The functional and psychological status of patients with amyotrophic lateral sclerosis: some implications for rehabilitation

Factors associated with psychological distress in patients with amyotrophic lateral sclerosis: A retrospective medical records study

OBJECTIVE

Although psychological distress is a prevalent issue among patients with amyotrophic lateral sclerosis (ALS) and can impact survival, the risk factors contributing to this distress remain insufficiently understood.

METHODS

Patients with ALS who completed the Profile of Mood States (POMS) between June 2017 and March 2022 were included. Participants with moderate to severe cognitive decline were excluded, resulting in the recruitment of 121 patients. The associations between POMS profiles and clinical characteristics were analyzed. Physical motor symptoms were evaluated using the Revised ALS Functional Rating Scale (ALSFRS-R) for objective measurement and the 40-item ALS Assessment Questionnaire (ALSAQ-40) for subjective assessment.

RESULTS

Our model, employing the ALSFRS-R, revealed significant factors associated with overall psychological distress, as assessed by the POMS, including upper limb symptoms, the presence of sleep apnea syndrome, older age at onset, and male sex, with an inverse association with tracheostomy. The POMS subscale scores revealed that anger and depression were significantly associated with upper limb symptoms. The second model, which employed subjective scales, yielded similar results, reinforcing the robustness of our findings. Moreover, subjective bulbar symptoms on the ALSAQ-40 were significantly associated with psychological distress, particularly in female patients.

CONCLUSION

This study identified the main clinical characteristics significantly associated with psychological distress in patients with ALS. Our findings may be useful in developing individualized psychological management strategies for these patients.

Prevalence of depression among amyotrophic lateral sclerosis (ALS) patients: A systematic review and meta-analysis

BACKGROUND

Amyotrophic lateral sclerosis (ALS) people have a high risk of severe mental disorders, like depression, which impacts their function, quality of life, and mobility. However, there are no estimates of depression based paper published. This study aimed conduct a systematic review and meta-analysis of the prevalence of depression in ALS patients around the world.

METHODS

PubMed/Medline, Web of science, Scopus, Embase, and Ovid are searched to identify papers that reporting the prevalence of depression. Studies are included in random-effects meta-analyses of the prevalence of depression. Subgroup analyses are performed on the severity of depression, instruments of depression, type of studies, and study regions.

RESULTS

46 eligible studies reported prevalence of depression. The pooled prevalence of depression among ALS people was 34% (27%-41%). According to the severity of depression, mild, moderate, and severe depression were 29%, 16%, and 8%, respectively. For studies using BDI, PHQ, and HADS, the pooled prevalence of depression was 50%, 20%, and 15%, respectively.

CONCLUSIONS

ALS people have a high prevalence of depression. The high prevalence of depression causes a reduction of quality of life and mobility. The study identifies a population group at high risk needing special attention in clinical practice.

Does a lack of social support and perceived stigma influence the relationship between motor neurone disease-related stress and psychological distress?

OBJECTIVES

This study aimed to investigate the mechanisms through which social support and felt stigma influence the relationship between motor neurone disease (MND)-related stress and psychological distress for people with MND. Although a lack of social support has been identified as a significant predictor of psychological distress for individuals with MND, the mechanisms through which this relationship exists have not been assessed, nor have the predictive nature of stigma. Furthermore, the theoretical model specifying the effects of enacted stigma on self-stigma has not been tested in individuals with MND.

DESIGN

A cross-sectional design utilizing an online survey method was used. It was hypothesized that social support would moderate the relationship between MND-related stress (operationalized as enacted stigma or physical functioning) and psychological distress (operationalized as depression, anxiety, and stress). Furthermore, felt stigma would significantly mediate the relationship between MND-related stress (enacted stigma) and psychological distress.

METHODS

Individuals with a diagnosis of MND were recruited internationally through social media and through various organizations and support services. Seventy-seven participants completed the online survey.

RESULTS

Significant correlations were identified between social support, felt, and enacted stigma and psychological distress. Moderation analysis was not significant. However, the mediation analyses identified felt stigma as a significant mediator of the relationship between enacted stigma and psychological distress. A direct relationship between enacted stigma and stress (but not depression and anxiety) was also evident.

CONCLUSIONS

A comprehensive approach to tackling stigma is important in ameliorating psychological distress for people with MND. Limitations of the current study are discussed, along with implications for clinical practice.

