Implementing a multidisciplinary approach for older adults with multiple sclerosis: geriatric neurology in practice

Abstract

Background:

Older adults with multiple sclerosis (MS) face unique challenges arising from age-related changes in MS pathophysiology and overlapping geriatric syndromes. There is a need for geriatrics-focused multidisciplinary care for the rapidly growing older MS population.

Objective:

To design and implement a geriatric multidisciplinary clinic for older adults with MS.

Methods:

We describe the development of a multidisciplinary approach to geriatric MS care within a single institution through the implementation of the Aging with MS Clinic. The clinic model was conceived through collaboration between neurology and geriatric medicine to provide comprehensive care for older adults with MS who are uniquely affected by overlapping symptoms of aging and MS (e.g., frailty, falls, functional decline, multiple comorbidities, polypharmacy, cognitive impairment, nutritional deficits, barriers to access healthcare). Multidisciplinary specialists were recruited to staff the clinic, and initial patient satisfaction outcomes were collected.

Results:

The team of multidisciplinary specialists staffing the clinic consists of a MS advanced practice practitioner, MS pharmacist, physical therapist, neuropsychologist, dietitian, and social worker. A clinic template was devised where 4 patients with MS over age 60 are seen by each specialist during each a half-day clinic session. Initial patient satisfaction surveys from 25 participants showed overwhelmingly positive feedback. A majority of participants (92%) agreed that the clinic was well-organized, while 89% felt they benefitted from attending. Additionally, 70% of participants reported that the clinic improved their overall quality of care.

Conclusion:

The Aging with MS clinic outlines a model for comprehensive geriatric assessment and care in older adults with MS by a team of multidisciplinary specialists. Initial feedback from patients who attended the clinic conveyed improved quality of care.

1. Introduction

Multiple sclerosis (MS) is a chronic immune-mediated inflammatory and neurodegenerative disease of the central nervous system (CNS).^1–3 The disease affects over 2.8 million people worldwide and is the leading cause of non-traumatic disability in younger adults, commonly diagnosed between age 20 to 40.^2,4,5 Age has the greatest impact on the clinical course of MS.^6–9 The disease commonly manifests in young adults who initially experience self-limited episodes of neurological dysfunction (relapses) separated by clinically quiescent periods (remissions). With advancing age, many people with relapsing-remitting MS (RRMS) transition to secondary progressive MS (SPMS), characterized by a gradual accrual of irreversible neurological disability. This unpredictable trajectory of MS disease progression is compounded by aging, resulting in unique challenges in the care of older adults with MS.^4,5

With an early age of diagnosis and increased treatment options, older adults constitute a growing proportion of people with MS, where the peak disease prevalence is between age 55–64.¹² Older adults with MS have increased age-related physiological symptoms and socioeconomical needs.^6,7 MS symptoms can occur at any point during the MS disease course leading to sensory, motor, and cognitive impairments.⁸ A wide spectrum of common MS symptoms include weakness, paresthesia, ataxia, spasticity, heat intolerance, visual disturbances, fatigue, pain, depression, cognitive impairment, bowel and genitourinary dysfunction, and sexual disturbances, each requiring unique treatments. Often many of these symptoms require multidisciplinary management by subspecialties outside of neurology. Aging further complicates and compounds on MS symptoms.⁴ Moreover, aging reduces the risk-to-benefit ratio of disease-modifying therapies (DMT) for MS through increased side effects and higher risk of infections.¹⁵ Additionally, DMTs are generally ineffective for SPMS. Furthermore, multiple chronic conditions and polypharmacy can result in drug interactions and higher levels of treatment toxicity for older adults with MS. ^10,13,14

Multidisciplinary MS care units are common. ¹However, no literature has described a multidisciplinary clinic model for geriatric MS care. Clinical practice in the care of older adults with MS often overlooks the geriatric needs of this patient population due to unavailability of best practice guidelines and neurologists’ lack of formal training in geriatric medicine. Geriatric syndromes such as frailty, cognitive decline, mobility concerns, polypharmacy, and psychosocial factors require dedicated assessment tools and treatment strategies. To improve the treatment of older adults with MS, we describe the implementation of a novel multidisciplinary clinic model at our institution centered on geriatric MS care and developed in consultation with geriatricians.^1,4,9

