Motor neurone disease: assessment and management

This guideline covers assessing and managing motor neurone disease (MND). It aims to improve care from the time of diagnosis, and covers information and support, organisation of care, managing symptoms and preparing for end of life care.

# Recommendations
People have the right to be involved in discussions and make informed decisions about their care, as described in making decisions about your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) or our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

# Recognition and referral
Ensure that robust protocols and pathways are in place to:
inform healthcare professionals about motor neurone disease (MND) and how it may present
inform healthcare professionals in all settings about local referral arrangements
ensure continued and integrated care for people with MND across all care settings. 
Be aware that MND causes progressive muscular weakness that may first present as isolated and unexplained symptoms. These symptoms may include:
functional effects of muscle weakness, such as loss of dexterity, falls or trips
speech or swallowing problems, or tongue fasciculations (this is known as bulbar presentation)
muscle problems, such as weakness, wasting, twitching, cramps and stiffness
breathing problems, such as shortness of breath on exertion or respiratory symptoms that are hard to explain
effects of reduced respiratory function, such as excessive daytime sleepiness, fatigue, early morning headache or shortness of breath when lying down. 
Be aware that MND may first present with cognitive features, which may include:
behavioural changes
emotional lability (not related to dementia)
frontotemporal dementia. 
If you suspect MND, refer the person without delay and specify the possible diagnosis in the referral letter. Contact the consultant neurologist directly if you think the person needs to be seen urgently. 
Provide information and support for people and their family members and/or carers (as appropriate) throughout the diagnostic process, particularly during periods of diagnostic uncertainty or delay. 

# Information and support at diagnosis
Please also refer to the recommendations in the NICE guideline on patient experience in adult NHS services, which includes recommendations on communication, information and coordination of care.
Information about the diagnosis, prognosis and management of MND should be given by a consultant neurologist with uptodate knowledge and experience of treating people with MND unless it is clinically necessary to give the diagnosis in an urgent situation. The neurologist should have knowledge and expertise in the following:
Symptoms of MND.
Types and possible causes of MND.
Treatment options.
How MND may progress (including cognitive and behavioural changes) and how progression may affect the treatments offered.
Crisis prevention (for example, if there is an acute hospital admission or a breakdown in care arrangements).
Opportunities for people with MND to be involved in research.
Likely needs and concerns of people with MND and their family members and/or carers (as appropriate).
Advance care planning. 
Ask people about how much information they wish to receive about MND, and about their preferences for involving their family members and/or carers (as appropriate). 
Ensure people are provided with information about MND and support at diagnosis or when they ask for it. If the person agrees, share the information with their family members and/or carers (as appropriate). Information should be oral and written, and may include the following:
What MND is.
Types and possible causes.
Likely symptoms and how they can be managed.
How MND may progress.
Treatment options.
Where the person's appointments will take place.
Which healthcare professionals and social care practitioners will undertake the person's care.
Expected waiting times for consultations, investigations and treatments.
Local services (including social care and specialist palliative care services) and how to get in touch with them.
Local support groups, online forums and national charities, and how to get in touch with them.
Legal rights, including social care support, employment rights and benefits.
Requirements for disclosure, such as notifying the Driver and Vehicle Licensing Agency (DVLA).
Opportunities for advance care planning. 
When MND is diagnosed, provide people with a single point of contact for the specialist MND multidisciplinary team (see section 1.5). Provide information about what to do if there are any concerns between assessments or appointments, during 'outofhours' or in an emergency, or if there is a problem with equipment. 
Offer the person with MND a facetoface, followup appointment with a healthcare professional from the multidisciplinary team, to take place within 4 weeks of diagnosis. 
When MND is suspected or confirmed, inform the person's GP without delay and provide information about the likely prognosis. 
Set aside enough time to discuss the person's concerns and questions, which may include the following:
What will happen to me?
Are there any treatments available?
Is there a cure?
How long will I live?
What will the impact on my daytoday life be?
What will happen next with my healthcare?
Will my children get MND?
How do I tell my family and friends?
How will I die? 
If the person has any social care needs, refer them to social services for an assessment. Be aware that some people with MND may not have informal care available, and may live alone or care for someone else. 
Advise carers about their right to carer assessment, and assessment for respite care and other support (see the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of families and carers). 

# Cognitive assessments
Please also refer to the recommendations in the NICE guideline on patient experience in adult NHS services.
Be aware that people with MND and frontotemporal dementia may lack mental capacity. Care should be provided in line with the Mental Capacity Act 2005. 
At diagnosis, and if there is concern about cognition and behaviour, explore any cognitive or behavioural changes with the person and their family members and/or carers as appropriate. If needed, refer the person for a formal assessment in line with the NICE guideline on dementia. 
Tailor all discussions to the person's needs, taking into account their communication ability, cognitive status and mental capacity. 

# Prognostic factors
When planning care take into account the following prognostic factors, which are associated with shorter survival if they are present at diagnosis:
Speech and swallowing problems (bulbar presentation).
Weight loss.
Poor respiratory function.
Older age.
Lower Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS or ALSFRSR) score.
Shorter time from first developing symptoms to time of diagnosis. 

