Impact of aging on treatment considerations for multiple sclerosis patients

Oligodendroglial heterogeneity in health, disease, and recovery: deeper insights into myelin dynamics

Decades of research asserted that the oligodendroglial lineage comprises two cell types: oligodendrocyte precursor cells and oligodendrocytes. However, recent studies employing single-cell RNA sequencing techniques have uncovered novel cell states, prompting a revision of the existing terminology. Going forward, the oligodendroglial lineage should be delineated into five distinct cell states: oligodendrocyte precursor cells, committed oligodendrocyte precursor cells, newly formed oligodendrocytes, myelin-forming oligodendrocytes, and mature oligodendrocytes. This new classification system enables a deeper understanding of the oligodendroglia in both physiological and pathological contexts. Adopting this uniform terminology will facilitate comparison and integration of data across studies. This, including the consolidation of findings from various demyelinating models, is essential to better understand the pathogenesis of demyelinating diseases. Additionally, comparing injury models across species with varying regenerative capacities can provide insights that may lead to new therapeutic strategies to overcome remyelination failure. Thus, by standardizing terminology and synthesizing data from diverse studies across different animal models, we can enhance our understanding of myelin pathology in central nervous system disorders such as multiple sclerosis, Alzheimer's disease, and amyotrophic lateral sclerosis, all of which involve oligodendroglial and myelin dysfunction.

Mapping the complexity of multiple sclerosis: a novel perspective on genetic, environmental, and neurobiological insights

Multiple sclerosis (MS) is the most common chronic demyelinating disease of the central nervous system (CNS) that mainly affects young adults. MS is a neuroinflammatory disease traditionally classified as an autoimmune disorder; however, its exact cause remains unknown. A wide variety of etiology and risk factors have been proposed to contribute, among which genetics and environment are the leading ones. The heterogeneity of MS can be attributed to a variety of factors, including diverse pathobiological mechanisms. In this narrative review, before discussing the most prevalent etiologies of MS and risk factors, we look at the main neurobiological pathways, blood-brain barrier (BBB) breakdown, and glymphatic system dysfunction. Several intrinsic factors, including genetics and epigenetic implications, hormones, immune system dysregulation, age, and microbiome, have definite roles in developing and worsening MS severity. However, external factors like viruses, bacteria, bioclimate impacts, environmental toxins, lifestyle factors, stress, and psychological factors revealed different or controversial impacts on MS disease. On the other hand, some nascent ones, such as intestinal dysbiosis and COVID-19, need to be further experimentally and clinically investigated. Both may contribute to MS by promoting inflammation and triggering autoimmune responses. Although it assumes that more than one factor contributes to MS development, finding the leading underlying cause and, consequently, the probable involvement mechanisms certainly could help take appropriate, efficient, and personalized therapeutic strategies.

Role of Immune Reconstitution Therapy with Cladribine Tablets in the Management of Relapsing Multiple Sclerosis in Older Patients

The pathophysiology and presentation of relapsing multiple sclerosis (RMS) differ importantly between younger and older patients. Older patients usually suffer fewer MS relapses but present with a chronically inflammatory phenotype (inflammaging) associated with accelerated age-related changes to the adaptive and innate immune systems (immunosenescence). The efficacy of most disease-modifying therapies (DMTs) appears to decline with increasing age, likely because of a shift away from focal inflammation as the main driving force for progression of MS. These observations led to suggestions that DMT may be withdrawn for an older person with very stable MS. However, this approach risks the resumption of MS disease activity. In contrast, analyses of evaluations of immune reconstitution therapy with cladribine tablets (CladT) show that this high-efficacy DMT appears to be effective and well tolerated irrespective of age. Achieving long-term freedom from MS disease activity for an older patient with MS is feasible using this approach. Switching to CladT is a rational option for reducing the dual burdens of continuous treatment (including side effects associated with continuous immunosuppression with some DMTs) and monitoring for older people with RMS. This includes possible use as an "exit therapy", beyond which some patients may not need pharmacological therapy for their RMS in the future.

Invited review: Impact of age: When to change, when to stop therapy

Older patients age ≥55 account for almost half of the total MS population. While focal inflammatory demyelinating processes and progressive processes such as compartmentalized CNS inflammation, neurodegeneration, and failure of compensatory mechanisms co-occur from disease onset, there is a shift in the predominant disease processes with notable clinical progression occurring in the fifth decade of life. Clinically, this manifests in reduction in clinical relapses and MRI activity as persons with MS age, with an increase in slow disability progression independent of relapses. As disease modifying therapies have demonstrated efficacy on relapse reduction, but not centrally mediated progressive processes, the benefit of DMT wanes with age due to change in underlying biological disease processes. Contrastingly, risks of DMTs increase due to biological changes related with age, setting up a scenario where considerations on switching or stopping DMT become more clinically important based on risk-benefit ratios. This review will cover evidence regarding DMT use in older patients with MS and discuss age considerations in the management of patients with MS.