2. Methods

We developed and implemented a multidisciplinary clinical approach through the creation of the Aging with MS Clinic that integrates neurological care, pharmacy consultation, social work, neuropsychological evaluation, nutrition assessment, and physical therapy, to improve health outcomes in older adults with MS.² Patients with MS over age 60 are seen for a single visit where they undergo a comprehensive geriatric assessment, and recommendations are communicated to the patient’s primary MS neurologist. This model is comprised by a six-member clinical team, including a MS advanced practice provider (APP), pharmacist, physical therapist (PT), social worker, dietitian, and neuropsychologist (Table 1). Patients are seen by each specialist during a 30-minute or 1 hour visit throughout a 4-hour clinic session (Figure 1). Each clinical team member completes targeted assessments to analyze risk factors specific to age-related changes associated with MS. The MS advanced practice practitioner (APP) serves as the point of contact for the coordination of multidisciplinary care during the clinic visit. At the end of the one-time visit, a complete summary of the evaluation, along with the resulting therapeutic treatment plan is discussed with the patient and caregivers, and recommendations are relayed to the patient’s primary MS neurologist (Figure 2).

Table 1:

Aging with Multiple Sclerosis Clinic Team and Assessment Parameters

	Assessments
MS Advanced Practice Practitioner	MS medical history - initial symptoms, diagnosis, previous and current treatments
	Geriatric syndromes - incontinence, insomnia, delirium, falls, constipation/diarrhea
	Frailty assessment - CFSa, EDSSb
	Quality of life - MSQLIc
	Comprehensive post-visit summary
	Optical coherence tomography, ultrasound bladder scan*
Pharmacist	Medication reconciliation - review of medication names, purpose, dose, regimen, and side effects
	Medication use evaluation - Beers Criteria, adherence, compliance, patient education, document high-risk medications, suggest adjustments, and promote adherence tools
	Polypharmacy - therapeutic overlaps, interactions, and deprescribing recommendations
	Immunization records review and vaccinations recommendations
	Smoking cessation intervention
Physical Therapist	Mobility (fall risk) - 10MWTd, TUGe, T25-FWf, Berg Balance Scale, Four Square Step Test
	Higher-level balance and postural stability (fall risk) - Functional Gait Assessment
	Functional lower limb strength (fall risk) - 5X sit to stand
	Independence - ADLsg and IADLsh
	Pelvic health screening - incontinence, urgency, delay, hesitancy, dysuria, dyspareunia
	Ambulatory assistive device (fall risk) - canes, walkers, scooters, and manual or motorized wheelchair
	Review of patient history - behavioral health, barriers to exercise/mobility, medical history
Neuropsychologist	Cognition - mood, psychosocial stressors, suicidality
	Geriatric assessment metrics - fatigue
	Social isolation - caregiver and social support
Social Worker	Socioeconomic evaluation and assessment of financial needs
	Decision making preparedness - review of advance care planning, advanced directives
	Comprehensive social assessment - evaluation of social support, resources, home safety concerns, and coping skills
Dietitian	Dietary evaluation - current diet and supplements, eating habits, dysphagia, weight changes
	Anthropometrics - height, weight, body mass index, and ideal, usual, and goal body weight
	Review of nutrition-related labs - cholesterol, triglycerides, LDL, HDL, CRP, HbA1C, etc.
	Malnutrition assessment and diagnosis - Mini nutritional assessment
	Development of nutritional interventions

^aCFS: Rockwood Clinical Frailty Scale

^bEDSS: Expanded Disability Status Scale

^cMSQLI: Multiple Sclerosis Quality of Life Inventory

^d10MWT: 10 Meter Walk Test

^eTUG: Timed Up and Go

^fT25-FW: Timed 25-Foot Walk

^gADLs: Activities of Daily Living

^hIADLs; Instrumental Activities of Daily Living

^*Available tests for same-day completion by medical assistants

Figure 1.

Template for the Aging with MS clinic: 4 patients are seen by 6 multidisciplinary specialists for 30 minutes or 1 hour during a half-day visit.

Figure 2.

Overview of the patient-centered approach to the multidisciplinary Aging with MS Clinic. Patients are roomed simultaneously, and providers see patients in a rotating sequential manner. Providers compile a summary of the patients’ needs to create an individualized therapeutic treatment plan and recommendations are relayed to the patient, caregiver, primary care physician, and primary MS neurologist.

The recommendation for referral is for people with MS over age 60 due to the potential for accelerated biological aging and the earlier manifestations of geriatric syndromes in MS,¹⁶ though there is no age-threshold for referrals as geriatric syndromes may present at younger ages. The multiple disciplines were selected by the clinic director (Y Zhang), who is a fellowship-trained neuroimmunologist, in consultation with geriatricians providing multidisciplinary care at our institution. Other disciplines were considered, but were unable to be integrated into the final clinic model due to time constraints (urology, sleep medicine, ophthalmology, occupational therapy, psychiatry). These specialties are available at our institution for separate referrals.

