1
|
James E, Ellis C, Brassington R, Sathasivam S, Young CA. Treatment for sialorrhea (excessive saliva) in people with motor neuron disease/amyotrophic lateral sclerosis. Cochrane Database Syst Rev 2022; 5:CD006981. [PMID: 35593746 PMCID: PMC9121913 DOI: 10.1002/14651858.cd006981.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Motor neuron disease (MND), also known as amyotrophic lateral sclerosis (ALS), is a progressive neurodegenerative condition that may cause dysphagia, as well as limb weakness, dysarthria, emotional lability, and respiratory failure. Since normal salivary production is 0.5 L to 1.5 L daily, loss of salivary clearance due to dysphagia leads to salivary pooling and sialorrhea, often resulting in distress and inconvenience to people with MND. This is an update of a review first published in 2011. OBJECTIVES To assess the effects of treatments for sialorrhea in MND, including medications, radiotherapy and surgery. SEARCH METHODS On 27 August 2021, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, AMED, CINAHL, ClinicalTrials.gov and the WHO ICTRP. We checked the bibliographies of the identified randomized trials and contacted trial authors as needed. We contacted known experts in the field to identify further published and unpublished papers. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs, including cross-over trials, on any intervention for sialorrhea and related symptoms, compared with each other, placebo or no intervention, in people with ALS/MND. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified four RCTs involving 110 participants with MND who were described as having intractable sialorrhea or bulbar dysfunction. A well-designed study of botulinum toxin B compared to placebo injected into the parotid and submandibular glands of 20 participants showed that botulinum toxin B may produce participant-reported improvement in sialorrhea, but the confidence interval (CI) was also consistent with no effect. Six of nine participants in the botulinum group and two of nine participants in the placebo group reported improvement (risk ratio (RR) 3.00, 95% CI 0.81 to 11.08; 1 RCT; 18 participants; low-certainty evidence). An objective measure indicated that botulinum toxin B probably reduced saliva production (in mL/5 min) at eight weeks compared to placebo (MD -0.50, 95% CI -1.07 to 0.07; 18 participants, moderate-certainty evidence). Botulinum toxin B may have little to no effect on quality of life, measured on the Schedule for Evaluation of Individual Quality of Life direct weighting scale (SEIQoL-DW; 0-100, higher values indicate better quality of life) (MD -2.50, 95% CI -17.34 to 12.34; 1 RCT; 17 participants; low-certainty evidence). The rate of adverse events may be similar with botulinum toxin B and placebo (20 participants; low-certainty evidence). Trialists did not consider any serious events to be related to treatment. A randomized pilot study of botulinum toxin A or radiotherapy in 20 participants, which was at high risk of bias, provided very low-certainty evidence on the primary outcome of the Drool Rating Scale (DRS; range 8 to 39 points, higher scores indicate worse drooling) at 12 weeks (effect size -4.8, 95% CI -10.59 to 0.92; P = 0.09; 1 RCT; 16 participants). Quality of life was not measured. Evidence for adverse events, measured immediately after treatment (RR 7.00, 95% CI 1.04 to 46.95; 20 participants), and after four weeks (when two people in each group had viscous saliva) was also very uncertain. A phase 2, randomized, placebo-controlled cross-over study of 20 mg dextromethorphan hydrobromide and 10 mg quinidine sulfate (DMQ) found that DMQ may produce a participant-reported improvement in sialorrhea, indicated by a slight improvement (decrease) in mean scores for the primary outcome, the Center for Neurologic Study Bulbar Function Scale (CNS-BFS). Mean total CNS-BFS (range 21 (no symptoms) to 112 (maximum symptoms)) was 53.45 (standard error (SE) 1.07) for the DMQ treatment period and 59.31 (SE 1.10) for the placebo period (mean difference) MD -5.85, 95% CI -8.77 to -2.93) with a slight decrease in the CNS-BFS sialorrhea subscale score (range 7 (no symptoms) to 35 (maximum symptoms)) compared to placebo (MD -1.52, 95% CI -2.52 to -0.52) (1 RCT; 60 participants; moderate-certainty evidence). The trial did not report an objective measure of saliva production or measure quality of life. The study was at an unclear risk of bias. Adverse events were similar to other trials of DMQ, and may occur at a similar rate as placebo (moderate-certainty evidence, 60 participants), with the most common side effects being constipation, diarrhea, nausea, and dizziness. Nausea and diarrhea on DMQ treatment resulted in one withdrawal. A randomized, double-blind, placebo-controlled cross-over study of scopolamine (hyoscine), administered using a skin patch, involved 10 randomized participants, of whom eight provided efficacy data. The participants were unrepresentative of clinic cohorts under routine clinical care as they had feeding tubes and tracheostomy ventilation, and the study was at high risk of bias. The trial provided very low-certainty evidence on sialorrhea in the short term (7 days' treatment, measured on the Amyotrophic Lateral Scelerosis Functional Rating Scale-Revised (ALSFRS-R) saliva item (P = 0.572)), and the amount of saliva production in the short term, as indicated by the weight of a cotton roll (P = 0.674), or daily oral suction volume (P = 0.69). Quality of life was not measured. Adverse events evidence was also very uncertain. One person treated with scopolamine had a dry mouth and one died of aspiration pneumonia considered unrelated to treatment. AUTHORS' CONCLUSIONS There is some low-certainty or moderate-certainty evidence for the use of botulinum toxin B injections to salivary glands and moderate-certainty evidence for the use of oral dextromethorphan with quinidine (DMQ) for the treatment of sialorrhea in MND. Evidence on radiotherapy versus botulinum toxin A injections, and scopolamine patches is too uncertain for any conclusions to be drawn. Further research is required on treatments for sialorrhea. Data are needed on the problem of sialorrhea in MND and its measurement, both by participant self-report measures and objective tests. These will allow the development of better RCTs.