Beyond Denial and Despair: ALS and Our Heroic Potential for Hope

Because the patient with amyotrophic lateral sclerosis (ALS) knows at the outset that he or she is facing an incurable and always fatal illness, the experience of hope may be different in the ALS community from that in the general palliative care community. Although the word “hope” is frequently and passionately used by both patients and professionals in the ALS community, to date there has been little published on the subject. Hopelessness and despair are a very real part of the ALS experience. But true hope, of a kind more powerful than mere physical survival, can also be part of the ALS journey. What is this “hope” the professional is expected to engender and the patient is encouraged not to lose? How can professionals help the ALS patient find hope and meaning? This article is an exploration of hope by someone who has experienced ALS, first as an occupational therapist, then as the daughter and caregiver of an ALS patient. Based on literature review and personal experience, factors leading to both hope and hopelessness are explored. Finally, the author offers several strategies that palliative care professionals can use to help ALS patients find hope.

Interaction of physical function, quality of life and depression in Amyotrophic lateral sclerosis: characterization of a large patient cohort

Background

Due to lack of any curative therapy for ALS, symptomatic treatment and maintenance of quality of life (QoL) is very important. We aimed to characterize the affected domains of QoL in ALS patients and to identify factors which are associated with reduced QoL and increased depression.

Methods

159 ALS patients answered standardized questionnaires (Beck Depression Inventory-II, SF-36 Health Survey questionnaire, revised ALS functional rating scale). Multiple regression analysis was used to identify correlations between clinical features of ALS patients and depression/QoL scores. In addition, QoL data from ALS patients were compared to age-matched reference values representing the German normal population.

Results

QoL of ALS patients was reduced in nearly all SF-36-categories. Progression of physical impairment was positively correlated with depression but reduced QoL scores only in items directly related to physical function. However, QoL was considerably influenced by depression, independently from physical impairment. Regarding distinct patient characteristics one of the most interesting findings was that increasing age was correlated with significantly worse QoL results regarding social functioning.

Conclusions

Depressive symptoms had a strong influence on QoL, hence their detection and treatment is of particular importance. Different domains of QoL are differently affected in subgroups of ALS patients. Being aware of these differences can be valuable for both ALS professional and family caregivers and physicians.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-015-0340-2) contains supplementary material, which is available to authorized users.

Expressive disclosure to improve well-being in patients with amyotrophic lateral sclerosis: a randomised, controlled trial

Amyotrophic lateral sclerosis (ALS) is a terminal neurological disease associated with progressive paralysis, loss of communicative ability and functional decline. Expressive disclosure may help people with ALS, particularly those who are emotionally or socially inhibited, meet psychological challenges associated with the disease. People with ALS (N = 48) were randomised to expressive disclosure about their disease or no disclosure. Psychological well-being (affect, depression and quality of life) was assessed pre-intervention and also three and six months later. Results of multi-level models indicated that the group that disclosed thoughts and feelings about ALS had higher well-being than the control group at three months post-intervention, but not six months. Ambivalence over emotional expression (AEE) moderated three-month post-intervention well-being. Those low in AEE had higher well-being than those high in AEE regardless of condition. Those high in AEE, who disclosed, had increased well-being from pre-intervention, whereas controls had decreased well-being from pre-intervention. Expressive disclosure may be helpful for people with ALS, but only those who have difficulty expressing emotions. In addition, the intervention had only temporary effects; the dynamic challenges of ALS progression may mean that the effect of processing thoughts and feelings about the disease in one stage may not generalise to later stages.

Disease progression in a mouse model of amyotrophic lateral sclerosis: the influence of chronic stress and corticosterone

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by motor neuron cell loss, muscular atrophy, and a shortened life span. Survival is highly variable, as some patients die within months, while others live for many years. Exposure to stress or the development of a nonoptimal stress response to disease might account for some of this variability. We show in the SOD1(G93A) mouse model of ALS that recurrent exposure to restraint stress led to an earlier onset of astrogliosis and microglial activation within the spinal cord, accelerated muscular weakness, and a significant decrease in median survival (105 vs. 122 d) when compared to nonstressed animals. Moreover, during normal disease course, ALS mice display a cacostatic stress response by developing an aberrant serum corticosterone circadian rhythm. Interestingly, we also found that higher corticosterone levels were significantly correlated with both an earlier onset of paralysis (males: r(2)=0.746; females: r(2)=0.707) and shorter survival times (males: r(2)=0.680; females: r(2)=0.552) in ALS mice. These results suggest that stress is capable of accelerating disease progression and that strategies that modulate glucocorticoid metabolism might be a viable treatment approach for ALS.

