Multiple Sclerosis Treatment in Millennials: Expert Q&A

Individuals who represent the millennial generation were born between 1982 and 2000 and recently surpassed baby boomers (born between 1946 and 1964) to become the largest subpopulation in the United States.¹ Millennials are more ethnically and racially diverse than any previous generation, and their education level is expected to exceed that of earlier generations.²

“The most defining characteristic of the millennial generation is undoubtedly their usage and demand of technology,” wrote the authors of a review published in Neurology Clinics.³ As “digital natives,” they “have grown up with computers and the Internet from an early age and, hence, use technology in almost every aspect of their lives.”

As the average age of multiple sclerosis (MS) onset is 30 years, millennials are currently the generation with the highest risk of the disease. This highlights the need for healthcare providers to understand and accommodate the specific preferences of this patient group, similar to the ways in which educational practices are now incorporating millennial-friendly modes of communication, such as delivering content via social media sites and providing medical residents with iPads to facilitate learning.^4,5

“Just as the education system has transformed and adapted to the demands of the millennial generation, so too will the health care system as this generation ages,” according to the authors of the review.³ “A new wave of patients having distinct preferences regarding their approach to acquiring and assimilating information is upon specialists in neuroimmunology, and prior management approaches used in other age demographics may be suboptimal for this contemporary group.”

Two general health concerns of relevance to millennials are the substantially higher rates of obesity and mental disorders – especially depression and anxiety – compared to other generations.³ Obesity has been linked with an increased risk of MS, with at least twice the risk found among young adults with a body mass index (BMI) ≥27 kg/m² compared with young adults with a lower BMI.^6,7

Other findings suggest that an MS diagnosis may increase the risk of depression, which is particularly concerning with a patient group that has already been shown to have higher rates of depression.⁸ It is likely that the elevated rates of obesity and mental illness among millennials will affect the course of MS and treatment needs of these patients.

Another key challenge with these patients may be their extreme cost-consciousness. One in 5 millennials is unable to afford basic health care expenses, and more than half have reported delaying or foregoing medical care because of cost.^9,10 “The increased likelihood of millennials omitting key components of disease management in an effort to reduce costs is a major concern,” as noted in the article.³ “In general, millennials need to be better motivated to prioritize their health even if it means incurring additional costs.”

Additional challenges may arise from millennials’ expectation of frequent and immediate feedback, and their declining use of primary care physicians could negatively affect continuity and overall quality of care.

“The most effective treatment plan for a patient with MS is one that is specifically tailored to the patient’s individual needs and preferences,” the authors concluded. “Neurologists and MS specialists who care for patients with MS should recognize the unique characteristics, preferences, and trends shared by this generation as a whole and use this information to drive innovative solutions.”

For further insight into how to best care for patients from the millennial generation, Neurology Advisor interviewed one of the coauthors of the Neurology Clinics paper, Darin T. Okuda, MD, who is a professor of neurology and neurotherapeutics at UT Southwestern Medical Center at Dallas and director of the Multiple Sclerosis and Neuroimmunology Imaging Program there; as well as Nicoline Schiess, MD, MPH, an assistant professor of neurology at Johns Hopkins University; and Jennifer Graves, MD, PhD, an assistant professor of neurology at the University of California, San Francisco.

Neurology Advisor: Dr Okuda, what are the top clinical takeaways of your review?

Dr Okuda: As MS is a lifelong, chronic disease without a cure, patient engagement is critical to preventing disability. Personalized care for millennials must extend beyond treatment plans and involve molding each part of patient management to fit the unique needs and preferences of the millennial generation. These strategies will change over time with each new generation to follow.

Neurology Advisor: What are some of the challenges in treating patients from the millennial generation, and how might these be addressed?

Dr Schiess: While the Internet has been a tremendous resource for patients educating themselves about MS, I’ve found that many become profoundly disheartened after searching “MS.” The face of MS has changed so dramatically in the past 10 years, with many new drugs approved to treat the disease. However, the images of MS on the internet are often severely disabled patients who were diagnosed decades ago when we did not have many drugs to treat the disease. I feel it is imperative that physicians who give a new diagnosis of MS tell the patient this and emphasize that the face of MS has changed dramatically due to all the new immunomodulatory therapies available.

Dr Graves: There can be a gap in how physicians are accustomed to providing information and how millennials are accustomed to receiving information. We tend to still provide paper booklets to patients. Millennials overwhelmingly prefer to email us rather than call us for questions about their disease or treatment. 

Millennials may tend to want feedback about their clinical or other data as soon as possible, so providing patient portals where they can view their own results can be very helpful. They are typically very comfortable with telemedicine, and this format can work well for providing feedback on results more quickly than is possible with in-person appointments.  

