Advancing multiple sclerosis management in older adults

Multiple sclerosis (MS) typically presents in early to middle adulthood, but owing to advancements in health care, many individuals with MS now live a normal lifespan, and approximately half of the people currently living with MS are ≥50 years of age. As people living with MS age, their diagnosis, treatment and disease management become more complex owing to the effects of ageing, immunosenescence and comorbidities. Furthermore, diagnosis of late-onset MS (onset above 50 years of age) often requires additional tests, such as spinal cord imaging and cerebrospinal fluid analysis, to differentiate the disease from age-associated conditions such as cerebrovascular disease. Monitoring disease progression also becomes more complicated with increasing age, as physiological age-related changes can confound MRI findings and measurements of disability and cognition. Treatment decisions in older people with MS are also challenging, as high-efficacy treatments carry increased risks with ageing and their benefits can be reduced, yet little evidence is available to guide treatment in older adults. In this Consensus statement, we present the outcomes of an International Advisory Committee on Clinical Trials (IACCT) in MS workshop on ageing and MS; we review the current status of the field and identify knowledge gaps, and provide recommendations to advance the areas of unmet need.