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The burden of Inflammatory Bowel Disease (IBD) is increasing worldwide, with a particular increase in the prevalence in the elderly population, due to the ageing of young-onset IBD as well as to the increasing incidence in elderly patients.
Elderly IBD patients present specific challenges to the treating physician, as they have comorbidities, lower functional reserves, and higher risk of treatment-related complications. The diagnosis of IBD in the elderly may be difficult due to a more subtle disease presentation and to a wide range of differential diagnosis. Moreover, as these patients are often excluded from clinical trials, there is a lack of high-quality evidence to inform on the most appropriate management.
Despite an increasing prevalence, the management of IBD in the elderly is still hindered by frequent misconceptions by physicians treating these patients. Due to a erroneous notion of a milder disease course and fear of adverse events, elderly IBD-patients are managed with frequent and continuous use of steroids and undertreated with effective medical therapies.
In this review, we describe the principles of management of IBD in the elderly, which is a topic of increasing importance to IBD clinics, that will have to progressively adapt to care for an ageing population.
Inflammatory bowel disease (IBD), comprising Crohn's disease (CD) and ulcerative colitis (UC) is a global disease with an increasing burden worldwide [
While newly industrialized countries in Latin America and Asia are currently experiencing a rapidly rising incidence of IBD but still have a low prevalence, in the Western world IBD is in the “Compounding Prevalence” epidemiological stage. The incidence of the disease is stabilizing, but prevalence is increasing [
]. This means that, while IBD is typically thought of as a disease of the young, soon IBD populations will be increasingly comprised of an ageing population with longstanding disease [
] and in a recent nationwide study conducted in Canada, Coward et al. estimated an increase in prevalence from 0.7% to 1.0% in 2030, most evident in the elderly population [
Besides patients diagnosed earlier in life who later transition to old-age (“non-elderly onset IBD”) one should consider a specific group diagnosed at an older ager (“late-onset” or “elderly-onset” IBD) [
], elderly-onset IBD was defined as disease-onset at an age of 60 years or older. Approximately 10 to 20% of new IBD diagnosis are reported in this group of patients, and these numbers are expected to be greater with progressive ageing societies [
] (Fig. 1). According to a recent systematic review of 68 population-based studies evaluating the worldwide incidence of elderly-onset IBD, one in 8600 older adults are diagnosed annually with UC and one in 22.000 with CD, on average, in the Western world [
Fig. 1Compounding Prevalence and Ageing of the Inflammatory Bowel Disease (IBD) population. Elderly IBD patients, who constitute 25 to 30% of the IBD population, include elderly-onset IBD patients (∼10–20% of new IBD diagnosis) and patients diagnosed earlier in life that later transition into old age. In the Western World, IBD is in the "Compounding Prevalence" epidemiological stage, as the incidence of the disease is stabilizing but prevalence is increasing due to a low mortality rate. As such, the number of elderly-IBD patients is expected to increase, also as a result of ageing of the population.
Even though elderly-onset and non-elderly-onset are often grouped together in studies evaluating older IBD patients, the distinction between these two groups is important, as they might have different epidemiology, phenotypes, outcomes, and specific safety concerns with the available treatments. One aspect that emphasizes the differences between these groups is the likely weight of genetic factors on the pathophysiology of IBD, which seem to be greater in non-elderly onset IBD [
]. On the other hand, overall risk factors seem to be the same as in non-elderly-onset IBD, with the caveat of limited data, as most results were obtained in younger patients [
In the past, the recognition of the particularities of paediatric-onset IBD led to the subcategorization of the age of onset of CD with an A1 category for those with an age of diagnosis of 16 or younger [
Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a working party of the 2005 montreal world congress of gastroenterology.
]. The current A3 category includes a broad group of patients diagnosed over the age of 40 which does not consider the specificities and challenges of elderly-onset IBD. In this review, we discuss the particularities of the management of IBD in the elderly, as IBD clinics will have to adapt and evolve their models of care to an ageing IBD population.
2. Challenges in the elderly population
Older patients with IBD are a real challenge to the clinician throughout all phases of the disease, as there are still uncertainties regarding clinical presentation, diagnosis, disease course, and treatment considerations in this population (Fig. 2). In the following sections, we review the main challenges and points to consider in the management of elderly IBD patients.
