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MS research update - Can MS begin in the over fifties? - 14 October 2013

Summary

At one time, it was thought that MS rarely developed in people over 50 but opinion is changing as more cases are now being identified. This study looked at the characteristics of MS when it begins over the age of 50.

People in south-east Wales whose MS began at age 50 or above were identified from a regional database of 2654 people with MS. Some distinct differences were found compared with those whose MS began at a younger age. The researchers found that sensory and motor symptoms were more frequently found, there were fewer relapses and faster progression of disability.

The researchers comment that this makes it even more important to identity this group and to ensure that they have the support they need from MS services.

Background

MS is often diagnosed when someone is in their twenties or thirties. At one time, it was thought that MS rarely developed in people over 50 but opinion is changing as more cases are now being identified.

Diagnosing MS can be difficult in a person of any age but there are additional challenges as people get older. This is because there are other age related conditions which need to be taken into consideration when deciding what the correct diagnosis might be. In addition, there is little information available on the long term pattern of MS in people who develop it late in life.

How this study was carried out

People in south-east Wales whose MS began at age 50 or above were identified from a regional database of 2654 people with MS. The over 50's group was named "late onset MS" and was compared with an adult (under age 50) onset group.

The medical notes of the late onset group were reviewed to see what diagnoses were considered apart from MS.

What was found

132 people (5.2%) had late onset MS which had begun between the ages of 50 and 72. Some distinct differences were found:

  • Over half (58%) of the late onset group were women as compared with just over two thirds (70%) of the adult onset group.
  • Almost half (47%) had primary progressive MS (PPMS) whereas less than one in ten (9%) had PPMS in the adult onset group
  • The average time from first symptoms to diagnosis was 2.7 years as compared with 4.6 years
  • People in the late onset group were more likely to test negative when cerebrospinal fluid from a lumbar puncture was analysed for oligoclonal bands (23% as compared with 16%)

In four out of ten (42%) cases of late onset MS, no other diagnosis was considered likely and so diagnosis was made more rapidly (on average after 1.8 years).

For those where other possible diagnoses were considered, it took an average of 3.2 years to come to the definite diagnosis of MS. The most common possibilities considered were cerebrovascular disease (16%), degenerative spinal disease (8%) and motor neurone disease (6%).

The most common first symptoms were sensory and cerebellar symptoms for the older age group whereas optic neuritis was most common in the adult onset group.

The late onset group had about half as many relapses in the first ten years compared with the adult onset group. However, they reached disability milestones more quickly as judged by the time taken to reach a particular EDSS score. For example they took an average of 4.8 years to reach an EDSS of 4 as compared with 15.5 years; an average of 5.7 years to reach an EDSS of 6 as compared with 20.4 years; an average of 16.8 years to reach an EDSS of 4 as compared with 39.0 years. However, as their MS had begun later in life, the late onset group were between five and 11 years older when they got to each disability milestone.

What does it mean?

When MS occurs in adults over 50 it can be difficult to diagnose as it may be quite different from MS in younger adults and because it may appear similar to other conditions which occur in older age groups. The most common differences in the older age group are that sensory and motor symptoms are more frequently found, there are fewer relapses and faster progression of disability.

Once MS has begun, disability progresses more rapidly than in younger people with MS. The researchers comment that this makes it even more important to diagnose the older group and to ensure that they have the support they need from MS services.

Harding K, Griffiths M, Wardle M, et al.
Late-onset multiple sclerosis in south-east Wales.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

More about diagnosing MS

MS can be very difficult to diagnose and it often takes a long time to get a definite diagnosis.

All the symptoms of MS can also be symptoms of other conditions so the neurologist has to work out which of all the possibilities is the correct one. This can mean lots of tests to rule out other conditions and then more tests to see if it might be MS. It is sometimes a question of watching and waiting to see how symptoms develop as this can help distinguish MS from the other possibilities. All this can be very frustrating and worrying but it is quite a common experience.

Tests used in the diagnosis of MS

There is no simple test for MS which will say "yes" or "no" like a pregnancy test. The neurologist has to take a multi-pronged approach and use their experience to decide if it is MS or not. Sometimes, it is still impossible to be absolutely certain.

