Can Multiple Sclerosis (MS) present in patients in their 60s?

Multiple Sclerosis Can Present in Patients in Their 60s

Yes, multiple sclerosis (MS) can present in patients in their 60s, although it is uncommon, with only about 0.6% of MS patients experiencing their first symptoms after age 60. 1

Epidemiology of Late-Onset MS

• MS typically presents in young adults between 20-30 years of age 2
• Late-onset MS (LOMS) is defined as symptom onset after age 50 3
• Very late-onset MS (after age 60) is rare:
  • Only 0.6% of MS patients have first symptoms at age 60 or older 1
  • In larger MS populations, approximately 5.01% of cases present after age 50 3
• The International Panel on Diagnosis of MS specifically notes that their diagnostic criteria best apply to individuals between 10 and 59 years of age 4

Clinical Presentation in Older Patients

The presentation of MS in older adults differs from younger patients:

• Predominant symptoms: Slow deterioration of motor function is the characteristic initial presentation in older patients 5, 1
• Disease course: Most (10 of 12) very late-onset patients have a progressive course from onset 1
• Progression rate: Disability progression tends to be more rapid in older-onset patients compared to younger patients 5
• Disease phenotype:
  • 49.8% present with relapsing-remitting MS 3
  • Progressive forms are predominant in many studies of late-onset MS 3
  • First presentation is typically motor dysfunction (35.4-100% of cases), followed by sensory problems (5-94%) 3

Diagnostic Considerations

Special care must be taken when diagnosing MS in patients older than 59 years:

• The American Academy of Neurology recommends more stringent MRI criteria for patients older than 50 years 6
• Diagnostic workup should include:
  • Evoked response studies and CSF electrophoresis, which have high diagnostic yield in older patients 5
  • CSF analysis for oligoclonal bands (positive in 46-98% of LOMS cases) 3
  • IgG index (positive in 45-66% of LOMS cases) 3

Differential Diagnosis

Several conditions may mimic MS in older adults and should be ruled out:

• Multifocal areas of cerebral ischemia or infarction from conditions like phospholipid antibody syndrome, CADASIL, or carotid dissection 4
• Infections such as HTLV1 and Lyme disease 4
• Cerebellar ataxia from paraneoplastic disorders 4
• Vascular disease is more common in older adults and may cause similar symptoms

Management Implications

• Treatment decisions should consider:
  • More rapid disability progression in older patients 5
  • Higher prevalence of comorbidities in MS patients over 60, particularly pain, cardiac disease, depression, and hypertension 7
  • Depression is significantly more common in older MS patients (51.5%) compared to the general older population (21.7%) 7

Key Takeaway

While MS is primarily a disease of young adults, it can present in patients in their 60s, typically with a progressive course and predominant motor symptoms. Clinicians should maintain a high index of suspicion when evaluating older adults with progressive neurological symptoms, as prompt diagnosis and management may help slow disability progression.