3. Results

3.1. Implementation of the clinic

The implementation of the Aging with MS Clinic required commitment and support from hospital administration, clinical providers, and leadership from the Department of Neurology. Within the Department of Neurology, a dedicated Director of Multidisciplinary Clinics oversaw implementation including staff allocation, creation of standardized documentation templates in the electronic medical record, billing and financial analysis, marketing, and encounter formatting to allow access from multiple providers. Providers met with the director of the Aging with MS Clinic to select assessment tools and design the documentation template. A designated scheduler for multidisciplinary clinics within the Department of Neurology ensures that four patients are scheduled during each half-day clinic session and makes phone calls to confirm appointments. The MS APP leads the clinic to ensure patients are seen by each provider and provides a summary of recommendations to the patient and their MS neurologist. Each provider bills separately.

Initial challenges encountered included coverage for gaps in staffing, potentially lengthy duration of the four-hour clinic visit, and occasional no-shows. An afternoon clinic time has been chosen to accommodate patients with longer commutes. Discussions are ongoing to potentially shorten certain provider visits to reduce the overall clinic duration, and efforts are underway to increase the frequency of clinic due to demand.

3.2. Patient response to the multidisciplinary model

A written patient satisfaction survey was given to each patient at their clinic visit, and participants were asked about their level of agreement with 7 statements on their experience with the clinic. The study was determined by the Ohio State University institutional review board to be exempt human research. The questionnaire, designed specifically for the clinic, demonstrated an overall increase in satisfaction, with percentage point improvements observed across several key items. Responses from 25 participants were collected and shown in Figure 3. The majority of participants felt that the clinic met their expectations (92% agreed or strongly agreed). Similarly, 92% of participants felt they benefitted from attending the multidisciplinary clinic. Organization of the clinic was also highly rated, with 92% of patients agreeing or strongly agreeing that the clinic was well-organized. Most participants (80%) felt the duration of the clinic was appropriate, and 80% agreed or strongly agreed that the clinic improved their quality of care. The clinic was highly recommended with 92% of participants agreeing or strongly agreeing with recommending the clinic to others. Lastly, when asked if participants would benefit from returning to the clinic, 79% indicated desire to return to the Aging with MS clinic in the future. Overall, these initial results reflect a high level of patient satisfaction with the multidisciplinary clinic, highlighting its effectiveness in meeting patient expectations, providing tangible benefits, maintaining organization, and improving quality care.

Figure 3.

Patient satisfaction survey results for the multidisciplinary clinic. The survey was completed by 25 patients who completed the half-day clinic visit, with data collected throughout the first year of the clinic's operation. The figure displays the percentage of patients who responded with each level of agreement to various statements.

4. Discussion

The Aging with MS clinic provides multidisciplinary care for older adults with MS through implementing a comprehensive geriatric assessment and managing geriatric syndromes that coexist with MS-related symptoms. To our knowledge, the Aging with MS Clinic is the first multidisciplinary unit dedicated to providing neurogeriatric care in MS. Initial clinic participants showed markedly positive feedback that highlighted the organization of the clinic, and patients benefitted from attending the clinic through perceived improvements in quality of care. This initial success is reflected by the breadth of expertise offered by the multidisciplinary specialists who staff the clinic.

This study has some limitations. Although the sample size was small, the overwhelmingly positive patient feedback highlights the success of the specialized multidisciplinary approach to MS care in the aging patient population. Despite the limited sample, patient perspectives remain valuable, and the positive survey results underscore the need for a comprehensive approach in managing these patients diverse and evolving medical needs. The survey data provided critical insights into the multifactorial challenges of MS care and guided targeted improvements. This study demonstrates the importance of a holistic approach to addressing the complex needs of aging MS patients, serving as a model for other clinics and encouraging larger-scale research. Secondly, the exclusion of specialties like urology and sleep medicine may have left gaps in care that affect the overall management of MS. These areas are essential for a more complete care strategy and should be included in future studies. While the model is promising, further research with larger populations and longer follow-up is necessary to validate its effectiveness and sustainability.

Patient satisfaction, a validated proxy for care quality, showed clear improvement in how the clinic and its services were perceived. Previous research suggests that satisfied patients are more likely to adhere to treatment, actively participate, and maintain a positive outlook—crucial for those managing a chronic condition like MS.⁵ The improved patient satisfaction and clear benefits of this multidisciplinary approach underscore its potential to enhance care quality and patient outcomes, reinforcing the need for its broader implementation and continued evaluation.