# Organisation of care
Provide coordinated care for people with MND, using a clinicbased, specialist MND multidisciplinary team approach. The clinic may be community or hospital based. 
The multidisciplinary team should:
include healthcare professionals and social care practitioners with expertise in MND, and staff who see people in their home
ensure effective communication and coordination between all healthcare professionals and social care practitioners involved in the person's care and their family members and/or carers (as appropriate)
carry out regular, coordinated assessments at the multidisciplinary team clinic (usually every 2 to 3 months) to assess people's symptoms and needs
provide coordinated care for people who cannot attend the clinic, according to the person's needs. 
The multidisciplinary team should assess, manage and review the following areas, including the person's response to treatment:
Weight, diet, nutritional intake and fluid intake, feeding and swallowing (see section 1.10).
Muscle problems, such as weakness, stiffness and cramps (see recommendations 1.8.1 to 1.8.9).
Physical function, including mobility and activities of daily living (see section 1.9).
Saliva problems, such as drooling of saliva (sialorrhoea) and thick, tenacious saliva (see recommendations 1.8.10 to 1.8.15).
Speech and communication (see section 1.11).
Cough effectiveness (see section 1.13).
Respiratory function, respiratory symptoms and noninvasive ventilation (see section 1.12 and section 1.14).
Pain and other symptoms, such as constipation.
Cognition and behaviour (see section 1.3).
Psychological support needs (see recommendations 1.6.1 to 1.6.4).
Social care needs (see recommendations 1.6.5 and 1.6.6).
End of life care needs (see section 1.7).
Information and support needs for the person and their family members and/or carers (as appropriate) (see section 1.2). 
The core multidisciplinary team should consist of healthcare professionals and other professionals with expertise in MND, and should include the following:
Neurologist.
Specialist nurse.
Dietitian.
Physiotherapist.
Occupational therapist.
Respiratory physiologist or a healthcare professional who can assess respiratory function.
Speech and language therapist.
A healthcare professional with expertise in palliative care (MND palliative care expertise may be provided by the neurologist or nurse in the multidisciplinary team, or by a specialist palliative care professional). 
The multidisciplinary team should have established relationships with, and prompt access to, the following:
Clinical psychology and neuropsychology.
Social care.
Counselling.
Respiratory ventilation services.
Specialist palliative care.
Gastroenterology.
Orthotics.
Wheelchair services.
Assistive technology services.
Alternative and augmentative communication (AAC) services.
Community neurological care teams. 
Tailor the frequency of the multidisciplinary team assessments to the person's symptoms and needs, with more or less frequent assessments as needed. 
Ensure arrangements are in place to trigger an earlier multidisciplinary team assessment if there is a significant change in symptoms identified by the person, family members and/or carers (as appropriate), or healthcare professionals. 
Tailor the multidisciplinary team assessment to the person's needs, for example, adjust the format if the person has cognitive or behaviour changes or difficulties with communication. 
Inform all healthcare professionals and social care practitioners involved in the person's care about key decisions reached with the person and their family members and/or carers (as appropriate). 
Ensure that all healthcare professionals and social care practitioners involved in the person's care are aware that MND symptoms may get worse quickly, and that people with MND will need repeated, ongoing assessments. Priority should be given to ensuring continuity of care and avoiding untimely case closure. 
Consider referral to a specialist palliative care team for people with current or anticipated significant or complex needs, for example, psychological or social distress, troublesome or rapidly progressing symptoms and complex future care planning needs. 
For guidance on the use of riluzole for people with MND, see the NICE technology appraisal guidance on the use of riluzole (Rilutek) for the treatment of motor neurone disease. 

# Psychological and social care support
During multidisciplinary team assessments and other appointments, discuss the psychological and emotional impact of MND with the person and ask whether they have any psychological or support care needs. Topics to discuss may include the following:
Their understanding of MND and how it affects daily living.
Accepting and coping with the diagnosis and prognosis, including concerns and fears about dying.
Their ability to continue with current work and usual activities.
Adjusting to changes in their life and their perception of self.
Changes in relationships, familial roles and family dynamics.
Sexuality and intimacy.
Concerns about their family members and/or carers.
Decision-making. 
Offer the person information about sources of emotional and psychological support, including support groups and online forums. If needed, refer the person to counselling or psychology services for a specialist assessment and support. 
During multidisciplinary team assessments and other appointments, discuss the psychological and emotional impact of MND with family members and/or carers (as appropriate), and ask whether they have any psychological or social care support needs. Topics to discuss may include the following:
Their understanding of MND and how it affects daily living.
Accepting and coping with the diagnosis and prognosis, including concerns and fears about the person with MND dying.
Adjusting to changes in their life.
Changes in relationships, familial roles and family dynamics, including their change to a carer role (if appropriate).
Sexuality and intimacy.
Involvement in decisionmaking.
Impact on other family members and/or carers.
Their ability and willingness to provide personal care and operate equipment.See the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of families and carers. 
Offer family members and/or carers (as appropriate) information about respite care and sources of emotional and psychological support, including support groups, online forums and counselling or psychology services. 
A social care practitioner with knowledge of MND or rapidly progressive complex disabilities should discuss the person's needs and preferences for social care, and provide information and support for them to access the following:
Personal care, ensuring there is continuity of care with familiar workers, so that wherever possible, personal care and support is carried out by workers known to the person and their family members and/or carers (as appropriate).
Equipment and practical support (see section 1.9).
Financial support and advice (for example, money management, how to access carers' and disability benefits and grants, continuing healthcare funding and funeral expenses).
Support to engage in work, social activities and hobbies, such as access to social media and physical access to activities outside their home.
Respite care. 
Be aware that as MND progresses, people may develop communication problems and have difficulty accessing support or services. For example, they may be unable to access a call centre. Ensure people are given different ways of getting in touch with support or services, and a designated contact if possible. 

