June Halper: Frontline Diagnosis, Care for Elderly MS

What is average point of multiple sclerosis (MS) diagnosis in most patients? Well, it’s often too far into disease progression to know.

In an interview with MD Magazine®, June Halper, MSN, APN-C, chief executive officer of the Consortium of Multiple Sclerosis Centers (CMSC), explained why it’s doubtful that MS is just presenting in older patients at the time of diagnosis, and why primary care physicians’ first move on diagnosis may be a specialist referral.

MD Mag: Is there an issue with distinguishing or diagnosing multiple sclerosis among other conditions in older patients?

Halper: The theory is—it's not like a heart attack. You get a heart attack on day 1, and you have a heart attack. MS may be slowly and insidiously developing over time, and then just get to that 1 trigger point, and suddenly there it is.

It's very rare, I believe and that most clinicians feel that way as well, that you’re just diagnosed and that's the day it started. It could have been for many, many years, and mild. You know, I've seen patients with sensory MS, where they have a little numbness and tingling, or they develop a little facial problem, a little tick, a little numbness on the side of the face. Nobody bothers following up on it—a little loss of vision which nobody followed up on.

So MS just doesn't happen like that. It happens over time. The geriatric population though, or anybody over 60, might very well just start having MS at that age. But it's kind of doubtful. We've learned a lot with what they call RIS—radiologically isolated syndrome—where a person has a migraine or has an automobile accident, and maybe they're in their 40s or 50s, and they do an MRI to check out for head injury and there are lesions.

So we really don't know if MS diagnosed at a younger age had that person bopped themselves on the head. I don't know. But yes, we are seeing them being diagnosed at older age, and we see them being treated very comfortably at an older age.

What is the role of a primary care physician in diagnosis and care?

If the primary care doctor or an NP or a PA accidentally orders some tests, it’s because there's some symptom, and then there it was. But most primary people are going to refer to a local neurologist or neurologic specialist.

I have a friend of mine who's an NP in center state Iowa and he refers to a center when. And he's diagnosed quite a few, but he sends them to an MS center, but then they come back and he knows how to manage them. But usually they go for second opinions to a larger academics facility or an MS specialist.

Many of the primary care physicians or clinicians are not comfortable with these new drugs. I think they were more comfortable with the injectables. But now we're talking about Gilenya, Ocrevus, or Tysabri. These drugs are a little tricky.