4.1. MS advanced practice provider

The MS APP, who is the clinical lead of the Aging with MS Clinic, works directly with neurologists at the MS center. The APP performs a review of each patient’s relevant medical history and identifies each patient’s goals and barriers to optimizing their quality of life in the context of aging and MS. Dialogue is centered on the patient but also inclusive of their caregivers, focusing on promoting independence and autonomy through a shared decision-making process. Frailty is recognized as a cornerstone of geriatric medicine, as it increases risk of concomitant geriatric syndromes and adverse health outcomes. A comprehensive assessment approach utilizing composite testing is also performed including the Rockwood Clinical Frailty Scale,¹⁰ expanded disability status scale (EDSS) and MS quality of life inventory (MSQLI). Final assessments and recommendations are prepared by the MS APP in conjunction with findings and recommendations from the other members of the multidisciplinary clinic team.

4.2. MS pharmacist

A dedicated MS pharmacist with expertise in MS DMTs reviews the patients’ current prescriptions and over-the-counter (OTC) medications and supplements, in addition to their purpose, dose, scheduling regimen, and potential side effects. The pharmacist assesses the patient’s overall understanding of their medication regimen, adherence, and compliance. Patient education is provided on MS DMTs, including counseling on side-effects and assessment of compliance. Potential therapeutic overlaps, drug-drug interactions, inappropriate medication use utilizing the Beers criteria, and other concerns are addressed, including but not limited to administration questions, cost, adverse drug reactions, and safety.¹¹ Additionally, the pharmacist documents medication side effects and barriers to medication access and conveys findings to the appropriate providers and prior authorization teams. The pharmacist also reviews immunization records for recommended vaccinations. This includes annual influenza, pneumonia-conjugate (PCV13/15/20), pneumonia-polysaccharide (PPSV23), Shingrix, COVID-19, and Td/Tdap records.

A key issue in the management of older adults with MS involves discontinuation of MS DMTs. The ongoing medication regimen analysis by a pharmacist who is knowledgeable about MS DMTs ensures that the evolving risk-to-benefit ratio of medications used in older patients is appropriately considered. A meta-analysis conducted by Weideman et al. highlighted the challenges faced by progressing MS patients, indicating that age is a crucial modifier of drug efficacy. The meta-analysis further suggested that high efficacy treatment options provide maximal benefits primarily during earlier stages of MS seen in younger patients compared to older adults at similar stages in disease progression. However, in the average MS patient beyond 53 years of age, there is no predictable benefit of receiving or continuing a DMT.¹² The DISCOMS trial presented evidence that it may be reasonable to discontinue MS DMTs in middle-aged and older adults with stable disease activity. The deprescription of MS DMTs in appropriate circumstances emphasizes the importance of tailoring treatment approaches to older patients with MS and recognizing reduced treatment responsiveness to DMTs due to age-related factors such as heightened sensitivity to side effects and potential higher levels of treatment toxicity with polypharmacy.¹³

4.3. Neuropsychologist

Neuropsychologists play an important role in the diagnosis and management of psychiatric and cognitive impairments. The Aging with MS Clinic includes a neuropsychologist to evaluate each patient. After a review of each patient’s history including behavioral health, substance use, and past medical history, the neuropsychological evaluation consists of evaluations of cognitive dysfunction, mood complaints, level of fatigue and psychosocial stressors.²¹ With fatigue being one of the most persistent and disabling MS symptom and being linked to executive control processes, the opportunity to make direct patient observations of mental exertion during task completion provides an important insight and objective assessment into the patient’s energy level. These observations are useful in guiding therapeutic interventions to address potential learning barriers while optimizing their quality of life. Mood changes are also assessed via a suicide and violence risk factor assessment. The importance of this assessment addresses the high prevalence of depression, the most common mood disorder in this patient population with an associated 7.5% higher suicide rate compared to the general population.¹⁰

4.4. Social worker

A social worker from the clinic evaluates each patient to provide assistance in navigating the healthcare system and supportive counseling for patients and families. Older adults face increasing challenges in access to healthcare. Lack of neurologists, especially in rural areas, results in increased travel beyond 50 miles in 20% of medicare beneficiaries to see a neurologist.¹⁴ Accessibility for older adults with MS is further complicated by common mobility impairments complicating transportation and cognitive difficulties in navigating the healthcare system. The high cost of care for MS averaging nearly $90,000 per year in the US can create difficulty decisions to choosing between healthcare and living expenses.¹⁵ The common barriers to care for older adults with MS are often insufficiently assessed during clinical visits.¹⁶ A dedicated visit with the social worker seeks to improve care through assessment of the patient’s sociodemographic status including living situations, access to transportation, social support, insurance and financial considerations. Additionally, information is provided on access to healthcare navigators, palliative care, and advance care planning.

