MS Resource for Long-Term Care Staff

MS is a neurological disease of the central nervous system (CNS), including the brain, spinal cord, and optic nerves. Each person is affected by MS differently.

In MS, the immune system attacks myelin, the protective covering of nerve fibers in the brain, spinal cord and optic nerves. Myelin is important because it helps messages travel quickly and smoothly between the brain and the rest of the body. When myelin, gets damaged (a process called demyelination), it can also harm the nerve fibres themselves. Scar tissue (lesions) may form in these damaged areas, which can block or slow down the communication between nerves and the rest of the body, causing various symptoms.

Canada has one of the highest rates of MS in the world, with an estimated 1 in every 400 Canadians living with the disease. Although it’s most often diagnosed in adults aged 20 to 49, younger children and older adults are also diagnosed with the disease. MS is three times more likely to occur in women than in men. 

While the exact cause of MS is unknown, it’s believed to be caused by a combination of genetic, environmental, and lifestyle factors. There are many environmental and lifestyle risk factors for MS like vitamin D deficiency, adolescent obesity, smoking, and infection with Epstein-Barr virus (EBV). 

Symptoms of MS can be unpredictable and vary greatly from person to person. Many symptoms are invisible to everyone but the person living with the disease. Symptoms depend on the area within the CNS that’s been damaged and can include fatigue, problems with balance, weakness, odd sensations like tingling or numbness, vision problems, bladder and bowel problems, and cognitive and mood changes. Although different symptoms can be experienced in MS, it’s unlikely that people will experience all the symptoms listed above.

MS is a continuous disease process because it progresses through different stages over time. Everyone with MS has a unique disease course that can vary widely in severity, symptoms, progression rate, and response to treatment. Individuals may be initially diagnosed with one of the following depending on the pattern of symptoms or progression.

Radiologically isolated syndrome (RIS) refers to demyelination seen on MRI which is highly suggestive of MS but without any physical symptoms or signs of the disease. Nearly half of people with RIS will be diagnosed with MS within ten years.

Clinically isolated syndrome (CIS) refers to a single episode of neurological symptoms suggestive of MS. Not everyone with CIS will be diagnosed with MS however over the longer term, about 80% of people develop more MS disease activity that leads to a diagnosis of MS.  

Between 85-90% of people living with MS are initially diagnosed with relapsing-remitting MS (RRMS), characterized by neurological symptoms called relapses (also called attacks, exacerbations, and flare-ups) followed by complete or partial recovery (remission). 
 

Progressive MS

Some people with RRMS will transition to a phase of the disease called secondary progressive MS (SPMS). This phase of the disease has fewer relapses with increasing disability progression. The rate of worsening is different for everyone and typically is more gradual than the worsening experienced with MS relapse. About 10 percent of people will be diagnosed with primary progressive MS (PPMS). PPMS is characterized by a slow build-up of disability, usually without relapses. Overall, there are no periods of significant improvement or return of function over time. 

In MS, the immune system does not behave normally. This leads to inflammation that damages the protective covering around nerve fibers (myelin). Over time, the nerve fibers are also damaged. The damage (lesions) blocks or slows down communication between nerves and the body. This causes neurological symptoms like weakness, tingling or numbness, and changes in thinking or memory.

MS can be described as active or inactive. Relapses and new or growing lesions seen on MRI scans or both mean MS is active. When there are no relapses or visible changes on MRI scans then MS is inactive. However, even if MS is inactive a person with MS may still have ongoing symptoms. Neurologists use MRI scans, physical exams, and other biomarkers (blood or spinal fluid tests) to check if MS is active or not.

Each person will experience MS differently. This includes how their disease progresses. Disability progression can result from relapses. Progression also occurs independent of relapses due to ongoing inflammation and other processes in the brain and spinal cord. Both play a role in disability progression over time, starting in the early stages of MS and continuing throughout the disease.

