Multiple Sclerosis and Aging: A Preview of the CMSC Consensus Papers

The Consortium of Multiple Sclerosis Centers (CMSC) recently released a pamphlet consensus statement on multiple sclerosis (MS) and aging (available at https://www.mscare.org/publications/) and plans to publish papers supporting the statement in 2025 in the International Journal of MS Care (IJMSC). IJMSC interviewed the project’s coleaders, Yinan Zhang, MD, and Sarah A. Morrow, MD, MS, FRCPC, FAAN. Zhang is an assistant professor of neurology at The Ohio State University (OSU) in Columbus whose research interests include biological aging in people with MS and who is involved in the care of older adults with MS at OSU hospitals. Morrow is a professor of neurology and director of the Calgary MS Program in Calgary, Alberta, Canada. She also serves on the boards of CMSC and IJMSC.

Yinan Zhang, MD

(Credit: The Ohio State University)

Yinan Zhang, MD: The consensus statement for aging and MS started about a year and a half ago, when I realized that we don’t have much consensus on the topic of how we treat and manage older adults with MS. I approached the CMSC asking if there was interest in gathering a group of experts to survey the community to find out what the needs are and then review the evidence and put forward some initial thoughts and guidelines.

Sarah A. Morrow, MD, MS, FRCPC, FAAN: From a CMSC point of view, it was a topic of interest to us. We are dealing with an aging population [with] MS, which is a privilege but also daunting in that with the disease-modifying therapies (DMTs) we have now, patients are living longer and living more independently. We haven’t had to [treat] people with MS in their 50s and 60s and 70s as much as we [do] now. CMSC focuses on how we can best care for our patients [with] MS, so this was a topic that was of great interest to us. We want to be able to help our members give the best care possible to people as they age [and live longer] with MS.

Sarah Morrow MD, MS, FRCPC, FAAN

(Credit: University of Calgary)

IJMSC: What was the process? Who were the other clinicians who joined you on the consensus statement?

YZ: We assembled a panel of experts on various topics of aging and MS, and [then] we devised a set of survey questions that we administered at the 2023 CMSC Annual Meeting in [Aurora, Colorado]. We had over 100 responses. Based on [those responses], we compiled a list of topics that we thought were the most relevant fields that people wanted more insight into.

SM: Yes, we got topic experts from all areas that were identified as areas of need by our CMSC members. [With] the pathobiology of aging and MS, that expert is Dr Jennifer Graves. We also talked a lot about DMTs. Who do you put on them? Which ones are safe? When do you stop? And Dr John Corboy, who has done a lot of work in discontinuation, was one of our experts in this area. Another…identified area of need was managing comorbidities, because as we age, we accumulate other health issues, and trying to manage both MS and other health issues at the same time can be complicated. We enlisted Dr Ruth Ann Marrie, who’s done a lot of great work in the area of comorbidities and MS. We also wanted to look at collaboration or comprehensive care for people living with MS. And one of the experts in that area is Dr Fred Foley, who has worked a lot on depression and anxiety and comprehensive care for people living with MS. Finally, we wanted to look at access to care…and we had a few expert nurse practitioners, specifically Rachael Stacom and Renee Stewart, who deliver care outside of what we as neurologists often think of as care for people living with MS.

YZ: After we assembled the team, we [turned to] the 5 topics from the survey results: the risks and benefits of DMTs, the integration of multidisciplinary specialists, the management of comorbidities and polypharmacy, age and MS-related changes, and finally, access to care. For each, we included additional members from the MS care community…from multidisciplinary backgrounds, people like pharmacists, dietitians, physical therapists, nurse practitioners, [to] provide the well-rounded team reflective of all the different specialists who are involved in MS care. So in addition to the team leaders who Sarah mentioned, we also enlisted Dr Le Hua, Dr Scott Newsome, Jacci Bainbridge, Mona Bostick, Patty Bobryk, Dr Jeff Wilken, and geriatrician Dr Maureen Choman.

IJMSC: How did you arrive at consensus for the 5 identified areas?

SM: We started by dividing and conquering…. Each group did evidence-based reviews and came up with evidence-based consensus [and] expert-based consensus. A lot of what we’re talking about does not have a lot of evidence behind it yet, because this is somewhat of a new topic in the area of MS. Each group then brought it to the whole [team]…at the [2024] CMSC meeting. Each group presented what they had found, what they felt we know about MS and aging in their area, what we don’t know yet, and then the areas…to focus on further in the future. We then discussed it as a group…to be able to come up with a consensus. At the end, we had the document written and circulated it for all members to…vet or review to make sure it reflects the evidence…as well as the expert opinions that were presented at our consensus meeting.

IJMSC: During the process, did anything come up that was added or that changed what you thought the document was going to be when you began?

YZ: During our literature review, we realize[d what] an underexplored topic [this is] in MS…. We have very little evidence on, for example, whether DMTs are safe or effective in the older population. Or what are the exact benefits of multidisciplinary care? We don’t have any randomized trials or have any evidence from multidisciplinary clinics. These led us to develop a section on what research still needs to be done.

IJMSC: What was a surprising or interesting discovery during this process for each of you?

SM: One of the things I was aware of but didn’t understand the extent of how [much of an impact it has] was in some ways a bias we have in medicine, not just in neurology or MS practice but in medicine for aging patients, who may have a lot more barriers to care than we realize. I think [this is] especially [true right now] because we see our patients [with] MS doing so much better. [However], many of them live in what are called care deserts, where they don’t have access to a neurologist or an MS specialty care clinic. [This] makes it difficult when it’s complicated care, when they have MS and many other things or if they’re on a limited budget because of disability or because of age…. I was aware of it, but I guess I didn’t realize what a huge impact it was having on our patients living with MS, especially in rural areas. [They] don’t always have access to proper care for their MS, and even when they do, can they even get there? Or can they afford to get there? That struck me as something that, as [I am] someone who cares about patient care and cares about patients, [is] something we need to focus on and think about when we’re providing care.

YZ: For me, the takeaway message is that the care of older adults with MS is focused equally on the aspect of aging and on MS. As neurologists, we don’t have any formal training in geriatrics or the management of older adults, even though many people who have neurological disorders are older adults. [We can] take a lot of principles from geriatric practice like doing a comprehensive geriatric assessment and keeping in mind the unique socioeconomic challenges that older adults face, like access to care, as Sarah mentioned. And these are all important topics that we should be mindful of as we approach our patients who are getting older. I think this consensus document provides a great starting point for making the neurologist aware…of [some of] these issues in aging.

SM: I agree! I think this document is a good starting point for us to discuss aging in MS and the care of older people with MS. One of the things that [we] found when doing the literature reviews is, as [Zhang] mentioned, there are not a lot of data, there’s not a lot of evidence, and so we rely on expert opinion. And yet the number of people living with MS as they age or with other comorbidities is growing. This is going to be an issue for us going forward in practice, and it’s something that we need to build on and grow. [We can] use this consensus statement as a stepping stone in order to try and get better evidence or more evidence about caring for people living with MS as they age.

YZ: [Our] future plans are to publish the sections of this statement in the peer-reviewed journal IJMSC next year, so we can [all] look forward to that.

Transcript edited for clarity.