# Planning for end of life
Offer the person with MND the opportunity to discuss their preferences and concerns about care at the end of life at trigger points such as: at diagnosis, if there is a significant change in respiratory function, or if interventions such as gastrostomy or noninvasive ventilation are needed. Be sensitive about the timing of discussions and take into account the person's current communication ability, cognitive status and mental capacity. 
Be prepared to discuss end of life issues whenever people wish to do so. 
Provide support and advice on advance care planning for end of life. Topics to discuss may include:
What could happen at the end of life, for example, how death may occur.
Providing anticipatory medicines in the home.
Advance care planning, including Advance Decisions to Refuse Treatment (ADRT) and Do Not Attempt Resuscitation (DNACPR) orders, and Lasting Power of Attorney.
How to ensure advance care plans will be available when needed, for example, including the information on the person's Summary Care Record.
When to involve specialist palliative care.
Areas that people might wish to plan for, such as:
what they want to happen (for example, their preferred place of death)
what they do not want to happen (for example, being admitted to hospital)
who will represent their decisions, if necessary
what should happen if they develop an intercurrent illness. 
Think about discussing advance care planning with people at an earlier opportunity if you expect their communication ability, cognitive status or mental capacity to get worse. 
Offer people the opportunity to talk about, and review any existing, ADRT, DNACPR orders and Lasting Power of Attorney when interventions such as gastrostomy and noninvasive ventilation are planned. 
Provide additional support as the end of life approaches, for example, additional social or nursing care to enable informal carers and family to reduce their carer responsibilities and spend time with the person with MND. 
Towards the end of life, ensure there is prompt access to the following, if not already provided:
A method of communication that meets the person's needs, such as an AAC system.
Specialist palliative care.
Equipment, if needed, such as syringe drivers, suction machines, riserrecliner chair, hospital bed, commode and hoist.
Anticipatory medicines, including opioids and benzodiazepines to treat breathlessness, and antimuscarinic medicines to treat problematic saliva and respiratory secretions. 
Offer bereavement support to family members and/or carers (as appropriate). 

# Managing symptoms

## Pharmacological treatments for muscle problems
Discuss the available treatment options for muscle problems. Take into account the person's needs and preferences, and whether they have any difficulties taking medicine (for example, if they have problems swallowing). 
Consider quinine as firstline treatment for muscle cramps in people with MND. If quinine is not effective, not tolerated or contraindicated, consider baclofen instead as secondline treatment. If baclofen is not effective, not tolerated or contraindicated, consider tizanidine, dantrolene or gabapentin.In February 2016 this was an off-label use of quinine, baclofen, tizanidine, and dantrolene. See NICE's information on prescribing medicines and the MHRA safety advice on prescribing gabapentin. 
Consider baclofen, tizanidine, dantrolene or gabapentin to treat muscle stiffness, spasticity or increased tone in people with MND. If these treatments are not effective, not tolerated or contraindicated, consider referral to a specialist service for the treatment of severe spasticity.In February 2016 this was an off-label use of dantrolene. See NICE's information on prescribing medicines and the MHRA safety advice on prescribing gabapentin. 
Review the treatments for muscle problems during multidisciplinary team assessments, ask about how the person is finding the treatment, whether it is working and whether they have any adverse side effects. 

## Exercise programmes
Consider an exercise programme for people with MND to:
maintain joint range of movement
prevent contractures
reduce stiffness and discomfort
-ptimise function and quality of life. 
Choose a programme that is appropriate to the person's level of function and tailored to their needs, abilities and preferences. Take into account factors such as postural needs and fatigue. The programme might be a resistance programme, an activeassisted programme or a passive programme. 
Check that family members and/or carers (as appropriate) are willing and able to help with exercise programmes. 
Give advice to the person and their family members and/or carers (as appropriate) about safe manual handling. 
If a person needs orthoses to help with muscle problems, they should be referred to orthotics services without delay, and the orthoses should be provided without delay. 