Collapse
Affiliation(s)
- Eleanor James
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Cathy Ellis
- Motor Nerve Clinic, Academic Neurosciences Centre, King's College Hospital, London, UK
| | - Ruth Brassington
- Cochrane Neuromuscular, Queen Square Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | | | | |
Collapse
|
2
|
Shehee L, O'Rourke A, Garand KL. The Role of Radiation Therapy and Botulinum Toxin Injections in the Management of Sialorrhea in Patients With Amyotrophic Lateral Sclerosis: A Systematic Review. J Clin Neuromuscul Dis 2020; 21:205-221. [PMID: 32453096 DOI: 10.1097/cnd.0000000000000273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Half of patients with amyotrophic lateral sclerosis experience sialorrhea due to facial weakness. Although anticholinergic medications are first-line therapy, they often lead to unacceptable side effects. Radiation therapy and botulinum toxin may be considered when medical management fails. In this systematic review, we investigated the effectiveness of these interventions. METHODS Eligible studies were retrieved from PubMed and Scopus databases up to March 2017 along with hand-searching of references from primary articles. RESULTS Fourteen studies (N = 138) examined the benefits of botulinum toxin. Studies varied in salivary glands treated, dosages used, and the use of botulinum toxin subtype A or B. A majority of studies showed benefit after treatment. Although most studies reported only mild adverse effects, 2 case studies revealed severe complications including recurrent TMJ dislocations and rapid deterioration in bulbar function. Ten studies (N = 171) examined the benefits of radiation. Most studies reported improvement with only mild adverse events reported. CONCLUSIONS Both radiation and botulinum toxin are effective treatments for sialorrhea in patients with amyotrophic lateral sclerosis and should be considered when medical management fails. Radiation may offer longer duration of symptom improvement with fewer complications.
Collapse
Affiliation(s)
- Lindsey Shehee
- Department of Otolaryngology, Medical University of South Carolina, Charleston, SC; and
| | - Ashli O'Rourke
- Department of Otolaryngology, Medical University of South Carolina, Charleston, SC; and
| | - Kendrea L Garand
- Department of Speech Pathology and Audiology, University of South Alabama, Mobile, AL
| |
Collapse
|
3
|
Garuti G, Rao F, Ribuffo V, Sansone VA. Sialorrhea in patients with ALS: current treatment options. Degener Neurol Neuromuscul Dis 2019; 9:19-26. [PMID: 31118868 PMCID: PMC6498144 DOI: 10.2147/dnnd.s168353] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder of the motor neuron, which selectively affects it both at central (first motor-neuron) and peripheral level (second motor-neuron). The disease shows up at a mean age of 56 years and the most affected are males. Although ALS may start as a bulbar or spinal disease, with the progression of the disease typically both become evident. Pharmacological approved treatments for ALS are still limited and include riluzole and edaravone which improve survival over time. Despite this, ALS leads to progressive muscle involvement and requires a complex multidisciplinary approach to manage increasing disability which goes beyond motor neurons. Sialorrhea is, amongst others, one of the most disabling symptoms in ALS. The complexity in managing saliva is due to a muscular spasticity and to a scarce palatino-lingual muscles control, rather than to an overproduction of saliva. These features could increase the risk of aspiration pneumonia and limit the use of noninvasive mechanical ventilation. We reviewed the treatment for sialorrhea in ALS patients that are available at this time, emphasizing pros and cons for each approach. Our purpose is to create a practical tool for the diagnosis, in order to facilitate the quantification and management of sialorrhea in everyday practice.
