Practice Points
- Multidisciplinary care for older adults with multiple sclerosis (MS) should address geriatric issues, which can be done using a comprehensive geriatric assessment by providers in disciplines including but not limited to neurology, geriatrics, rehabilitation, social work, pharmacy, neuropsychology, psychology/psychiatry, nutrition, urology, ophthalmology, and audiology.
- Providers should assess for health care access issues such as structural and financial barriers in older adults with MS.
- Recognition of health care disparities facing older adults with MS, such as ageism and ableism, can improve quality of care.
The most recent estimate of the prevalence of multiple sclerosis (MS) in the United States is approaching 1 million individuals, with the highest peak prevalence between the ages of 55 and 64 years, followed by the 65- to 74-year-old age group, suggesting an increasing number of aging individuals.1This partly reflectsthe advances in disease-modifying therapies (DMTs) and supportive care that have extended the life expectancy of individuals with MS.2 Older adults with MS often have unique health care needs and challenges arising from worsening disability, comorbid conditions, and socioeconomic vulnerabilities. These issues require a comprehensive multidisciplinary approach to achieve a high-quality level of care. At the same time, access to health care in general is a documented challenge for both the general aging population and people with MS. Limited research has examined the intersection of aging and MS regarding multidisciplinary care and access to care. In this review, we discuss the known benefits of geriatric multidisciplinary care and challenges in access to care for older adults with MS, identify similar concepts from the general aging population, and address opportunities for improvement. Although the majority of cited literature originates from the US, we also included studies from other countries to capture relevant international perspectives.
Multidisciplinary Care
It is commonly accepted that multidisciplinary care is optimal for MS treatment, as advocated by both providers and patients.3,4 Older adults with MS experience unique issues related to aging and accumulating neurological disability, which require management by providers in disciplines including but not limited to neurology, geriatrics, rehabilitation, social work, pharmacy, neuropsychology, psychology/psychiatry, nutrition, urology, ophthalmology, and audiology (Table).
MS multidisciplinary care units integrate many of the aforementioned specialties,5 but they do not routinely perform a comprehensive geriatric assessment (CGA). In the primary care setting, integrated geriatric care has been shown to reduce medical costs and the number of prescription drugs used and to decrease the frequency of emergency department visits and hospitalizations of older adults who attended an integrated geriatric outpatient clinic compared with a nongeriatric clinic.6 Another study evaluating the effect of outpatient CGA-based care by a multidisciplinary team found improvements in frailty and mortality among older adults with multimorbidity.7
Currently, no studies have adequately evaluated whether team-based comprehensive management improves MS health care utilization or neurological function outcomes. Improved health care utilization refers to measurable changes in how people with MS use health care services that reflect more effective, appropriate, and efficient care.8In other neurological conditions such as stroke, CGA was associated with decreased hospital mortality and patients receiving more rehabilitation intervention and home health care.9
The results of a study by Bahri et al were encouraging. The study describes the implementation of a neurogeriatric MS clinic that provides same-day access to MS care, rehabilitation, nutrition, social work, pharmacy, and neuropsychology during a 4-hour clinic session for adults with MS aged 60 years or older.10 Providers in the clinic delivered a CGA covering functional capacity, cognition, mood, frailty, polypharmacy, nutrition, social/financial need, and goals of care. Recommendations were communicated to the patient, their neurologist, and their primary care physician. An initial survey of clinic participants reflected self-reported improvements in the quality of care.
Future research to evaluate the efficacy of multidisciplinary care in MS could include short-term measures such as the assessment of decision-making aligned with treatment guidelines and patient-reported outcomes, as well as long-term measures, such as assessment of DMT efficacy and safety and reducing claims for disability benefits.3 Additional areas of future research on multidisciplinary care for older adults with MS could include improving understanding of the perspectives of older adults with MS to align with their goals of care, developing pathways to implement CGA, methods to identify patients who benefit from such care, and evaluations of cost-effectiveness.
Barriers to Health Care Access
Penchansky and Thomas identified 5 dimensions of health care access: availability, accommodation, accessibility, affordability, and acceptability.11 Availability refers to the adequacy of the supply of services, including physicians, clinics, hospitals, and specialized programs, in relation to the needs and volume of clients. Accommodation focuses on how services are organized to meet client needs, such as appointment systems, hours of operation, walk-in options, and telephone services. Accessibility describes the geographic relationship between sites of services and client location, considering transportation, travel time, distance, and cost. Affordability is the cost of services relative to clients’ incomes, including insurance coverage, co-payments, and perceived value. Last, acceptability relates to a patient’s satisfaction with the delivery of equitable care. All of these affect the health care available to older adults with MS.