Prevalence of depression in a 12-month consecutive sample of patients with ALS

There is an impression both in clinical practice and in research literature that patients with amyotrophic lateral sclerosis (ALS) possess 'heroic stoicism with a low frequency of depression'. Reliance on specific interview methods may have contributed to differing estimates of mood disorder in people with ALS. The objective of the current study was to compare prevalence rates of depression and anxiety in ALS using different assessment tools. The Beck Depression Inventory (BDI), The Hospital Anxiety and Depression Scale (HADS) and the Spielberger State-Trait Anxiety Inventory (STAI) were sent to a 12-month consecutive sample of 190 patients with ALS attending a tertiary referral clinic in the UK. Data were collected from 104 patients with ALS. Using BDI scores, 44% were categorized as not depressed, 37% were mild-moderately depressed, 13% were moderately-severely depressed, and 6% were severely depressed. In contrast, the HADS depression subscale identified 75% as not depressed, 13% were in the borderline range, and 13% were categorized as meeting 'caseness' for depression. Twenty-five percent of the patients were using antidepressant medication. The estimated prevalence of mood disorder amongst patients with ALS may vary significantly depending on the measure used.

A review of psychosocial aspects of motor neurone disease

Motor neurone disease (MND) is an illness involving the progressive degeneration of upper and lower motor neurones. There is no known cause or cure. The physical aspects of MND frequently receive the majority of attention, with psychosocial aspects accorded secondary importance. We undertook a comprehensive search of the available literature published between 1966 and 2006 on the psychosocial aspects of MND, including quality of life (QoL), depression, social support, life sustaining treatment (LST), coping, spirituality and current practice. The literature identified that QoL correlated more strongly with measures of suffering, social support and hopelessness than with the physical state of the patient. Depression is relatively common (prevalence rates up to 50%), as are other forms of psychological distress in the MND population, and is not associated with illness severity and functional status. Depression strongly correlates with QoL. Social support is often limited for MND patients and this also influences QoL. Hope and hopelessness are important issues for MND patients with hopelessness contributing significantly to suffering and, for some, a desire for hastened death. Choices and decisions about life sustaining treatments pose a burden for patients and carers. Despite the physical and emotional suffering associated with MND, a significant number cope well and find positive meaning in life. Many patients opting for life sustaining treatment report a satisfactory QoL. In conclusion, psychosocial aspects of life are important for patients with MND. Depression and other expressions of distress require recognition and treatment. Issues of hope, spirituality and life and death also require attention in clinical practice. Although guidelines exist to direct physicians to attend to the physical care, there is a distinct lack of guidance to attend to the psychological state of the MND patient.

Severity of depressive symptoms and quality of life in patients with amyotrophic lateral sclerosis

OBJECTIVES

The authors aimed at investigating the occurrence of depression and the level of quality of life in patients with amyotrophic lateral sclerosis (ALS), an incurable neurodegenerative disease leading to progressive motor paralysis. They further wished to elucidate correlates of depression and quality of life, such as physical impairment, time since diagnosis, age, sex, and education. Additionally, the authors attempted to confirm previous studies that had shown quality of life to be underestimated by partners or caregivers.

METHODS

To assess severity of depressive symptoms, the authors used Beck's Depression Inventory (BDI) and the ALS-Depression Inventory. To assess the patients' quality of life, they used the Scales to Assess Quality of Life. The same questionnaire was presented to partners or caregivers to estimate the patients' quality of life.

RESULTS

Severity of depressive symptoms was everything from not depressed to clinically relevant depressed. On average, quality of life was rated as satisfactory. Severity of depressive symptoms and quality of life showed a moderate positive relation to physical impairment and a weak negative relation to time since diagnosis. Partners or caregivers rated patients' quality of life significantly lower than did the patients.

CONCLUSIONS

Although depression occurs among ALS patients, it is not inevitable. Patients can remain free of depression and maintain a good quality of life. Depression should be treated, and patients have to be provided with unbiased information, including their medical and palliative care options.

Das ALS-Depressionsinventar (ADI):

Zusammenfassung. Theoretischer Hintergrund: Bei der amyotrophen Lateralsklerose (ALS) handelt es sich um eine fortschreitende degenerative Erkrankung, die zu vollständigem motorischen Funktionsausfall führen kann. Depressive Stimmung bei ALS-Patienten wirkt sich verkürzend auf die verbleibende Lebensspanne aus. Zur quantitativen Erfassung von Depression bei ALS-Patienten werden Fragebögen verwendet, die die spezifische Situation der zunehmenden körperlichen Beeinträchtigung bis hin zur vollständigen Lähmung und künstlicher Ernährung und Beatmung nicht berücksichtigen. Fragestellung: Die Entwicklung eines speziell auf diese Patientengruppe ausgerichteten Inventars zur Messung depressiver Symptomatik. Methode: Das neu entworfene Inventar wurde gesunden Personen (93), ALS-Patienten (76) und depressiven Patienten (56) vorgelegt. Anhand der Ergebnisse wurde das ursprüngliche Inventar auf 12 Items reduziert (ADI-12). Ergebnis: 75% der ALS-Patienten wiesen depressive Symptome auf. Patienten mit ALS waren signifikant weniger depressiv als Patienten mit Depression. Schlussfolgerungen: Bei ALS-Patienten ist mit depressiver Verstimmung zu rechnen. Mit dem ADI-12 kann Depression auch noch bei schwerstbeeinträchtigten ALS-Patienten gemessen werden.

