Cognitive Impairment
in MS
A Case Study
Anne Bateman, CNP, CRRN
PVA Summit 2012
Disclosures/Commercial
Support for this Activity:
 This continuing education activity is managed and
accredited by Professional Education Service Group.
The information presented in the activity represents the
opinion of the author/faculty. Neither PESG, nor any
accrediting organization endorses any commercial
products displayed or mentioned in conjunction with
this activity.
 Commercial support was not received for this activity.
Disclosures
 Anne M. Bateman, NP, CRRN has no financial interest
or relationships to disclose.
 CME Staff Disclosures:
 Professional Education Services Group staff have no
financial interest or relationships to disclose.
Learning Objectives
At the conclusion of this activity, the participant will be
able to:
1. Describe how cognitive and physical deficits can
create a dependency relationship between a
patient and his/her caregiver.
2. Identify how MS-related cognitive impairment can
bring about maladaptive coping behavior in the
caregiver.
3. Recognize and discuss how decision making is
impaired in caregiver crisis and how this can be
mitigated.
Case Study
 57 yr. old male EDSS 8.0
 Married to German-born spouse while serving in the
Army. Two college-aged sons.
 Home: Non-accessible split entry house
 Education 1.5 yrs. college, 4 yrs. trade school
 Employment: Union carpenter, retired for disability.
History
 History of alcohol abuse, tobacco use.
 Age 24: MS symptoms: blurred vision, fatigue
 Age 27: MS Diagnosis: after exacerbation with lower
extremity weakness
 Two other exacerbations over the next 10 yrs. And
continued progression of disability thereafter, including
cognitive and vision deficits.
Rocky Progression
 2000: Suicide attempt by overdose of Paroxetine,
Neurontin, and Clonazepam
 2000: Suicide gesture by superficially lacerating his
wrists and legs.
 Beta Interferon is switched to Glatiramer Acetate for
suicide attempts and “ineffectiveness”.
 2001: Legally blind, severe executive dysfunction,
increased physical impairments, falls, unable to self
cath.
More Trouble at Home
 2002: Suicide attempt by drinking drain cleaner, liquid
cleaning products and washing it down with coffee.
 Depakote started for “behavior”
 Wheelchair bound, increased spasticity, dependent
edema, heel wound. Patient is now overweight.
 Wife continues to be sole caregiver. Couple becomes
more isolated due to inaccessibility of the home and his
aberrant behavior. Declines home care services.
Safety Concerns
 2008: Admitted for one week Caregiver Respite.
 Found to have multiple cigarette burn marks on
bilateral thighs. Supervision and welder’s apron to
protect from dropped cigarettes is advised.
 Spouse is unwilling to stop providing cigarettes,
“beer and shots” about 5/day. Social Services
involved.
 “I can’t do this anymore”. Long term placement
strongly advised, spouse vacillates, eventually
declines placement and home care services.
Caregiver Crisis
 2009, 2010: Respite admissions notable for episodes of
inappropriate sexual behavior toward nurses and angry
outbursts. He is otherwise, pleasant, cooperative. Likes
to watch baseball, favorite music: AC/DC
 Spouse continues to vacillate about long term placement
and caregiver burnout “I can’t do this anymore”.
Followed closely by Social Worker.
 2011: Spouse states she is no longer able to care for her
husband, presents to the VA ER where he is admitted for
“Detox” and failure to thrive.
 ETOH: 7 drinks/day, no withdrawal signs.
Evaluation
 Neuropsychological testing: confusion, disorientation
and gross cognitive impairment.
 Behavior problems manageable with distraction and
redirection in the hospital setting.
 MRI suboptimal due to pt. unable to lie still. Did show
increased lateral and 3rd ventriculomegaly.
Decision Making
• Neurologist: “It is up to her whether she wants to keep
him on the (Glatiramer).”
• Eventually, the medication is discontinued “because it
is reasonable to stop since the patient has not had a
relapse in many years”.
• Spouse is relieved at not having to make that decision.
A Big Decision
 Spouse agrees to long term placement in a VA CLC.
Thoughts to Consider
1. In what ways does emotional investment, isolation, and
fatigue from years of stressful caregiving interfere with a
caregiver’s ability to make safe decisions?
Thoughts to Consider
2. When cognitive impairment prevented informed self
determination about stopping disease modifying therapy,
the burden fell to the spouse. How was this decision
similar to her impaired ability to choose long term
placement?
Thoughts to Consider
3. A cognitive and physically disabled person is
dependent upon a caregiver. In what ways did this
caregiver also become “disabled”?
Do you see this as a mutually disabled couple?
Thank you
Thank you for your attention.
Thank you for the excellent care you provide to our
Veterans and their caregivers.
Anne M. Bateman, CNP, CRRN
SCI/D Center, Minneapolis VA HCS
[email protected]
Obtaining CME/CE Credit
 If you would like to receive continuing education credit
for this activity, please visit:
 http://www.pesgce.com/PVA2012