Individuals with MS who are aging often have complex and evolving health care needs, and addressing these needs requires access to coordinated, specialized care. MS is characterized by a high burden of chronic comorbidities, cognitive decline, and increasing physical disability10,11; these challenges increase with age. Disparities in access and quality of care are further influenced by social determinants of health, defined as the conditions in which people are born, grow, live, work, and age that affect health outcomes and contribute to inequities in disease progression, access to care, and quality of life12 (Figure).
Availability of Providers
Older adults with MS highly value access to trusted health care providers with expertise in MS13; however, many individuals with MS in the US live in a neurology desert, defined as living more than 60 miles from a neurologist. Specialist access particularly affects those in rural areas and in regions where there is a large number of people with disabilities who do not have insurance.14 A cross-sectional study of Medicare beneficiaries found that nearly 20% of those living with MS traveled 50 miles or more each way to access neurologic care, with older adults disproportionately affected.15 The shortage of MS clinicians is further exacerbated by the limited availability of geriatricians, who provide value n managing the complex medical, cognitive, and psychosocial needs of aging individuals. While the US Department of Health and Human Services projects growth in the number of geriatricians, a projected shortfall of nearly 27,000 physicians remains concerning, especially in rural areas, where only approximately 10% of geriatricians currently practice.16
Increased Need for Care
A 2015 systematic review of cross-sectional studies found that individuals with MS commonly experience a high burden of comorbidities.17 The prevalence of many of these comorbid conditions increases with age, including hypertension, hyperlipidemia, diabetes, ischemic heart disease, cerebrovascular disease, and chronic lung disease. This age-related rise in comorbidity burden was most recently described in a meta-analysis of 14 clinical trials that included over 17,000 individuals with MS. The study reported that people with MS over the age of 50 were 5 times more likely to be diagnosed with hypertension compared with those between 30 and 40 years of age.18 The cohort of individuals aged 50 years or older was also 3.5 times more likely to be diagnosed with diabetes and 5 to 6 times more likely to have ischemic heart disease and cerebrovascular disease.These individuals tend to be high utilizers of health care services and face increased risks of adverse health outcomes, underscoring the need for improved, coordinated systems of care.
In the general aging population, cognitive impairment also plays a pivotal role in shaping health care access.Between 12% and 18% of US adults over age 60 have mild cognitive impairment. These individuals often have difficulty managing appointments, using telehealth platforms, advocating for themselves, and conveying accurate medical histories.19Cognitive deficits are well documented in people with MS and have a greater association in those of both older age and higher levels of disability. These overlapping factors may contribute to a compounding effect, further limiting health care access and exacerbating challenges as individuals with MS age.20
Transportation Barriers
Older adults with MS often face transportation challenges. Chiu et al reviewed barriers to the accessibility and continuity of health care services for people with MS and highlighted that transportation barriers significantly impact their ability to attend medical appointments, which can lead to delays in care and potential deterioration of health outcomes.21 The study emphasized the need for health care systems to address these barriers by implementing more accessible transportation options and improving the overall accessibility of health care facilities to better serve people with MS.16 Similar studies among the general aging population show the same, as about 20% of older adults do not drive and up to one-third face driving restrictions.22 A qualitative study in rural communities identified 5 primary barriers to care, with limited transportation being the most prevalent. The additional barriers noted were limited health care supply (eg, fewer per capita hospital beds, doctors, nurses, and other health care services), lack of quality health care (eg, concerns about provider competence and service quality), social isolation, and financial constraints.16
Financial Challenges
Income plays a critical role in determining an individual’s ability to address their health care needs. Limited financial resources can restrict access to essential services, including specialist visits, transportation, medications, assistive devices, and home- and community-based services. When looking at people with MS without distinguishing by age, direct medical costs (eg, doctor’s appointments and medications) are the biggest contributor to the high cost of MS. The cost of living with MS in the US is estimated to be $88,487 annually, and the average lifetime cost of care for a person with MS exceeds $4 million.23 The annual US economic burden (ie, the societal cost)—including individuals living with MS, the government (federal, state, and local), employers, health insurers, and more—is $85.4 billion.