A cross sectional study on determinants of quality of life in ALS

BACKGROUND

Understanding the determinants of quality of life (QoL) in amyotrophic lateral sclerosis (ALS) has become increasingly important with the recent emphasis on the comprehensive management of patients.

OBJECTIVE

To evaluate the determinants of QoL in ALS using two scales with different theoretical constructs: the Schedule for the Evaluation of QoL-Direct Weighting (SEIQoL-DW), which evaluates subjective aspects of QoL, and the McGill QoL Questionnaire (MQOL), which evaluates both health related and non-health related factors of QoL.

METHODS

Eighty consecutive patients with ALS underwent a battery of tests evaluating QoL and a series of physical, emotional, psychological, and socioeconomic predictor variables. A stepwise linear regression model was used to compare QoL scores and explicatory variables.

RESULTS

SEIQoL-DW score was related to social support, depression, religiosity, and socioeconomic status. Total MQOL score was related to social support, socioeconomic status, and clinical status. MQOL single item score (MQOL-SIS) was related to social support, depression, social withdrawal, and socioeconomic status. SEIQoL-DW score was not related to total MQOL score. Conversely, a significant correlation was found between SEIQoL-DW and MQOL-SIS.

CONCLUSIONS

With both QoL scales, the most important explicatory variable of QoL was the self perceived quality of social support. Physical status was not relevant in determining QoL. This study indicates that health related QoL measures are not adequate to assess QoL in patients with ALS, because their appreciation of QoL mainly relies on psychological, supportive, and spiritual factors. Therapeutic interventions should consider the psychological needs of patients and pay greater attention to caregivers' issues.

Assessing individual quality of life in amyotrophic lateral sclerosis

BACKGROUND

Quality of life (QoL) assessment in amyotrophic lateral sclerosis (ALS) has typically involved the use of general or disease-specific health status questionnaires. This study assessed the feasibility of using a patient-centered approach to QoL measurement in ALS.

OBJECTIVES

(1) To assess the internal consistency reliability and validity of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL) as a measure of QoL in ALS. (2) To provide a brief description of QoL in ALS, and to examine the relationships between QoL, illness severity and psychological distress in this group.

METHODS

Twenty-six patients with ALS were recruited through the Irish Register for ALS/motor neurone disease (MND). Illness severity was assessed with the ALS Functional Rating Scale (ALSFRS). Levels of psychological distress were measured with the Hospital Anxiety and Depression Scale (HADS). Individual QoL was assessed with SEIQoL.

RESULTS

Patients were at various stages of ALS. Mean levels of anxiety and depression were in the normal range. Twenty-one patients completed SEIQoL; five patients completed a shorter version, SEIQoL-Direct Weighting (SEIQoL-DW). Internal consistency reliability and validity results for SEIQoL were high.

CONCLUSIONS

SEIQoL is generally acceptable for use in ALS in terms of its practical feasibility, and has high internal validity and consistency reliability in this patient group. However, patients severely disabled by ALS may not be able to complete SEIQoL; further research is required to confirm the use of SEIQoL-DW as an alternative measure of individual QoL in ALS.

Quality of life issues in motor neurone disease: the development and validation of a coping strategies questionnaire, the MND Coping Scale

A person's ability to cope with having motor neurone disease may be an important factor in determining their quality of life. We have developed a scale to measure coping strategies in people with MND. A disease-specific and patient-focused approach was employed. Open-ended interviews were used to generate initial items. Coping with the condition was an important consideration for all subjects. The final scale was administered to a sample of 44 people with MND. A factor analysis of the results demonstrated subscales comprised of distinct styles of coping. Reliability and validity were demonstrated within individual subscales. Significant correlations were shown between coping styles and psychological well being, disease duration and disability. Although still at a preliminary stage of development, the MND Coping Scale is proposed as a useful tool for further longitudinal study of coping in MND, with the potential to discover cause effect relationships between coping and psychological outcome.