Neurologists will usually ask about any history of unexplained symptoms.The most common next step is to have an MRI scan which can detect the tiny scars caused by MS. These show up as little white patches in the brain and spinal cord and are usually called lesions. Everyone gets more white patches in their brain as they get older so the neurologist has to judge if they are all age-related or possibly due to MS. Sometimes a chemical called gadolinium is injected into a vein before the scan as it can help the radiologist and neurologist distinguish between active MS lesions and old areas of scarring.

Some people will have a lumbar puncture also known as a spinal tap. In this test, a sample is taken of the cerebrospinal fluid which bathes the brain and spinal cord. The fluid can be analysed in the laboratory and if more protein bands are seen than usual (called oligoclonal bands) this can suggest MS.

In some cases, evoked potential tests are carried out. This involves putting small electrodes on the head, arms or legs to measure the speed of messages travelling along the nerves from the eyes, ears or skin on the limbs. If the messages are slowed then this may be due to MS.

The neurologist will review all the test results alongside a person's medical history to decide if it all adds up to a diagnosis of MS.

Research by topic areas...

Diagnosis

Lumley R, Davenport R, Williams A.
Most neurologists in Scotland do not use the McDonald 2010 criteria to diagnose multiple sclerosis.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Symptoms and symptom management

Castel-Lacanal E, Gamé X, Clanet M, et al.
Urinary complications and risk factors in symptomatic multiple sclerosis patients. Study of a cohort of 328 patients.
Neurourol Urodyn. 2013 Sep 23. [Epub ahead of print]
abstract

Veauthier C.
Younger age, female sex, and high number of awakenings and arousals predict fatigue in patients with sleep disorders: a retrospective polysomnographic observational study.
Neuropsychiatr Dis Treat. 2013;9:1483-1494.
abstract
Read the full text of this paper

Disease modifying treatments

Fragoso YD, Adoni T, Alves-Leon SV, et al.
Long-term effects of exposure to disease-modifying drugs in the offspring of mothers with multiple sclerosis: a retrospective chart review.
CNS Drugs. 2013 Oct 10. [Epub ahead of print]
abstract

Shields S, Parkes L.
Baseline responses of multiple sclerosis patients participating in the proms survey: impact of disease-modifying therapies and support services on patient-reported outcomes.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Lonergan R, Kinsella K, Kelly S, et al.
Does JCV antibody positivity encourage cessation of natalizumab therapy in multiple sclerosis?
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Hanna J, Rosen JP, Smethurst C.
Efficacy and safety of natalizumab treatment for relapsing-remitting multiple sclerosis: interim results of the Tysabri observational programme in the UK.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Gafson A, Worthington V, Lakdawala N, et al.
Neutralising antibodies to interferon-beta predict conversion to secondary progressive multiple sclerosis in patients with multiple sclerosis.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Duddy M, Palace J.
A decade of data for the UK multiple sclerosis risk-sharing scheme
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Agashivala N, Wu N, Abouzaid S, et al.
Compliance to fingolimod and other disease modifying treatments in multiple sclerosis patients, a retrospective cohort study.
BMC Neurol. 2013 Oct 4;13(1):138. [Epub ahead of print]
abstract
Read the full text of this paper

Other treatments

Mallik S, Ball S, Dalton C, et al.
Cannabinoid use in progressive inflammatory brain disease (CUPID) MRI sub-study.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Hadavi S, Giovannoni G, Dobson R.
A service development audit OF Fampridine use in MS.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Cameron MH, Overs S, Murchison C, et al.
Dalfampridine improves walking speed, walking endurance, and community participation in veterans with multiple sclerosis: a longitudinal cohort study.
Mult Scler. 2013 Oct 7. [Epub ahead of print]
abstract

Epidemiology

Mackenzie IS, Morant SV, Bloomfield GA, et al.
Changing face of multiple sclerosis in the United Kingdom 1990-2010. An incidence and prevalence study.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Albor C, Richards O, Ramagopalan S, et al.
Using routine point-of-care data for research: the east London multiple sclerosis cohort.
Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Koffman J, Gao W, Goddard C, et al.
Progression, symptoms and psychosocial concerns among those severely affected by multiple sclerosis: a mixed-methods cross-sectional study of black Caribbean and white British People.
PLoS One. 2013 Oct 2;8(10):e75431.
abstract
Read the full text of this paper