4.5. Dietitian

People with MS are more prone to obesity and related cardiometabolic problems, and diet may influence disease course.¹⁵ The dietician’s nutritional intervention is geared towards improved dietary adherence and nutritional status to prevent and/or reverse nutritional deficits and improve cardioprotective health outcomes. The certified dietitian assesses nutrition status, oral supplementations, hunger, calorie consumption, and any obstacles to oral intake (e.g., dysphagia). Anthropometric measurements are also recorded including, weight, height, body mass index, and ideal, usual, and goal body weight. The dietitian will also administer the mini nutritional assessment to assess malnutrition,²⁴ which may exacerbate MS symptoms²⁵ and recommends nutritional interventions, symptom management, and oral nutritional supplements.

4.6. Physical therapist

PT evaluates each patient to assess fall history (e.g., fear of falling, recent falls, injuries related to falls), whether a cognitive screen has been collected in past assessments, and qualitative report of urinary function. Participation in physical activity is discussed with the patient and caregiver to assess current exercise participation and barriers to exercise. Objective measures of occupational capacity, such as upper extremity function, fine motor control, activities of daily living, and vision changes as well as speech-language pathologies such as, memory difficulties, changes in sound of speech, coughing or choking when eating or drinking, and difficulty thinking of words or communicating are assessed for potential future intervention. Functional mobility screening is collected to assess ability of the patient to climb one flight of stairs, walk a quarter of a mile without stopping, and get up from the floor. A complete evaluation of fall risk is screened using the 10 Meter Walk Test (10MWT), 5 Times Sit-to-Stand, Timed Up and Go, Berg Balance Scale, Four Square Step Test, and/or the Functional Gait Assessment. The fall risk screen is imperative to determine the need and proper use of assistive devices including the condition of existing devices and potential concerns or issues with their use. Augmented and alternative communication is collected by the patient and caregivers by assessing difficulty to understand or speak and ability to communicate within the home, social-media, or over text. Additionally, potential difficulties accessing the environment (computer, light switch, phone, TV, etc.) are screened, and referrals to occupational therapy are made as needed. A pelvic health screening is completed by the PT to evaluate incontinence, urgency or delay, hesitancy, dysuria, and dyspareunia. Potential concerns regarding bowel, bladder, or sexual health are gauged to assess utility of pelvic health therapy services. Upon complete assessment and determination of impairments contributing towards the patient’s functional limitations and addressing the patients stated goals, a comparative analysis of relevant measures from previous physical therapy visits is analyzed to aid in the identification of therapeutic interventions and development a personalized plan to improve mobility, minimize pain, reduce disability, and improve overall quality of life.

In the geriatric MS patient population, PT assessments and interventions play a crucial role. Approximately 62% of patients with progressive MS exhibit corticospinal tract involvement, resulting in weakness and spasticity that predominantly affect the lower extremities. This weakness is compounded by lower motor neuron denervation and muscular atrophy associated with aging. The combination of impaired balance, leg weakness, and older age increases the risk of falls, necessitating fall prevention strategies such as home safety evaluation, appropriate footwear, and PT assessment of orthotic use.¹⁰ Gait disturbance in MS patients is influenced by several factors, including muscle weakness, ataxia, sensory loss, and spasticity. To promote safe mobility, a range of devices such as canes, walkers, scooters, and manual or motorized wheelchairs are available. However, before initiating the use of an assistive technology, it is crucial for PTs to conduct a comprehensive assessment to identify potential deficits in cognition, vision, and manual dexterity, ensuring that the patient can safely operate the device.¹⁰

Furthermore, it is noteworthy that in patients with MS for more than 10 years, 96% will experience some form of urologic symptoms.²⁶ PT assessment and intervention remain critical in improving the overall quality of life of geriatric MS patients. Moreover, older patients are particularly sensitive to the urologic side effects of MS medications, which further underscores the complexity of treating these symptoms and provides additional evidence for the necessity of a multidisciplinary approach for this specific patient population.¹⁰

5. Conclusion

The Aging with MS Clinic is a novel multidisciplinary, neurogeriatric clinic specifically tailored to meet the unique needs of older adults with MS. Through a comprehensive geriatric assessment performed by a MS APP, PT, MS pharmacist, neuropsychologist, dietitian, and social worker, this multidisciplinary clinic aims to address the challenges of the natural aging process in combination with MS disease progression with promising responses from its initial participants.