MND/ALS Nursing Guide

MND Subtypes

Subtype	Motor Neurone Involvement	Key Features	Survival
ALS (Amyotrophic Lateral Sclerosis)	UMN + LMN — both limb and/or bulbar onset	Most common (80%). Mixed spasticity + wasting. Bulbar-onset ALS: dysphagia, dysarthria prominent early	Median 2–3 years
PLS (Primary Lateral Sclerosis)	UMN only	Spasticity, pseudobulbar affect, slow progression	Longer (>10 yrs)
PMA (Progressive Muscular Atrophy)	LMN only	Wasting, fasciculations, weakness; may convert to ALS	Variable
PBP (Progressive Bulbar Palsy)	Bulbar UMN/LMN	Early dysphagia, dysarthria, emotional lability; high aspiration risk	1–3 years

El Escorial Diagnostic Criteria

ALS diagnosis requires evidence of LMN degeneration by clinical/EMG, UMN degeneration by clinical examination, and progressive spread — in the absence of other disease explanations.

Category	Criteria
Definite ALS	UMN + LMN signs in 3 regions (bulbar, cervical, thoracic, lumbar)
Probable ALS	UMN + LMN signs in ≥2 regions, with UMN rostral to LMN
Possible ALS	UMN + LMN signs in 1 region, or UMN in ≥2 regions
Suspected ALS	LMN signs in ≥2 regions only

Awaji criteria (2008) gave EMG evidence equal weight to clinical findings — improves diagnostic sensitivity.

UMN vs LMN Signs

Upper Motor Neurone (UMN)

Spasticity (increased tone)
Hyperreflexia
Clonus
Positive Babinski (extensor plantar)
Pseudobulbar affect (emotional lability)
Jaw jerk brisk (bulbar UMN)

Lower Motor Neurone (LMN)

Muscle wasting (atrophy)
Fasciculations
Weakness
Hyporeflexia / areflexia
Flaccid tone
Tongue fasciculations (bulbar LMN)

Mixed signs in the same limb (e.g. wasting + hyperreflexia) are a hallmark of ALS and should prompt urgent neurology referral.

Cognitive Involvement

ALS-FTD (frontotemporal dementia) occurs in ~15% of ALS patients. A further 35–50% have executive dysfunction without full dementia.

Disinhibition, apathy, executive dysfunction
Language variants (non-fluent/semantic)
Impacts decision-making capacity — assess early
Screen with Edinburgh Cognitive and Behavioural ALS Screen (ECAS)

Cognitive impairment affects ACA (advance care planning) and caregiving — document while patient retains capacity.

Disease-Modifying Treatments

Riluzole (oral — standard of care)

Glutamate antagonist — modest survival benefit (~3 months)
Dose: 50 mg BD
Monitoring: LFTs at baseline, months 1–3, 6, then annually; FBC for neutropenia
Contraindicated: severe hepatic impairment (ALT >5× ULN)

Edaravone (IV infusion)

Free radical scavenger — limited to selected early ALS with rapid decline
Limited availability in GCC — available in some Saudi/UAE tertiary centres
28-day on/off infusion cycles
Benefit modest and patient-selection dependent

Respiratory Failure — Overview

Progressive respiratory failure is the leading cause of death in MND — occurs in 80–90% of patients. Caused by respiratory muscle weakness (diaphragm, intercostals, accessory muscles).

Monitoring Schedule

FVC (Forced Vital Capacity) — spirometry every 3–6 months in stable patients, more frequently if declining
SNIP (Sniff Nasal Inspiratory Pressure) — useful when facial weakness impairs spirometry seal
Overnight pulse oximetry if nocturnal symptoms
Arterial/capillary blood gases if FVC <50%

Non-Invasive Ventilation (NIV / BiPAP)

Indications for NIV Referral

FVC <50% predicted
SNIP <40 cmH₂O (men) / <37 cmH₂O (women)
Orthopnoea — unable to lie flat
Morning headache (CO₂ retention)
Daytime sleepiness / fatigue
Nocturnal hypoxia (SpO₂ <90% >5% of night)
Weak cough (peak cough flow <270 L/min)

NIV Benefits

Improves survival (median +7 months in non-bulbar)
Improves quality of life and sleep
Reduces daytime hypercapnia

BiPAP settings typically IPAP 12–20 cmH₂O, EPAP 4–6 cmH₂O, backup rate 12–16/min. Titrate to comfort and SpO₂/TcCO₂.