Brain reserve is the brain’s ability to protect against damage due to disease or aging. People with more reserve may experience more damage to the brain without showing any symptoms. The brain also has some natural ability to repair itself. As we get older, this ability decreases, and the brain can’t repair itself as well. In MS, this natural loss of brain reserve can make old damage show up as disability. There are currently no medications to treat nerve repair (remyelination) but this is an area of ongoing and promising research.

There is no definitive diagnostic test for MS. The symptoms a person may have experienced over months or years may resemble other conditions and a neurologist must rule out other diseases and conditions before making a definite diagnosis of MS. To diagnose MS, a neurologist will first take a detailed medical history and complete a neurological examination to check a person’s strength, reflexes, sensations, eye movements, and how they walk.  Other diagnostic tests include magnetic resonance imaging (MRI) to show areas of damage (lesions) in the CNS, lumbar puncture (spinal tap) to test the cerebrospinal fluid (CSF) for the presence of specific proteins (antibodies), and evoked potentials (EP) to measure nerve impulses in the CNS.

Currently, there is no cure for MS. Researchers in Canada and around the world are focusing on research areas with the greatest potential to stop MS, restore function, and repair damage from the disease, and end MS through prevention.

There are several medication options for MS. Disease-modifying therapies (DMTs) are medications that modify or influence the underlying disease course. DMTs do not treat symptoms of MS but target the inflammation that causes damage to the CNS. There are also medications to treat relapses and diverse medications that help relieve the various symptoms that can be experienced in MS.

Many strategies can be used to maintain overall wellness and improve quality of life, like physical activity, physiotherapy, rehabilitation, and following an overall healthy lifestyle with a balanced diet. In addition to wellness strategies, there are several medication options for MS. 

Providing information about health problems, preferences, and needed care to clinical staff at the center, in advance of admission, will help staff to prepare. 

Ask families to gather detailed information about all healthcare providers including:

• contact numbers
• details about diagnosis
• completed physician’s examination form with up-to-date assessments
• information about hospitalizations, current treatment, and medication regimens 

Long-term care facilities provide care to people of all ages, each with unique needs and challenges. Understanding the differences between younger and older people is important to give the best care to each person. The facility must have experience and expertise in managing MS. This includes having staff trained in MS-specific care and symptom management.

To help maintain and improve the mobility and function of younger people, access to the comprehensive rehabilitation services listed below is crucial:

• physical therapy
• occupational therapy
• speech therapy

Younger people should get different tools, technologies and equipment that help them with everyday activities and allow them to be more independent.  They might also have different emotional and social challenges compared to older people. This is why it's important to offer customized psychosocial support, including counseling, support groups, and recreational activities that are age appropriate. Specialized assessment tool for younger people in long-term care, have been developed and should be used as part of the admission process.

The CSA Group (Canadian Standards Association) published Mental health and well-being in long-term care (LTC) and assisted living (AL) settings which includes standards related to transitions to long term care. Long-term care facilities should create a customized transition plan for younger people, addressing their unique social, emotional, and physical needs. The specialized assessment tool for younger people can help create a tailored plan. 

Encourage families to communicate openly with one another about the difficult transition ahead and seek professional counseling if needed. This might allow for a smoother transition, minimizing the guilt, anger, resistance, and sadness that may come along with this decision. It’s not uncommon for families to experience considerable guilt when placing their loved one in long-term care. 

Careful evaluation of existing financial resources for long-term care may require the services of a certified financial planner. 

Choosing someone to make healthcare decisions and plans for medical care: It’s important to choose a person or persons who will make medical decisions if the individual can’t as determined by a physician. It’s also important that the family talks about resuscitation, artificial feeding, mechanical ventilation, treatment with antibiotics, etc. prior to admission. 

Getting medical equipment that’s needed before someone moves in might be easier than ordering it after they become a resident.  For example, anticipating the need for a specialized wheelchair or seating equipment, might avoid problems gaining approval after long-term care admission.

Issues with balance cause someone to feel unsteady. In MS it can cause difficulty in walking, unsteadiness, loss of coordination, and trunk instability when seated. Taking notice of how well someone sits is an important safety concern. Occupational and physical therapists can suggest ways to provide support while sitting, and supervised exercises to improve balance, like using a Swiss Ball, which could help to improve balance. 

