Managing Myasthenia Gravis in the Elderly with Comorbidities

From Crisis to Care: The Challenge of Managing Myasthenia Gravis in an Elderly Patient with Multiple Comorbidities

Punitha Selvi¹, Fathima.S², Bharani³, Sabari Divya Nandhini. R⁴

¹ANS, Neuro Intensive Critical Care Unit, Kauvery Hospital, Vadapalani

²Registered Nurse, Neuro Intensive Critical Care Unit, Kauvery Hospital, Vadapalani

³Registered Nurse, Neuro Intensive Critical Care Unit, Kauvery Hospital, Vadapalani

³Nurse Educator, Kauvery Hospital, Vadapalani, Kauvery Hospital, Vadapalani

Introduction

Myasthenia Gravis (MG) is an autoimmune disorder characterized by weakness and fatigability of skeletal muscles due to antibodies that target acetylcholine receptors at the neuromuscular junction. Symptoms often include ocular involvement, such as ptosis and diplopia, and may progress to generalized weakness, including respiratory muscle impairment. Though MG can occur at any age, its presentation in elderly individuals is rare and poses unique management challenges due to the presence of comorbidities. This case report discusses the multidisciplinary management of an elderly female with MG and multiple comorbid conditions.

Case Presentation

A 79-year-old female, Mrs. Shanthi Krishnan B, was admitted to the hospital with complaints of slurred speech, drooping eyelids, and double vision.

Her past medical history included:

Type 2 Diabetes Mellitus
Systemic Hypertension
Dyslipidemia

Neurological examination and nerve conduction studies confirmed a diagnosis of Myasthenia Gravis.

On Examination

Ptosis and dysarthria present
Respiratory distress noted
GCS on admission: E4V5M6
BP: 130/80 mmHg, PR: 94 bpm, SpO2: 91% on room air
Pupils reactive, normal tone and reflexes present.

Clinical Course and Management

The patient’s clinical condition deteriorated rapidly. She developed diabetic ketoacidosis (DKA), followed by respiratory failure necessitating intubation and mechanical ventilation. During her ICU stay, she developed further complications including Seizures, Bradycardia, and Atrial fibrillation

She was treated with IV immunoglobulin, steroids, cholinergic drugs, insulin infusion, and supportive care. After multiple failed attempts to wean off the ventilator, a tracheostomy was performed on February 1, 2025. Physiotherapy, suctioning, and back care were part of her routine management. She was gradually weaned from mechanical ventilation to BIPAP and then to T-piece oxygen.

Investigations

Parameter	Value
Hemoglobin	10.2 g/dL
Blood Glucose	>300 mg/dL (DKA episode)
Sodium	138 mmol/L
Potassium	4.5 mmol/L

ECG – Atrial fibrillation, Bradycardia

EEG – Abnormal, consistent with seizure disorder

Medications

Drug	Dosage	Frequency
Pyridostigmine	60 mg	QID
Methylprednisolone	500 mg	OD (IV pulse)
Levetiracetam	500 mg	BD
Metoprolol	25 mg	BD
Insulin	Variable	Sliding scale
Omeprazole	20 mg	OD

Nursing Management

The nursing team implemented round-the-clock care with the following interventions:

Airway and Respiratory Management: Tracheostomy care, suctioning, oxygen therapy, ventilator support
Monitoring: Continuous cardiac and neurological monitoring
Medication Administration: Timely administration of antiepileptics, steroids, and cholinergic drugs
Nutrition: NG feeding support with diabetic diet monitoring

Infection Control:

Sterile technique for suctioning and wound care

Patient and Family Education:

Tracheostomy care, seizure precautions, medication adherence

Rehabilitative Nursing:

Respiratory physiotherapy and mobilization

Psychological counseling and caregiver support

Encouragement of communication through assistive methods

Nutrition Support:

NG feeding with diabetic-friendly, protein-rich semi-solid diet

Gradual reintroduction of oral intake post-respiratory improvement

Monitoring of blood glucose levels and electrolyte balancess

Conclusion

This case illustrates the importance of early recognition and comprehensive management of Myasthenia Gravis in elderly patients with comorbidities. Timely interventions like mechanical ventilation, tracheostomy, immunotherapy, and seizure control were pivotal in the patient recovery. Nursing care played a central role in ensuring continuous monitoring, medication compliance, nutrition, and patient education. Multidisciplinary collaboration was key to favorable patient outcomes.

From Crisis to Care: The Challenge of Managing Myasthenia Gravis in an Elderly Patient with Multiple Comorbidities

From Crisis to Care: The Challenge of Managing Myasthenia Gravis in an Elderly Patient with Multiple Comorbidities

Punitha Selvi1, Fathima.S2, Bharani3, Sabari Divya Nandhini. R4

Nightingale Journals

Punitha Selvi¹, Fathima.S², Bharani³, Sabari Divya Nandhini. R⁴