Inflammatory Bowel Disease in the Elderly
Inflammatory Bowel Disease in the Elderly
Background. Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population.
Aim. To critically review available data regarding the care of elderly IBD patients.
Methods. Bibliographic searches (MEDLINE) up to June 2013.
Results. 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 of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function.
Conclusions. Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.
Inflammatory bowel disease (IBD), which comprises Crohn's disease (CD) and ulcerative colitis (UC), is thought to be primarily a condition of young individuals. However, a significant proportion of new cases of IBD are diagnosed in elderly persons, and, given the negligible impact of IBD on mortality, younger patients with IBD will contribute to an increasing pool of 'elderly' IBD patients as they age. The prevalence of IBD is increasing worldwide, with the result that ageing of the population makes IBD in the elderly a growing problem. Recent estimations indicate that approximately 20% of the United States (US) population will be aged >65 years by the year 2030. At present, 10–15% of patients diagnosed with IBD are aged >60 years. Of these, 65% present in their 60s, 25% in their 70s and 10% in their 80s. Consequently, the number of elderly patients with IBD is expected to grow.
Caring for older IBD patients who have either presented later in life or have had IBD for several decades presents the physician with unique challenges. The characteristics of IBD in the elderly remain uncertain because data are scarce at the population level and come mainly from referral centres. Moreover, data from clinical trials cannot be extrapolated to this population, as older patients are excluded in the vast majority. Other recent trials did not set an upper age limit for eligibility, but the median age in most was the fourth decade.
Since it was first reported in 1935, late-onset IBD has attracted much interest among clinical investigators. Despite advances in our knowledge of IBD, controversy remains concerning the epidemiology, clinical presentation, diagnosis, clinical course and management of IBD in the elderly. Management of late-onset IBD is complex because of problems with misdiagnosis, treatment of comorbid diseases, multiple drug interactions, impaired mobility and cognition, and difficult social and financial issues.
The ageing population has a huge impact on the costs of health care delivery. For example, in Canada in 2005, individuals aged ≥65 years accounted for 14% of the population, but 60% of all acute care service spending. It is therefore important to study and optimise health care delivery to the elderly.
Elderly patients with IBD can be divided into two groups: elderly patients with onset of IBD at a late age (late-onset IBD); and elderly patients with long-standing IBD, that is, those who had first been diagnosed as having IBD at a younger age (long-standing IBD). Most authors make no distinction between the age within each of the groups, although this, as will be reviewed, may be clinically relevant.
In the present review, we address questions that commonly arise in the care of elderly IBD patients. No consensus has been reached on the definition of 'elderly'. The World Health Organization defines elderly persons as those aged ≥65 years; however, we focus on patients aged ≥60 years, as most studies agree on this threshold and old-age colitis is generally considered to refer to patients aged >60 years.
Abstract and Introduction
Abstract
Background. Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population.
Aim. To critically review available data regarding the care of elderly IBD patients.
Methods. Bibliographic searches (MEDLINE) up to June 2013.
Results. 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 of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function.
Conclusions. Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.
Introduction
Inflammatory bowel disease (IBD), which comprises Crohn's disease (CD) and ulcerative colitis (UC), is thought to be primarily a condition of young individuals. However, a significant proportion of new cases of IBD are diagnosed in elderly persons, and, given the negligible impact of IBD on mortality, younger patients with IBD will contribute to an increasing pool of 'elderly' IBD patients as they age. The prevalence of IBD is increasing worldwide, with the result that ageing of the population makes IBD in the elderly a growing problem. Recent estimations indicate that approximately 20% of the United States (US) population will be aged >65 years by the year 2030. At present, 10–15% of patients diagnosed with IBD are aged >60 years. Of these, 65% present in their 60s, 25% in their 70s and 10% in their 80s. Consequently, the number of elderly patients with IBD is expected to grow.
Caring for older IBD patients who have either presented later in life or have had IBD for several decades presents the physician with unique challenges. The characteristics of IBD in the elderly remain uncertain because data are scarce at the population level and come mainly from referral centres. Moreover, data from clinical trials cannot be extrapolated to this population, as older patients are excluded in the vast majority. Other recent trials did not set an upper age limit for eligibility, but the median age in most was the fourth decade.
Since it was first reported in 1935, late-onset IBD has attracted much interest among clinical investigators. Despite advances in our knowledge of IBD, controversy remains concerning the epidemiology, clinical presentation, diagnosis, clinical course and management of IBD in the elderly. Management of late-onset IBD is complex because of problems with misdiagnosis, treatment of comorbid diseases, multiple drug interactions, impaired mobility and cognition, and difficult social and financial issues.
The ageing population has a huge impact on the costs of health care delivery. For example, in Canada in 2005, individuals aged ≥65 years accounted for 14% of the population, but 60% of all acute care service spending. It is therefore important to study and optimise health care delivery to the elderly.
Elderly patients with IBD can be divided into two groups: elderly patients with onset of IBD at a late age (late-onset IBD); and elderly patients with long-standing IBD, that is, those who had first been diagnosed as having IBD at a younger age (long-standing IBD). Most authors make no distinction between the age within each of the groups, although this, as will be reviewed, may be clinically relevant.
In the present review, we address questions that commonly arise in the care of elderly IBD patients. No consensus has been reached on the definition of 'elderly'. The World Health Organization defines elderly persons as those aged ≥65 years; however, we focus on patients aged ≥60 years, as most studies agree on this threshold and old-age colitis is generally considered to refer to patients aged >60 years.