Should we stay or should we go? Recent insights on drug discontinuation in multiple sclerosis

BACKGROUND

The decision to discontinue disease-modifying therapies (DMTs) in patients with multiple sclerosis (PwMS) is a critical clinical challenge. Historically, DMTs were discontinued due to side effects, treatment limitations, or progression to secondary progressive MS. However, advancements in MS therapies, particularly high-efficacy DMTs (HE-DMTs) and the increased knowledge on disease courses and phenotypes have resulted in more personalized treatment approaches and introduced discussion on scheduled DMT discontinuation. This review explores the current evidence on DMT discontinuation, focusing on its implications for aging populations and the interplay between cardiovascular diseases (CVD) and MS.

CURRENT EVIDENCE AND INTERPLAY WITH CVD

Randomized trials such as DISCOMS and DOT-MS have provided insights into discontinuing DMTs in stable patients. In summary, both randomized clinical trials highlight the risk of disease reactivation following treatment discontinuation. Due to the limited sample size, neither study was able to conduct subgroup analyses based on age groups. Additionally, DOT-MS was terminated prematurely, direct comparisons with other studies should be avoided. While older studies and observational data (e.g., OFSEP) have shown relapse risks associated with discontinuation, particularly for drugs like natalizumab and fingolimod, there is limited data on HE-DMT discontinuation outcomes. Comorbidities, particularly CVDs, further complicate decisions regarding the continuation of DMTs in older adults. MS patients bear a higher burden of CVD, which is also associated with unfavorable disease courses. While optimizing cardiovascular risk profiles appears advisable, it remains unclear whether DMTs themselves have a positive impact on CVDs.

CONCLUSION

Given the complexities associated with discontinuing DMTs in MS patients, it is essential to balance the avoidance of polypharmacy with the potential risks of disease reactivation and the impact of comorbidities, especially CVDs, on disease progression. The interplay between MS and CVD highlights the importance of a holistic risk assessment when considering DMT discontinuation.

Disparities in patient share and characteristics between disease-modifying therapy-treated and -untreated people with multiple sclerosis in Germany: a claims data analysis from 2017 to 2022

Introduction

Despite significant advances in multiple sclerosis (MS) treatment, a substantial proportion of people with MS (pwMS) remains untreated with disease-modifying therapies (DMTs). This study aimed to assess the proportion of DMT-untreated pwMS according to clinical and sociodemographic characteristics, the differences in healthcare utilization patterns, including MRI frequency and physiotherapy use, between DMT-treated and DMT-untreated pwMS, as well as to examine the time to first prescription among newly diagnosed pwMS in Germany from 2017 to 2022.

Methods

Longitudinal routine data from 4.5 million individuals insured by German statutory health insurance were analyzed. PwMS were identified by ICD-10-GM code G35 in at least two quarters within a calendar year. PwMS who filled a DMT prescription during the observation period were classified as DMT-treated. Newly diagnosed pwMS had no recorded G35 code and DMT prescription in the 2 years prior to initial MS coding. MRI scans and physiotherapy sessions were identified using OPS codes and the German Heilmittelkatalog. Group differences were tested with two-sided χ2-tests and t-tests.

Results

In total, 45.6% of pwMS were DMT-untreated. DMT-untreated rates were higher in secondary progressive (SPMS) and primary progressive MS (PPMS) than relapsing-remitting MS (RRMS; p < 0.0001). Older pwMS (>45 years) were more frequently DMT-untreated (56.0%) compared to younger pwMS (≤45 years; 27.4%; p < 0.0001). Regional differences ranged from 37.5% in eastern Germany to 54.0% in the south-west. More than half of newly diagnosed pwMS did not receive their first prescription for DMT within 6 months of their initial MS coding, with longer times to first DMT prescription among pwMS with a progressive compared to a relapsing disease onset (p < 0.0001). DMT-untreated pwMS averaged more physiotherapy sessions (DMT-untreated: 23.7, SD 35.0; DMT-treated: 20.2, SD 28.7; p < 0.0001) and less MRI scans (DMT-untreated: 0.8, SD 0.8; DMT-treated: 1.5, SD 0.8; p < 0.0001) annually over the observation period than DMT-treated pwMS.

Conclusion

These real-world data offer valuable insights into patient care and treatment allocation.

