Inflammatory Bowel Disease in the Elderly
Although IBD is generally considered to affect young individuals, elderly patients represent an increasing proportion of the IBD population. Approximately 10–15% of cases of IBD are diagnosed in patients aged >60 years, and 10–30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis.
The clinical features in older patients with IBD are generally similar to those in younger patients, with some notable exceptions. Genetic factors seem to play a greater role in paediatric patients with IBD than in older individuals. The symptoms of CD at diagnosis are more subtle in the elderly. CD in the elderly patient is characterised by a predominantly colonic location and uncomplicated behaviour with slower progression (less change in disease behaviour) over time than in younger patients. Similarly, in elderly patients with UC, symptoms seem to be more subtle, and proctitis and left-sided UC are more common.
Compared with the general population, older patients diagnosed with CD are at increased risk for several types of cancer. The risk of non-Hodgkin's lymphoma and nonmelanoma skin cancer associated with immunomodulators and anti-TNF agents increases with age. Increased age is an independent risk factor for mortality among IBD patients. Infections (including C. difficile and opportunistic infections) have been independently associated with age and account for significant mortality in patients with IBD.
In general, the treatment of IBD in the elderly is similar to that administered to younger patients, with a few relevant exceptions. A clinical distinction must be made between fit elderly and frail elderly. The former should not be excluded from newer therapies or clinical trials simply because of age. Polypharmacy, which is very common among elderly patients, and complex regimens increase the likelihood of non-adherence. Once-daily dosing can improve adherence, particularly in older IBD patients. When polymedication is used for elderly patients, it is important to consider possible interactions.
One approach to drug therapy in the elderly IBD patient is the 'start low-go slow' approach, by which patients are regularly reassessed for progression to more aggressive therapy if their response is inadequate. Corticosteroids are associated with a greater number of adverse events, mainly osteoporosis, in the elderly. The potential benefit of azathioprine in older CD patients remains debatable. No differences in the toxicity of thiopurine agents have been found between patients aged >60 years and younger patients. However, a higher frequency of toxicity occurs in elderly patients treated with methotrexate.
Although the indications for anti-TNFs in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Thus, in patients older than 60 years, a gentler approach may be used, and a combination of immunosuppressive agents should probably be avoided because of an increased risk of infectious and neoplastic complications.
Surgical treatment in elderly patients should not differ from that of younger patients with IBD. Age is currently not considered a contraindication for performing IPAA, which can be successful, provided the patient retains good anal sphincter function.
Conclusions
Although IBD is generally considered to affect young individuals, elderly patients represent an increasing proportion of the IBD population. Approximately 10–15% of cases of IBD are diagnosed in patients aged >60 years, and 10–30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis.
The clinical features in older patients with IBD are generally similar to those in younger patients, with some notable exceptions. Genetic factors seem to play a greater role in paediatric patients with IBD than in older individuals. The symptoms of CD at diagnosis are more subtle in the elderly. CD in the elderly patient is characterised by a predominantly colonic location and uncomplicated behaviour with slower progression (less change in disease behaviour) over time than in younger patients. Similarly, in elderly patients with UC, symptoms seem to be more subtle, and proctitis and left-sided UC are more common.
Compared with the general population, older patients diagnosed with CD are at increased risk for several types of cancer. The risk of non-Hodgkin's lymphoma and nonmelanoma skin cancer associated with immunomodulators and anti-TNF agents increases with age. Increased age is an independent risk factor for mortality among IBD patients. Infections (including C. difficile and opportunistic infections) have been independently associated with age and account for significant mortality in patients with IBD.
In general, the treatment of IBD in the elderly is similar to that administered to younger patients, with a few relevant exceptions. A clinical distinction must be made between fit elderly and frail elderly. The former should not be excluded from newer therapies or clinical trials simply because of age. Polypharmacy, which is very common among elderly patients, and complex regimens increase the likelihood of non-adherence. Once-daily dosing can improve adherence, particularly in older IBD patients. When polymedication is used for elderly patients, it is important to consider possible interactions.
One approach to drug therapy in the elderly IBD patient is the 'start low-go slow' approach, by which patients are regularly reassessed for progression to more aggressive therapy if their response is inadequate. Corticosteroids are associated with a greater number of adverse events, mainly osteoporosis, in the elderly. The potential benefit of azathioprine in older CD patients remains debatable. No differences in the toxicity of thiopurine agents have been found between patients aged >60 years and younger patients. However, a higher frequency of toxicity occurs in elderly patients treated with methotrexate.
Although the indications for anti-TNFs in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Thus, in patients older than 60 years, a gentler approach may be used, and a combination of immunosuppressive agents should probably be avoided because of an increased risk of infectious and neoplastic complications.
Surgical treatment in elderly patients should not differ from that of younger patients with IBD. Age is currently not considered a contraindication for performing IPAA, which can be successful, provided the patient retains good anal sphincter function.