Bladder problems are common in MS and can pose a serious threat to health, so it’s important to do regular checks on bladder health. Proper management is necessary to prevent urinary tract infections and dangerous urinary retention that may damage the bladder or kidneys. Bladder problems can include frequency and/or urgency of urination, incontinence, hesitancy in starting or maintaining urine flow, or, in some cases, complete inability to urinate (retention). Frequent nighttime urination (nocturia) may interfere with sleep. Assessment of bladder function by a urologist is the first step in dealing with bladder issues. People with internal catheters experience more urinary tract infections. If an internal catheter is necessary, a suprapubic tube should be considered as it may decrease the risk of infection. Some women may still be menstruating and/or have bladder incontinence, which increases the risk of infection with internal catheters. Bladder problems can also impact someone's willingness to participate in social activities. For example, urinary incontinence may cause people to not want to participate in activities or going on outings, because they will worry about having an accident. This can contribute to isolation and depression, greatly impacting their overall quality of life.

Constipation is defined as an uncomfortable feeling of having a full rectum but being unable to have a bowel movement, having less than three bowel movements per week, or stools that are difficult to pass. Constipation can happen if there isn’t enough fluid or fibre in the diet, decreased physical activity, medication side effects, or as a symptom of MS. Diarrhea could happen because of leakage around fecal impaction or intestinal disease. To help constipation, the below list should be considered: 

• drinking more fluids
• eating more fiber
• following a routine bowel schedule
• taking fiber supplements or stool softeners
• using laxatives, glycerin suppositories, or mechanical stimulation

Frequent use of enemas should be avoided but may be necessary occasionally. Be sure to check the temperature of an enema as the person may not be able to feel it if it is too hot.  Diarrhea can happen because of a blockage in the bowels, or overuse of laxatives, or medications. Fecal incontinence (loss of bowel control) may also occur because of a weakened control of the sphincter or hyper-reflexive bowel. Check the perianal area (area between the anus and the genitals) often for any signs of irritation. A structured, daily plan for bowel management can lead to more predictable bowel habits.

Memory, information processing, attention, concentration, short-term memory, and judgment may be impaired in people living with MS. LTC staff should be aware of the cognitive changes associated with MS, so that they can be recognized, and appropriate care can be put in place. Cognitive changes affecting judgment, planning, and organizational function may impact the safety of operating wheelchairs, especially power-operated wheelchairs, or scooters. An occupational therapist should be consulted to address issues of safe operation of power devices for people with MS who are experiencing cognitive problems.

Fatigue is one of the most common symptoms of MS.  Occupational therapists can advise on energy-saving techniques, like pacing activities, planning, and balancing rest and activities. Overheating should be avoided.

Like other symptoms, fatigue can vary from hour to hour or day to day. A person with MS may be able to do many tasks in the early part of the day but need assistance with the same tasks in the afternoon because of MS fatigue. Fatigue can worsen if the person has other illnesses, a fever, or exposure to heat (including things like hot baths, using an electric blanket, or the room temperature being set too high). Other causes of fatigue should also be ruled out, for example, sleep apnea, iron deficiency, and thyroid dysfunction. 

Heat aggravates MS symptoms in many people with MS. This temporary worsening of symptoms, which can be relieved by cooling, does not mean the disease is getting worse. Air conditioning is very important for people with MS. Cold drinks, cool showers and ice packs/cooling vests may also help people who are affected by heat. Symptoms experienced with heat should get better as the resident cools off.

Musculoskeletal pain is a result of MS-related impact on the bones, muscles, tendons, and ligaments that make up the musculoskeletal system. Poor posture can lead to back and neck pain that can be helped with better body positioning strategies. Depending on the source and type of pain, anti-spasticity drugs, anticonvulsants, and antidepressants may help. Severe pain might need more invasive treatments. Other pain management strategies like acupuncture, ultrasound, and meditation may help.

