As the entire world learns to embrace ageing, it brings with challenges for healthcare service delivery and economy. Although, MS is a disease of the young (median age of onset is 32) ageing looms in the horizon and cannot be blithely ignored. In some instances, the MS isn’t picked up until much later (the oldest patient I’ve diagnosed is 84 years old!), which raises questions around treatments; particularly when the maximum age of inclusion in clinical trials is 55. Moreover, other conditions that occur with ageing also need to be considered.
In this review articel by Ostolaza et al. they mention the following conditions that are seen with and can occur with ageing:
- Heart disease. Increases from 9% in those aged 8-65, to 28% in those 65 or older. It’s co-existence with MS is known to increase disease progression. Other risk factors, such as elevated cholesterol and LDL are known to correlate with the occurrence of new MRI lesions.
- Other autoimmune disorders. Although, our immune system ages like the rest of us, many autoimmune disorders are known to develop in the second half of life and peak in the elderly – rheumatoid arthritis and giant cell arteritis are examples.
- Psychiatric disorders. Namely depression, anxiety and psychosis are more prevalent than previously assumed in the elderly. In MS per se, depression shows the strongest association with 15-50% occurrence in studies.
- Memory impairment. With the greatest prevalence in older and those with secondary progressive MS. The domains mostly affected are speed of processing information, attention, thinking, spacial ability, long term memory, and learning new information and consolidating this with existing memory. Language and recent memory are usually preserved in advanced MS.
MS treatments in the older individual is also another conundrum. Progressive MS becomes more prevalent with ageing, but most pivotal trials exclude those older than 55. Moreover, the success of current DMTs in progressive disease is small. Therefore safety of these DMTs remain open to question as does efficacy. In a recent meta-analysis, age was the biggest determinant of efficacy, with little effect from the age of 53 on wards.
Treatment discontinuation is another thorny subject, but lack of efficacy is usually a common reason for discontinuation and even the milder side effects that younger patients tolerate may be an issue. Polypharmacy is another concern. The risk of relapse has been evaluated after stopping DMTs, but more studies are needed in this area. They found that being older than 45, and without evidence of active disease (clinical or radiological) in the preceding 4 years were less likely to experience a relapse following treatment discontinuation.
On balance, despite the lack of dedicated studies in the older MS population, with regards to co-existing medical conditions at least we know what to expect.
Multiple sclerosis and aging: comorbidity and treatment challenges
Mult Scler Relat Disord. 2021 Feb 4;50:102815. doi: 10.1016/j.msard.2021.102815. Online ahead of print.
Background: The prevalence of elderly patients with MS is increasing, in conjunction with the ageing general population. This review will examine the principal characteristics of elderly patients with MS and how the concomitant pathologies affect them. Finally, it will assess the impact of the medications on these patients and whether it would be safe to discontinue the disease-modifying treatment.
Methods: Searches using PubMed were conducted in October 2020 to collect studies assessing the impact of age and comorbidities on patients with MS.
Results: Several studies showed that aged patients develop concomitant pathologies that could worsen the disease’s prognosis. Also, MS itself may be closely related to cognitive impairment, even though the exact etiopathogenic mechanism of it is still unclear. To date, safety and efficacy of currently available drugs remain unassessed in elderly populations. These treatments may not be beneficial in preventing the progression of disability in ageing people with no signs of inflammatory activity, and discontinuation of treatment is often discussed in this subgroup of patients.
Conclusions: The presence of cardiovascular pathology, psychiatric disorders, diabetes or cancer is further associated with increased mortality in MS patients. The diagnosis and treatment of the disease is challenged by both age-related comorbidities and clinical variations compared to younger patients. It may be safe to discontinue treatment in elderly patients with no clinico-radiological activity.