Collapse
Affiliation(s)
- Giancarlo Garuti
- Pneumology Unit, Santa Maria Bianca Hospital, Mirandola, AUSL Modena, Modena, Italy
| | - Fabrizio Rao
- Respiratory Unit, Neuromuscular OmniCentre (NeMO), Neurorehabilitation, University of Milan, Niguarda Hospital, Milan, Italy
| | - Viviana Ribuffo
- Pneumology Unit, Santa Maria Bianca Hospital, Mirandola, AUSL Modena, Modena, Italy
| | - Valeria A Sansone
- Neuromuscular Omnicentre (NeMO), Neurorehabilitation, University of Milan, Niguarda Hospital, Milan, Italy
| |
Collapse
|
4
|
Weikamp JG, Schinagl DAX, Verstappen CCP, Schelhaas HJ, de Swart BJM, Kalf JG. Botulinum toxin-A injections vs radiotherapy for drooling in ALS. Acta Neurol Scand 2016; 134:224-31. [PMID: 26803950 DOI: 10.1111/ane.12559] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Botulinum neurotoxin (BoNT) injections in the salivary glands and radiotherapy (RT) on these glands are commonly used to alleviate severe drooling in patients with amyotrophic lateral sclerosis (ALS). This study compares BoNT type A with RT based on patient-rated evaluations. MATERIALS & METHODS A prospective randomized controlled pilot study to compare RT (n = 10; on the parotid and the posterior part of the submandibular glands) with BoNT-A treatment (n = 10; in the parotid glands only, because of the risk of increasing oropharyngeal weakness) in patients with ALS. The primary outcome was the drooling status (burden of drooling), and our secondary interests were the degree of salivation, global change of drooling after treatment, and level of satisfaction with the treatment and negative experiences. RESULTS There were no statistically significant between-treatment differences for the drooling status after treatment. Only at twelve weeks more saliva reduction was achieved by RT (P = 0.02). Patients treated with RT also described more transient negative experiences (like pain in mandible) directly after treatment. Subgroup analysis showed that patients with very severe dysphagia (no oral intake) were less satisfied and experienced a lower global change of drooling after treatment. CONCLUSIONS This pilot study showed no significant difference in the burden of drooling between the treatments. However, with RT more saliva reduction was achieved, including negative experiences directly after treatment, but without the risk of decreasing oropharyngeal function. In addition, patients with very severe dysphagia do not seem to benefit from either treatment.
Collapse
Affiliation(s)
- J. G. Weikamp
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
| | - D. A. X. Schinagl
- Radboud University Medical Centre; Department of Radiotherapy; Nijmegen The Netherlands
| | - C. C. P. Verstappen
- Canisius Wilhelmina Ziekenhuis; Department of Neurology; Nijmegen The Netherlands
| | | | - B. J. M. de Swart
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
| | - J. G. Kalf
- Radboud University Medical Centre; Donders Centre for Neuroscience (DCN); Department of Rehabilitation/Speech-Language Pathology; Nijmegen The Netherlands
| |
Collapse
|
5
|
McGeachan AJ, Hobson EV, Al-Chalabi A, Stephenson J, Chandran S, Crawley F, Dick D, Donaghy C, Ellis CM, Gorrie G, Hanemann CO, Harrower T, Jung A, Malaspina A, Morrison KE, Orrell RW, Talbot K, Turner MR, Williams TL, Young CA, Shaw PJ, McDermott CJ. A multicentre evaluation of oropharyngeal secretion management practices in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:1-9. [PMID: 27579520 DOI: 10.1080/21678421.2016.1221433] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Failure to clear oral secretions can be debilitating for patients with amyotrophic lateral sclerosis (ALS), but the treatment of this symptom is poorly defined and there is no consensus on best practice. The objective of this study was to identify the treatments that are commonly prescribed, and to describe how experienced clinicians manage a patient with treatment resistant symptoms. Twenty-three clinicians were approached, of which 19 from 16 centres across the UK provided case report forms for a total of 119 ALS patients identified as having problematic oral secretions. The use of five anticholinergics, salivary gland botulinum toxin injections, conservative management approaches and carbocisteine were reported. Of the 72 patients who were evaluated following the initiation of a first anticholinergic, 61% had symptomatic improvement. Only 19% of patients achieved symptomatic improvement with the use of an alternative anticholinergic when an initial anticholinergic achieved no symptomatic improvement. Problems with thick and thin secretions often coexisted, with 37% of patients receiving treatment for both types of problem. In conclusion, a variety of treatment options are employed by expert clinicians for problematic oral secretions in ALS patients. The variation in management highlights the need for further prospective research in this area.
Collapse
Affiliation(s)
- Alexander J McGeachan
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | - Esther V Hobson
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | - Ammar Al-Chalabi
- b King's College London, Institute of Psychiatry , Department of Clinical Neuroscience , London
| | - Jodie Stephenson
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | | | - Francesca Crawley
- d Department of Neurology , West Suffolk NHS Foundation Trust , Bury St. Edmunds
| | - David Dick
- e Department of Neurology , Norfolk and Norwich University Hospital , Norwich
| | - Colette Donaghy
- f Department of Neurology , Royal Victoria Hospital , Belfast
| | - Cathy M Ellis
- g Motor Neuron Disease Care and Research Centre , Kings College Hospital , London
| | - George Gorrie
- h Institute of Neurological Sciences, Southern General Hospital , Glasgow
| | - C Oliver Hanemann
- i Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry , Plymouth
| | - Timothy Harrower
- j Department of Neurology , Royal Devon and Exeter Foundation Trust Hospital
| | - Agam Jung
- k Department of Neurology , Leeds General Infirmary , Leeds
| | - Andrea Malaspina
- l Centre for Neuroscience and Trauma , Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, & Department of Neurology, Basildon University Hospital , Basildon
| | - Karen E Morrison
- m Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, and Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust , Birmingham
| | - Richard W Orrell
- n Department of Clinical Neuroscience , University College London Institute of Neurology, London, & MND Care and Research Centre, National Hospital for Neurology and Neurosurgery , Queen Square , London
| | - Kevin Talbot
- o Oxford University Nuffield Department of Clinical Neurosciences , John Radcliffe Hospital , Oxford
| | - Martin R Turner
- o Oxford University Nuffield Department of Clinical Neurosciences , John Radcliffe Hospital , Oxford
| | - Timothy L Williams
- p Department of Neurology , Royal Victoria Infirmary , Newcastle-upon-Tyne , and
| | - Carolyn A Young
- q The Walton Centre for Neurology and Neurosurgery , Liverpool , UK
| | - Pamela J Shaw
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| | - Christopher J McDermott
- a Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, & Academic Directorate of Neurosciences, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield
| |
Collapse
|
6
|
Rudnicki S, McVey AL, Jackson CE, Dimachkie MM, Barohn RJ. Symptom Management and End-of-Life Care in Amyotrophic Lateral Sclerosis. Neurol Clin 2015; 33:889-908. [PMID: 26515628 PMCID: PMC5031364 DOI: 10.1016/j.ncl.2015.07.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The number of available symptomatic treatments has markedly enhanced the care of patients with amyotrophic lateral sclerosis (ALS). Once thought to be untreatable, patients with ALS today clearly benefit from multidisciplinary care. The impact of such care on the disease course, including rate of progression and mortality, has surpassed the treatment effects commonly sought in clinical drug trials. Unfortunately, there are few randomized controlled trials of medications or interventions addressing symptom management. In this review, the authors provide the level of evidence, when available, for each intervention that is currently considered standard of care by consensus opinion.