Cough Assist (MI-E)

Mechanical Insufflation-Exsufflation (MI-E) — the "Cough Assist" device applies positive pressure to inflate lungs, then rapidly reverses to negative pressure to simulate cough.

Indicated: peak cough flow <270 L/min (unable to clear secretions)
Typical settings: +40 / −40 cmH₂O, 1–3 sec each phase
Can be used via mask or tracheostomy
Use before NIV sessions and during chest infections
Teach caregiver technique — key skill for home management

Avoid in patients with bullae, pneumothorax, or recent barotrauma. Use with caution in significant bulbar weakness — may require manual assistance.

Secretion Management

Thin/Excessive Secretions

Hyoscine hydrobromide patch (1.5 mg/72 h) — anticholinergic, reduces saliva
Glycopyrronium 200 mcg oral TDS
Amitriptyline 10–25 mg nocte (also aids sleep)
Suction — oral suction for pooling, nasopharyngeal if needed

Thick/Sticky Secretions

Nebulised 0.9% or hypertonic saline (3%) to loosen
Adequate systemic hydration (via PEG if oral reduced)
Hyoscine — paradoxically thickens secretions; use with caution
Mucolytics (carbocisteine) in selected patients
High-frequency chest wall oscillation (HFCWO) vest

Suction Technique

Yankaur for oral cavity, soft suction catheter for nasopharyngeal
Apply suction only on withdrawal — max 15 sec per pass
Pre-oxygenate if SpO₂ borderline
Document colour, consistency, volume

Invasive Ventilation & ACP

Tracheostomy-Invasive Ventilation (TIV)

Provides full ventilatory support — extends life significantly
Requires 24-hour carer support — very high burden
Once initiated, weaning/withdrawal is ethically complex
More common in Japan (~30%) than Western countries (<5%)
GCC: increasing uptake in younger patients with strong family support

Advance Care Planning — Ventilation

Initiate discussion before respiratory crisis — ideally at ALS diagnosis
Cover: NIV, TIV, DNACPR, preferred place of care/death
Cultural and religious factors central in GCC (see Tab 6)
Document decisions — anticipatory prescribing if NIV not preferred

Respiratory Crisis: If patient declines NIV and is in extremis — use midazolam 2.5–5 mg SC + morphine 2.5–5 mg SC for dyspnoea relief. Call palliative care team.

Parameter	Threshold for NIV	Urgency
FVC % predicted	<50%	Refer to respiratory team
SNIP	<40 cmH₂O (M) / <37 (F)	Refer if symptomatic
Peak Cough Flow	<270 L/min	Add MI-E; <160 urgent
Nocturnal SpO₂	<90% for >5% of recording time	Initiate NIV promptly
Morning PaCO₂	>6 kPa (45 mmHg)	Urgent NIV initiation
Symptoms alone	Orthopnoea, morning HA, daytime sleepiness	Initiate even if FVC >50%

FVC alone may underestimate respiratory impairment in bulbar-dominant ALS. Prioritise symptoms + SNIP in these patients.

MND Respiratory Status Monitor

Enter patient parameters to assess respiratory status and NIV referral need.

FVC % Predicted

Peak Cough Flow (L/min)

Symptoms present:

Respiratory Status

NIV Referral

MI-E / Cough Assist

Monitoring Frequency

Anticipated Action

Bulbar Assessment

Voice: nasal quality (palatal weakness), wet/gurgling voice (pooling), dysphonia
Speech: dysarthria — assess intelligibility, rate, effort
Swallow: coughing/choking on liquids or solids, slow meal times (>30 min), food residue, weight loss
Saliva: drooling (hypersalivation), difficulty managing secretions
Tongue: fasciculations, atrophy, restricted movement

Refer to SALT at first sign of bulbar involvement — do not wait until dysphagia is severe. Early SALT input prevents aspiration and malnutrition.