## Saliva problems
If a person with MND has problems with saliva, assess the volume and viscosity of the saliva and the person's respiratory function, swallowing, diet, posture and oral care. 
If a person with MND has problems with drooling of saliva (sialorrhoea), provide advice on swallowing, diet, posture, positioning, oral care and suctioning. 
Consider a trial of antimuscarinic medicine as the firstline treatment for sialorrhoea in people with MND.In February 2016 this was an off-label use of antimuscarinic medicine. See NICE's information on prescribing medicines. 
Consider glycopyrrolate as the firstline treatment for sialorrhoea in people with MND who have cognitive impairment, because it has fewer central nervous system side effects.In February 2016 this was an off-label use of glycopyrrolate. See NICE's information on prescribing medicines. 
If first-line treatment for sialorrhoea is not effective, not tolerated or contraindicated, consider referral to a specialist service for Botulinum toxin A. In September 2019 Xeomin was the only Botulinium toxin A with a UK marketing authorisation for this indication.
If a person with MND has thick, tenacious saliva:
review all current medicines, especially any treatments for sialorrhoea
provide advice on swallowing, diet, posture, positioning, oral care, suctioning and hydration
consider treatment with humidification, nebulisers and carbocisteine. 

# Equipment and adaptations to aid activities of daily living and mobility
Healthcare professionals and social care practitioners, which will include physiotherapists and occupational therapists, should assess and anticipate changes in the person's daily living needs, taking into account the following:
Activities of daily living, including personal care, dressing and bathing, housework, shopping, food preparation, eating and drinking, and ability to continue with current work and usual activities.
Mobility and avoiding falls and problems from loss of dexterity.
The home environment and the need for adaptations.
The need for assistive technology, such as environmental control systems. 
Provide equipment and adaptations that meet the person's needs without delay, so that people can participate in activities of daily living and maintain their quality of life as much as possible. 
Refer people to specialist services without delay if assistive technology such as environmental control systems is needed. People should be assessed and assistive technology provided without delay. 
Refer people to wheelchair services without delay if needed. Wheelchair needs should be assessed and a manual and/or powered wheelchair that meets the person's needs should be provided without delay. 
Ensure that equipment, adaptations, daily living aids, assistive technology and wheelchairs meet the changing needs of the person and their family and/or carers (as appropriate) to maximise mobility and participation in activities of daily living. 
Ensure regular, ongoing monitoring of the person's mobility and daily life needs and abilities as MND progresses. Regularly review their ability to use equipment and to adapt equipment as necessary. 
Healthcare professionals, social care practitioners and other services providing equipment should liaise to ensure that all equipment provided can be integrated, for example, integrating AAC aids and devices and environmental control systems with wheelchairs. 
Enable prompt access and assessment for funding for home adaptation. If the person is not eligible for funding, continue to offer information and support in arranging home environment adaptations. 

# Nutrition and gastrostomy
Please also refer to the recommendations in the NICE guideline on nutrition support for adults.
At diagnosis and at multidisciplinary team assessments, or if there are any concerns about weight, nutrition or swallowing, assess the person's weight, diet, nutritional intake, fluid intake, hydration, oral health, feeding, drinking and swallowing, and offer support, advice and interventions as needed. 
Assess the person's diet, hydration, nutritional intake and fluid intake by taking into account:
fluids and food intake versus nutritional and hydration needs
nutritional supplements, if needed
appetite and thirst
gastrointestinal symptoms, such as nausea or constipation
causes of reduced oral intake (for example, swallowing difficulties, limb weakness or the possibility of low mood or depression causing loss of appetite). 
Assess the person's ability to eat and drink by taking into account:
the need for eating and drinking aids and altered utensils to help them take food from the plate to their mouth
the need for help with food and drink preparation
advice and aids for positioning, seating and posture while eating and drinking
dealing with social situations (for example, eating out). 
Arrange for a clinical swallowing assessment if swallowing problems are suspected. 
Assess and manage factors that may contribute to problems with swallowing, such as:
positioning
seating
the need to modify food and drink consistency and palatability
respiratory symptoms and risk of aspiration and/or choking
fear of choking and psychological considerations (for example, wanting to eat and drink without assistance in social situations). 
Discuss gastrostomy at an early stage, and at regular intervals as MND progresses, taking into account the person's preferences and issues, such as ability to swallow, weight loss, respiratory function, effort of feeding and drinking and risk of choking. Be aware that some people will not want to have a gastrostomy. 
Explain the benefits of early placement of a gastrostomy, and the possible risks of a late gastrostomy (for example, low critical body mass, respiratory complications, risk of dehydration, different methods of insertion, and a higher risk of mortality and procedural complications). 
If a person is referred for a gastrostomy, it should take place without unnecessary delay. 
Pay particular attention to the nutritional and hydration needs of people with MND who have frontotemporal dementia and who lack mental capacity. The multidisciplinary team assessment should include the support they need from carers, and their ability to understand the risks of swallowing difficulties. 
Before a decision is made on the use of gastrostomy for a person with MND who has frontotemporal dementia, the neurologist from the multidisciplinary team should assess the following:
The person's ability to make decisions and to give consent (see Mental Capacity Act 2005).
The severity of frontotemporal dementia and cognitive problems.
Whether the person is likely to accept and cope with treatment.Discuss with the person's family members and/or carers (as appropriate; with the person's consent if they have the ability to give it). 