Collapse
Affiliation(s)
- Stacy Rudnicki
- University of Arkansas for Medical Sciences, 501 Jackson Stephens Drive, Room 769, Little Rock, Arkansas 72205-7199
| | - April L. McVey
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
| | - Carlayne E. Jackson
- University of Texas Health Science Center, 8300 Floyd Curl Drive, Mail Code 7883, San Antonio, TX 78229-3900
| | - Mazen M. Dimachkie
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
| | - Richard J. Barohn
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
| |
Collapse
|
7
|
Slade A, Stanic S. Managing excessive saliva with salivary gland irradiation in patients with amyotrophic lateral sclerosis. J Neurol Sci 2015; 352:34-6. [PMID: 25881952 DOI: 10.1016/j.jns.2015.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 01/12/2015] [Accepted: 02/04/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE A significant fraction of patients with amyotrophic lateral sclerosis (ALS) are unable to swallow saliva, which may result in the spillage of saliva outside of the oral cavity. Although anticholinergic agents and botulin toxin injections are considered the first line of treatment, they have not been effective for all patients. We performed a literature search on therapeutic salivary gland irradiation in patients with ALS. METHODS We searched the PubMed for English language publications up to December 2014 on therapeutic salivary gland irradiation in patients with ALS. The search was performed using the following key words: amyotrophic lateral sclerosis, excessive salivation, sialorrhea, and radiation therapy. RESULTS The majority of ALS patients with excessive salivation respond well to salivary gland irradiation. The whole bilateral submandibular, and whole or partial bilateral parotid glands have been the target tissue for radiation therapy in most of the published studies. Various radiation therapy regimens have been utilized. The response to radiation therapy lasts for several months. CONCLUSIONS The majority of ALS patients with excessive salivation respond well to salivary gland irradiation. Neurologists should consider this treatment option for select patients with ALS and excessive salivation.
Collapse
Affiliation(s)
- Alexander Slade
- Department of Radiation Oncology at Carle Cancer Center, University of Illinois College of Medicine at Urbana-Champaign, Urbana, IL, USA
| | - Sinisa Stanic
- Department of Radiation Oncology at Carle Cancer Center, University of Illinois College of Medicine at Urbana-Champaign, Urbana, IL, USA.
| |
Collapse
|
8
|
Radiation Therapy for Hypersalivation: A Prospective Study in 50 Amyotrophic Lateral Sclerosis Patients. Int J Radiat Oncol Biol Phys 2014; 88:589-95. [DOI: 10.1016/j.ijrobp.2013.11.230] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/31/2013] [Accepted: 11/17/2013] [Indexed: 11/22/2022]
|
9
|
Salivary glands radiotherapy to reduce sialorrhea in amyotrophic lateral sclerosis: Dose and energy. Cancer Radiother 2013; 17:191-5. [DOI: 10.1016/j.canrad.2013.01.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 01/01/2013] [Accepted: 01/09/2013] [Indexed: 12/11/2022]
|
10
|
Hobson EV, McGeachan A, Al-Chalabi A, Chandran S, Crawley F, Dick D, Donaghy C, Ealing J, Ellis CM, Gorrie G, Hanemann CO, Harrower T, Jung A, Majeed T, Malaspina A, Morrison K, Orrell RW, Pall H, Pinto A, Talbot K, Turner MR, Williams TL, Young CA, Shaw PJ, McDermott CJ. Management of sialorrhoea in motor neuron disease: A survey of current UK practice. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:521-7. [DOI: 10.3109/21678421.2013.790452] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
11
|
Abstract
Amyotrophic lateral sclerosis (ALS), the most common adult motor neuron disease, is an acquired disorder that results in loss of function in multiple domains. Although there is no treatment that can halt or reverse this progressive condition, there are many opportunities for interventions that can lead to improved quality of life for the patient and caregiver. Physical and occupational therapy can assist with mobility and activities of daily living. Interventions by speech pathology can optimize nutrition and communication. Respiratory function can be managed noninvasively or invasively. Depression, hopelessness, anxiety, and other mental health issues can and should be aggressively addressed and treated. Many symptoms such as pseudobulbar affect, sialorrhea, constipation, spasticity, and cramps can be treated effectively with medications. Spirituality and religion are important issues to address, as are end-of-life concerns, including advance directives, hospice, and the dying process. In contrast to the discouraging view that "there is nothing we can do," a broad approach to management, through collaboration with a multidisciplinary team, will permit the ALS physician to make a meaningful difference in the lives of individuals living with ALS.