SALT Assessment Tools

Videofluoroscopic Swallowing Study (VFSS)

Gold standard — real-time X-ray of swallow with barium
Identifies silent aspiration (common in MND)
Guides texture/liquid modification decisions

Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

Flexible nasoendoscope — no radiation
Can be done bedside — useful in severely deconditioned patients
Evaluates pharyngeal phase, secretion management

The ALS Functional Rating Scale — Revised (ALSFRS-R) scores 12 domains (0–4 each, total 0–48). Lower scores = greater disability.

Domain	Score 4 (Normal)	Score 0 (Worst)
Speech	Normal	Loss of useful speech
Salivation	Normal	Marked drooling
Swallowing	Normal	Nothing by mouth / NGT
Handwriting	Normal	Unable to grip pen
Cutting food	Normal	Gastrostomy fed
Dressing/Hygiene	Normal	Total dependence
Turning in bed	Normal	Helpless
Walking	Normal	No purposeful leg movement
Climbing stairs	Normal	Cannot do
Dyspnoea	None	Significant difficulty at rest
Orthopnoea	None	Unable to sleep without NIV
Respiratory insufficiency	None	Invasive ventilation

A decline of >1 point/month predicts rapid progression. Use longitudinally to track disease trajectory.

IDDSI Texture Modification

Level	Name	Use in MND
0	Thin liquid	Normal (aspiration risk — may need thickening)
1	Slightly thick	Early mild dysphagia
2	Mildly thick	Mild–moderate dysphagia
3	Liquidised	Moderate dysphagia
4	Puréed	Moderate-severe dysphagia
5	Minced & moist	Moderate dysphagia, some chew preserved
6	Soft & bite-sized	Mild-moderate chewing difficulty
7	Regular	No modification needed

Thickened liquids may reduce aspiration but can increase effort and dehydration risk. Re-evaluate regularly as disease progresses.

PEG / RIG Timing

Gastrostomy feeding is a key decision in MND — timing is critical.

Indications for Gastrostomy Referral

Weight loss >10% body weight
BMI <18.5 kg/m² or rapid BMI decline
Meal times >30–45 minutes
Significant dysphagia causing aspiration risk
Dehydration
FVC declining toward 50% (refer while FVC adequate for procedure)

PEG vs RIG

	PEG	RIG
Guidance	Endoscopy (sedation needed)	Radiological (less sedation)
Preferred when	FVC >50%, good respiratory reserve	FVC <50%, high respiratory risk
Caution	Avoid if FVC <50% without NIV support	More complex placement

Do not delay referral until FVC <50% — procedure risk increases significantly below this threshold. Refer when FVC 50–60%.

Gastrostomy Nursing Care

Site Care

Clean daily with soap and water — dry thoroughly
Rotate external bumper daily to prevent buried bumper syndrome
Monitor for granulation tissue, leakage, infection
Document stoma condition at each nursing visit

Feeding Regimen

Continuous or bolus feeding — patient/carer preference
Flush with 30–50 mL water before and after feeds + medications
Head of bed elevation ≥30° during feeds and 1 hr after
Monitor residual volumes if large-bore tube (check local protocol)
Dietitian review every 3 months minimum

Hydration

Minimum 1500 mL free water daily via gastrostomy
Increased needs: hot climate (GCC), fever, increased secretions

Saliva & Secretion Management

Hypersalivation (drooling)

Treatment	Dose/Route	Notes
Hyoscine hydrobromide patch	1.5 mg patch / 72 h (behind ear)	Anticholinergic SE; avoid in glaucoma
Amitriptyline	10–50 mg nocte oral/PEG	Also aids sleep, depression
Glycopyrronium	200 mcg TDS oral	Less CNS SE than hyoscine
Botulinum toxin	Injection to parotid/submandibular glands	Specialist procedure; effect 3–4 months
Low-dose radiotherapy	Salivary glands	Last resort; irreversible