# Communication
When assessing speech and communication needs during multidisciplinary team assessments and other appointments, discuss facetoface and remote communication, for example, using the telephone, email, the Internet and social media. Ensure that the assessment and review is carried out by a speech and language therapist without delay. 
Provide AAC equipment that meets the needs of the person without delay to maximise participation in activities of daily living and maintain quality of life. The use of both lowlevel technologies, for example, alphabet, word or picture boards and highlevel technologies, for example, PC or tabletbased voice output communication aids may be helpful. Review the person's communication needs during multidisciplinary team assessments. 
Liaise with, or refer the person with MND to, a specialised NHS AAC hub if complex high technology AAC equipment (for example, eye gaze access) is needed or is likely to be needed. 
Involve other healthcare professionals, such as occupational therapists, to ensure that AAC equipment is integrated with other assistive technologies, such as environmental control systems and personal computers or tablets. 
Ensure regular, ongoing monitoring of the person's communication needs and abilities as MND progresses, and review their ability to use AAC equipment. Reassess and liaise with a specialised NHS AAC hub if needed. 
Provide ongoing support and training for the person with MND, and their family members and/or carers (as appropriate), in using AAC equipment and other communication strategies. 

# Respiratory function and respiratory symptoms
Assess and monitor the person's respiratory function and symptoms. Treat people with MND and worsening respiratory impairment for reversible causes (for example, respiratory tract infections or secretion problems) before considering other treatments. 
Offer non-invasive ventilation as treatment for people with respiratory impairment (see section 1.14). Decisions to offer noninvasive ventilation should be made by the multidisciplinary team in conjunction with the respiratory ventilation service, and the person (see recommendations 1.5.1 to 1.5.5). 
Consider urgent introduction of noninvasive ventilation for people with MND who develop worsening respiratory impairment and are not already using noninvasive ventilation. 
Consider opioids as an option to relieve symptoms of breathlessness. Take into account the route of administration and acquisition cost of medicines.In February 2016 this was an off-label use of opioids. See NICE's information on prescribing medicines for more information. 
Consider benzodiazepines to manage breathlessness that is exacerbated by anxiety. Take into account the route of administration and acquisition cost of medicines.In February 2016 this was an off-label use of benzodiazepines. See NICE's information on prescribing medicines. 

# Cough effectiveness
Offer cough augmentation techniques such as manual assisted cough to people with MND who cannot cough effectively. 
Consider unassisted breath stacking and/or manual assisted cough as the firstline treatment for people with MND who have an ineffective cough. 
For people with bulbar dysfunction, or whose cough is ineffective with unassisted breath stacking, consider assisted breath stacking (for example, using a lung volume recruitment bag). 
Consider a mechanical cough assist device if assisted breath stacking is not effective, and/or during a respiratory tract infection. 

# Non-invasive ventilation

## Information and support about noninvasive ventilation
Offer to discuss the possible use of noninvasive ventilation with the person and (if the person agrees) their family and carers, at an appropriate time and in a sensitive manner. This may be at one or more of the following times:
soon after MND is first diagnosed
when monitoring respiratory function
when respiratory function deteriorates
if the person asks for information. 
Discussions about noninvasive ventilation should be appropriate to the stage of the person's illness, carried out in a sensitive manner and include information on:
the possible symptoms and signs of respiratory impairment (see table 1)
the purpose, nature and timing of respiratory function tests, and explanations of the test results
how noninvasive ventilation (as a treatment option) can improve symptoms associated with respiratory impairment and can be life prolonging, but does not stop progression of the underlying disease. 
When discussing noninvasive ventilation, explain the different ways that people can manage their breathlessness symptoms. This should include:
non-invasive ventilation, and its advantages and disadvantages
using non-invasive ventilation at different points in the course of the person's lifetime
the possibility of the person becoming dependent on noninvasive ventilation
-ptions for treating any infections
support and information on how to recognise and cope with a distressing situation
the role of medication for breathing problems
psychological techniques and support. 
Check that the person thinking about noninvasive ventilation:
understands what noninvasive ventilation is and what it can achieve
recognises the need for regular review
has enough information about noninvasive ventilation and other options for breathing problems to make decisions about how and when to use it.
understands possible problems with compatibility with other equipment, for example, eye gaze access systems. 
Explain that non-invasive ventilation can be stopped at any time. Reassure people that they can ask for help and advice if they need it, especially if they are dependent on noninvasive ventilation for 24 hours a day, or become distressed when attempting to stop it. Inform people that medicines can be used to alleviate symptoms (see recommendation 1.14.29). 
Ensure that families and carers:
have an initial assessment if the person they care for decides to use noninvasive ventilation, which should include:
their ability and willingness to assist in providing noninvasive ventilation
their training needs
have the opportunity to discuss any concerns they may have with members of the multidisciplinary team, the respiratory ventilation service and/or other healthcare professionals. 