Collapse
Affiliation(s)
- Zachary Simmons
- Department of Neurology, Pennsylvania State University College of Medicine, Hershey, PA, USA.
| |
Collapse
|
12
|
The management of drooling in adults with neurological conditions. Curr Opin Otolaryngol Head Neck Surg 2012; 20:171-6. [DOI: 10.1097/moo.0b013e32835328ec] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
13
|
Blackhall LJ. Amyotrophic lateral sclerosis and palliative care: Where we are, and the road ahead. Muscle Nerve 2012; 45:311-8. [DOI: 10.1002/mus.22305] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
14
|
Andersen PM, Abrahams S, Borasio GD, de Carvalho M, Chio A, Van Damme P, Hardiman O, Kollewe K, Morrison KE, Petri S, Pradat PF, Silani V, Tomik B, Wasner M, Weber M. EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)--revised report of an EFNS task force. Eur J Neurol 2011; 19:360-75. [PMID: 21914052 DOI: 10.1111/j.1468-1331.2011.03501.x] [Citation(s) in RCA: 722] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The evidence base for the diagnosis and management of amyotrophic lateral sclerosis (ALS) is weak. OBJECTIVES To provide evidence-based or expert recommendations for the diagnosis and management of ALS based on a literature search and the consensus of an expert panel. METHODS All available medical reference systems were searched, and original papers, meta-analyses, review papers, book chapters and guidelines recommendations were reviewed. The final literature search was performed in February 2011. Recommendations were reached by consensus. RECOMMENDATIONS Patients with symptoms suggestive of ALS should be assessed as soon as possible by an experienced neurologist. Early diagnosis should be pursued, and investigations, including neurophysiology, performed with a high priority. The patient should be informed of the diagnosis by a consultant with a good knowledge of the patient and the disease. Following diagnosis, the patient and relatives/carers should receive regular support from a multidisciplinary care team. Medication with riluzole should be initiated as early as possible. Control of symptoms such as sialorrhoea, thick mucus, emotional lability, cramps, spasticity and pain should be attempted. Percutaneous endoscopic gastrostomy feeding improves nutrition and quality of life, and gastrostomy tubes should be placed before respiratory insufficiency develops. Non-invasive positive-pressure ventilation also improves survival and quality of life. Maintaining the patient's ability to communicate is essential. During the entire course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end-of-life care should be discussed early with the patient and carers, respecting the patient's social and cultural background.
Collapse
Affiliation(s)
-
- Umeå University, Umeå, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Young CA, Ellis C, Johnson J, Sathasivam S, Pih N. Treatment for sialorrhea (excessive saliva) in people with motor neuron disease/amyotrophic lateral sclerosis. Cochrane Database Syst Rev 2011:CD006981. [PMID: 21563158 DOI: 10.1002/14651858.cd006981.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Motor neuron disease (MND), also known as amyotrophic lateral sclerosis, is a progressive, neurodegenerative condition which may cause dysphagia, as well as limb weakness, dysarthria, emotional lability and respiratory failure. Since normal salivary production is 0.5 to 1.5 litres daily, loss of salivary clearance due to dysphagia leads to salivary pooling and sialorrhea, often resulting in distress and inconvenience to patients. OBJECTIVES To systematically review evidence on treatment of sialorrhea in MND, including medications, radiotherapy and surgery. SEARCH STRATEGY We searched the Cochrane Neuromuscular Disease Group Specialized Register (1 October 2010), the Cochrane Central Register of Controlled Trials )(CENTRAL) (The Cochrane Library issue 3, 2010), MEDLINE (January 1966 to September 2010), EMBASE (January 1980 to September 2010), AMED (1985 to September 2010) and CINAHL Plus (January 1937 September 2010). All bibliographies of the identified randomized trials were reviewed and authors contacted as needed. Known experts in the field were contacted to identify further published and unpublished papers. SELECTION CRITERIA We included randomized and quasi-randomised controlled studies on any intervention for sialorrhea and related symptoms, in people with MND. DATA COLLECTION AND ANALYSIS Review authors summarised data independently in a customised data collection form and confirmed data presented in Cochrane Review Manager software. MAIN RESULTS Only one randomized controlled trial was identified. This was a well designed study of botulinum toxin B injected into parotid and submandibular glands of 20 patients, which showed positive results for four weeks (Jackson 2009). There was low risk of bias in the study and no significant adverse events reported. AUTHORS' CONCLUSIONS There is some evidence for use of botulinum toxin injections to salivary glands for the treatment of sialorrhea in MND. Further research is required on this important symptom. Data are needed on the problem of sialorrhea in MND and its measurement, both by patient self report measures and objective tests. These will allow the development of better randomized controlled trials.
