BrainHealth & ClinicSpeak: how should we treat MS in old age?

How should we manage MS in old age? #BrainHealth #ClinicSpeak #MSBlog 

"Public Health England (PHE) published their life expectancy report today. It shows life expectancy increasing. In parallel the latest data from the Framingham study showing the decreasing incidence of dementia. This Framingham data confirms recent dementia trends in the UK. Will this apply to MS? Will pwMS be living longer with a lower incidence of dementia? I don't know. I suspect that life expectancy in pwMS will have been increased by the impact of DMTs. We know already that simply being treated with interferon-beta 3-years earlier increases your chances of being alive at 21-years by close to 50%, compared to pwMS with delayed access to IFNbeta. However, survival, or mortality, data says nothing about the state of  cognition in pwMS in old age. How many pwMS when the get to 60 have dementia? How should we manage pwMS when they are old? How healthy are their bones? Have they all signed-up to an advanced directive? And the list goes on. These issues raise the thorny philosophical question about whether ageing is a comorbidity or disease, or is a physiological process? These issues are not trivial; if ageing is a disease it becomes a druggable problem that pharma can commercialise. If it is not a disease then pharma will have no incentive to develop drugs to target ageing; healthcare payers only pay for drugs and services linked to diseases. This is why pharma are lobbying so hard to get old-age classified as a disease."

"What about pwMS? What happens to them when they get older? Because MS reduces brain and spinal cord reserve pwMS are more susceptible to the ravages of ageing. This is something people with MS should think about now. How do you want to live your life when you are older? It makes sense to do everything in your power in the now to optimise your brain health for later. This rallying call should be a general one to everyone reading this post. How healthy are you and what are you doing to improve your brain health? Have you joined the brain health challenge?"


"Someone asked the other day how things are going with my brain health challenge. Very well. I have lost some weight, but have some way to go until I get down to my target weight of 1993; the year I arrived in London. I am exercising 4+ times a week; I do more rowing that running, simply to protect my hip. I have changed my diet; it tends to be a high-fat, high-protein, high-fibre and low carbohydrate diet. I have cut down massively on processed carbohydrates; I have virtually stopped eating bread.  I have not adopted a ketogenic, or gluten-free, or any other fad diet; I not convinced by the evidence. I have reduced my alcohol intake and only drink on ~3 or 4 days of the week. I don't smoke. My blood pressure is normal. I am due to have my cholesterol checked next month and if still high I may still need a statin. I am taking my supplements on most day of the week (vitamin D, metamucil and glucosamine/chondroitin); please note the metamucil and glucosamine/chondroitin have been prescribed for my diverticular disease and joints, respectively. I still struggling with sleep hygiene; I try to get at least 6 hours of sleep a night, but have several 4 hour nights a week. I am doing a lot of leisure reading to keep my mind from thinking about MS too much. With spring arriving I will have a lot of gardening to do. I haven't managed to complete my online JavaScript (computer coding) course; this was my New Year's challenge to myself. Overall I am feeling better than I have for some years. So yes, my brain health campaign is going well. What about wellness? Do I feel well? No not yet I still have too much work-related stress and a work-load that is unstainable."

Public Health England. Recent Trends in Life Expectancyat Older Ages. February 2015

Key Points:


Satizabal et al. Incidence of Dementia over Three Decades in the Framingham Heart Study. N Engl J Med. 2016 Feb 11;374(6):523-32.

BACKGROUND: The prevalence of dementia is expected to soar as the average life expectancy increases, but recent estimates suggest that the age-specific incidence of dementia is declining in high-income countries. Temporal trends are best derived through continuous monitoring of a population over a long period with the use of consistent diagnostic criteria. We describe temporal trends in the incidence of dementia over three decades among participants in the Framingham Heart Study.

METHODS: Participants in the Framingham Heart Study have been under surveillance for incident dementia since 1975. In this analysis, which included 5205 persons 60 years of age or older, we used Cox proportional-hazards models adjusted for age and sex to determine the 5-year incidence of dementia during each of four epochs. We also explored the interactions between epoch and age, sex, apolipoprotein E ε4 status, and educational level, and we examined the effects of these interactions, as well as the effects of vascular risk factors and cardiovascular disease, on temporal trends.

RESULTS: The 5-year age- and sex-adjusted cumulative hazard rates for dementia were 3.6 per 100 persons during the first epoch (late 1970s and early 1980s), 2.8 per 100 persons during the second epoch (late 1980s and early 1990s), 2.2 per 100 persons during the third epoch (late 1990s and early 2000s), and 2.0 per 100 persons during the fourth epoch (late 2000s and early 2010s). Relative to the incidence during the first epoch, the incidence declined by 22%, 38%, and 44% during the second, third, and fourth epochs, respectively. This risk reduction was observed only among persons who had at least a high school diploma (hazard ratio, 0.77; 95% confidence interval, 0.67 to 0.88). The prevalence of most vascular risk factors (except obesity and diabetes) and the risk of dementia associated with stroke, atrial fibrillation, or heart failure have decreased over time, but none of these trends completely explain the decrease in the incidence of dementia.

CONCLUSIONS: Among participants in the Framingham Heart Study, the incidence of dementia has declined over the course of three decades. The factors contributing to this decline have not been completely identified. (Funded by the National Institutes of Health.).

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