## Identification and assessment of respiratory impairment
Monitor the symptoms and signs listed in table 1 to detect potential respiratory impairment. 
Symptoms
Signs
Breathlessness
Increased respiratory rate
Orthopnoea
Shallow breathing
Recurrent chest infections
Weak cough
Disturbed sleep
Weak sniff
Non-refreshing sleep
Abdominal paradox (inward movement of the abdomen during inspiration)
Nightmares
Use of accessory muscles of respiration
Daytime sleepiness
Reduced chest expansion on maximal inspiration
Poor concentration and/or memory
Confusion
Hallucinations
Morning headaches
Fatigue
Poor appetite
Weak cough could be assessed by measuring peak cough flow.
As part of the initial assessment to diagnose MND, or soon after diagnosis, a healthcare professional from the multidisciplinary team who has appropriate competencies should perform the following tests (or arrange for them to be performed) to establish the person's baseline respiratory function:
-xygen saturation measured by pulse oximetry (SpO2):
this should be a single measurement of SpO2 with the person at rest and breathing room air
if it is not possible to perform pulse oximetry locally, refer the person to a respiratory ventilation service.Then one or both of the following:
forced vital capacity (FVC) or vital capacity (VC)
sniff nasal inspiratory pressure (SNIP) and/or maximal inspiratory pressure (MIP). Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes.
If the person has severe bulbar impairment or severe cognitive problems that may be related to respiratory impairment:
ensure that SpO2 is measured (at rest and breathing room air)
do not perform the other respiratory function tests (FVC, VC, SNIP and MIP) if interfaces are not suitable for the person. 
A healthcare professional with appropriate competencies should perform the respiratory function tests every 2 to 3 months, although tests may be performed more or less often depending on:
whether there are any symptoms and signs of respiratory impairment (see table 1)
the rate of progression of MND
the person's preference and circumstances. 
Perform arterial or capillary blood gas analysis if the person's SpO2 (measured at rest and breathing room air):
is less than or equal to 92% if they have known lung disease
is less than or equal to 94% if they do not have lung disease.If it is not possible to perform arterial or capillary blood gas analysis locally, refer the person to a respiratory ventilation service. 
If the person's SpO2 (measured at rest and breathing room air) is greater than 94%, or 92% for those with lung disease, but they have sleeprelated respiratory symptoms:
consider referring them to a respiratory ventilation service for continuous nocturnal (overnight) oximetry and/or a limited sleep study and
discuss both the impact of respiratory impairment and treatment options with the patient and (if the person agrees) their family and carers. 
If the person's arterial partial pressure of carbon dioxide (PaCO2) is greater than 6 kPa:
refer them urgently to a respiratory ventilation service (to be seen within 1 week) and
explain the reasons for and implications of the urgent referral to the person and (if the person agrees) their family and carers. 
If the person's PaCO2 is less than or equal to 6 kPa but they have any symptoms or signs of respiratory impairment, particularly orthopnoea (see recommendation 1.14.15):
refer them to a respiratory ventilation service for nocturnal (overnight) oximetry and/or a limited sleep study and
discuss both the impact of respiratory impairment and treatment options with the person and (if the person agrees) their family and/or carers (as appropriate). 
If any of the results listed in table 2 is obtained, discuss with the person and (if appropriate) their family and carers:
their respiratory impairment
their treatment options
possible referral to a respiratory ventilation service for further assessment based on discussion with the person, and their wishes. 
Forced vital capacity (FVC) or vital capacity (VC)
Sniff nasal inspiratory pressure (SNIP) and/or maximal inspiratory pressure (MIP)
(if both tests are performed, base the assessment on the better respiratory function reading)
FVC or VC less than 50% of predicted value
SNIP or MIP less than 40 cmH2O
FVC or VC less than 80% of predicted value plus any symptoms or signs of respiratory impairment (see recommendation 1.14.7), particularly orthopnoea
SNIP or MIP less than 65 cmH2O for men or 55 cmH2O for women plus any symptoms or signs of respiratory impairment (see recommendation 1.14.7), particularly orthopnoea
Repeated regular tests show a rate of decrease of SNIP or MIP of more than 10 cm H2O per 3 months
Base decisions on respiratory function tests for a person with a diagnosis of frontotemporal dementia on considerations specific to their needs and circumstances, such as:
their ability to give consent
their understanding of the tests
their tolerance of the tests and willingness to undertake them
the impact on their family and carers
whether they are capable of receiving noninvasive ventilation. 