Collapse
Affiliation(s)
- Carolyn A Young
- The Walton Centre for Neurology and Neurosurgery, Lower Lane, Fazakerley, Liverpool, UK, L9 7LJ
| | | | | | | | | |
Collapse
|
16
|
Guy N, Bourry N, Dallel R, Dualé C, Verrelle P, Lapeyre M, Clavelou P. Comparison of Radiotherapy Types in the Treatment of Sialorrhea in Amyotrophic Lateral Sclerosis. J Palliat Med 2011; 14:391-5. [DOI: 10.1089/jpm.2010.0308] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Nathalie Guy
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
- CHU de Clermont Ferrand, Service de neurologie, Centre SLA, Clermont Ferrand, France
| | | | - Radhouane Dallel
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
| | - Christian Dualé
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
- CHU de Clermont Ferrand, Inserm CIC 501, Clermont Ferrand, France
| | | | | | - Pierre Clavelou
- Université d'Auvergne, Clermont Ferrand, France
- Inserm, U929, Neurobiologie de la Douleur Trigéminale, Clermont Ferrand, France
- CHU de Clermont Ferrand, Service de neurologie, Centre SLA, Clermont Ferrand, France
| |
Collapse
|
17
|
Abstract
Drooling is a common and potentially distressing symptom in those with motor neurone disease. A coordinated multidisciplinary approach is required to optimally manage this symptom. Both pharmacological and non-pharmacological strategies are required, and when drugs are used, off-label prescribing in terms of indication or route of administration is common. Further research needs to explore ways of enhancing swallowing ability as well as ways of optimizing drug therapies.
Collapse
Affiliation(s)
- Pauline Dand
- Pilgrims Hospices, East Kent, Canterbury, Kent, United Kingdom
| | | |
Collapse
|
18
|
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease associated with a life expectancy of approximately 3 years after symptom onset, but the range of survival extends from a few months for some to decades for approximately 5% of patients. There is no clear cause in the majority of cases and just one medication, riluzole, has been shown to modestly prolong survival. Research has identified some of the cellular processes that occur after disease onset, including mitochondrial dysfunction, protein aggregation, generation of free radicals, excitotoxicity, inflammation and apoptosis, but for most patients the underlying cause is unknown. While ALS is considered to be a complex genetic disorder in which multiple genes in combination with environmental exposures combine to render a person susceptible, few genetic or environmental risks have been discovered to date. The diagnosis is based on the history and examination showing progressive upper and lower motor neuron findings. The electromyogram can help confirm the diagnosis, and additional tests are used to exclude other conditions. Published practice parameters guide the care of patients with ALS. Until the elucidation of aetiologies leads to the development of more robust neuroprotective agents, both pharmacological and nonpharmacological treatments are directed at maintaining quality of life and prolonging life to the greatest extent possible. Riluzole, ventilatory support for those with respiratory insufficiency, gastrostomy for those with dysphagia and multidisciplinary care may help extend life. The off-label use of many symptomatic agents can have a meaningful impact for those with the illness. Palliative care ensures dignity toward the end stages of the disease. Clinical trials currently aim to slow disease progression by testing drugs that impact one or more of the processes that are initiated after disease onset. Novel therapies currently in trials include potential neuroprotective agents with differing mechanisms of action, vaccine therapies, stem cell injections and diaphragmatic pacing.
Collapse
Affiliation(s)
- Paul H Gordon
- Fédération des Maladies du Système Nerveux, Centre référent maladie rare SLA, Assistance Publique-Hôpitaux de Paris, Hôpital de la Pitié-Salpêtrière, Paris, France.
| |
Collapse
|
19
|
Miller RG, Jackson CE, Kasarskis EJ, England JD, Forshew D, Johnston W, Kalra S, Katz JS, Mitsumoto H, Rosenfeld J, Shoesmith C, Strong MJ, Woolley SC. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2009; 73:1227-33. [PMID: 19822873 DOI: 10.1212/wnl.0b013e3181bc01a4] [Citation(s) in RCA: 413] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS). METHODS The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include breaking the news, multidisciplinary clinics, symptom management, cognitive and behavioral impairment, communication, and palliative care for patients with ALS. RESULTS The authors identified 2 Class I studies, 8 Class II studies, and 30 Class III studies in ALS, but many important areas have been little studied. More high-quality, controlled studies of symptomatic therapies and palliative care are needed to guide management and assess outcomes in patients with ALS. RECOMMENDATIONS Multidisciplinary clinic referral should be considered for managing patients with ALS to optimize health care delivery and prolong survival (Level B) and may be considered to enhance quality of life (Level C). For the treatment of refractory sialorrhea, botulinum toxin B should be considered (Level B) and low-dose radiation therapy to the salivary glands may be considered (Level C). For treatment of pseudobulbar affect, dextromethorphan and quinidine should be considered if approved by the US Food and Drug Administration (Level B). For patients who develop fatigue while taking riluzole, withholding the drug may be considered (Level C). Because many patients with ALS demonstrate cognitive impairment, which in some cases meets criteria for dementia, screening for cognitive and behavioral impairment should be considered in patients with ALS (Level B). Other management strategies all lack strong evidence.