Pain from MS can also be nerve-related, caused by damage in the CNS. The most common type of neurogenic pain in MS involves burning, prickling, band-like, or tingling sensations. Allodynia is when something that usually doesn’t cause pain, like a light touch, feels painful. 

Not all pain is associated with MS, so people need to discuss any pain with their healthcare provider to find a proper diagnosis. 

Weakness of the respiratory muscles due to MS makes people more likely to experience influenza, pneumonia, and pulmonary infection. While a common cold may not cause a problem for most people, having respiratory muscle weakness, inadequate deep breathing and an inability to cough, increases the risk of developing pneumonia. People with weak respiratory muscles might have trouble breathing, which makes it hard to clear mucus. A respiratory therapist can evaluate the resident and suggest ways to help, like breathing exercises, and mechanical devices to stimulate breathing. People with tracheostomies may need suctioning or respiratory treatments. Routine vaccinations are recommended according to the guidelines set by local public health authorities.

Seizures can occur in about 5% of people with MS. Most seizures can be managed using the right anticonvulsant medication and continuing regular check-ups with their healthcare team. 

Numbness and tingling are common in MS and some people may experience sensitivity to touch or experience unusual sensations in response to touch. Others may experience an electric shock sensation when they bend their neck forward called Lhermitte's sign. Sensory disturbances can cause safety risks during activities like bathing and eating (exposure to hot water, beverages, and food), smoking, and wheelchair driving. Numbness may delay or prevent someone from reporting incontinence.

Pressure sores: Reduced sensation and limited movement can lead to skin damage. Anyone who’s not ambulatory should be considered high risk and follow the centre’s high-risk protocols. Urinary and fecal incontinence may delay the healing of pressure sores, so it’s important to keep the area clean and dry. In some cases, short-term urinary catheterization or a colostomy may be needed to allow healing. Pressure sores must be monitored closely for signs of infection. Spasticity, impaired sensory awareness, and cognitive change also increase the risk. 

Prevention of pressure sores includes wheelchairs that are designed to give proper support and pressure-relieving seat cushions and mattresses with shearless covers and pressure relief in the heel and sacral areas to prevent skin breakdown.

Spasticity is involuntary muscle stiffness or spasms. Management of spasticity or too much muscle tone (hypertonia) can be a challenge because of coexisting symptoms like weakness and fatigue. Management includes stretching exercises and medications. 

If spasticity is not managed, it can affect personal care, and cause complications like skin breakdown, restricted muscle movement, and pain. On the other hand, some people may rely on lower limb spasticity for transfers, standing, and walking.

Dysarthria is the most common speech problem in MS. It’s characterized by slurred speech or a change in normal speech rhythm. People may have difficulty with pronunciation and articulation, which makes communication difficult. Some people have slowed speech and have word-finding difficulty, making ordinary conversation difficult. Hypophonia, a problem with volume control (reduced speech intensity), might also occur. Speech and language pathologists may be able to recommend assistive devices to help with communication, like voice synthesizers, voice amplifiers, and computerized communication devices.

People who have trouble swallowing may benefit from adjusting the positioning of their head and chin, food consistency, and planning rest periods before meals. These techniques may help prevent choking and help with getting enough nutrition. Swallowing studies (barium swallow) are available as an outpatient procedure at most hospitals. They work best alongside speech therapy to determine the cause of the swallowing problem. The swallowing process is complicated, and if a person is given the wrong diet or fluid consistency, it could worsen the problem. Some people can’t swallow enough fluids in a 24-hour period to maintain hydration, causing weakness and fatigue. Others must eat such small bites of food that it would take nearly an hour for every meal to receive sufficient nutrition. If the person becomes tired after 30 minutes, their risk of choking increases as the meal continues. If the meal is stopped, malnutrition could happen. 

It’s best to consult with the facility’s Registered Dietician, who can make proper recommendations for texture and fluid consistency.

The most common tremor in MS is a intention tremor that happens with the intentional movement of the arm, leg, or head. This type of tremor is often exaggerated with stress. Certain medications might help along with physical techniques, for example, weighting, immobilization, and patterning. Tremors may be challenging to control. Speech therapy may help control tremors of the lips, tongue, and jaw.