Experimental autoimmune encephalomyelitis pathogenesis alters along animal age: impact of S100B expression

Multiple Sclerosis (MS) is the leading inflammatory and non-traumatic cause of disability in young adults, with late-onset MS emerging in middle-aged patients often resulting in poorer treatment responses and worse prognoses. The calcium-binding protein S100B is elevated in MS patients, and its targeting has shown promise in reducing disease severity in experimental autoimmune encephalomyelitis (EAE) models. However, most studies on MS pathology have focused on young animal models, leaving a gap in understanding the effects of age and S100B ablation on disease progression throughout the lifespan. This study aimed to characterize EAE in mice of different ages, examining demyelination, inflammation, and immune responses to determine whether S100B ablation could mitigate MS pathogenesis across the lifespan. EAE was induced in six cohorts of C57BL/6 mice: young adults (3 months), older adults (6 months), and middle-aged (12 months), including corresponding S100B knockout (KO) groups, followed for 23 days. Upon sacrifice, spinal cords were assessed via immunohistochemistry and Real-Time qPCR, while splenocytes were analyzed for immune cell characterization. Results indicated a more severe disease course in 12-month-old mice, marked by increased gliosis, inflammation, and impaired microglial phagocytic activity. Notably, S100B absence reduced gliosis and inflammatory markers across all ages, with 12-month-old S100B KO mice showing increased regulatory T cells. These findings highlight the exacerbating role of age and elevated S100B in MS progression, underscoring the importance of identifying age-specific MS markers and therapeutic targets.

Global, regional, and national burden of tobacco-related neurological disorders from 1990 to 2021: Trends and future projections

INTRODUCTION

Tobacco use is as a major public health concern around the world, adversely impacting quality of life. Our study aims to analyze the trends in the burden of tobacco-related neurological disorders (ND) at global, regional, and national levels from 1990 to 2021, as well as potential future trends.

METHODS

We performed a secondary dataset analysis for the assessment of mortality and disability-adjusted life years (DALYs) using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, to explore the burden of tobacco-related ND. We also analyzed the associations between the burden of ND and factors such as age, gender, and the Sociodemographic Index (SDI).

RESULTS

In 2021, the age-standardized mortality rate (ASMR) and age-standardized DALYs rate (ASDR) for neurological disorders were 0.50 per 100000 persons (95% UI: -0.15-1.98) and 11.25 per 100000 persons (95% UI: 1.36-34.36), respectively. Alzheimer's disease and other dementias (ADOD) had a particularly significant impact on the burden of ND. However, the ASDR for Parkinson's disease was -8.38 per 100000 persons (95% UI: -10.72 - -6.20). The burden of disease was greater in men and older people, with substantial regional variation. While aging and population growth might contribute to the increase in DALYs for tobacco-related ND, epidemiological changes have the potential to reduce the burden. From 2022 to 2050, the BAPC model predicted a decline in the age-standardized rate (ASR) of DALYs and mortality for tobacco-related ND, globally.

CONCLUSIONS

Tobacco use increased the burden of ND such as ADOD and multiple sclerosis (MS), while reducing the burden of Parkinson's disease (PD). The burden of disease was disproportionately higher among older individuals and males, with significant disparities across nations and regions. Over the past 32 years, the burden of these diseases has gradually decreased, and this trend is expected to continue from 2022 to 2050.

Prevalence and incidence of multiple sclerosis in healthcare district IV of Asturias, Spain

BACKGROUND

Multiple sclerosis is an inflammatory demyelinating autoimmune disease of the central nervous system. Studies conducted in recent years point to an increase in its prevalence and a change in the age profile of patients. This study aims to analyse the prevalence and incidence of multiple sclerosis in healthcare district IV of the region of Asturias, in north-western Spain.

METHODS

We conducted a retrospective epidemiological study of the population of said healthcare district with a diagnosis of multiple sclerosis according to the 2017 McDonald criteria. The prevalence of the disease was calculated cross-sectionally (prevalence date: December 31, 2022), while the incidence was determined retrospectively over a six-year period, from 2017 to 2022. We gathered data from the registries and databases of the tertiary hospital in healthcare district IV, and from one private hospital. Relevant demographic and clinical data were gathered from electronic records.

RESULTS

The prevalence of multiple sclerosis in the population studied was 198 cases per 100 000 population. The incidence of multiple sclerosis during the study period (2017-2022) was 6.6 cases per 100 000 person-years. On the prevalence date, 66.5% of patients were women and 82.4% presented relapsing-remitting multiple sclerosis. Mean age was 33.98 years at symptom onset and 50.84 years on the prevalence date.

CONCLUSIONS

Asturias currently presents the highest multiple sclerosis prevalence rate in Spain; the estimated rate represents an increase with respect to those reported in studies conducted in the same region in the 1990s.

