Navigating MS Diagnosis in Older Adults: Distinguishing Comorbidities and Mimics

Announcer:
Welcome to NeuroFrontiers on ReachMD. On this episode, Dr. Le Hua will be discussing challenges in diagnosing older patients with multiple sclerosis, a topic she presented at ECTRIMS 2025. Dr. Hua is the Director of Clinical Operations and Director of the Multiple Sclerosis Program at the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas. Let’s hear from her now.

Dr. Hua:
Aging complicates a differential diagnosis of multiple sclerosis mainly due to comorbidities. As we get older, we just collect health issues and health problems. And a lot of these health issues and health problems can be confused for signs and symptoms of multiple sclerosis. And if we don’t use it appropriately, then someone can either be misdiagnosed, or the opposite—there could be delays in diagnosis of MS. Both are problematic, and therefore, there needs to be special care and attention when we’re approaching an older person who has concerns that we are worried about MS. We just have to be extra careful to ensure that it truly is due to MS and not due to some other process that is also typical with aging.

In evaluation of older patients where we mentioned that they had comorbidities and then they present with neurological symptoms, there are several MS mimics that come up. Primarily, it has to do with MRI findings. So when someone comes in and they have maybe some numbness or tingling, some headaches, some nonspecific symptoms, and dizziness, and we do an MRI of their brain, we’ll see small white spots, and these white spots can be read by a radiologist with a very broad differential. And they’ll mention broad possibilities of everything under the sun that could be responsible for this, so they’ll mention it could be small vessel ischemic disease, it could be demyelinating, or it could be infections. And without knowing the clinical story, the radiologists have to be pretty broad to cover their bases. But then there’s overemphasis on that demyelinating disease, and then, therefore, someone might be diagnosed with MS when it’s not really appropriate.

We see white matter lesions in two groups of people: people who have migraines and people who have vascular disease, primarily hypertension. And we know that white matter disease just increases with age. So if you take large studies of populations and you do MRIs serially over time, we see that the number of these nonspecific white matter spots just increases in a normal healthy population. So when we over-apply an imaging finding to someone with pretty nonspecific symptoms, we can then get caught into the concern of this might be an MS mimic.

With that, as long as we’re talking about the vascular issues, with that hypertension, strokes can actually also be a mimic of MS. So someone who comes in with odd changes of numbness or weakness when we do an MRI, that can be where, if we’re not catching it at the time of their symptom, we might be catching imaging findings of prior strokes, but again, concerned that it might be something more like MS or not.

Lastly, one of the more common mimics we see is actual spinal stenosis. So with degenerative disc disease, as we all get older, we start getting arthritis of the spinal column, and those bulging discs can kind of push on nerves and push on the spinal cord, causing neurological symptoms. And they can actually cause signal changes in the spinal cord itself, and then that becomes then a misdiagnosis of MS or a mimic of MS when it’s truly a different process.

I would just advise clinicians to be really thorough about the clinical history, and if the clinical history makes sense for an MS process, then that is applied. When it doesn’t fit, it’s nonspecific, it’s vague, and they don’t really have any objective sign and symptoms that can support the diagnosis of MS, then I would be a lot more cautious.

Everybody has weird numbness and tingling. Dizziness is actually really common. Headaches are really common, and more often than not, if they’re common, they’re probably going to suffer from a common process. We want to be very cautious then when it’s nonspecific, when the story and the presentation is not typical for MS.

The new McDonald criteria for the diagnosis of MS should be published soon. In that, there is particular caution of how we want to be careful in older individuals, especially over the age of 50. And when we’re trying to make the diagnosis of MS over 50, one of the things that we want to then pay attention to is the use of paraclinical studies that might help us make the diagnosis. So using spinal taps in the presence of oligoclonal bands or kappa light chains can help us confirm the diagnosis of MS versus a noninflammatory process.

Announcer:
That was Dr. Le Hua discussing challenges in diagnosing MS in aging patients, which she spoke about at ECTRIMS 2025. To access this and other episodes in this series, visit NeuroFrontiers on ReachMD.com, where you can be part of the knowledge. Thanks for listening!