MASLD in Older Adults Demands an Age-Specific Clinical Approach: Frontline Gastroenterology

Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD) is now one of the most common chronic liver diseases worldwide, affecting nearly one in four adults. Although much of the clinical focus has centered on middle-aged populations, MASLD in older adults is increasingly relevant as global populations age and metabolic disease becomes more prevalent. In elderly individuals, MASLD presents unique diagnostic and therapeutic challenges that are often under-recognized in routine care.

Problem Statement

MASLD in adults aged 65 years and older is shaped by a distinct biological and clinical context marked by frailty, sarcopenia, multimorbidity and polypharmacy. Age-related changes in liver biology, including mitochondrial dysfunction, impaired autophagy and reduced regenerative capacity, may accelerate disease progression, while conventional diagnostic tools can overestimate fibrosis in this population. At the same time, therapeutic strategies developed in younger cohorts may not translate directly to older adults, who are frequently excluded from clinical trials and remain underrepresented in evidence-based treatment frameworks.

Summary

This review highlights ageing as a major modifier of MASLD biology, clinical presentation and management. In older adults, MASLD is influenced by age-related molecular changes such as telomere shortening, epigenetic drift and mitochondrial dysfunction, alongside shifts in body composition that favor visceral adiposity and sarcopenia. These factors increase vulnerability to advanced liver disease while complicating risk assessment and treatment. The authors emphasize that commonly used non-invasive fibrosis tools, particularly fibrosis-4, may overestimate fibrosis in elderly patients and should be interpreted with age-adjusted caution. Lifestyle modification remains the cornerstone of therapy, but interventions must be individualized to preserve muscle mass and avoid malnutrition. Emerging therapies, including resmetirom and glucagon-like peptide-1 receptor agonists, show promise, yet robust evidence in elderly populations remains limited. This review underscores the urgent need for age-adapted diagnostic pathways, inclusion of older adults in MASLD trials and a more geriatric-informed approach to steatotic liver disease care.