Visual problems in MS may include optic neuritis (inflammation of the optic nerve), double vision, and involuntary movement of the eye (nystagmus). Problems with eye muscles make it hard to focus on objects, causing blurred or double vision. Dysfunction in the brain centers that control eye movement may also result in a jerking movement of the eyes. This can also cause vertigo and dizziness. Reduced vision might make it difficult for the person to read, watch TV, go to the movies, etc., reducing opportunities for activities and social interaction.

Weakness is caused by damage to nerve fibres in the brain and spinal cord, as well as the result of reduced mobility. Weakness can increase fall risk, buckling of the lower limbs, clumsiness, slowness of movement, and loss of strength. Strengthening exercises may improve the strength of muscles that are weak from lack of use, but they will not improve muscle weakness due to CNS damage. Managing weakness must be done at the same time as the management of spasticity and fatigue to be effective.

Long-term use of corticosteroids as well as reduced mobility over time can cause osteoporosis. All people with MS in a long-term care home should be considered at risk for osteoporosis. Treatment and prevention with exercise programs, calcium-rich foods, and dietary supplements, including vitamin D, as well as the use of medication are likely to be needed. Care should be taken in transfers. Prevention of falls is particularly important as fractures may occur easily and heal slowly.

Sleep disturbances can worsen daytime fatigue, and might be related to nighttime muscle spasms, bladder disorders, pain, depression, or other factors.

Lack of activity caused by disability, as well as depression, can contribute to obesity. Exercise, diet, and medication should be considered, as obesity is associated several other serious health conditions. Long-term care staff monitor individuals’ weight and provide a diet that not only meets nutritional needs but also prevents weight gain and obesity. If people have gained weight, their mobility and stability aids (e.g., seating and bracing) should be reassessed. 

For people who have underlying weakness and impaired ability to clear secretions, there’s a greater risk for infections which can then lead to pneumonia. Pneumonia can occur more frequently in people with MS who are not active and have shallow breathing.

People with MS should follow the recommendations based on provincial and territorial routine vaccination programs, or as directed by their healthcare provider. Flu can be serious in someone with reduced lung function. Also, high fever accompanying flu may worsen MS symptoms. Live vaccines, which contain a live, weakened virus are not recommended for a person with MS because there is a risk that their immune system can’t control the weakened virus properly, leading to an actual infection.

All people in long-term care homes must consider and inform family and staff about their wishes for medical care (advance directives). This includes their wishes regarding medical treatments and end-of-life care if they become unable to make health care decisions for themselves.

People living with MS and their families may be hesitant to discuss these difficult matters in depth, especially when the person with MS is young or middle-aged. However, they must define their wishes clearly so that family and staff understand what measures to take or avoid regarding end-of-life care. Questions like hospital versus no hospital, intubation or not, antibiotics or not, and continued nutrition or not, need to be addressed. 

When the quality of life seems to deteriorate for people with very advanced MS, they may express a wish to die, discontinue treatment, refuse nutrition, or engage in risky behaviours. Staff must understand the best ways to discuss matters like these with the person and bring in other professionals as needed (e.g., clergy, psychiatrists, social workers, hospice professionals). The cause of death for people with MS is typically complications related to the disease. If there’s significant clinical compromise and respiratory weakness, UTIs leading to sepsis, stage 4 pressure ulcers, critical nutritional impairment, or other life-threatening complications, it might be time to consider end-of-life care options.

The decision to enter long-term care, even a home of high quality, is difficult. When the loved one is a younger person with MS, the decision is much harder. When it becomes too difficult to continue to care for someone at home, long-term care often becomes the safest option. The psychological effects of placing or transitioning a young–middle-aged person into an environment generally geared towards the care of older adults make the decision difficult for both the person with MS and their loved ones. 

Generational differences mean that the person with MS will undoubtedly have different needs, interests, and adjustment issues compared to the older adults at the long-term care center. Younger people living with MS who enter long term care may have young children, a spouse, or aging parents. 