Collapse
Affiliation(s)
- R G Miller
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Stone CA, O'Leary N. Systematic review of the effectiveness of botulinum toxin or radiotherapy for sialorrhea in patients with amyotrophic lateral sclerosis. J Pain Symptom Manage 2009; 37:246-58. [PMID: 18676117 DOI: 10.1016/j.jpainsymman.2008.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Revised: 02/11/2008] [Accepted: 02/18/2008] [Indexed: 12/12/2022]
Abstract
Fifty percent of patients with amyotrophic lateral sclerosis (ALS) experience problems handling serous saliva and 20% fail to achieve adequate control of sialorrhea with anticholinergic medications, or experience intolerable adverse effects from these drugs. Both botulinum and radiotherapy have been suggested in the literature as treatments for intractable sialorrhea. In this review, we assess the evidence for the effectiveness and toxicity of botulinum toxin and radiotherapy for sialorrhea in patients with ALS. Relevant studies were retrieved from Medline, Embase and Cochrane Databases. Handsearching of Neurology, Journal of Pain and Symptom Management, and Palliative Medicine and of reference lists, was carried out. Five studies (28 patients) were included in the analysis of botulinum. Of the four studies using an intraglandular method of injection, no adverse effects occurred. Two of these had positive findings of the effect of botulinum in salivary secretion rate and quality of life. In contrast, significant adverse effects were experienced by two patients in a study of retrograde injections into the salivary ducts. Two studies were included in the analysis of radiotherapy (27 patients). Both demonstrated a positive effect of radiotherapy on salivary secretion rate. Some patients experienced mild acute side effects. Because of the small numbers of studies, small sample sizes, and poor quality of reporting, it is not possible to draw firm conclusions. There is some evidence indicating that both botulinum and radiotherapy are well tolerated, effective treatments for persistent sialorrhea in patients with ALS and that the duration of action is up to three months with botulinum and six months with radiotherapy.
Collapse
|
21
|
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a devastating progressive disease of all voluntary muscles. Bulbar symptoms with reduced ability to swallow occur frequently and may also be an early symptom. For some patients drooling may represent a severe social problem. AIM To review the literature on treatment of sialorrhea in ALS and describe possible treatments. METHOD PubMed was searched combining the words amyotrophic or ALS with sialorrhea or drooling. Publications more recent than 2000 were selected. RESULTS A total of 31 publications were found. Of these, 22 are from 2000 or later. Thirteen of the 22 most recent publications are original papers whereas 9 are review articles. Of the original articles, four describe treatment of sialorrhea with radiotherapy, five describe effects of botolinum toxin injections into the salivary grands and two describe serious side-effects of botolinum toxin injections for sialorrhea in ALS. The remaining original articles are case descriptions or practice surveys. DISCUSSION The treatment of sialorrhea in ALS is discussed in the view of current knowledge.
Collapse
Affiliation(s)
- O-B Tysnes
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.
| |
Collapse
|
22
|
Meijer JWG, van Kuijk AA, Geurts ACH, Schelhaas HJ, Zwarts MJ. Acute Deterioration of Bulbar Function After Botulinum Toxin Treatment for Sialorrhoea in Amyotrophic Lateral Sclerosis. Am J Phys Med Rehabil 2008; 87:321-4. [DOI: 10.1097/phm.0b013e318164a931] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
Andersen PM, Borasio GD, Dengler R, Hardiman O, Kollewe K, Leigh PN, Pradat PF, Silani V, Tomik B. Good practice in the management of amyotrophic lateral sclerosis: clinical guidelines. An evidence-based review with good practice points. EALSC Working Group. ACTA ACUST UNITED AC 2007; 8:195-213. [PMID: 17653917 DOI: 10.1080/17482960701262376] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The evidence base for diagnosis and management of ALS is still weak, and curative therapy is lacking. Nonetheless, early diagnosis and symptomatic therapy can profoundly influence care and quality of life of the patient and relatives, and may increase survival time. This review addresses the current optimal clinical approach to ALS. The literature search is complete to December 2006. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. We conclude that a diagnosis of ALS can be achieved by early examination by an experienced neurologist. The patient should be informed of the diagnosis by the consultant. Following diagnosis, a multi-diciplinary care team should support the patient and relatives. Medication with riluzole should be initiated as early as possible. PEG is associated with improved nutrition and should be inserted early. The operation is hazardous in patients with VC <50%: RIG may be a better alternative. Non-invasive positive pressure ventilation improves survival and quality of life but is underused in Europe. Maintaining the patient's ability to communicate is essential. During the course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end of life care are important and should be discussed early with the patient and relatives if they so wish.
Collapse
|
24
|
Neppelberg E, Haugen DF, Thorsen L, Tysnes OB. Radiotherapy reduces sialorrhea in amyotrophic lateral sclerosis. Eur J Neurol 2007; 14:1373-7. [DOI: 10.1111/j.1468-1331.2007.01983.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
Abstract
A significant number of patients with Parkinson's disease (PD) experience sialorrhea. This problem can cause social embarrassment, and because saliva pools in the mouth, may lead to aspiration pneumonia. Sialorrhea in PD is thought to be caused by impaired or infrequent swallowing, rather than hypersecretion. Oral medications, botulinum toxin injections, surgical interventions, radiotherapy, speech therapy, and trials of devices may be used to treat sialorrhea in PD, but few controlled trials have been published. This article reviews current knowledge regarding the frequency, etiology, assessment, and treatment of sialorrhea in PD.