Co-existing conditions

Uribe-San-Martín R, Ciampi-Díaz E, Suarez-Hernández F, et al.
Prevalence of epilepsy in a cohort of patients with multiple sclerosis.
Seizure. 2013 Sep 21. [Epub ahead of print]
abstract

Assessment tools

Leddy S, Hadavi S, Carren AM, et al.
A novel internet-based method of capturing outcomes in multiple sclerosis.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Hadavi S, Shribman S, Nagy A, et al.
The Bradykinesia-Akinesia incoordination test: a simple objective test in multiple sclerosis.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Motl RW, Cadavid D, Sandroff BM, et al.
Cognitive processing speed has minimal influence on the construct validity of Multiple Sclerosis Walking Scale-12 scores.
J Neurol Sci. 2013 Sep 24. [Epub ahead of print]
abstract

Causes of MS

Dobson R, Topping J, Ramagopalan S, et al.
Towards an endophenotype in multiple sclerosis.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Salzer J, Stenlund H, Sundström P.
The interaction between smoking and Epstein-Barr virus as multiple sclerosis risk factors may depend on age.
Mult Scler. 2013 Oct 9. [Epub ahead of print]
abstract

Vitamin D

Moghtaderi A, Tamadon GH, Haghighi F.
25-hydroxyvitamin D3 concentration in serum and cerebrospinal fluid of patients with remitting-relapse multiple sclerosis.
Prague Med Rep. 2013;114(3):162-171.
abstract
Read the full text of this paper (PDF)

Psychological aspects

Connick P, Chandran S, Bak T.
Patterns of cognitive dysfunction in progressive multiple sclerosis.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Prognosis

Lovera J, Reza T.
Stress in multiple sclerosis: review of new developments and future directions.
Curr Neurol Neurosci Rep. 2013 Nov;13(11):398.
abstract

Bove R, Chitnis T, Houtchens M.
Menopause in multiple sclerosis: therapeutic considerations.
J Neurol. 2013 Oct 8. [Epub ahead of print]
abstract

Provision of care

Finkelstein J, Cha E, Wood J, et al.
Predictors of successful acceptance of home telemanagement in veterans with Multiple Sclerosis.
Conf Proc IEEE Eng Med Biol Soc. 2013 Jul;2013:7314-7317.
abstract

Willis M, Harding K, Robertson N.
Use of services for multiple sclerosis patients according to EDSS.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Pregnancy and childbirth

Hughes SE, Spelman T, Gray OM, et al.
Predictors and dynamics of postpartum relapses in women with multiple sclerosis.
Mult Scler. 2013 Oct 9. [Epub ahead of print]
abstract

Bone health

Murphy O, Zandi MS, Lindenberg N, et al.
Patients with an acute multiple sclerosis relapse: a high risk group for osteopenia and osteoporosis.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Falls

Hoang PD, Cameron MH, Gandevia SC, et al.
Neuropsychological, balance and mobility risk factors for falls in people with multiple sclerosis: a prospective cohort study.
Arch Phys Med Rehabil. 2013 Oct 3. [Epub ahead of print]
abstract

Kalron A, Achiron A.
Postural control, falls and fear of falling in people with multiple sclerosis without mobility aids.
J Neurol Sci. 2013 Sep 29. [Epub ahead of print]
abstract

Stem cells

Connick P, Chandran S.
Autologous mesenchymal stem cells for the treatment of secondary progressive multiple sclerosis: an open-label phase 2a proof-of-concept study.
J Neurol Neurosurg Psychiatry. 2013 Nov;84(11):e2.
abstract

Rice CM, Kemp K, Wilkins A, et al.
Cell therapy for multiple sclerosis: an evolving concept with implications for other neurodegenerative diseases.
Lancet. 2013 Oct 5;382(9899):1204-1213.
abstract

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