Fig. 2Specific patient and disease-related challenges of the management of Inflammatory Bowel Disease in the elderly.
Establishing a diagnosis of IBD in the elderly is hampered by a wide list of differential diagnosis of disorders that may be more frequent in this age group than IBD. As a practical exercise, faced with a patient with rectal bleeding and anaemia, IBD would have a very different likelihood of diagnosis in a 30-year-old as opposed to a 70-year-old patient. The differentials list includes, amongst others, infections, cancer, diverticular disease, ischaemic colitis, and drug-induced colitis [
]. Due to the possible confusion with more common disorders, the rate of misdiagnosis at presentation is greater in this population (60%) when compared to younger-onset IBD (15%) [
]. The unawareness of the possibility of IBD diagnosis in the elderly may also account for the diagnostic delay which is significantly greater in this age group (6 years vs 2 years in the younger population) [
]. Despite the difficulties, clinicians should have the same approach in the diagnostic work-up in the elderly with an appropriate anamnesis, ileocolonoscopy and histology [
The literature on the clinical presentation of elderly-onset IBD is limited and heterogeneous, but most reports describe a different phenotypic pattern in elderly onset-IBD. Patients with CD may have a more subtle presentation, with symptoms of abdominal pain, weight loss and fever reported as less likely. In opposition, rectal bleeding may be more frequent, which is likely associated to the different disease location in the elderly. More frequently, elderly-onset CD seems to have an isolated colonic distribution and a predominantly inflammatory behaviour, while perianal involvement is less common [
]. However, these reports are not consistent between studies, and a population-based study described a higher proportion of ileal CD and stricturing phenotype in elderly-onset CD in China [
]. Other reports from Asia also describe a higher frequency of ileal location across all age groups, including the elderly, suggesting the possibility of different phenotypes between Western and Asian populations [
]. On the other hand, elderly-onset UC seems to be more like younger-onset IBD in terms of both symptoms and location, notwithstanding a more subtle clinical presentation and a slightly higher probability of left-side colitis as opposed to extensive colitis [
Data on disease course of IBD in the elderly is scarce, heterogeneous and limited by several factors, since, as opposed to disease phenotype, the definition of natural history may be affected by variables other than the biological evolution of the disease. A lower use of immunomodulators and biologics in the elderly is frequently reported [
Late-onset Crohn's disease: a comparison of disease behaviour and therapy with younger adult patients: the Italian Group for the Study of Inflammatory Bowel Disease ‘AGED’ study.
] than non-elderly IBD patients. Using rates of medical treatment as a proxy for disease course in the elderly is misleading, as it may reflect physician's reluctance to start immunosuppressants or patient acceptance of treatment rather than a true benign course of the disease [
]. In fact, in two multicentre retrospective Italian studies that evaluated medical treatment in the elderly based on disease patterns and behaviour, the authors reported a frequent undertreatment of elderly-onset UC and CD with a more aggressive course, suggesting that treatment decisions may be more influenced by comorbidities rather than disease severity [
Late-onset Crohn's disease: a comparison of disease behaviour and therapy with younger adult patients: the Italian Group for the Study of Inflammatory Bowel Disease ‘AGED’ study.
Another limiting factor when evaluating natural history of IBD in the elderly is that patients with elderly-onset IBD are often grouped together with younger-onset IBD as they progress into old age [
]. Rozich et al. hypothesize that the latter group, with a longer standing diagnosis, may have already adapted to cope with IBD as they age, building up adequate biological and functional reserve [
Association between tumour necrosis factor-α inhibitors and risk of serious infections in people with inflammatory bowel disease: nationwide Danish cohort study.
]. As such, disease course and prognosis in these two groups may be very different. In a retrospective comparison of patients over 60 years with adult-onset IBD with patients with elderly-onset IBD, disease-related complications (assessed by a composite variable incorporating IBD-related surgery, all cause hospitalization, treatment escalation, clinical flare or disease complications) were similar between these groups [
]. However, risk of IBD-related surgery was higher in the elderly-onset population, as were treatment-related complications (a composite of malignancy, death, and serious infections).