Transcranial direct current stimulation for cognitive rehabilitation in people with multiple sclerosis: A systematic review of randomized controlled trials

People with multiple sclerosis (PwMS) often experience cognitive impairments that affect independence in their activities. Transcranial direct current stimulation (tDCS) has been recently used for treating cognitive impairments in patients with neurological conditions. This review aims to investigate the effects of tDCS on cognitive function in PwMS. Databases including "PubMed, SCOPUS, MEDLINE, EMBASEe, and Web of Science" were searched until July 2024. The risk of bias was evaluated using the Cochrane Collaboration tool (CCT). Nine were selected for inclusion in this review, encompassing 274 PwMS, 77.74% of whom were females. Five studies have a low risk of bias, while four have a moderate risk of bias on the CCT. The findings revealed mixed evidence regarding the effects of tDCS on cognitive function in PwMS. In conclusion, most studies have shown that tDCS does not improve various cognitive domains in PwMS. However, due to the limited number of studies and their high heterogeneity, further research is needed to assess the immediate and long-term impacts of tDCS on numerous cognitive domains in PwMS, understand the relationship between PwMS characteristics and their response to the tDCS intervention, and define the optimal tDCS treatment protocols for treating cognitive impairments in PwMS.

Peripheral blood age-sensitive immune markers in multiple sclerosis: relation to sex, cytomegalovirus status, and treatment

BACKGROUND

Immunosenescence is accelerated by chronic infectious and autoimmune diseases and could contribute to the pathobiology of multiple sclerosis (MS). How MS and disease-modifying therapies (DMTs) impact age-sensitive immune biomarkers is only partially understood.

METHODS

We analyzed 771 serum samples from 147 healthy controls and 289 people with MS (PwMS) by multiplex immunoassays. We determined cytomegalovirus (CMV) serostatus and collected retrospective clinical information. We performed unsupervised and multivariable analyses.

FINDINGS

Unsupervised analyses revealed that MS immune profile was characterized by low relative levels of anti-inflammatory/neuroprotective factors IL-4, IL-10, TNF, and β-NGF but high levels of growth factors EGF and bFGF. Serum levels of IL-4, β-NGF, IL-27, BDNF, and leptin were significantly influenced by sex and/or CMV status. IL-4 and β-NGF levels were lower in untreated PwMS compared to controls, while EGF and bFGF levels were influenced by age and markedly elevated in PwMS in multivariable analysis. Samples from treated PwMS, but not untreated PwMS, showed lower levels of BDNF and TNF than controls. Initiation of high efficacy DMTs, but not low efficacy DMTs, was associated with reduced levels of bFGF and EGF. Samples associated with distinct DMTs exhibited specific profiles for age-sensitive immune markers. Finally, lower levels of IL-6, TNF, IL-10, and β-NGF were observed at baseline in PwMS who subsequently experienced clinical failure after DMTs initiation.

INTERPRETATION

Age, sex, CMV status, and specific DMTs significantly influence levels of age-sensitive immune biomarkers associated with MS and must be considered when investigating inflammation-related biomarkers.

FUNDING

This work was supported by a Grant for Multiple Sclerosis Innovation by Merck KGaA (ID: 10.12039/100009945).

Proteomics Reveals Age as Major Modifier of Inflammatory CSF Signatures in Multiple Sclerosis

BACKGROUND AND OBJECTIVES

Multiple sclerosis (MS) can start as relapsing or progressive. While their clinical features and treatment responses are distinct, it has remained uncertain whether their pathomechanisms differ. A notable age-related effect on MS phenotype and response to immunotherapies is well acknowledged, but the underlying pathophysiologic reasons are yet to be fully elucidated. We aimed to identify disease-specific and age-related proteomic signatures using a comprehensive targeted proteomic analysis.

METHODS

In our retrospective cohort study, we analyzed the CSF and serum proteome of age-matched individuals with treatment-naïve relapsing-remitting and primary progressive MS, neurologic controls (NC), and individuals with neuroborreliosis using targeted proteomics and validated findings in an independent cohort. Proteomic results were integrated with clinical and laboratory covariates.

RESULTS

Among 2,500 proteins, 47 CSF proteins were distinct between individuals with MS (n = 60) and NC (n = 20), with a subset also differing from those with neuroborreliosis (n = 8). We identified MS-associated proteins, including novel candidate biomarkers such as LY9 and JCHAIN, and putative treatment targets, such as SLAMF7, BCMA, and IL5RA, for which drugs are already licensed in other indications. The CSF proteome differences between relapsing and progressive MS were minimal, but major changes were noted in individuals older than 50 years, indicating a shift from MS-associated inflammatory to age-related protein signature. NEFL was the only serum protein that differed between individuals with MS and controls.

DISCUSSION

This study unveils a unique CSF proteomic signature in MS, providing new pathophysiologic insights and identifying novel biomarker candidates and potential therapeutic targets. Our findings highlight similar immunologic mechanisms in relapsing and progressive MS and underscore aging's profound effect on the intrathecal immune response. This aligns with the observed lower efficacy of immunotherapies in the elderly, thus emphasizing the necessity for alternative therapeutic approaches in treating individuals with MS beyond the age of 50.

