The life expectancy in multiple sclerosis (MS) continues to increase and is now comparable to that of the general population.¹ This increase comes with the challenge of learning how to manage MS in the aging population. Prof. Dr Thomas Berger from the Medical University of Vienna discussed these concerns in his talk ‘MS in the elderly – Immunosenescence and implications for management’, held during the MS State of the Art Symposium.

Aging and immunosenescence

The process of aging is believed to be driven by an accumulation of factors during the lifespan of an organism, including telomere attrition, genetic and epigenetic instability, mitochondrial dysfunction, stem cell exhaustion and altered intercellular communication. Immunosenescence is the aging of the immune system, an important feature of which is inflammation. Inflammaging, a chronic low-grade inflammation that develops with increasing age, is believed to be involved in the development of most age-related chronic diseases.^2,3

MS in the elderly population

The mean age of the MS population is 55 years, with approximately 25% of this population aged >65 years.^2,4 Inflammation decreases over the duration of MS, which in turn results in decreased relapse rates, as confirmed by MRI data.⁵ It is important to note however that, along with relapses, the functional recovery also decreases. In other words, the older the patient, the less likely they are to have complete recovery after a relapse. The chances of disability accumulation also increase with disease progression. Prof. Berger further highlighted the effect that these prolonged periods of inflammation have on the development of smoldering lesions and the need to further understand the mechanisms involved.

MS and COVID-19

While there were initial concerns about whether the MS population was more likely to develop COVID-19, or would have a more severe response, it was soon clear that these patients have the same risk factor as other individuals, i.e., one driven by cardiovascular disease, obesity, diabetes etc. There was only one MS-specific concern that increased the risk, namely, impaired mobility, which influences the risk of infections (including COVID-19).²

Therapies in the elderly population

There are a huge spectrum of disease modifying therapies (DMTs) available for the treatment of MS. These treatments are more likely to be effective in the inflammatory phase. In other words, these treatments are less effective in the later stages of MS. Similarly, immunosenescence also results in older patients being more likely to have lymphopenic reactions due to immunomodulatory or immunosuppressive drugs. There are also studies showing that the older the patient, the more likely they are to develop Progressive Multifocal Leukoencephalopathy (PML).² These are all aspects that need to be considered while prescribing therapy for the aging MS population.

Conclusions

Improved healthcare practices, and access to a wide range of DMTs, have helped increase the life expectancy of an MS patient. This has, of course, also lead to a new set of challenges in elucidating various aspects of disease progression. There is a need to further understand the mechanisms of aging directly involved in MS. Aging might be a contributing factor for adverse events in case of certain DMTs.²

Read more MS State of the Art Symposium 2022 coverage by following this link.

Reference

1. Lunde HMB et al. Journal of Neurology, Neurosurgery & Psychiatry 2017;88 :621–625.
2. Berger T. ‘MS in the elderly – Immunosenesce and implications for management’ Presented at MS State of the Art Symposium, 31 January 2022.
3. Franceschi et al. Nat Rev Endocrinol 2018;14(10):576–590.
4. Wallin MT et al. Neurology 2019;92(10) : 1029–1040
5. Koch MW et al. Neurology 2021;97(13) :1334–1342