Finally, data on the natural history of elderly patients with IBD are often derived from studies from referral centres or single regions, which may not be truly representative of elderly-onset IBD. In many of these studies, IBD in the elderly is described as having a milder course [
]. In this regard, data from population-based studies from unselected cohorts may be more illustrative of the phenotype and clinical course of the elderly IBD population. A recent systematic review based on population-based cohorts that compared the natural history and outcomes of elderly-onset IBD to adult-onset IBD found similar risks of surgery, hospitalization and corticosteroid exposure between these groups, suggesting a similar disease course [
Even with the limitations of the available data, it seems likely that elderly-onset IBD is not milder than younger-onset disease. Both patients and physicians should be aware of the possibility of an aggressive behaviour even later in life, and should make appropriate treatment decisions based on the potential implications of active disease on health-related quality of life, associated comorbidities and disease complications.
2.3 Patient-related challenges
Other than disease-specific factors, there are unique characteristics of elderly patients that influence their management, which include comorbidities, drug interactions, immunological dysfunction, and somatic, cognitive, and social abilities [
] reported that comorbidities rather than age at diagnosis were the main drivers of delayed immunomodulator use in both CD and UC. As comorbidities were more frequent in elderly-onset IBD patients, immunomodulator use was lower in this age group. Indeed, comorbidities may increase the risk of treatment-related complications [
In accordance with frequent comorbidities, polypharmacy (defined as the simultaneous use of ≥5 drugs) is common in IBD patients, particularly in those older than 62 years old where the prevalence may reach 48% [
]. Polypharmacy may have a potential impact on drug adherence and drug interactions, and should be a variable to consider when selecting a treatment for an IBD patient [
]. For example, steroids can interfere with the efficacy of antiepileptics. Moreover, not only steroids, but also azathioprine and 5-aminosalycilates alter the action of anticoagulants [
Immunosenescence is an impairment of the innate and adaptive immune systems that occurs with age, and that may promote an aberrant immune response to environmental antigens [
]. The relative immunodeficiency of the elderly may be responsible for an increased infection risk, and older patients are more vulnerable to opportunistic infections and C. difficile [
]. Hospitalized older IBD patients are at higher risk of in-hospital mortality, and age is an independent risk factor for mortality even after adjusting for comorbidity [
], which underline the importance of excluding malignancy before starting immunosuppressive treatments.
2.4 Impact of functional status
Despite the focus on chronological age to define IBD in the elderly, there is an increased recognition that biological age and functional status may be a more important determinant of health outcomes and more appropriate as clinical risk stratification tools [
Frailty is a state of increased vulnerability where a relatively minor insult may cause a dramatic and disproportionate change in health status, with a poor resolution of homoeostasis [
], which determined the presence or absence of five physical criteria (unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity). Later, a model based on an accumulation of deficits was developed, including both physical and psychosocial elements of frailty [
]. In addition to these scores, surrogate markers of frailty have also been evaluated. These include sarcopenia (defined as the reduction of lean muscle mass), malnutrition and disability. While these entities are associated with frailty, these terms are not interchangeable [
]. Frailty was demonstrated to be an important determining factor of outcomes such as hospital readmission, length of hospital-stay, treatment-related complications, perioperative IBD outcomes and mortality, independently of age, comorbidity, and disease severity [
Pretreatment frailty is independently associated with increased risk of infections after immunosuppression in patients with inflammatory bowel diseases.
]. In geriatric assessment, deficits in various domains are highly prevalent in elderly IBD patients and are associated with lower health-related quality of life [
]. This underlines the importance of systematic assessment of frailty in IBD patients. Despite the existence of numerous frailty indexes for both clinical and research purposes [
Although no specific guidelines are currently available, the principles of IBD treatment in the elderly should be similar to the younger population, with the consideration of the specific challenges aforementioned [
] (Fig. 3). According with this view, therapy should be focused on inducing and maintaining remission, preventing disease-related complications and improving quality of life. Endoscopic remission should be considered the ideal treatment target according to current guidelines [
STRIDE-II: an update on the selecting therapeutic targets in inflammatory bowel disease (STRIDE) initiative of the international organization for the study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD.