Dorsoventral photobiomodulation therapy safely reduces inflammation and sensorimotor deficits in a mouse model of multiple sclerosis

BACKGROUND

Non-invasive photobiomodulation therapy (PBMT), employing specific infrared light wavelengths to stimulate biological tissues, has recently gained attention for its application to treat neurological disorders. Here, we aimed to uncover the cellular targets of PBMT and assess its potential as a therapeutic intervention for multiple sclerosis (MS).

METHODS

We applied daily dorsoventral PBMT in an experimental autoimmune encephalomyelitis (EAE) mouse model, which recapitulates key features of MS, and revealed a strong positive impact of PBMT on the sensorimotor deficits. To understand the cellular mechanisms underlying these striking effects, we used state-of-the-art tools and methods ranging from two-photon longitudinal imaging of triple fluorescent reporter mice to histological investigations and patch-clamp electrophysiological recordings.

RESULTS

We found that PBMT induced anti-inflammatory and neuroprotective effects in the dorsal spinal cord. PBMT prevented peripheral immune cell infiltration, glial reactivity, as well as the EAE-induced hyperexcitability of spinal interneurons, both in dorsal and ventral areas, which likely underlies the behavioral effects of the treatment. Thus, aside from confirming the safety of PBMT in healthy mice, our preclinical investigation suggests that PBMT exerts a systemic and beneficial effect on the physiopathology of EAE, primarily resulting in the modulation of the inflammatory processes.

CONCLUSION

PBMT may therefore represent a new valuable therapeutic option to treat MS symptoms.

Disease-modifying therapies for Parkinson disease: lessons from multiple sclerosis

The development of disease-modifying therapies (DMTs) for neurological disorders is an important goal in modern neurology, and the associated challenges are similar in many chronic neurological conditions. Major advances have been made in the multiple sclerosis (MS) field, with a range of DMTs being approved for relapsing MS and the introduction of the first DMTs for progressive MS. By contrast, people with Parkinson disease (PD) still lack such treatment options, relying instead on decades-old therapeutic approaches that provide only symptomatic relief. To address this unmet need, an in-person symposium was held in Toronto, Canada, in November 2022 for international researchers and experts in MS and PD to discuss strategies for advancing DMT development. In this Roadmap article, we highlight discussions from the symposium, which focused on therapeutic targets and preclinical models, disease spectra and subclassifications, and clinical trial design and outcome measures. From these discussions, we propose areas for novel or deeper exploration in PD using lessons learned from therapeutic development in MS. In addition, we identify challenges common to the PD and MS fields that need to be addressed to further advance the discovery and development of effective DMTs.

Unveiling the fate and potential neuroprotective role of neural stem/progenitor cells in multiple sclerosis

Chronic pathological conditions often induce persistent systemic inflammation, contributing to neuroinflammatory diseases like Multiple Sclerosis (MS). MS is known for its autoimmune-mediated damage to myelin, axonal injury, and neuronal loss which drive disability accumulation and disease progression, often manifesting as cognitive impairments. Understanding the involvement of neural stem cells (NSCs) and neural progenitor cells (NPCs) in the remediation of MS through adult neurogenesis (ANG) and gliogenesis-the generation of new neurons and glial cells, respectively is of great importance. Hence, these phenomena, respectively, termed ANG and gliogenesis, involve significant structural and functional changes in neural networks. Thus, the proper integration of these newly generated cells into existing circuits is not only key to understanding the CNS's development but also its remodeling in adulthood and recovery from diseases such as MS. Understanding how MS influences the fate of NSCs/NPCs and their possible neuroprotective role, provides insights into potential therapeutic interventions to alleviate the impact of MS on cognitive function and disease progression. This review explores MS, its pathogenesis, clinical manifestations, and its association with ANG and gliogenesis. It highlights the impact of altered NSCs and NPCs' fate during MS and delves into the potential benefits of its modifications. It also evaluates treatment regimens that influence the fate of NSCS/NPCs to counteract the pathology subsequently.

Investigation of differences between chronological and vascular age in persons with multiple sclerosis

OBJECTIVE

To determine vascular age (VA) in a cohort of persons with multiple sclerosis (PwMS) in Belgrade, Serbia, and to assess the difference between chronological age (CA) and VA, in this population.

MATERIAL AND METHODS

A case-control study was conducted at the Clinic of Neurology, University Clinical Center of Serbia in Belgrade. Study participants (n = 274) were recruited during regular outpatient visits. Demographic and clinical characteristics including the presence of CVD comorbidities of PwMS were collected. Data were obtained using a questionnaire, designed and adapted for the study purposes. Additionally, fasting blood samples were collected from all participants, in order to determine their lipid profile. VA was calculated based on the patient's sex, age, smoking status, total serum cholesterol level and systolic blood pressure (SBP) value. Afterwards, the study sample was divided into five groups with the different levels of the atherosclerotic burden, as follows: 1) PwMS without any CVD comorbidity; 2) PwMS with hyperlipidemia (HLP); 3) PwMS with HLP and hypertension (HTA); 4) PwMS with HLP, HTA and type 2 diabetes, and 5) PwMS with coronary artery disease (CAD). In the statistical analysis, for the determination of factors that are independently associated with the discrepancy between CA and VA in persons with MS, hierarchical regression analysis was performed.

