid, has been associated with a number of major congenital malformations (MCM) and, more recently, disorders affecting behavior and learning including autism spectrum disorders. The risk is even higher with use of more than one of these medications at a time. While most of the data supporting the association of certain AEDs with birth defects come from Epilepsy Pregnancy Registries, there is little reason to believe that this data would not apply to women using these medications for other indications.

The reason for the increased risk of birth defects is clear with certain enzyme inducting AEDs such as phenytoin, carbamazepine and the barbiturates (primidone and phenobarbital), all of which cause a reduction in folic acid levels. For valproic acid it has been suggested that the drug interferes with folic acid metabolism. Other more recently introduced AEDs such as gabapentin, lamotrigine, oxcarbazepine and zonisamide have no significant effect on folic acid metabolism and the data on MCM is mixed. Yet most epilepsy specialists recommend folic acid supplementation in all women taking these drugs.

So what should you do with this information if you are (a woman) women of childbearing potential regardless of whether you are on birth control? (Birth control can fail)

Even if you are on no drugs, you should be taking at least 0.4 mg of folic acid a day if there is a chance you could become pregnant
If you are on an enzyme-inducing drug such as phenytoin, carbamazepine, primidone, or phenobarbital, you should strongly consider stopping the drug if a pregnancy is planned or take at least 1.0 mg of folic acid a day. Folic acid levels should be checked to make sure you are on enough supplementation and doses of Folic acid should be increased as needed. This folic acid dosage requirement may increase during pregnancy as well.
Valproic acid should not be used unless absolutely necessary.
If an AED is required, try to avoid the enzyme inducing drugs mentioned above, use the lowest dose required and take at least 0.8 mg a day of folic acid
If there is a history of birth defects involving neural tube closure in prior births, most experts recommend at least 5 mg per day of folic acid supplementation. Of course, women with a prior history of offspring with birth defects should be monitored in high-risk pregnancy clinics even before conception.

While the use of folic acid supplementation will not guarantee a child without birth defects, you can at least know you are doing something to reduce this risk. If you have daughters or grandchildren of childbearing ages, please pass this information along.

-- Rip Kinkel, MD

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Reflections On Observing Caregivers Of People With MS

Folic Acid Supplementation In Pregancy Age Women With MS

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