], but in elderly population, physicians may opt to tolerate mild endoscopic activity in view of the perceived lower long-term risks of IBD-related complications, resulting from a relatively shorter lifespan compared to the younger population [
]. Still, one of the most important factors to evaluate in elderly-IBD is patients’ desires and treatment expectations. With patient-reported outcomes, which are more often used in the elderly, patients are directly involved in choosing the management strategy with their physician [
The choice of the most appropriate therapeutic approach in older patients should be driven by balancing potential benefits and risks on an individual basis [
]. If the risks of IBD-related complications prevail, or in case of a fit old patient, a top-down approach could be cautiously considered, as it has been demonstrated that early combined immunosuppression had similar efficacy in older and younger CD patients, and was more effective than conventional treatment in lowering disease-related complications [
]. Conversely, in a frail patient, the risks of treatment-related complications could induce clinicians to opt for a more conservative step-up approach. Still, one should consider that a flare of IBD in a frail patient with diminished functional reserves may have very deleterious effects on the patient health status [
]. Notably, a recent study showed that an effective use of anti-TNF drugs was able to improve frailty in elderly IBD patients, with a greater impact on patients with higher pre-treatment frailty [
]. As such, treating physicians should consider the possibility of frailty improvement with IBD treatment during the risk-benefit assessment for each individual patient.
A key principle of management is to avoid undertreating patients, a common mistake in clinical practice, where physicians rely on the frequent use of steroids and delay treatment escalation. The underuse of the most effective therapies in elderly IBD could have several explanations including, (i) the misperception of a milder course of disease in this population [
Gastroenterologists' preference and risk perception on the use of immunomodulators and biological therapies in elderly patients with ulcerative colitis: an international survey.
A major limitation in choosing an appropriate treatment strategy and target in the elderly with IBD is that elderly patients are often excluded from clinical trials as many factors serving as barriers for recruitment are more likely to affect this age group (such as comorbidities and malignancies) [
]. This limits the generalization of their RCT results to guide treatment in the elderly. In a systematic review of inclusion of older adults in the randomized controlled trials (RCT) of approved drugs to treat IBD, Kochar et al. found that less than 1% of participants were ≥ 65 years [
]. Methotrexate is not widely used in elderly patients, but a retrospective study showed similar outcomes in these patients compared to a younger cohort [
Biological agents in the elderly IBD population are rarely utilized, with rates as low as 2% in UC patients and 6% in CD patients at 5 years following date of diagnosis, compared to 7% and 20% in the adult population [
]. Data from the large TARGET-IBD multicenter cohort indicated that older patients with IBD were prescribed more aminosalicylate monotherapy and less anti-TNF therapy compared with younger patients [
Concerning the efficacy of anti-TNF drugs in the elderly, available data is conflicting. A pooled analysis of RCT comparing patients >60 years with younger ones showed that they had similar rates of clinical remission after both induction (OR, 0.78; 95% CI, 0.51–1.19) and maintenance (OR, 0.65; 95% CI, 0.41–1.06) [
Safety and efficacy of tumor necrosis factor antagonists in older patients with ulcerative colitis: patient-level pooled analysis of data from randomized trials.
]. However, elderly patients may need more time to obtain remission after starting anti-TNF treatment, suggesting that pharmacokinetic mechanisms could play a role [
]. Interestingly, a large multicenter Italian study showed that vedolizumab effectiveness in elderly UC patients may be reduced in terms of treatment persistence, clinical and biochemical remission, while no age-dependant effect on effectiveness was observed in CD [
Limited data are available for ustekinumab, with only one study in IBD setting showing a similar rate of clinical response in elderly and young patients, but the first group was less likely to achieve complete clinical remission [
An early identification of patients responding to biological therapies could have a significant impact in clinical management of elderly IBD patients. Unfortunately, the most used biomarkers in IBD setting, such as C-reactive protein (CRP) or faecal calprotectin (FC) have a significantly lower reliability in the elderly population, mainly due to their low specificity [
]. Indeed, both CRP and FC could be increased by several non-IBD conditions and by several drugs, such as proton pump inhibitors and nonsteroidal anti-inflammatory drugs, which are commonly used in the elderly population [
]. A recent study pointed out that the serum triiodothyronine-to-thyroxine (T3/T4) ratio before starting a biological therapy in elderly IBD patients could predict therapeutic outcome in terms of mucosal healing at one year [
]. If the results of this study would be confirmed in future larger studies, the assessment of T3/T4 ratio could help clinicians in identifying patients with higher probability of therapeutic response, maximizing the results, and reducing the rate of treatment-related complications.