RESULTS

The mean values of CA and VA were statistically significantly different among the groups(p<0.001). Additionally, a significant difference was also detected between CA and VA (p<0.001). The highest VA (66.4±15.8 years) and the difference between CA and VA (6.5±7.3 years) were registered only in the group comprising PwMS, HPL, HTA and type 2 diabetes. Results of the hierarchical linear regression analysis showed that the Expanded Disability Status Scale (EDSS) score, Body mass index (BMI), physical activity and the presence of type 2 diabetes, explained a total of 24% of the variations in the difference between CA and VA, in our cohort of MS patients.

CONCLUSION

Our study showed significant difference between CA and VA in PwMS and additionally, increasing VA with atherosclerotic burden. Additionally, it has been demonstrated that crucial factors which led to the occurrence of these differences were BMI, physical activity, EDSS and the presence of type 2 diabetes.

The ageing central nervous system in multiple sclerosis: the imaging perspective

The interaction between ageing and multiple sclerosis is complex and carries significant implications for patient care. Managing multiple sclerosis effectively requires an understanding of how ageing and multiple sclerosis impact brain structure and function. Ageing inherently induces brain changes, including reduced plasticity, diminished grey matter volume, and ischaemic lesion accumulation. When combined with multiple sclerosis pathology, these age-related alterations may worsen clinical disability. Ageing may also influence the response of multiple sclerosis patients to therapies and/or their side effects, highlighting the importance of adjusted treatment considerations. MRI is highly sensitive to age- and multiple sclerosis-related processes. Accordingly, MRI can provide insights into the relationship between ageing and multiple sclerosis, enabling a better understanding of their pathophysiological interplay and informing treatment selection. This review summarizes current knowledge on the immunopathological and MRI aspects of ageing in the CNS in the context of multiple sclerosis. Starting from immunosenescence, ageing-related pathological mechanisms and specific features like enlarged Virchow-Robin spaces, this review then explores clinical aspects, including late-onset multiple sclerosis, the influence of age on diagnostic criteria, and comorbidity effects on imaging features. The role of MRI in understanding neurodegeneration, iron dynamics and myelin changes influenced by ageing and how MRI can contribute to defining treatment effects in ageing multiple sclerosis patients, are also discussed.

Comprehensive analysis of multiple sclerosis hospitalization trends in Spain (1998-2022)

OBJECTIVE

To analyse the trends in MS hospitalization rates in Spain (1998-2022) considering age, period, and birth cohort (A-P-C) effects.

METHODS

This retrospective study used data on MS hospitalizations from the Spanish National Health System Minimum Basic Data Set (CMBD). Age-Standardized Hospitalization Rates (ASHRs) and Joinpoint analysis were used to assess trends. A-P-C analysis was performed to estimate age-specific rates, period and cohort effects.

RESULTS

From 1998 to 2022, MS hospital admissions in Spain declined annually by -2.1 %, with women showing a slightly greater decrease (-2.3 %) than men (-1.7 %). Joinpoint analysis revealed non-parallel trends, with three inflection points indicating distinct periods of stabilization and decline. ASHR showed an overall decrease, with -2.0 % for men and -2.2 % for women annually. Risk of hospitalization peaked in the 25-29-year age group for men and 30-34-year age group for women, declining with age. Women consistently had higher risk ratios across age groups. Cohort analysis showed periods of stabilization and decline in MS hospitalization risk, aligning with joinpoint analysis findings. Risk increased for cohorts born in the early 20th century, peaking around 1938, followed by a progressive decline in later cohorts.

CONCLUSIONS

Despite an aging population, MS hospitalization rates in Spain decreased. The risk of hospitalization for MS is affected by a person's age, the time period they were born in, the historical context of healthcare received, and potentially their sex.

Active and non-active secondary progressive multiple sclerosis patients exhibit similar disability progression: results of an Italian MS registry study (ASPERA)