Thick/Sticky Secretions

Nebulised 0.9% NaCl or hypertonic (3%) saline
Adequate hydration (via gastrostomy)
Beta-blockers (propranolol) — can reduce secretion viscosity
Carbocisteine mucolytic

Dysarthria & AAC Progression

Stage-Based Communication Plan

Stage	Communication Status	Interventions
Early	Mild dysarthria, intelligible	SLT review, voice banking (ModelTalker/VocaliD), rate reduction strategies
Moderate	Reduced intelligibility, effort increased	Voice amplifier, alphabet board to clarify, SLT 1–2 monthly
Severe	Severely dysarthric, minimal speech	AAC device (GRID 3/Proloquo2Go tablet-based), letter board, partner-assisted scanning
Locked-in	No voluntary speech, limb movement minimal	Eye-gaze technology (Tobii Dynavox), switch-access, brain–computer interface (emerging)

Voice banking: Encourage early — patient records phrases to create a synthetic personal voice for AAC. Available for Arabic (limited) and English.

Spasticity Management

Treatment	Details	Monitoring
Baclofen oral	5 mg TDS → titrate to max 80 mg/day. GABA-B agonist	Drowsiness, falls risk; withdraw slowly
Intrathecal baclofen pump	For severe spasticity — requires surgical implant. Very effective for lower limb spasticity	Pump malfunction → withdrawal crisis; 24h emergency
Tizanidine	2 mg TDS → up to 36 mg/day. Alpha-2 agonist	LFTs monthly for 6 months; hypotension
Botulinum toxin	Focal spasticity (e.g. hand, ankle). IM injection. Effect 3–4 months	Specialist only; monitor weakness spread
Physiotherapy	Stretching, positioning, splinting, hydrotherapy	Ongoing — essential adjunct to pharmacotherapy

Muscle Cramps & Pain

Muscle Cramps

Very common (70–95%) — LMN irritability
Stretching, physiotherapy, adequate hydration
Quinine sulphate 200–300 mg nocte — if severe; monitor ECG (QT prolongation)
Magnesium supplementation (weak evidence)
Mexiletine — specialist use

Pain in MND

Nociceptive: musculoskeletal (joint stiffness, immobility) — paracetamol, NSAIDs, positioning, physiotherapy
Neuropathic: burning/shooting pain — gabapentin, pregabalin, amitriptyline
Pressure areas: immobility → pressure ulcer risk — regular repositioning, pressure mattress
Analgesic ladder — WHO principles; opioids in advanced disease (also reduce dyspnoea)

Sleep Disorders

Nocturnal hypoventilation — most common cause; treat with NIV (BiPAP)
Insomnia — pain, cramps, anxiety, inability to reposition
REM sleep behaviour disorder — seen in ALS-FTD
Excessive daytime sleepiness — may indicate CO₂ retention; check blood gases

Management

NIV for nocturnal hypoventilation (first-line)
Amitriptyline 10–25 mg nocte — sleep, pain, secretions
Zopiclone/zolpidem — short-term only; caution in respiratory compromise
Low-dose diazepam/lorazepam — if anxiety-driven insomnia; monitor respiratory status
Regular positioning schedule (2-hourly if immobile)

Fatigue Management

Fatigue affects ~80% of MND patients — multifactorial: muscle weakness, poor sleep, respiratory compromise, depression, medication side effects.

OT & Energy Conservation

Activity pacing — prioritise high-value activities for peak energy periods
Environmental modifications: grab rails, ramp access, hospital bed at home, hoist
Adaptive aids: powered wheelchair, electric recliner, one-handed utensils
Wrist/arm supports for writing and eating
Ceiling track hoists for transfers — reduces carer burden
Smart home technology for communication/environment control

Physiotherapy

Moderate exercise — safe in early/mid MND; avoid overexertion
Hydrotherapy — buoyancy offloads muscle effort
Passive range of motion — prevents contractures

Pseudobulbar Affect (PBA)

Uncontrolled laughing or crying disproportionate to emotional state — UMN pathway disruption. Distressing for patient and family.