Providing appropriate training for staff in MS care, offering age-appropriate programming, and suitable space and facilities that accommodate accessibility issues, will make this difficult transition smoother and improve the quality of life for people with MS. The recommendations below focus on the psychosocial needs of a younger person with MS: 

Grief may be experienced from the time of diagnosis and throughout the disease. Every change or symptom can represent a loss of self and personal identity, autonomy and personal control, of a particular skill or ability — things that most adults cherish. Every loss of ability or control requires a change in the person’s self-image; every time the self-image changes, the person may grieve. 

Anxiety is a common response to the unpredictability of MS. From year to year, even day to day, people with MS do not know how they’re going to feel or what parts of their bodies are going to be affected. Unpredictability makes people feel out of control of their bodies and their lives, and when people feel out of control, it’s not unusual for them to become anxious.

Resentment may be experienced by people who feel their life’s goals have been taken away. Expressing anger constructively is key - focusing it on the disease rather than on those around them. Sometimes people feel stuck with anger that has no outlet.

Depression can be in reaction to living with a chronic disease and can also be caused by neurologic changes of the disease itself. Clinicians should be attentive to signs of depression and offer counseling, consultation with mental health specialists, and pharmacologic treatment. More than half of all people with MS will experience a major depressive episode at some point over the disease course. Fatigue is a primary symptom of MS and can also contribute to depression. Intervention with psychotherapy and antidepressants usually helps. Long-term care staff should refer people experiencing depression to community mental health professionals if this service isn’t provided in-house. 

Long-term care staff should be trained in identifying signs of severe depression and suicide risk. Research suggests that suicide risk in people living with MS is more linked to feeling isolated and having a negative self-view, rather than the level of disability. 

Other helpful resources include: 

Canadian Association for Suicide Prevention
The Center for Addiction and Mental Health- Suicide resources
Canada.ca - Suicide Prevention

By the time people with MS come to live in a long-term care setting, most have been cared for by family members for some time. MS is a family disease. All family members must come to terms with the disease in their own way and may have different, and sometimes conflicting, coping styles. Because the disease can vary greatly, a family’s rhythm and roles are often shifting and might need many different forms of family organization. MS can impact family resources in terms of money, time, and energy. Placement of a family member with MS into long-term care can be an extremely difficult decision for families.

Offer age-appropriate and meaningful exercise, social, vocational, and leisure activities for people living with MS. Activities might include fitness classes, continuing education, computer activities, volunteer opportunities outside of the long-term care home, theatre trips, and shopping trips into the community. Younger adults will enjoy different music, watch different movies/TV shows, eat different foods, and stay up later at night than older adults.

If the LTC site has a recreational therapist (RT) on staff, they can be referred to recreation therapy services and have a leisure needs assessment completed. The RT can work with the person to develop a tailored Leisure Plan and set measurable goals to enhance their well-being and maintain their current level of leisure lifestyle. This plan may also include leisure education, and opportunities for the person with MS to learn how to adapt activities to their level of physical and cognitive functioning. Activities and leisure opportunities offered should include all dimensions of wellness like physical, social, community engagement, environmental, emotional, intellectual, and spiritual. 

Spiritual programming offers emotional support and a sense of community for people who may have been active members of their local place of worship before entering long term care.

Provide opportunities for private interaction with loved ones who visit. Provide appropriate spaces for visits with spouses and young children. Accommodations that allow opportunities for private sexual expression may also be appropriate for many people with partners who visit.

Offer as much choice and independence as possible regarding activities of daily living, for example, when to get out and go to bed, showering schedule, clothing, makeup choices, etc. All people in long term care should have choices in their daily activities, but younger people often have specific preferences for things like showering or bathing schedules, clothing, food, and personal grooming. Independence may be expressed as accomplishing some tasks alone, making independent choices, and directing their own care.

Encourage as much independence in eating as possible, since self-feeding is often a priority for people.  Involve a speech therapist and occupational therapist to provide advice about positioning during eating, appropriate exercises for muscles of the mouth, other swallowing and self-feeding techniques, and adaptive equipment that might be useful.

