Presenting with multiple sclerosis (MS) later in life is less common but can be associated with an increased risk of worsening disease and accompanying disability. Effective treatment is critical in this population to prevent the potential for the rapid accumulation of disability.

There is a broad age range of individuals who receive an MS diagnosis, from teenagers up to people in their 60s, and studies have identified patients who are diagnosed with MS at an older age as having a more concerning prognosis and a more rapid increase in the Expanded Disability Status Scale vs patients who are diagnosed at a younger age. There is, however, a tendency not to treat or to undertreat older patients with MS, perhaps due to concerns about safety or not fully understanding the prognosis in this special population. One of the newer concepts in late-onset MS is the decision to be more aggressive with treatment. Within my practice, I have a lower threshold for using high-efficacy therapies in patients who are between the ages of 45 and 55 years because I want to maximize the benefit while they are still in the inflammatory phases of the disease and are still in a relatively young and less disabled state.

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Some older patients present initially with a relapse and no prior neurologic symptoms, whereas others may have had unrecognized symptoms in the past or a more insidious subclinical progression before the relapse coming to medical attention. In either case, because the therapeutic window is closing, consideration of using highly effective therapy is warranted. It is important to consider comorbidities and risks, as we know that highly effective therapies are going to be riskier in older patients.

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Older patients with comorbidities such as hypertension and vascular disease may have white matter changes that mimic those of MS, so it is important to scrutinize the imaging to make sure that the full criteria are being met for an MS diagnosis. Spinal cord imaging has greater specificity for MS compared with vascular disease and would be helpful when the diagnosis is not clear.

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Because older patients are typically not included in clinical trials of MS treatments, the impact of some of these therapies on outcomes and the risks associated with their use are not as well defined. Certain patients may continue to benefit from high-efficacy therapies, but the risks and benefits should be considered. My general approach as patients get into their mid-60s is to discuss a potential de-escalation strategy, which may mean switching from a monoclonal antibody to an oral MS therapy that has continued activity against disease recurrence but without the risks that we see with some of the highly effective therapies when used in older patients. Discontinuation with ongoing monitoring can also be a consideration if patients are not taking a disease-modifying therapy with a high risk for rebound, such as natalizumab or certain S1P receptor modulators. MS treatment discontinuation was studied in 2 recently reported trials (ie, DISCOMS, which studied patients aged 55 and older, and DOT-MS, which evaluated younger patients [≥18 years]), giving us additional context for these treatment decisions.

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Finally, a number of neurologic diseases, including MS, can be associated with decreased mobility, and this can make patients more susceptible to pneumonia, urinary tract infections, skin breakdown, bladder dysfunction, and even a decreased ability to turn in bed because of pain or weakness. All these consequences of severe neurologic disease can contribute to increased morbidity and reduced quality of life in patients with MS, so we want to make sure that people maintain their mobility and independence so that they can prevent them from developing.