We know that when the cost of health care becomes a significant financial burden, patients often forgo health care to afford other essential needs. A Canadian study showed that a cohort of older people with MS, who described themselves as financially challenged, prioritized housing, food, and transportation over their health care needs.13 In older adults living in the US, health-related quality of life was found to be significantly associated with household income.24 In 2022, 5.9 million people 65 years or older lived below the poverty level, and another 2.7 million had incomes at or just above the poverty level (near-poor).25 This economic insecurity contributes to older adults missing provider visits, skipping recommended medical tests or treatment, not filling prescription medications, and taking less medication than prescribed or skipping doses.25 Despite decreased rates of uninsured older adults after the implementation of Medicare, cost remains a barrier to care access.26
Health Equity and Access Disparities
People with MS and significant disability also face extensive challenges in nearly all facets of health care delivery, particularly access to care.24,25 While mobility impairments are a primary barrier to receiving comprehensive and coordinated care, these difficulties are compounded by inaccessible, fragmented health care systems and societal issues.6,26 Further, structural ageism and ableism within health care systems can marginalize older adults.27 Ageism refers to stereotypes, biases, and discriminatory behaviors based on age. Similarly, ableism involves these same prejudices and discriminatory attitudes, but in relation to disability. Race and ageism also have an amplifying effect on aging individuals from marginalized communities and can lead to increased disparities in social determinants of health, including poor access to health care and poor health outcomes.28
Discussion
There are limited studies addressing multidisciplinary care and access to care in older adults with MS. However, there is more literature on geriatric care in the general population supporting the value of a multidisciplinary approach, including the use of the comprehensive geriatric assessment. As outlined in the 2024 MS and Aging Consensus Statement by the Consortium of Multiple Sclerosis Centers, utilizing an access-to-care framework allows a significant opportunity to enhance care for aging individuals with MS.29
Considering these dimensions will allow health care systems to recognize and comprehensively address barriers to care.30 Highlighting how social disparities affect access, particularly among individuals with multiple risk factors, is essential. The National Institutes of Health’s NIMHD Research Framework (developed by the National Institute on Minority Health and Health Disparities) offers a valuable approach to understanding Health Disparities) offers a valuable approach to understanding and addressing these barriers.31 Research specifically targeting aging individuals with MS is urgently needed. Distributing a needs-based assessment through a known MS registry, such as the North American Research Committee on Multiple Sclerosis Registry, could begin to identify and address common barriers.
Access to coordinated, person-centered care has been shown to improve patient satisfaction and perceived health among older adults with MS.4 Incorporating palliative care principles, such as aligning care with patients’ priorities, could enhance patient satisfaction and improve care delivery for the complex needs of this population.32 As people with MS continue to age and lose function, health interventions must account for the diverse ability levels of older adults. For aging individuals with disability, the concept of successful aging is unique. Their experiences offer key insights as they have adapted to and lived with loss of function over time. A qualitative study by Molton and Yorkston highlights the complex nature of successful aging among individuals with physical disabilities extending beyond those living with MS.33 A comprehensive, tightly integrated, community house call practice has been shown to be a viable solution to improve care for people with MS experiencing significant disability.34 In recent years, there has been a resurgence of home-based primary care services in the US, due to the needs of our aging society.35 The expansion of alternative care models such as home-based services offers the potential to improve access to care for aging individuals with MS, particularly for those with significant disability, and could offer an opportunity to address both MS and primary care needs while removing transportation barriers.
Policy reforms are needed to support efforts to expand access to care and ensure adequate payment models. Expanding and protecting telehealth services is of particular interest, given the prevalence of neurology deserts and the nationwide shortage of geriatricians. Hubs in community-based centers, with staff available to provide in-person aid, could be used by older adults who need more technical support.36 Reducing structural and attitudinal barriers, as well as supporting community-based programs that specialize in addressing unmet needs, could further support equitable access to care for aging people with MS.
Conclusions
Older adults with MS have unique health care needs that benefit from having a multidisciplinary provider team with a specialization in geriatric care; at the same time, health care access barriers hinder this patient population from receiving optimal care. By developing awareness, providing training in recognizing geriatric issues and circumventing health care barriers, and advancing understanding through research, clinicians can better serve the needs of the growing population of aging people with MS.