3.3 Drug safety in the elderly
Safety profile should be considered as a significant issue in the elderly IBD population for almost all therapeutic agents, as elderly IBD patients seem to have higher risks of treatment-related complications, especially those with elderly-onset IBD [
Aminosalicylates and sulfasalazine are undoubtedly drugs with a good safety profile, but they are associated with an increased risk of nephrotoxicity, particularly in patients with concomitant renal dysfunction or heart failure [
Corticosteroid treatment is clearly associated with higher risks of complications in elderly patients as compared with younger ones, especially in case of a prolonged use [
]. The TREAT registry highlighted that age, use of corticosteroids and narcotics were independent predictors of mortality, whereas mortality rates were similar between infliximab- and non-infliximab-treated patients [
]. In fact, most studies agree that infections, and particularly serious infections, are more common in elderly IBD patients, especially in those receiving corticosteroids [
]. Corticosteroids are also associated with other complications, such as osteoporosis, alteration in mental status, fluid retention, ocular problems, and drug interactions [
]. Given all of these risks, corticosteroids in the elderly should be initiated with an appropriate ‘exit strategy’, planning a transition to a safer maintenance therapy [
Safety problems are significant in case of immunosuppressive treatment with thiopurines. Their use increases the risk of infections, nonmelanoma skin cancers and lymphoproliferative disorders, particularly in elderly patients [
Risk of lymphoma associated with combination anti-tumor necrosis factor and immunomodulator therapy for the treatment of Crohn's disease: a meta-analysis.
Association between use of thiopurines or tumor necrosis factor antagonists alone or in combination and risk of lymphoma in patients with inflammatory bowel disease.
] indicated that older age is an independent risk factor for the development of lymphomas. Even though azathioprine therapy increases life expectancy in patients with CD, the incremental gain in life expectancy decreases with increasing patients’ age due to the increasing risk of lymphoma [
], suggesting a long-term monitoring of elderly IBD patients treated with these drugs. Moreover, the ENEIDA registry showed that patients starting thiopurines after 60 years had higher rates of myelotoxicity, digestive intolerance and hepatotoxicity [
]. Thiopurines should be avoided in the case of chronic renal disease and lower renal clearance, in those with a history of neoplasms or lymphoma, and in patients requiring the use of xanthine oxidase inhibitors [
Biological agents seem to have a safer profile in comparison with thiopurines, although all the immune-suppressive therapies could increase the risks of infections and cancer [
Balancing benefit vs risk of immunosuppressive therapy for individual patients with inflammatory bowel diseases. Clinical gastroenterology and hepatology: the official clinical practice journal of the American.
]. The ENEIDA registry showed that elderly patients with IBD have a similar risk of developing infliximab-related adverse events in comparison with younger patients [
Risk of immunomediated adverse events and loss of response to infliximab in elderly patients with inflammatory bowel disease: a cohort study of the ENEIDA registry.
]. In a pooled analysis of data from RCT, even though elderly UC patients had an increased baseline risk of serious adverse events, no increase in risk could be attributed to anti-TNF therapy [
Safety and efficacy of tumor necrosis factor antagonists in older patients with ulcerative colitis: patient-level pooled analysis of data from randomized trials.
] observed a threefold risk of discontinuation of anti-TNF treatment in patients starting the therapy over the age of 60. On the same line, an Italian multicenter study showed that elderly IBD patients treated with anti-TNFs displayed an increased risk of infections (particularly respiratory infections) malignancy and mortality when compared to a younger group or to elderly patients treated with other drugs [
Advanced age is an independent risk factor for severe infections and mortality in patients given anti-tumor necrosis factor therapy for inflammatory bowel disease.
]. These findings were confirmed by a more recent study that took into consideration all serious adverse events, which were significantly higher in patients >65 years treated with anti-TNF as compared to younger ones [
]. The IBDREAM registry confirmed these data, indicating that older patients treated with anti-TNF have higher rates of treatment discontinuation, although the concomitant use of thiopurines at baseline was associated with lower failure rates, but with higher risk of serious adverse events and infections [
Gastroenterologists' preference and risk perception on the use of immunomodulators and biological therapies in elderly patients with ulcerative colitis: an international survey.
