September 2025
Global call to transform multiple sclerosis care for older adults
By Dr Sasha Ellery BM BCh
A new international consensus statement outlines recommendations to improve the management of multiple sclerosis (MS) in people aged 50 years and older, who now represent more than half of the global MS population.
Published in Nature Reviews Neurology, the statement, noted that ageing altered MS biology, with inflammatory relapses becoming less frequent and, in those with late-onset MS (onset at age ≥50 years), disability progression occurred more rapidly.
First author, Associate Professor Anneke van der Walt, Lead of the MS and Neuro-ophthalmology Research Group at the School of Translational Medicine, Monash University, Melbourne, said that diagnosing MS in older adults (aged ≥50 years) was particularly challenging due to overlapping age-related conditions that could mimic MS, such as degenerative spinal pathology.
‘Clinically, older people are more likely to present with progressive symptoms, like a slow deterioration in gait. This could easily be misattributed to back problems, ageing, fatigue, fitness and so forth,’ she said.
She added that confirmation of the diagnosis relied heavily on MRI, which could be confounded by nonspecific white matter changes associated with cardiovascular risk factors, migraine or ageing.
‘There is the perception of MS as being a disease of young adults, leading to a lower index of suspicion that further contributes to delays in diagnosis,’ she said.
The consensus statement, which was produced by an expert panel co-convened by the International Advisory Committee on Clinical Trials in MS and the European Committee for Treatment and Research in MS, recommended the use of advanced spinal cord imaging, visual testing and cerebrospinal fluid analysis to improve diagnostic specificity.
Treatment decisions had to balance the reduced efficacy of some disease-modifying therapies (DMTs) against increased risks in older adults due to immunosenescence and comorbidities. The expert panel suggested that de-escalation or discontinuation of DMTs might be appropriate for stable patients, but stressed the need for more research to guide these decisions.
‘As the immune system ages, there can be increased disruption of the interaction between the innate and adaptive parts of the immune system. This increases the risk of infection while also leading to less obvious focal inflammation. In a disease like MS, this means fewer relapses and a lower likelihood of new lesions on MRI scans,’ Associate Professor van der Walt told Medicine Today. ‘Nevertheless, DMTs are still very effective in older people with MS, and should be offered as first-line treatment.’
The consensus statement recommended a personalised approach that integrated comorbidity management, functional status and patient preferences. Nonpharmacological strategies, including exercise, diet, mental health care and cardiovascular risk management, were emphasised as fundamental to preserve cognitive and physical reserve.
‘GPs play an essential role in older people with MS,’ Associate Professor van der Walt said. ‘At times, people with MS neglect their general health and may not realise that they still need to have regular preventive health care checks and management of other conditions that can affect their long-term health and quality of life. Reinforcing healthy ageing that is relevant to all people is critical – exercise, a nutritious diet, stopping smoking, reducing alcohol intake and managing stress are all essential to brain health.’