## Non-invasive ventilation for treatment of respiratory impairment in people with MND
Offer a trial of non-invasive ventilation if the person's symptoms and signs and the results of the respiratory function tests indicate that the person is likely to benefit from the treatment. 
Consider a trial of noninvasive ventilation for a person who has severe bulbar impairment or severe cognitive problems that may be related to respiratory impairment only if they may benefit from an improvement in sleeprelated symptoms or correction of hypoventilation. 
Before starting non-invasive ventilation, the multidisciplinary team together with the respiratory ventilation service should carry out and coordinate a patientcentred risk assessment, after discussion with the person and their family and carers. This should consider:
the most appropriate type of noninvasive ventilator and interfaces, based on the person's needs and lifestyle factors and safety
the person's tolerance of the treatment
the risk, and possible consequences, of ventilator failure
the power supply required, including battery backup
how easily the person can get to hospital
risks associated with travelling away from home (especially abroad)
whether a humidifier is required
issues relating to secretion management
the availability of carers. 
Before starting non-invasive ventilation, the multidisciplinary team together with the respiratory ventilation service should prepare a comprehensive care plan, after discussion with the person and their family and carers (who should be offered a copy of the plan). This should cover:
long-term support provided by the multidisciplinary team
the initial frequency of respiratory function tests and monitoring of respiratory impairment
the frequency of clinical reviews of symptomatic and physiological changes
the provision of carers
arrangements for device maintenance and 24hour emergency clinical and technical support
secretion management and respiratory physiotherapy assessment, including cough augmentation (if required)
training in and support for the use of non-invasive ventilation for the person and their family and carers
regular opportunities to discuss the person's wishes in relation to continuing or withdrawing noninvasive ventilation. 
When starting noninvasive ventilation:
perform initial acclimatisation during the day when the person is awake
usually start regular treatment at night, before and during sleep
gradually build up the person's hours of use as necessary. 
Continue non-invasive ventilation if the clinical reviews show:
symptomatic and/or physiological improvements for a person without severe bulbar impairment and without severe cognitive problems
an improvement in sleeprelated symptoms for a person with severe bulbar impairment or with severe cognitive problems that may be related to respiratory impairment. 
Provide the person and their family and/or carers (as appropriate) with support and assistance to manage noninvasive ventilation. This should include:
training on using noninvasive ventilation and ventilator interfaces, for example:
emergency procedures
night-time assistance if the person is unable to use the equipment independently (for example, emergency removal or replacement of interfaces)
how to use the equipment with a wheelchair or other mobility aids if required
what to do if the equipment fails
assistance with secretion management
information on general palliative strategies
an offer of ongoing emotional and psychological support for the person and their family and carers. 
Discuss all decisions to continue or withdraw noninvasive ventilation with the person and (if the person agrees) their family and carers. 
Before a decision is made on the use of noninvasive ventilation for a person with a diagnosis of frontotemporal dementia, the multidisciplinary team together with the respiratory ventilation service should carry out an assessment that includes:
the person's capacity to make decisions and to give consent (see Mental Capacity Act 2005)
the severity of dementia and cognitive problems
whether the person is likely to accept treatment
whether the person is likely to achieve improvements in sleeprelated symptoms and/or behavioural improvements
a discussion with the person's family and/or carers (with the person's consent if they have the capacity to give it). 
Consider prescribing medicines to help ease breathlessness that people using noninvasive ventilation can take on an 'asneeded' basis at home, for example, opioids or benzodiazepines.In February 2016 this was an off-label use of opioids and benzodiazepines. See NICE's information on prescribing medicines. 
Inform services that may see the person in crisis situations, such as their GP and services that provide emergency or urgent care, that the person is using noninvasive ventilation. 

## Stopping non-invasive ventilation
The healthcare professionals responsible for starting noninvasive ventilation treatment in people with MND should ensure that support is available for other healthcare professionals who may be involved if there is a plan to stop noninvasive ventilation, including the legal and ethical implications. 
If a person on continuous noninvasive ventilation wishes to stop treatment, ensure that they have support from healthcare professionals with knowledge and expertise of:
stopping noninvasive ventilation
the ventilator machine
palliative medicines (see the NICE guideline on care of dying adults in the last days of life)
supporting the person, family members and/or carers (as appropriate)
supponad rting other healthcare professionals involved with the person's care
legal and ethical frameworks and responsibilities. 
If a person on continuous noninvasive ventilation wishes to stop treatment, seek advice from healthcare professionals who have knowledge and experience of stopping noninvasive ventilation. 
Healthcare professionals involved in stopping noninvasive ventilation should have uptodate knowledge of the law regarding the Mental Capacity Act, DNACPR, ADRT orders, and Lasting Power of Attorney. # Context
Motor neurone disease (MND) is a neurodegenerative condition that affects the brain and spinal cord. MND is characterised by the degeneration of primarily motor neurones, leading to muscle weakness.
The presentation of the disease varies and can be as muscle weakness, wasting, cramps and stiffness of arms and/or legs; problems with speech and/or swallowing or, more rarely, with breathing problems. As the disease progresses, the pattern of symptoms and signs becomes similar, with increasing muscle weakness in the person's arms and legs, problems swallowing and communicating and weakness of the muscles used for breathing, which ultimately leads to death. Most people die within 2 to 3 years of developing symptoms, but 25% are alive at 5 years and 5% to 10% at 10 years. The most common type of MND is amyotrophic lateral sclerosis (ALS). There are rarer forms of MND such as progressive muscular atrophy or primary lateral sclerosis, which may have a slower rate of progression.
Every person with MND has an individual progression of the disease. About 10% to 15% of people with MND will show signs of frontotemporal dementia, which causes cognitive dysfunction and issues in decisionmaking. A further 35% of people with MND show signs of mild cognitive change, which may affect their ability to make decisions and plan ahead.
MND is a disorder which can affect adults of any age. It is most common in people aged 55 to 79 years, and onset below the age of 40 years is uncommon. There are approximately 4,000 people living with MND in England and Wales at any one time. The cause of MND is unknown. About 5% to 10% of people with MND have a family history of the disease and several abnormal genes have been identified.
As there is no cure for MND, care focuses on maintaining functional ability and enabling people with MND and their family members to live as full a life as possible. Early diagnosis, without delay after investigation, may be helpful, as it allows medication and the provision of aids, as well as communication about the disease and advance care planning to be undertaken appropriately.
Care of people with MND varies across England and Wales, with MND care centres and networks providing coordinated multidisciplinary care. However, some people with MND are left isolated and their care is less than ideal. This guideline aims to consider the clinical and costeffectiveness evidence for the care of people with MND from the time of diagnosis, including communication of the diagnosis, monitoring of disease progression, management of symptoms (in particular muscle weakness, excess secretions, breathing and nutrition problems), ongoing support and services available, mobility, emotional and psychological changes, and the preparation for end of life care. Particular emphasis is placed on the importance of a multidisciplinary team approach to the care and management of people with MND.# Recommendations for research
The Guideline Committee has made the following recommendations for research. The Committee's full set of recommendations for research is detailed in the full guideline.