]. This could be related to its gut-selectivity, which a perceived lower risk of adverse events. Indeed, a post-hoc analysis of GEMINI trials showed no age-related differences in the incidence of adverse haematological events, malignancy, or death [
]. Accordingly, Kochar et al. observed that older IBD patients treated with vedolizumab had a lower risk of infection-related hospitalization compared with those initiating anti-TNF therapies [
] reported an increased risk of pneumonia in elderly IBD patients treated with vedolizumab, similar to the rates obtained in patients treated with anti-TNF. A larger subsequent study of 3 population-based cohorts confirmed that the risk of serious infections was not decreased with vedolizumab versus anti-TNF in patients with CD, whereas it decreased of 32% in patients with UC, suggesting that the disease phenotype could play a role in the development of infections in vedolizumab-treated patients [
Fewer data are currently available for ustekinumab. UNITI-1 and UNITI-2 registration trials found that the proportion of patients who developed infections was similar between those treated with ustekinumab and those treated with placebo [
]. However, a real-life study showed no significant differences in infusion reactions, infection, or postsurgical complications in patients stratified by age category (>65 vs <65 years old) [
Despite the notion that newer biologics may have better safety profiles, in a recent meta-analysis evaluating safety of biologics in elderly-IBD, the rate of adverse events and infections was not different between the investigated biologics [
]. The authors concluded that data was still lacking to propose sequencing of biologics in the elderly based on safety, and that larger studies are needed.
Tofacitinib is a Janus kinase (JAK) inhibitor, a small molecule with proven efficacy in IBD. However, as increasing age seems to be a risk factor for adverse events reported with this drug (namely a higher risk of infections and of thrombotic events), its use in the elderly should be carefully considered [
]. This may be caused by an underuse of effective medical therapies with subsequent complications needing a surgical procedure, as previously mentioned. However, it may also be a conscious decision by the physician to avoid medical therapy, as surgery may be seen as a safer alternative to immunosuppressive treatment in patients with comorbidities [
Gastroenterologists' preference and risk perception on the use of immunomodulators and biological therapies in elderly patients with ulcerative colitis: an international survey.
], the presence of comorbidities was the most important factor influencing gastroenterologists’ decision on recommending colectomy in UC patients. However, comorbidities also significantly impact the postoperative outcomes of IBD patients, being associated with an important increase in mortality rate [
]. There are conflicting data on the risk of postoperative complications in elderly IBD patients, but many studies demonstrate a higher risk of complications and mortality [
Safety and efficacy of tumor necrosis factor antagonists in older patients with ulcerative colitis: patient-level pooled analysis of data from randomized trials.
Increased postoperative mortality and complications among elderly patients with inflammatory bowel diseases: an analysis of the national surgical quality improvement program cohort.
ECCO recommends that age should not be used as a sole predictor of surgical risk in IBD patients and surgery must not be delayed when clearly indicated [
]. Some groups advocate a timely proctocolectomy rather than combination treatment in elderly-onset UC, particularly due to the potential curative nature of the procedure [
]. Ileal J pouch anal anastomosis is a preferential surgical technique in UC if the patient has good anal sphincter function and no history of faecal incontinence, with a high rate of satisfaction in this group [
]. Patients with diminished anal sphincter function may have superior quality of life with colectomy and ileorectal anastomosis or end-ileostomy surgery [
The decision of surgery should be balanced against medical treatment, considering patient and disease-associated factors. Since emergency surgery is the main factor accounting for post-operative complications, surgery should preferably be performed in an elective rather than emergent setting [
] As such, gastroenterologists and surgeons should work in a multidisciplinary team aiming at avoidance of emergency surgical procedures by adequately controlling disease activity, whether by an appropriate medical treatment, an elective surgical procedure or a combination of both.
3.5 Health maintenance
Concerning preventive medicine in elderly IBD patients, we refer to the published ECCO guidelines on the prevention and management of infections in IBD [
Advanced age is an independent risk factor for severe infections and mortality in patients given anti-tumor necrosis factor therapy for inflammatory bowel disease.