'Active' and 'non-active' secondary progressive MS (SPMS) have distinct pathophysiological mechanisms and clinical characteristics, but there is still no consensus regarding the frequency of these MS forms in the real-world setting. We aimed to evaluate the frequency of 'active' and 'non-active' SPMS in a large cohort of Italian MS patients and the differences in terms of clinical and MRI characteristics and disease progression. This multicenter study collected data about MS patients who have transitioned to the SP form in the period between 1st January 2014 and 31st December 2019 and followed by the MS centers contributing to the Italian MS Registry. Patients were divided into 'active SPMS' and 'non-active SPMS', based on both reported MRI data and relapse activity in the year before conversion to SPMS. Out of 68,621, 8,316 (12.1%) patients were diagnosed with SPMS. Out of them, 872 (10.5%) were classified into patients with either 'active' or 'non-active' SPMS. A total of 237 were classified into patients with 'active SPMS' (27.2%) and 635 as 'non-active SPMS' (72.8%). 'Non-active SPMS' patients were older, with a longer disease duration compared to those with 'active SPMS'. The percentages of patients showing progression independent of relapse activity (PIRA) at 24 months were similar between 'active' and 'non-active' SPMS patients (67 [27.4%] vs 188 [29.6%]; p = 0.60). In the 'active' group, 36 (15.2%) patients showed relapse-associated worsening (RAW). Comparison of the survival curves to EDSS 6 and 7 according to disease activity did not show significant differences (p = 0.68 and p = 0.71). 'Active' and 'non-active' SPMS patients had a similar risk of achieving disability milestones, suggesting that progression is primarily attributed to PIRA and only to a small extent to disease activity.

De-escalation and Discontinuation of Disease-Modifying Therapies in Multiple Sclerosis

PURPOSE OF REVIEW

Long-term use of multiple sclerosis (MS) disease-modifying therapies (DMTs) is standard practice to prevent accumulation of disability. Immunosenescence and other age-related changes lead to an altered risk-benefit ratio for older patients on DMTs. This article reviews recent research on the topic of de-escalation and discontinuation of MS DMTs.

RECENT FINDINGS

Observational and interventional studies have shed light on what happens to patients who de-escalate or discontinue DMTs and the factors, such as age, treatment type, and presence of recent disease activity, that influence outcomes. Though many questions remain, recent findings have been valuable for the development of an evidence-based approach to making de-escalation and discontinuation decisions in MS.

Understanding the Complex Dynamics of Immunosenescence in Multiple Sclerosis: From Pathogenesis to Treatment

Immunosenescence, the gradual deterioration of immune function with age, holds profound implications for our understanding and management of multiple sclerosis (MS), a chronic autoimmune disease affecting the central nervous system. Traditionally diagnosed in young adults, advancements in disease-modifying therapies and increased life expectancy have led to a growing number of older individuals with MS. This demographic shift underscores the need for a deeper investigation into how age-related alterations in immune function shape the course of MS, influencing disease progression, treatment effectiveness, and overall patient outcomes. Age-related immunosenescence involves changes such as shifts in cytokine profiles, the accumulation of senescent immune cells, and compromised immune surveillance, collectively contributing to a state known as "inflammaging". In the context of MS, these immunological changes disturb the intricate balance between inflammatory and regulatory responses, thereby impacting mechanisms of central immune tolerance and peripheral regulation. This paper stands out by combining the most recent advancements in immunosenescence with both pathophysiological and treatment perspectives on multiple sclerosis, offering a cohesive and accessible discussion that bridges theory and practice, while also introducing novel insights into underexplored concepts such as therapy discontinuation and the latest senolytic, neuroprotective, and remyelination therapies. Enhancing our understanding of these complexities will guide tailored approaches to MS management, ultimately improving clinical outcomes for affected individuals.

Association of Higher Mediterranean Diet Adherence With Lower Prevalence of Disability and Symptom Severity, Depression, Anxiety, Stress, Sleep Quality, Cognitive Impairment, and Physical Inactivity in Older Adults With Multiple Sclerosis

A good nutritional status and healthy diets may decelerate disease disability and symptom severity and quality of life of peoples with multiple sclerosis (MS). Mediterranean diet (MD) can prevent several chronic diseases, including neurodegenerative disease. This is an observational, cross-sectional study on 279 older adults with MS, aiming to investigate the effects of MD against several aspects of mental health. Qualified questionnaires were used to assess disability and symptom severity, depression, anxiety, stress, sleep quality, cognitive status, physical activity, and MD adherence. Multivariate analysis showed that enhanced MD adherence was independently associated with lower prevalence of disability and symptom severity (P = .0019), depression (P = .0201), anxiety (P = .0287), perceived stress (P = .0021), inadequate sleep quality (P = .0033), cognitive impairment (P = .0018) and physical inactivity (P = .0028). Adopting MD may ameliorate mental health disturbances in older adults with MS. Future public health policies should inform older adults with MS for the favorable impacts of MD in improving the mental health MS comorbidities.