Expanding the role of hospice care in amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive, ultimately fatal, motor neuron disease that poses a myriad of clinical and end-of-life problems. The needs of advanced ALS patients are well suited to the interdisciplinary, multi-modality setting of hospice, where comprehensive palliative strategies may ease suffering and allow the patient to die with dignity in the home. Unfortunately, hospice services are far underutilized in this setting. There is a great need to increase awareness of both patients and clinicians regarding the effectiveness of hospice in the care of advanced ALS patients.

Evaluation and rehabilitation of patients with adult motor neuron disease

Adult motor neuron disease (amyotrophic lateral sclerosis [ALS]) is a neurodegenerative disorder characterized by loss of motor neurons in the cortex, brain stem, and spinal cord, manifested by upper and lower motor neuron signs and symptoms affecting bulbar, limb, and respiratory musculature. Clinically, the disease course is characterized by progressive weakness, atrophy, spasticity, dysarthria, dysphagia, and respiratory compromise, ultimately resulting in death or mechanical ventilation in the vast majority of patients. Patterns of presentation and pathological features of the disease, along with clinical and electrophysiologic criteria for diagnosis, are discussed in this review. Since 8% to 22% of patients survive more than 10 years without ventilator use, meticulous medical and rehabilitation management is extremely important to ensure optimal health and quality of life in these patients. Major issues in the care of individuals with ALS include weakness and spasticity, impairments in activities of daily living and mobility, communication deficits and dysphagia in those with bulbar involvement, respiratory compromise, fatigue and sleep disorders, pain, and psychosocial distress. Research in ALS changes rapidly, but is currently focused on potential etiologic factors such as glutamate excitotoxicity, role of oxidative stress, autoimmunity to calcium channels, and cytoskeletal abnormalities, as well as related treatment initiatives including glutamate modulators, neurotrophic factors, antioxidants, antiapoptotic factors, and gene therapy. Recently, mutations in the gene encoding Cu/Zn superoxide dismutase were identified in a subset of familial ALS patients. Riluzole, a glutamate antagonist and Na-channel blocker, became the only drug currently approved for treatment of ALS after studies showed a small positive effect on survival. Until a definitive treatment or cure for ALS is found, the multifaceted rehabilitation team approach remains the best hope for improving health and survival in this devastating illness.

The psychological impact of MND on patients and carers

Nineteen patients with Motor Neurone Disease (MND) who had been living with their partners for at least two years prior to the onset of their illness, together with their partners, completed self-report questionnaires to investigate the impact of MND on both patients and carers. Physical disability and impact of the illness on aspects of everyday functioning were related to levels of anxiety and depression in the patients; psychological coping strategies adopted depended to some extent on symptom duration. Carers also demonstrated signs of anxiety and depression, with the latter correlating with aspects of the patients' functional impairment. Perceived strain in carers over caring for the patient correlated with a loss in intimacy in their relationship, which in turn was predicted by patients' cognitive/behavioural and communication changes. Changes in patients' social performance also correlated with the extent to which carers felt that the illness was affecting other areas of their life, the extent to which their partner dominated their thoughts and the extent to which they could control their reactions when thinking about the patient. Satisfaction with formal services and the number of social groups to which carers belonged correlated with carers' self-predicted future ability to cope.

Analysis of health-related quality of life and muscle impairment in individuals with amyotrophic lateral sclerosis using the medical outcome survey and the Tufts Quantitative Neuromuscular Exam

OBJECTIVE

The Tufts Quantitative Neuromuscular Exam (TQNE) is commonly used to assess the rate of disease progression in individuals with amyotrophic lateral sclerosis (ALS). The Medical Outcome Study Short Form (SF-36) is a general method to assess health-related quality of life (HRQL). This study examined the relationship between the TQNE and SF-36, established the reliability and responsiveness of each, and contrasted the HRQL between individuals with ALS and the general population.

DESIGN

Subjects (31) completed the SF-36 and TQNE within 1 week to determine reliability. Subjects (17) also completed both the TQNE and SF-36 each month for 1 year after diagnosis of ALS to establish the relationship between the two assessment tools.

SETTING

A primary care university teaching hospital.

PATIENTS

Thirty-one subjects with an age range of 27 to 76 years (mean 59.1, SD 10.32), recently diagnosed with ALS.

RESULTS

Each test was highly reliable and responsive. The intraclass correlations (2, 1) were consistently higher for the TQNE (.93 to .98) than for the SF-36 (.57 to .90). Changes in physical function were correlated to changes in lower extremity force megascores (.48).

CONCLUSION

Both the TQNE and the SF-36 are reliable and responsive and appear important in characterization of patient status after ALS is diagnosed.