]. To counteract the increased risk of infections, vaccinations are strongly recommended before starting a biological or immune-suppressive therapy in all IBD patients, and particularly in elderly age [
Regarding colorectal cancer (CRC) screening, there is some evidence suggesting an increased risk of CRC in elderly-onset IBD, with a recommendation of an earlier start of surveillance in this group. However, other studies have not found an increased risk of CRC in this particular cohort [
Age at diagnosis of inflammatory bowel disease influences early development of colorectal cancer in inflammatory bowel disease patients: a nationwide, long-term survey.
]. The continuation of CRC screening in older patients should consider the general health status/frailty of the patient and impact of comorbidities against the potential increasing risks of colonoscopy with age [
]. Malabsorption, increased intestinal loss and decreased food intake play a role in protein-calorie malnutrition with subsequent associated infectious risk [
Osteoporosis and osteoporotic fractures are increased by 40–60% in IBD patients and older IBD patients have a further increased risk due to malnutrition, vitamin D deficiency and reduced physical activity besides age-related bone loss [
]. For this reason, dual energy X-ray absorptiometry screening is recommended amongst older IBD patients with corticosteroid use and/or other risk factors [
With the ageing of the population, IBD clinics must prepare for the expected increased number of elderly IBD patients. In this review we point out the specific challenges physicians face in the management of this group of patients, such as comorbidities, increased risk of treatment complications, and lack of high-quality evidence to inform clinical practice. Biological age may be more relevant than chronological age, and it is of upmost importance that specific risk stratification tools are developed to help guide treatment options.
The previous notion of a milder course of disease in the elderly was likely a misconception, often defined by a decreased use of immunomodulators and biologics in this age group. Awareness must be raised for the similarity of the disease course of elderly patients with that of adult-onset IBD. The same principles of management must be followed, with the same available treatments – whether medical or surgical – available to be used and obtain an adequate disease control. Newer biologics with maybe better safety profiles may be preferred. Desired outcomes must be individualized and discussed with each specific patient, considering a relatively shorter life expectancy and, consequently, a lower risk of developing long-term complications of both treatments and disease. A personalized management would maximise the benefit/risk ratio, obtaining the best results for patients’ quality of life, even in the long-term.
Declaration of Competing Interest
The authors have no conflicts of interest to declare.
References
Kaplan G.G.
Windsor J.W.
The four epidemiological stages in the global evolution of inflammatory bowel disease.
Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a working party of the 2005 montreal world congress of gastroenterology.
Late-onset Crohn's disease: a comparison of disease behaviour and therapy with younger adult patients: the Italian Group for the Study of Inflammatory Bowel Disease ‘AGED’ study.
Association between tumour necrosis factor-α inhibitors and risk of serious infections in people with inflammatory bowel disease: nationwide Danish cohort study.
Pretreatment frailty is independently associated with increased risk of infections after immunosuppression in patients with inflammatory bowel diseases.
STRIDE-II: an update on the selecting therapeutic targets in inflammatory bowel disease (STRIDE) initiative of the international organization for the study of IBD (IOIBD): determining therapeutic goals for treat-to-target strategies in IBD.
Gastroenterologists' preference and risk perception on the use of immunomodulators and biological therapies in elderly patients with ulcerative colitis: an international survey.
Safety and efficacy of tumor necrosis factor antagonists in older patients with ulcerative colitis: patient-level pooled analysis of data from randomized trials.
Risk of lymphoma associated with combination anti-tumor necrosis factor and immunomodulator therapy for the treatment of Crohn's disease: a meta-analysis.
Association between use of thiopurines or tumor necrosis factor antagonists alone or in combination and risk of lymphoma in patients with inflammatory bowel disease.
Balancing benefit vs risk of immunosuppressive therapy for individual patients with inflammatory bowel diseases. Clinical gastroenterology and hepatology: the official clinical practice journal of the American.
Risk of immunomediated adverse events and loss of response to infliximab in elderly patients with inflammatory bowel disease: a cohort study of the ENEIDA registry.
Advanced age is an independent risk factor for severe infections and mortality in patients given anti-tumor necrosis factor therapy for inflammatory bowel disease.
Increased postoperative mortality and complications among elderly patients with inflammatory bowel diseases: an analysis of the national surgical quality improvement program cohort.
Age at diagnosis of inflammatory bowel disease influences early development of colorectal cancer in inflammatory bowel disease patients: a nationwide, long-term survey.
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