Clinical decision-making in older adults with multiple sclerosis: A National Delphi survey of Israeli MS specialists

The aging population of people with multiple sclerosis (MS) presents growing clinical challenges that are insufficiently addressed by existing evidence. Age-related changes in disease biology, treatment effectiveness, and safety complicate therapeutic decision-making, particularly regarding treatment de-escalation and discontinuation.

To describe areas of agreement and uncertainty among Israeli MS specialists regarding clinical decision-making for older adults with MS.

A national two-round modified Delphi survey was conducted among 24 MS specialists in Israel. Round 1 included 23 items spanning age-related considerations, late-onset MS (LOMS), treatment continuation, de-escalation and discontinuation, progressive MS, monitoring, vaccination, and treatment decision factors. A structured expert discussion was followed by a focused second round. Consensus definitions were prespecified before response analysis after review of published Delphi methodology and were tailored to item structure.

All 24 specialists completed both Delphi rounds. Panel characteristics were subsequently provided by 23 participants (95.8%): median experience in MS care was 15 years (range, 3-35), median annual MS caseload was 500 patients (range, 100-800), 22 practiced primarily in academic or hospital-based settings, and one reported mixed academic and community practice. The panel endorsed age-specific risk-benefit assessment, recognized continuation, de-escalation, and discontinuation as legitimate options in selected stable older patients, and identified persistent uncertainty regarding exit strategies and non-active progressive disease. These findings describe national expert opinion rather than evidence-based recommendations.

This national modified Delphi survey describes areas of agreement and uncertainty among Israeli MS specialists. The findings support individualized treatment decisions integrating inflammatory activity, radiologic stability, safety, comorbidity burden, and patient preference, rather than age alone. They should not be interpreted as international consensus or as formal treatment recommendations.