Reassure — involuntary, not a sign of depression (though may coexist)
Treatment: Amitriptyline 10–25 mg TDS; or dextromethorphan/quinidine (Nuedexta — limited GCC availability)
SSRIs (fluoxetine/sertraline) — second-line

Psychological Adjustment & Diagnosis Disclosure

SPIKES Framework — Breaking Bad News

Step	Action
S — Setting	Private space, ensure patient not alone, no interruptions, sit at patient level
P — Perception	"What do you already know/understand about your symptoms?"
I — Invitation	"Are you ready to hear more information?" / "How much detail would you like?"
K — Knowledge	Deliver news clearly, in plain language. Pause. Allow silence. Avoid jargon.
E — Emotions	Acknowledge and name emotion. "I can see this is very difficult news." NURSE framework: Name, Understand, Respect, Support, Explore
S — Summary	Summarise, check understanding, provide written information, arrange follow-up

In GCC family-centred cultures, family may request disclosure to them before the patient. Respect patient autonomy while navigating family dynamics sensitively.

Emotional Responses — Non-Linear Grief

Shock / Disbelief Denial Anger Bargaining Acceptance Adjustment

Grief responses are non-linear and may cycle. Do not expect linear progression. Patients and carers may be at different stages.

Normalise all responses — there is no "right" way to cope
Screen for clinical depression/anxiety (PHQ-9, GAD-7)
Refer for psychological support when significant distress persists
MND Association peer support/buddy scheme — patients find this helpful
Online support — particularly valuable in GCC for social access

Anxiety & Depression

Prevalence: depression ~20–30%, anxiety ~30–40% in MND. Under-detected — symptoms overlap with disease itself.

Treatment

SSRIs: sertraline 50 mg OD or citalopram 20 mg OD — first-line
Mirtazapine: anxiety, depression, weight loss, insomnia — useful combination effect
Anxiolytics: lorazepam 0.5–1 mg PRN for acute anxiety — monitor respiratory function
Psychosocial support: CBT, mindfulness, existential therapy
Peer support: MND Association, online groups, chaplaincy

Amitriptyline is often first choice in MND as it addresses multiple symptoms: depression, pseudobulbar affect, insomnia, drooling, and pain.

Advance Care Planning (ACP)

Initiate ACP early — ideally at diagnosis, revisit at each significant decline
DNACPR: document clearly; review at each admission/deterioration
Preferred place of death: home, hospice, or hospital — most prefer home
Ventilation decisions: NIV continuation/withdrawal, TIV acceptance/refusal
Nutrition decisions: gastrostomy — timing, withdrawal if desired
Lasting Power of Attorney / equivalent (GCC: legal guardianship arrangements)
Cultural and religious considerations — central in GCC (see Tab 6)

Prescribe and ensure availability of emergency medications before the terminal phase — distressing symptoms can escalate rapidly in MND.

Symptom	Drug	Route/Dose
Dyspnoea / respiratory distress	Morphine sulphate	SC 2.5–5 mg PRN (opioid-naive); titrate
Anxiety / agitation	Midazolam	SC 2.5–5 mg PRN
Secretions / death rattle	Hyoscine hydrobromide	SC 400 mcg PRN or 1.2–2.4 mg/24h CSCI
Nausea	Haloperidol	SC 1.5 mg PRN or 3 mg/24h CSCI
Pain	Morphine	As above — also treats dyspnoea
Severe breathlessness	Morphine + Midazolam	Continuous SC infusion (syringe driver)

Ensure CSCI (continuous subcutaneous infusion) / syringe driver familiarity in team. Have emergency kit in home if home death preferred. Communicate plan clearly to out-of-hours services.

Carer Burden & Support

~80% of MND care is provided by family carers — predominantly spouses and adult children. High rates of burnout, depression, and social isolation.