Neurology Advisor: What are some ways in which clinicians may increase engagement with this population?

Dr Schiess: I feel that the most fundamental way that a physician can increase consistent long-term engagement with the millennial generation is to establish a regular in-person, face-to-face relationship over time. Having frequent follow-up visits, especially in the first year, maximizes the level of comfort and can often prevent anxiety and depression from developing.

Dr Graves: Being ready and willing to communicate electronically can be helpful in treating this population. [Editor’s note: In a 2015 report, 71% of millennials indicated a desire for their physicians to use mobile apps, and 74% of these patients prefer a physician who offers online appointment booking and bill payment.¹¹] I also provide web links for educational information and recommend webinars in addition to in-person educational events.  

Neurology Advisor: What should be the next steps in terms of research in this area?

Dr Okuda: Additional time and research need to be invested to develop more effective educational and disease-monitoring tools to emphasize preventive lifestyle choices. This focused approach will also engage patients with newly diagnosed MS early on. 

Dr Schiess: Without a doubt, one of the next goals in MS research would be neuroregenerative agents. Once parts of the central nervous system have been damaged, we are unable to regenerate them.

Dr Graves: It would be of interest to study this generation’s perceptions of disease, physicians, and the importance of medication adherence.

Neurology Advisor: Are there any additional key points you would like to note for clinicians?

Dr Okuda: When providing care for a millennial patient, it is important to understand and specifically address key outside factors like mental health disorders, obesity, and extreme cost-consciousness healthcare strategies that may hinder engagement and ultimately prognosis.

Dr Schiess: The National Multiple Sclerosis Society is particularly helpful in reaching patients through technology. They have a program by which new updates on research, medications, and studies are emailed on a regular basis to those on their mailing list. I highly recommend to all my patients that they sign up for these email alerts, as it is a very good way to stay up to date about MS.

Dr Graves: While every generation has interesting characteristics shaped by cultural influences, there are patient needs that will always transcend time: compassionate care, a physician who listens, and the best available personalized therapeutic approach.

References

1. United States Census Bureau. Millennials outnumber baby boomers and are far more diverse, Census Bureau reports. June 25, 2015. https://www.census.gov/newsroom/press-releases/2015/cb15-113.html. Accessed February 13, 2018.
2. Patten E, Fry R. How millennials today compare with their grandparents 50 years ago. Pew Research Center. March 19, 2015. http://www.pewresearch.org/fact-tank/2015/03/19/how-millennials-compare-with-their-grandparents. Accessed February 13, 2018.
3. Hansen MR, Okuda DT. Multiple sclerosis in the contemporary age: understanding the millennial patient with multiple sclerosis to create next-generation care. Neurol Clin. 2018; 36(1):219-230.
4. Bahner DP, Adkins E, Patel N, Donley C, Nagel R, Kman NE. How we use social media to supplement a novel curriculum in medical education.Med Teach. 2012;34(6):439-444.
5. Berkowitz SJ, Kung JW, Eisenberg RL, Donohoe K, Tsai LL, Slanetz PJ. Resident iPad use: has it really changed the game?J Am Coll Radiol. 2014;11(2):180-184.
6. Hedström AK, Olsson T, Alfredsson L. High body mass index before age 20 is associated with increased risk for multiple sclerosis in both men and women. Mult Scler. 2012;18(9):1334-1336.
7. Gianfrancesco MA, Acuna B, Shen L, et al. Obesity during childhood and adolescence increases susceptibility to multiple sclerosis after accounting for established genetic and environmental risk factors.Obes Res Clin Pract. 2014;8(5):e435-e447.
8. Brenner P, Piehl F. Fatigue and depression in multiple sclerosis: pharmacological and non-pharmacological interventions. Acta Neurol Scand. 2016;134(Suppl 200):47-54.
9. Transamerica Center for Health Studies. Millennial survey: young adults’ healthcare reality. June 2016. https://www.transamericacenterforhealthstudies.org/docs/default-source/research/tchs-2016-millennial-survey-embargoed.pdf. Accessed February 13, 2018.
10. PNC Healthcare. Five ways tech-savvy millennials alter health care landscapes. March 23, 2015. https://www.prnewswire.com/news-releases/five-ways-tech-savvy-millennials-alter-health-care-landscape-300054028.html. Accessed February 13, 2018.
11. Salesforce. 2015 state of the connected patient: healthcare insights from more than 1,700 adults. 2015. https://a.sfdcstatic.com/content/dam/www/ocms-backup/assets/pdf/industries/2015-State-of-the-Connected-Patient.pdf. Accessed February 13, 2018.