Managing multiple sclerosis (MS) in older adults presents significant challenges as the complexity of age-related factors, coexisting health issues, and the evolving nature of the disease influence treatment strategies. Disease-modifying therapies (DMTs) that have been prevalent for over two decades show promising benefits when initiated early in the disease course. These therapies can alter disease progression, slow disability accumulation, and enhance the quality of life for younger patients. Nevertheless, when it comes to older populations, especially those over 50 years of age, clinical trials have historically excluded individuals with higher disability levels and comorbid conditions. This exclusion limits the understanding and applicability of DMTs in older adults, even as these treatments are increasingly utilized in practice, evidenced by emerging data from post-approval studies and registries.
Active focal inflammatory diseases manifesting as relapses and new lesions on MRI scans strongly predict treatment responsiveness in older MS patients. The prevention of relapses becomes critically important in this demographic since older adults experience poorer recovery rates post-relapse. On the contrary, the patterns of inflammatory activity seen in older adults differ significantly from those in their younger counterparts, potentially leading to altered efficacy of immunomodulatory DMTs. This highlights the necessity of reevaluating treatment protocols to ensure they address the unique profiles of older patients effectively, particularly in light of age-related differences in disease activity and inflammatory response.
While numerous DMTs are available, the real-world data reflect a disparity in treatment application in older adults. According to recent studies, older patients tend to receive less aggressive therapies, resulting in undertreatment of relapsing forms of the disease. This trend is worrisome, as the repercussions of untreated inflammation can result in accelerated disease progression and a heightened risk of accumulating disability. The hesitation to employ high-efficacy medications in older groups possibly stems from concerns regarding safety and tolerability due to prevalent comorbidities, which can complicate treatment adherence and efficacy.
Clinicians face the delicate balance of potentially overprescribing therapies that may have limited benefits due to the individual’s biological frailty or age-related changes. Concerns about the long-term safety of DMTs among older adults remain at the forefront, as elderly patients are more susceptible to adverse effects such as serious infections or complications from polypharmacy. Furthermore, the impact of age-associated changes on the immune system, particularly immunosenescence, can modify treatment responses, necessitating ongoing research into age-stratified treatment approaches.
As the therapeutic landscape evolves, the need for incorporating preventative measures in the management of older adults with MS grows more critical. Non-pharmacological strategies, including exercise, nutritional interventions, and psychosocial support, are essential components that should complement DMT regimens. Exercise, for instance, not only alleviates physical deterioration associated with aging but also modifies the immune response in a more favorable, anti-inflammatory direction. Evidence suggests that routine physical activity can help mitigate brain atrophy and preserve cognitive function, aspects that are often compromised in older MS patients.
Developing neuroprotective and regenerative treatments offers hope for older individuals experiencing chronic neurodegeneration due to MS. The natural decline in the brain’s repair mechanisms highlights the pressing need for innovative therapies that specifically target neuroprotection and remyelination. As research progresses, identifying potential pharmaceutical agents that enhance these repair processes or mitigate age-associated decline in cellular function becomes imperative. The introduction of novel treatments such as metformin, which demonstrates regenerative properties and may also possess anti-aging effects, presents an exciting frontier in addressing the unique needs of older MS patients.
Simultaneously, addressing treatment discontinuation should be approached cautiously, as the balance between benefits and risks becomes increasingly pertinent with advanced age and prolonged disease duration. Current evidence suggests that certain patients may safely discontinue therapy if they have sustained stable disease over an extended period. Conversely, the risks associated with withdrawing high-efficacy treatments, particularly in individuals with higher disability scores, necessitate careful consideration of continued therapy to avoid exacerbating the disease.
The management of comorbidities in older MS patients further complicates treatment paradigms. Comorbid conditions such as cardiovascular diseases can obscure MS symptoms or mimic relapses, necessitating a more nuanced understanding of the patient’s overall health status. The healthcare community must develop comprehensive management strategies that do not only focus on MS but also account for the patient’s entirety, promoting wellness and enhancing the quality of life for those affected.
These observations call for systematic approaches to integrate holistic management techniques with conventional therapies to facilitate better outcomes. Shared decision-making between clinicians and patients, coupled with proper educational resources, can empower older MS patients in taking an active role in their treatment plans. By recognizing the unique challenges they face, healthcare professionals can foster supportive environments that address the psychological, emotional, and physical toll of living with MS as one ages.
Research and clinical guidelines must evolve to address the distinct requirements of older MS patients effectively. An emphasis on increasing participation of older patients in clinical trials should be prioritized, as this will yield insights into the safety and efficacy of treatments tailored for this demographic. With the growing population of elderly individuals living with MS, there is an urgent need for innovative solutions that encompass all aspects of care, ultimately improving life expectancy and the quality of life for this vulnerable group.
Investing in future research pathways that explore the interactions between MS, aging, and treatment efficacy is crucial. As we navigate this complex landscape, a concerted effort to redefine treatment protocols and standardize care for older adults with MS will guide improvements in clinical practice. The goal must be to ensure that all patients, regardless of age, have access to safe, effective, and personalized therapies that enhance their health and well-being.
Subject of Research: Multiple Sclerosis Management in Older Adults
Article Title: Advancing Multiple Sclerosis Management in Older Adults
Article References:
van der Walt, A., Strijbis, E.M.M., Bridge, F. et al. Advancing multiple sclerosis management in older adults. Nat Rev Neurol 21, 432–448 (2025). https://doi.org/10.1038/s41582-025-01115-5
Image Credits: AI Generated
DOI:
Keywords: Multiple Sclerosis, Disease-modifying therapy, Elderly, Neuroprotection, Comorbidities, Holistic management, Clinical trials, Treatment discontinuation
