BACKGROUND: Managing multiple system atrophy (MSA) is challenging. While invasive interventions for amyotrophic lateral sclerosis are well-studied, those for MSA remain less explored. OBJECTIVES: To explore factors influencing treatment choices and trends in advanced-stage MSA. METHODS: A retrospective cohort study analyzed 128 MSA patients at Hyogo Chuo National Hospital, Japan, from 2000 to 2024, focusing on treatment period and age at onset. RESULTS: Tracheostomy invasive ventilation (TIV) decreased after 2014 (26.9% vs. 9.2%
P = 0.023). TIV-treated patients remained similarly young before and after 2014 (age at onset 52.7 vs. 54.5 years
P = 0.659) and tracheostomy was chosen by younger patients after 2014 (58.3 vs. 51.5 years
P <
0.001). Conversely, enteral nutrition increased in older patients (57.4 vs. 62.9 years
P = 0.011). CONCLUSIONS: In Japanese MSA, preferences for invasive treatments shifted, with younger patients favoring TIV and tracheostomy, while older patients preferred less invasive options, emphasizing personalized care.