Have lift devices (e.g., Hoyer lifts or track lift systems) and other transfer aids (e.g., transfer belt, sliding board) available to all staff for transfers. People with MS may be heavier (as they are younger and less frail) and because of MS spasticity, spasms, and loss of upper or lower limb function, are usually more dependent on transfers than older adults. Make sure staff are appropriately trained in transfer techniques.

Staff may be closer in age to younger people with MS than to older adults, which can lead to stronger identification and potential friendships. There may be instances where inappropriate advances occur, either from a staff member toward a younger adult with MS or from a younger adult with MS toward a staff member. These complex relationship issues should be addressed in staff training, which should cover boundaries and appropriate relationships.

Provide training for staff on the potential behavioural and cognitive changes in people with MS. Understanding the emotional and cognitive impacts of MS can help staff be more sensitive to how these issues affect daily behaviour and relationships. For example, a person may be demanding and unpleasant to staff during daily routines. There may be angry outbursts and inappropriate behaviour. It is important to understand the emotional impact of the loss of control that comes with advanced MS. The person may make up for this loss by controlling people around them, or they may have cognitive changes affecting their behaviour.  

Behavioural support strategies like an individualized care plan (e.g., playing music during hands-on care, or allowing a resident to choose a female/ or male staff if preferred) are generally recommended as the standard for responding to behavioural issues. Learned helplessness is more common among people who have entered long-term care at a younger age. Staff training should focus on this concept and strategies to promote independence. 

Group programs provide the opportunity for socialization, peer support and therapeutic exercise (e.g., stretching, range of motion) and skills training (e.g., transfer training, ADL training). 

Music and art therapies, writing programs, pet therapy, etc. provide opportunities for self-expression. They can enhance adjustment to the long-term care setting, improve attitude and outlook, and provide fun, stimulating, and enjoyable activities in which to participate.

Communication problems due to MS include weakened (slurred) speech and scanning speech (words are split into syllables with pauses between them). These challenges can also be seen in older adults. Communication challenges in MS differ from those associated with stroke (aphasia). 

Speech and occupational therapists often work together to improve the communication abilities of people with MS. Some individuals may need communication devices, such as speech synthesizers, voice amplifiers, or letter boards. Most people would benefit from having access to email and the internet.

Self-controlled heating and air-conditioning in rooms are an important feature for people with MS. MS symptoms may temporarily worsen when they’re exposed to a hot environment, hot shower, or bath, or have a fever. MS spasticity may worsen in a cold environment.

People can apply to the MS Canada Quality of Life Program for cooling products (e.g., fans, portable air conditioners, etc.). For more information, please visit the Support & Services section at www.mscanada.ca, or contact an MS navigator at 1-844-859-6789 or email: msnavigators@mscanada.ca

• The physical layout of the space should make it easier for people to socialize and help them be independent and move around freely like elevator controls that can be operated independently, accessible lounges and socialization areas, and wide hallways to allow for larger wheelchairs.
• Younger adults may need more privacy as they may have young families who visit. Child-friendly (i.e., noise is OK, safe play) areas and lounges or rooms where families and spouses can go (and perhaps stay overnight) may help people with MS adjust to the long-term care setting.
• Staff and people living with MS should receive training on gym equipment, video game technology, or other recreation equipment before using it. 

Offer access to assistive technology for mobility, personal comfort, and intellectual stimulation. Assistive technology is any item, piece of equipment, or product system that helps people with disabilities increase, maintain, or improve their quality of life.  This includes power wheelchairs, adapted drive systems, computers, communication devices, etc. 

Technology can stimulate and promote self-sufficiency, enhance mental health, and encourage independence. Assistive technology often means adapting the user interface, (e.g., adding voice activation, breath-controlled switches and phones, head, or tongue switches, etc.) to existing devices. Personal comfort devices include adapted nurse call systems, accessible bed controls, and modified controls for heating and air conditioning.