Carer burden assessment — Zarit Burden Interview
Respite care: inpatient/community respite, day hospice
Home care services: district nursing, personal care, night sitters
Benefits/financial support — social work referral
Carer support groups (MND Association; GCC equivalent bodies)
Psychological support for carers — normalise need for help

In GCC, male carers may resist support services due to cultural gender roles. Female carers may be isolated without independent transport or social networks. Address proactively.

Spiritual Care & Bereavement

Spiritual Care

Meaning-making is central in progressive illness — "why me?" responses
Chaplaincy referral — hospital, community, or virtual
In GCC: Islamic perspective on illness as test (sabr) and divine will (tawakkul) — acknowledge respectfully
Prayer, Quran recitation — offer access; respect patient's religious practice

Bereavement Support

Begin grief work before death (anticipatory grief) — normalise
Post-bereavement contact from MND team — valued by families
Refer to bereavement counsellor / social worker when complicated grief
Support children and young family members — age-appropriate communication

GCC-Specific MND Context

MND less studied in GCC/Arab populations — limited epidemiological data
Consanguinity (cousin marriages common in GCC) — association with familial/juvenile ALS (SOD1, TARDBP, FUS gene mutations)
Limited ALS specialist multidisciplinary teams (MDT) in GCC — Saudi Arabia and UAE leading development
PEG and NIV access improving at tertiary centres: KKUH Riyadh, Cleveland Clinic Abu Dhabi, Hamad Medical Corporation Qatar
Arabic language AAC tools — very limited availability; English-dominant devices present communication barriers
Family-centred care model predominates — family as decision-maker rather than individual autonomy model
Cultural expectation: family to provide care rather than residential/hospice placement

Islamic Bioethics in MND

Withdrawing/Withholding Treatment

Withdrawal of NIV — contentious area; different scholarly opinions exist
Majority scholarly view: withholding (not starting) treatment is more permissible than withdrawing established treatment
However, many scholars distinguish withdrawal from killing — particularly where burden outweighs benefit
Seek input from hospital Islamic ethics committee/scholar in complex cases
Family consensus critical — individual patient decision-making may feel culturally inappropriate

Nutrition & Hydration

Gastrostomy withdrawal contentious — viewed as basic care by many Muslim scholars
Some GCC hospitals do not withdraw nutrition/hydration — document discussions clearly
Parenteral nutrition may continue where enteral not possible

Consult local DHA/DOH/MOH ethics guidance and Islamic affairs committee for individual complex cases. Do not assume a single "Islamic" position — heterogeneity exists.

Regulatory Standards — GCC

DHA (Dubai Health Authority)

End-of-life care framework — palliative care integrated nursing standards
Advance care planning documentation (DDST — Do Not Attempt Resuscitation)
DHA CPD requirements for neurological nursing competency

DOH (Department of Health — Abu Dhabi)

Palliative care standards aligned with international frameworks
NIV initiation and management in community nursing protocols

SCFHS (Saudi Commission for Health Specialties)

Saudi nursing licensing — neurology nursing competency framework
Exam focus: MND diagnosis, respiratory management, palliative care principles
Saudi Vision 2030 — expanding home care/hospice infrastructure

DHA / DOH / SCFHS Exam Prep

High-Yield Topics

NIV Indications (High-Yield)

FVC <50% predicted OR symptomatic (orthopnoea, morning headache)
SNIP <40 cmH₂O
Nocturnal SpO₂ <90%
BiPAP preferred over CPAP in MND

PEG Timing (High-Yield)

Refer when FVC 50–60% — avoid when FVC <50% (RIG preferred then)
Weight loss >10% = referral indication
Early referral before crisis = better outcomes

ALS Diagnosis (High-Yield)

Both UMN AND LMN signs = ALS hallmark
El Escorial: Definite = UMN+LMN in 3 regions
Riluzole: monitoring = LFTs + FBC (neutropenia)
Median survival ALS: 2–3 years from symptom onset

Palliative Care Principles (High-Yield)

ACP should be initiated at diagnosis — not crisis
Anticipatory prescribing: morphine (dyspnoea/pain), midazolam (anxiety), hyoscine (secretions)
DNACPR is a clinical decision — must be communicated to patient and family
NIV withdrawal = palliative measure if patient consent obtained