# Organisation of care
Is a networkbased model as effective as a clinicbased model to deliver multidisciplinary care to people with motor neurone disease (MND)?

## Why this is important
Multidisciplinary care improves survival in patients with MND. The evidence is drawn from models of multidisciplinary care that use a clinic based approach. However there are other models of care delivery in practice including care networks. Often these alternative models of care have arisen out of necessity in large geographical regions with low density populations. These alternative models may have similar survival advantages to patients with MND and this needs to be established.

# Cognitive assessment
What is the impact of assessing for cognitive and behaviour change in people with MND on clinical practice, the person and their family and carers? Does repeated assessment provide more benefit than assessment at a single point at diagnosis?

## Why this is important
Clinicbased and populationbased studies demonstrate that up to 15% of people with MND have frontotemporal dementia. A further third of people with MND have changes in behaviour and cognition. These impairments are present at diagnosis. Their course during the disease has shown varying patterns between studies although several studies have shown that cognitive and behavioural impairments predict poorer survival and increased carer burden. A randomised controlled trial is needed to assess whether formal assessment at diagnosis and/or repeated assessment improves clinical practice, subsequent care of the person and quality of life for the person, their family and carers.

# Prognostic tools
Is the ALS Prognostic Index an accurate predictor of survival in people with MND under NHS care in England and/or Wales?

## Why this is important
Accurate predictions of survival in people with MND would be of great use to clinicians and to the person with MND, their family and carers. Accurate predictions would enable people with MND to be clearer about their prognosis, make plans for the rest of their life and have a wellprepared and dignified transition into the end of life phase. Family members would similarly benefit in being more aware of the likely progression and prepare themselves for the death of their loved one.
Accurate predictions of survival would enable professionals to create and deliver more effective management and care plans and access services when it is most appropriate, for example specialist palliative care.
The ALS Prognostic Index (ALSPI) was developed in a cohort of people with ALS in the Republic of Ireland and externally validated in a cohort in Italy. However, it has not been validated in people with ALS, primary lateral sclerosis or progressive muscular atrophy in the NHS in England or Wales. The tool needs to be validated in a UK population using a simplified measure of executive function.

# Saliva
How is excessive drooling of saliva (sialorrhoea) managed in people with MND?

## Why this is important
Sialorrhoea affects up to 50% of people with MND and in 42% of these individuals the symptom is poorly controlled. There is no evidence base for clinicians to make decisions with regards to the treatment options available. Antimuscarinics are used firstline but there is no evidence to inform which antimuscarinic and at what dose. Botulinum toxin is used second- or thirdline although there is little evidence to guide dosing, which salivary glands to inject and which type of botulinum toxin to use. Currently there is no baseline information about how specialists are using these treatments and this information is required to inform comparative studies.

# Nutrition
Does a high calorific diet prolong survival of people with MND if initiated following diagnosis or following initiation of feeding using a gastrostomy?

## Why this is important
There is little specific guidance on the optimal calorie intake for people with MND. There is growing evidence that people with MND have a hypercatabolic state and have high energy requirements. A large cohort study in the UK has demonstrated that nearly half of people continue to lose weight following gastrostomy and most show no improvement in their weight. A small study has demonstrated that high fat and high carbohydrate feeding may prolong survival in gastrostomyfed people. A larger randomised trial is needed to inform clinical practice.

# Augmentative and alternative communication
What is the current pattern of provision and use of augmentative and alternative communication (AAC) by people with MND in England?

## Why this is important
Appropriate AAC equipment can have a significant effect on quality of life for people with MND. While the NHS has a responsibility to provide equipment and ongoing support in its use, there are no reliable data on the types of equipment found most useful at different stages of the disease process, or the number of people with MND who may benefit from AAC. A prospective census study of people with MND presenting with early onset of speech problems is needed to establish the current baseline provision and needs of this population and how best to utilise AAC equipment. The programme will begin with the collection and analysis of basic data. It will then progress to patientrelated outcomes.