Barts-MS rose-tinted-odometer ★★★
I belong to an international group that addresses important issues in multiple sclerosis that arise between HCPs and pwMS. For 2020 I have suggested we tackle the issue of ageing in MS. I have been asked why I think ageing an important topic in MS. I have put forward the following list of issues that have come to mind. Can you help me with suggestions or specific age-related issues I may have left off the list? Thanks.
As the MS population gets larger we are seeing more people with MS becoming old. This raises several important issues around their management.
- Most clinical trials exclude older people with MS. Can we be sure that DMTs have the same risk-benefit ratio in the older MS population as the younger population?
- Comorbidities are commoner in the older population. How do these affect the safety profile of DMTs? For example, the recent vascular complications seen with alemtuzumab were much commoner in patients with vascular comorbidity, who tended to older. Another example is PML; there is little doubt that age is a risk factor for developing PML.
- Non-specific white matter lesions or vascular lesions are common as you get older. How are we the MS community going to deal with these when we are so dependent on MRI as a monitoring tool for the effectiveness of DMTs. How do we differentiate between new MS lesions and new vascular lesions? Will the central vein sign be sufficient for this?
- Brain volume loss (BVL) accelerates with ageing. Does this also happen in MS? As we start to use annual brain volume loss as a treatment target in MS should we not be age-adjusting for what is considered normal BVL?
- Neurological function and cognition fall off with age. How do we know that it is ageing or MS that is causing the loss of neurological function?
- Because MS reduces brain and cognitive reserve are pwMS more likely to get other neurodegenerative diseases and at an early age?
- As you get older your immune systems don’t function well. This is called immunosenescence. How does this impact on the safety of immunosuppressive DMTs?
- Ageism is a problem in medicine; how do we prevent it from affecting how we manage older people with MS?
- DMTs become less effective as you get older. How can we be sure they are working in the older MS population?
- How do you stop DMTs in the older MS patient who is stable?
- Are their DMTs that are safer in the older population? Are their DMTs with greater risk in the older population? For example, I am sure anti-CD20 therapies and other continuous immunosuppressive therapies will have a worse risk profile in the older MS population, compared to, for example, cladribine that only causes short-term immunosuppression.
- Does MS cause premature ageing, i.e. premature biological ageing?
- Lifestyle and wellness programmes for helping to manage MS tend to be for younger people. How can we adapt these for the older MS population?
- We are seeing an increasing number of people presenting with syndrome compatible with demyelination in their fifties and sixties. How do the McDonald diagnostic criteria perform in this age-group? Do we need to modify our diagnostic criteria for the older population?
- Most of the information resources for pwMS is designed for younger people. Are the information resources appropriate for the older MS population? Do we need age-adjusted information resources? Do you think the current educational resources for the ageing MS population are adequate?
- How does ageing affect MS? Is premature ageing a driver of delayed worsening in MS?
- What can I do to prevent age-related neurodegeneration making MS worse?
- Do the anti-ageing interventions that work in the general population work in pwMS?
- What about advanced directives or living wills? Are these more important for the older MS population?
- Social isolation becomes more pronounced with ageing and increasing disability. Should there be age-specific social prescribing programmes?
- Sexual function is a problem in MS but is often ignored in the elderly. Should sexual function and other symptomatic problems be looked at in the older MS population to define the problem in this population group?