Collapse
Affiliation(s)
- Kelvin L Chou
- Department of Clinical Neurosciences, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | | | | | | |
Collapse
|
26
|
Gordon PH, Mitsumoto H. Chapter 20 Symptomatic therapy and palliative aspects of clinical care. HANDBOOK OF CLINICAL NEUROLOGY 2007; 82:389-424. [PMID: 18808905 DOI: 10.1016/s0072-9752(07)80023-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
27
|
Quels sont les traitements medicamenteux symptomatiques? Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
28
|
|
29
|
Simmons Z. Management strategies for patients with amyotrophic lateral sclerosis from diagnosis through death. Neurologist 2005; 11:257-70. [PMID: 16148733 DOI: 10.1097/01.nrl.0000178758.30374.34] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder that is inevitably fatal. There are no effective treatments to stop or reverse the natural course of the disease. The role of the physician is to provide comfort and optimize quality of life. REVIEW SUMMARY Management of patients with ALS is a process extending over months to years. It begins with breaking the news of the diagnosis and extends through the terminal phase. Medication may extend lifespan by a small amount. However, most efforts are centered around symptom management. Areas of importance include respiration, nutrition, secretions, communication, pseudobulbar affect, therapy and exercise, spasticity and cramps, pain, depression and suicide, spirituality and religion, cognitive changes, the development of advance directives, and care at the end of life. Multidisciplinary ALS clinics provide much-needed support for patients with ALS and their caregivers. CONCLUSION Although physicians cannot cure ALS or even halt progression, there is much that can be done to manage the physical and emotional symptoms, thereby maintaining or enhancing quality of life.
Collapse
Affiliation(s)
- Zachary Simmons
- Department of Neurology, Penn State College of Medicine, Hershey, 17033, USA.
| |
Collapse
|
30
|
Andersen PM, Borasio GD, Dengler R, Hardiman O, Kollewe K, Leigh PN, Pradat PF, Silani V, Tomik B. EFNS task force on management of amyotrophic lateral sclerosis: guidelines for diagnosing and clinical care of patients and relatives. An evidence-based review with good practice points. Eur J Neurol 2005; 12:921-38. [PMID: 16324086 DOI: 10.1111/j.1468-1331.2005.01351.x] [Citation(s) in RCA: 190] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite being one of the most devastating diseases known, there is little evidence for diagnosing and managing patients with amyotrophic lateral sclerosis (ALS). Although specific therapy is lacking, correct early diagnosis and introduction of symptomatic and specific therapy can have a profound influence on the care and quality of life of the patient and may increase survival time. This document addresses the optimal clinical approach to ALS. The final literature search was performed in the spring of 2005. Consensus recommendations are given graded according to the EFNS guidance regulations. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. People affected with possible ALS should be examined as soon as possible by an experienced neurologist. Early diagnosis should be pursued and a number of investigations should be performed with high priority. The patient should be informed of the diagnosis by a consultant with a good knowledge of the patient and the disease. Following diagnosis, the patient and relatives should receive regular support from a multidisciplinary care team. Medication with riluzole should be initiated as early as possible. PEG is associated with improved nutrition and should be inserted early. The operation is hazardous in patients with vital capacity < 50%. Non-invasive positive pressure ventilation improves survival and quality of life but is underused. Maintaining the patients ability to communicate is essential. During the entire course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end of life care are important and should be fully discussed early with the patient and relatives respecting the patients social and cultural background.
Collapse
Affiliation(s)
- P M Andersen
- Department of Neurology, Umeå University Hospital, Sweden.
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Heffernan C, Jenkinson C, Holmes T, Feder G, Kupfer R, Leigh PN, McGowan S, Rio A, Sidhu P. Nutritional management in MND/ALS patients: an evidence based review. ACTA ACUST UNITED AC 2004; 5:72-83. [PMID: 15204009 DOI: 10.1080/14660820410020349] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Catherine Heffernan
- Health Services Research Unit, Department of Public Health, University of Oxford, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Once thought to be a single pathological disease state, amyotrophic lateral sclerosis (ALS) is now recognized to be the limited phenotypic expression of a complex, heterogeneous group of biological processes, resulting in an unrelenting loss of motor neurons. On average, individuals affected with the disease live <5 years. In this article, the complex nature of the pathogenesis of ALS, including features of age dependency, environmental associations, and genetics, is reviewed. Once held to be uncommon, it is now clear that ALS is associated with a frontotemporal dementia and that this process may reflect disturbances in the microtubule-associated tau protein metabolism. The motor neuron ultimately succumbs in a state where significant disruptions in neurofilament metabolism, mitochondrial function, and management of oxidative stress exist. The microenvironment of the neuron becomes a complex milieu in which high levels of glutamate provide a source of chronic excitatory neurotoxicity, and the contributions of activated microglial cells lead to further cascades of motor neuron death, perhaps serving to propagate the disease once established. The final process of motor neuron death encompasses many features of apoptosis, but it is clear that this alone cannot account for all features of motor neuron loss and that aspects of a necrosis-apoptosis continuum are at play. Designing pharmacological strategies to mitigate against this process thus becomes an increasingly complex issue, which is reviewed in this article.
Collapse
Affiliation(s)
- Michael J Strong
- Department of Clinical Neurological Sciences, Robarts Research Institute, Room 7OF 10, University Campus, London Health Sciences Centre, University of Western Ontario, 339 Windermere Road, London, Ontario, Canada N6A 5A5.
| |
Collapse
|