As time goes by: Treatment challenges in elderly people with multiple sclerosis

A demographic shift in multiple sclerosis (MS) is leading to an increased number of elderly people with MS (pwMS) and a rise in late-onset MS (LOMS) cases. This shift adds complexity to the treatment management of these patients, due to enhanced treatment-associated risks and the possible interplay between immunosenescence and disease-modifying therapies (DMTs). In the present paper, we performed a systematic review of the current evidence concerning the relationship between aging and treatment management in elderly pwMS. Our literature search identified 35 original studies relevant to this topic. The gathered evidence consistently indicates a diminished efficacy of DMTs in older pwMS, particularly in preventing disability accrual. Against this background, high-efficacy therapies (HETs) appear to show less benefit over moderate-low-efficacy DMTs in older patients. These data mainly derive from observational retrospective studies or meta-analyses conducted on randomized clinical trials (RCTs). RCTs, however, exclude pwMS older than 55 years, limiting our ability to acquire robust evidence regarding this patient group. Regarding treatment discontinuation in elderly pwMS with stable disease, the available data, which mainly focuses on older injectable DMTs, suggests that their suspension appears to be relatively safe in terms of disease activity. Nevertheless, the first RCT specifically targeting treatment discontinuation recently failed to demonstrate the non-inferiority of treatment discontinuation over continuation, in terms of MRI activity. On the other hand, the evidence on the impact of discontinuation on disease progression is more conflicting and less robust. Furthermore, there is an important lack of studies concerning sequestering DMTs and virtually no data on the discontinuation of anti-CD20 monoclonal antibodies. De-escalation strategy is gaining attention as a de-risking approach alternative to complete treatment discontinuation. It may be defined as the decision to shift from HETs to less potent DMTs in elderly pwMS who have a stable disease. This strategy could reduce treatment-related risks, while minimizing the risk of disease activity and progression potentially associated with treatment discontinuation. This approach, however, remains unexplored due to a lack of studies. Given these findings, the present scenario underlines the urgent need for more comprehensive and robust studies to develop optimized, data-driven treatment strategies for elderly pwMS and LOMS, addressing the unique challenges of MS treatment and aging.

Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review

Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.

Association of Mediterranean diet adherence with disease progression, quality of life and physical activity, sociodemographic and anthropometric parameters, and serum biomarkers in community-dwelling older adults with multiple sclerosis: a cross-sectional study

BACKGROUND

Multiple sclerosis (MS) constitutes a chronic inflammatory and degenerative demyelinating disease, which can progressively lead to a broad range of sensorimotor, cognitive, visual, and autonomic function symptoms, independently of patient' age. However, the clinical studies that examine the role of dietary patterns against disease progression and symptomatology remain extremely scarce, especially concerning Mediterranean diet (MD) in the subgroup age of older adults with MS.

AIMS

The present study aimed to investigate the potential impact of MD compliance in disease progression and symptoms severity as well as quality of life and physical activity of community-dwelling older adults with MS.

METHODS

This is a cross-sectional conducted on 227 older adults with no history of other severe disease. Relevant questionnaires were applied to collect sociodemographic and anthropometric factors by face-to face interviews between patients and qualified personnel. Serum biomarkers were retrieved by patients' medical records.

RESULTS

Higher MD compliance was independently associated with younger patients' age, lower risk of overweight/obesity and abdominal obesity, decreased disease progression and higher muscle mass, as well as greater physical activity, better quality of life, and adequate serum ferritin and albumin levels CONCLUSIONS: MD may exert beneficial effects in older adults with MS. Future strategies and policies are highly recommended to inform both the general population and the older patients with MS for the beneficial effects of MD in preventing MS and in improving or even slowing down the disease progression and symptoms severity of MS.

From Animal Models to Clinical Trials: The Potential of Antimicrobials in Multiple Sclerosis Treatment

Multiple sclerosis (MS) is a chronic, autoimmune, demyelinating disease of the central nervous system (CNS). Microbes, including bacteria and certain viruses, particularly Epstein-Barr virus (EBV), have been linked to the pathogenesis of MS. While there is currently no cure for MS, antibiotics and antivirals have been studied as potential treatment options due to their immunomodulatory ability that results in the regulation of the immune process. The current issue addressed in this systematic review is the effect of antimicrobials, including antibiotics, antivirals, and antiparasitic agents in animals and humans. We performed a comprehensive search of PubMed, Google Scholar, and Scopus for articles on antimicrobials in experimental autoimmune encephalomyelitis animal models of MS, as well as in people with MS (pwMS). In animal models, antibiotics tested included beta-lactams, minocycline, rapamycin, macrolides, and doxycycline. Antivirals included acyclovir, valacyclovir, and ganciclovir. Hydroxychloroquine was the only antiparasitic that was tested. In pwMS, we identified a total of 24 studies, 17 of them relevant to antibiotics, 6 to antivirals, and 1 relevant to antiparasitic hydroxychloroquine. While the effect of antimicrobials in animal models was promising, only minocycline and hydroxychloroquine improved outcome measures in pwMS. No favorable effect of the antivirals in humans has been observed yet. The number and size of clinical trials testing antimicrobials have been limited. Large, multicenter, well-designed studies are needed to further evaluate the effect of antimicrobials in MS.