Common Exam Questions — MND

Question Topic	Key Answer
Leading cause of death in MND	Respiratory failure (progressive respiratory muscle weakness)
First-line drug for ALS	Riluzole 50 mg BD — monitor LFTs and FBC
FVC threshold for NIV referral	<50% predicted (or symptomatic above this)
PEG preferred FVC window	50–60% predicted
MI-E (Cough Assist) indication	Peak cough flow <270 L/min
ALS-FTD prevalence	~15% of ALS patients
Definite ALS (El Escorial)	UMN + LMN signs in 3 of 4 regions
Drug for hypersalivation	Hyoscine patch / amitriptyline / glycopyrronium
Terminal dyspnoea management	Morphine SC + Midazolam SC (syringe driver if ongoing)
Voice preservation intervention	Voice banking (early stage dysarthria)
Cognitive screening in MND	ECAS (Edinburgh Cognitive and Behavioural ALS Screen)
ALSFRS-R total score range	0–48 (48 = normal; decline >1 pt/month = rapid)

Multidisciplinary Team in MND

Neurologist Respiratory Physician SALT Dietitian Physiotherapist OT Palliative Care Social Worker MND Nurse Specialist Psychologist Chaplain / Islamic Scholar

MND MDT clinics improve outcomes and survival. In GCC where specialist MDT is limited, the neurology nurse is often the coordinator and primary liaison for all these services — a critical role.

Motor Neurone Disease (ALS/MND) — Nursing Guide

MND Subtypes

El Escorial Diagnostic Criteria

UMN vs LMN Signs

Upper Motor Neurone (UMN)

Lower Motor Neurone (LMN)

Cognitive Involvement

Disease-Modifying Treatments

Riluzole (oral — standard of care)

Edaravone (IV infusion)

Respiratory Failure — Overview

Monitoring Schedule

Non-Invasive Ventilation (NIV / BiPAP)

Indications for NIV Referral

NIV Benefits

Cough Assist (MI-E)

Secretion Management

Thin/Excessive Secretions

Thick/Sticky Secretions

Suction Technique

Invasive Ventilation & ACP

Tracheostomy-Invasive Ventilation (TIV)

Advance Care Planning — Ventilation

MND Respiratory Status Monitor

Bulbar Assessment

SALT Assessment Tools

Videofluoroscopic Swallowing Study (VFSS)

Fibreoptic Endoscopic Evaluation of Swallowing (FEES)

IDDSI Texture Modification

PEG / RIG Timing

Indications for Gastrostomy Referral

PEG vs RIG

Gastrostomy Nursing Care

Site Care

Feeding Regimen

Hydration

Saliva & Secretion Management

Hypersalivation (drooling)

Thick/Sticky Secretions

Dysarthria & AAC Progression

Stage-Based Communication Plan

Spasticity Management

Muscle Cramps & Pain

Muscle Cramps

Pain in MND

Sleep Disorders

Management

Fatigue Management

OT & Energy Conservation

Physiotherapy

Pseudobulbar Affect (PBA)

Psychological Adjustment & Diagnosis Disclosure

SPIKES Framework — Breaking Bad News

Emotional Responses — Non-Linear Grief

Anxiety & Depression

Treatment

Advance Care Planning (ACP)

Carer Burden & Support

Spiritual Care & Bereavement

Spiritual Care

Bereavement Support

GCC-Specific MND Context

Islamic Bioethics in MND

Withdrawing/Withholding Treatment

Nutrition & Hydration

Regulatory Standards — GCC

DHA (Dubai Health Authority)

DOH (Department of Health — Abu Dhabi)

SCFHS (Saudi Commission for Health Specialties)

DHA / DOH / SCFHS Exam Prep

NIV Indications (High-Yield)

PEG Timing (High-Yield)

ALS Diagnosis (High-Yield)

Palliative Care Principles (High-Yield)

Common Exam Questions — MND

Multidisciplinary Team in MND