Ask the Doctor

Questions from our Readers

Photo of Dr. Barry Hendin
Dr. Barry A. Hendin

By Dr. Barry A. Hendin
MSAA’s Chief Medical Officer

Q: I suffer from achalasia, similar to dysphagia. I have difficulty swallowing and have to have my throat stretched once a year during an endoscopy. I wanted to ask if you have any specific recommendations for people with this problem.

As a sidenote, I wanted to let you and your readers know that I received a tip through a chatline, and I am so grateful that I did. Anything that has fizz to it helps food to go down – and I choose sparkling mineral water because I only drink water. Whether it’s chicken, yogurt, or an apple, when I drink the fizzy water, it helps everything to go down and within seconds I can swallow normally again.

A: Thank you for your question regarding achalasia. As you point out, both achalasia and dysphagia have similarities, since both refer to problems swallowing. There are some important differences, however, which I will describe. In addition, I wanted to note that “dysphagia” (ending with “gia”) is often confused with “dysphasia” (ending with “sia”), which refers to problems with conceptualizing and understanding speech.

Regarding the differences between the two types of swallowing disorders, dysphagia is relatively common in MS due to weakness or incoordination of the muscles involved in swallowing, including the mouth, tongue, palate, and pharynx (throat). Achalasia, on the other hand, is due to structural problems in the distal esophagus; it’s association with multiple sclerosis is uncertain.

Achalasia is generally treated by the gastroenterologist with treatments that include stretching. The most useful clinician for the treatment of dysphagia is usually the speech therapist, who can educate and instruct regarding safer and more efficient swallowing techniques. And in your case, I’m especially pleased that you have found a simple technique to help you with your swallowing by drinking fizzy water!

Q: I will be 65 in a few weeks and was diagnosed with clinically isolated syndrome (CIS) in 2016 – when I was in my late fifties – after having optic neuritis (an ongoing symptom) in 2015. No one believed it could be MS. I was considered “too old” to have my first symptom. I had a relapse in 2019, which changed my diagnosis to relapsing-remitting MS (RRMS).

I am still fairly new to living with MS. I am finding it difficult to figure out what is MS and what is normal aging. I would be interested in hearing about patients who were diagnosed late in life. Have there been any studies on this topic?

A: Your experience with clinically isolated syndrome and MS is indeed instructive to the medical community. You are a living example of the fact that MS can occur in people in a wider age range than is considered typical. We have diagnosed MS in young children as well as in people in their 50s, 60s, and 70s. Studies show that 5% of MS diagnoses occur in people over the age of 50.

Although the diagnosis is usually made in young adults, people with MS will get older and ultimately have to deal with issues of aging. Distinguishing between the effects of aging and possible MS progression is difficult for patients and for clinicians. It is currently a hot topic in the MS world. Cognitive issues (such as prolonged processing speed) and motor issues (such as weakness and imbalance), while often associated with MS, also occur naturally in older age, independent of MS. In late MS, in general, the concern is less about acute inflammation, such as relapses, and more about possible progression.

Although separating the effects of natural aging from multiple sclerosis in later years can be difficult, the actions that we should be taking are more straightforward. People with multiple sclerosis, as they age, should be maintaining an exercise program, eating a healthy diet, staying active socially, and giving attention to general mental health as well as to the treatment of comorbidities, i.e., other health conditions.

You also asked about studies that have been done on the topic of individuals diagnosed at an older age. An article titled, “Clinical Features of Late-Onset Multiple Sclerosis: A Systematic Review and Meta-analysis,” appeared in the May 2021 edition of Multiple Sclerosis and Related Disorders (Naseri A, Nasiri E, Sahraian MA, et al.) and provides a good deal of information about late-onset MS, along with citing other relevant articles.

Q: I was diagnosed with MS in 2006, and at that time, I had 21 lesions. About a year ago, two more lesions “lit up.” Prior to this finding, another doctor told me I did not have MS, but could not tell me the cause of the lesions. I have several symptoms, including dizziness and balance problems. I would like to ask what other conditions might cause lesions and what suggestions you may have.

A: You bring up several important points: MS diagnostic criteria, symptomatic treatment of MS, and disease-modifying therapies (DMTs). I will try to address each one of these issues.

The diagnosis of MS is based on the appropriate history and examination, along with laboratory confirmation. We refer to the diagnostic criteria as the revised McDonald criteria. The discovery of brain lesions alone is insufficient to diagnose MS, although the number of entities that can create brain lesions is vast.

For most people who are diagnosed with multiple sclerosis, we suggest a DMT. Since there are more than 25 types and brands of DMTs approved by the FDA for the treatment of MS, we can generally find one that is appropriate and does not cause excessive side effects or risk. These DMTs reduce the likelihood of MS relapses and progressive disability.

For issues such as dizziness and imbalance, it’s appropriate to turn to symptomatic treatments. These symptomatic interventions can be medications, but more often they are evaluations and treatment by physical therapists.

Improving the quality of life for today, and maintaining function for the future, are the ultimate goals of MS therapies.

Q: In a recent cover story of The Motivator on aging, the term, “immunosenescence,” was used. I have only heard of “senescent cells,” which I understand are old cells that won’t die and affect the immune system. I am now 64 and I know that the turnover of cells slows down as we age. I want to ask how these cells affect the immune system and if there is anything we can do to get rid of the old cells more quickly.

A: Immunosenescence has become an increasing focus in MS. The term immunosenescence refers to the natural aging of the immune system. The general population is aging, but there has also been a specific increase in longevity in people with MS due to increasingly effective disease-modifying therapies (DMTs). As the immune system ages, the consequences can include an increased susceptibility to infections and tumor, a decreased effectiveness of vaccinations, and inflammation. This is not unique to multiple sclerosis. Immunosenescence occurs in the general population, but it has special importance in people with MS. For example, the risk/benefit ratio of our DMTs changes with aging, and similar to the consequences of the aging of one’s immune system, infections become more likely and the effectiveness of vaccination diminishes.

Immunosenescence is incompletely understood, and immunology is always complex! (I don’t think in terms of old cells that won’t die, but rather changes in the immune cells, such as T cells and B cells and natural killer cells.) Older cells do lose some of their immune capabilities, and fewer new or naïve cells are produced. The organs that generate immune cells, such as the thymus, diminish. As we try to understand this phenomenon better, we have also begun to ask what strategies we can employ to rejuvenate the immune system. Stay tuned!

Barry A. Hendin, MD, is a highly accomplished neurologist who specializes in MS. He is the chief medical officer for the Multiple Sclerosis Association of America (MSAA) and has spoken at several of MSAA’s educational programs. After 45 years as a neurologist with Phoenix Neurological Associates, Ltd., Dr. Hendin is now director of the newly created Multiple Sclerosis Center of Arizona. He is also director of the Multiple Sclerosis Clinic at Banner University Medical Center and clinical professor of neurology at the University of Arizona Medical School.

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