IBD and Older Adults
About 10 to 15 percent of people diagnosed for the first time with inflammatory bowel disease (IBD) are older than 60, according to some studies, and it’s estimated that older adults make up to 30 percent of the total IBD population.
Inflammatory bowel disease is an umbrella term for a group of chronic disorders that affect the gastrointestinal (GI) tract. The most common types of IBD are Crohn’s disease (a chronic inflammatory disorder that primarily affects the small intestine but can involve any segment of the gastrointestinal tract) and ulcerative colitis (a chronic inflammatory disease of the large intestine caused by an abnormal autoimmune reaction that causes the body to attack its own bowel).
The elusive diagnosis
Certain key features of IBD differ between older and younger adults. Older adults tend to have symptoms that are more subtle, a less aggressive disease course, and more frequent infections.
But diagnosing older adults with IBD can be a challenge—about 60 percent of older adults have a significant delay in diagnosis. IBD symptoms can be nonspecific and can mimic other conditions like diverticular disease, ischemic colitis, radiation injuries, and infection. And older people often take drugs, such as nonsteroidal anti-inflammatory drugs, that can cause gastrointestinal irritation.
According to a 2011 review in the American Journal of Gastroenterology, older patients can expect a delay in diagnosis of up to six years. Because their condition isn’t recognized, they face worse outcomes and don’t get timely treatment with effective drugs.
Overall, people older than 65 with IBD tend to be hospitalized more often than younger adults. Generally, older patients—especially those with other chronic illnesses—who are hospitalized tend to have a tougher time than younger patients, with a higher overall in-hospital risk of death.
All patients with IBD are prone to develop blood clots in the deep veins. People with Crohn’s disease face an increased risk of several types of cancer, including pancreatic, lung, kidney, and stomach. Both Crohn’s disease and ulcerative colitis increase the risk of colon cancer, and patients require routine surveillance colonoscopies. Some international studies have shown that being older at the time of diagnosis may increase the risk for a more rapid onset of colorectal cancer.
Treating inflammatory bowel disease in older adults presents certain challenges. A study published in Alimentary Pharmacology and Therapeutics in 2014 says that treatment strategies for older adults with long-standing and late-onset IBD should be adjusted because:
• Conventional treatment protocols for IBD weren’t created with older adults in mind. Most clinical trials investigating IBD treatment excluded older adults, leaving a research gap for those over 60.
• Chronic health conditions are more common as people age, which may affect choice and intensity of IBD treatment.
• Delay in diagnosis can allow IBD to progress to the point where more aggressive treatment is needed.
• Before being diagnosed with IBD, many older adults are already taking prescription drugs for other illnesses. IBD drugs have interactions with different classes of drugs, and some drug combinations are dangerous. For example: Some IBD drugs can interfere with the anticoagulant effects (the prevention of blood-clotting) of warfarin.
• Older adults may have physical and cognitive limitations, which can make it difficult for them to apply common topical IBD treatments in the form of enemas.
Sorting out drug therapies
Older patients are often able to tolerate an IBD drug regimen, but they may not respond as quickly to drugs as younger patients. When deciding on a drug regimen, doctors must weigh the risk of serious adverse effects against undertreating the disease, risking a poor outcome.
Several classes of drugs are commonly used to control IBD, for either short- or long-term use, depending on the severity of IBD and the patient’s overall health:
• Aminosalicylates, or 5-ASA (mesalamine, sulfasalazine, olsalazine, balsalazide), help reduce inflammation and achieve remission in ulcerative colitis. They’re typically the first-line treatment for mild to moderate IBD and work well in both young and old patients.
• Antibiotics (metronidazole, rifaximin, ciprofloxacin) are commonly used during flare-ups, usually for Crohn’s disease, though their use otherwise for IBD is controversial. The antibiotic metronidazole can produce side effects such as neuropathy (nerve pain) and nausea, which are more severe in older adults.
• Corticosteroids (prednisone, budesonide) are typically reserved for short-term use to treat flare-ups. Long-term use has been linked to severe adverse conditions in older patients, such as osteoporosis or high blood sugar.
• Immunomodulators (azathioprine, 6-mercaptopurine, methotrexate, cyclosporine) are prescribed for long-term use to suppress the immune system, but they pose a risk of infection, especially in older adults, as they reduce the body’s ability to fight infectious disease. Some immunomodulators have been associated with increased risk of developing lymphoma (cancer of the lymph nodes) and skin cancer. Cyclosporine has been shown to elevate risk of side effects in older adults and should be prescribed with great care by only experienced practitioners.
• Biologic agents, known as anti–tumor necrosis factor, or anti-TNF, medicines (infliximab, adalimumab, certolizumab), are potent drugs that help turn off the overactive immune system to reduce inflammation. They’re used more often in those with severe symptoms. Research is limited on the best use of biologics in IBD patients over age 60, but data links biologic agents to high risks in patients with chronic conditions such as heart failure, liver disease, infection, or ongoing bone marrow problems. Before receiving biologic agents, patients should be tested to ensure they don’t have tuberculosis or a history of exposure to tuberculosis.
Experts typically suggest beginning aggressive drug therapy for faster disease resolution. However, this may not be practical for older adults.
Instead, doctors should use a “start-low, go-slow” approach to drug therapy. This method calls for a lower dose to start, with patients regularly assessed to see if their disease is under control. If not, they’re transitioned to a more aggressive therapy or dose. That said, the study generally advises caution when considering combinations of immunosuppressive agents because of the increased risk of infections and malignant tumors.
The study also encourages doctors to prescribe a once daily drug, when possible, to help improve adherence.
When drugs don’t work
Failure of more conservative treatment is the most common reason older patients opt for surgery, although the severity of IBD can mean a quicker path to this intervention. According to the study, recent reports have found no increase in deaths related to surgery among older IBD patients, although outcomes may not be as good.
The study authors recommend that older adults with ulcerative colitis can safely undergo a procedure called ileal pouch-anal anastomosis, in which the colon and all or most of the rectum are removed. An internal pouch is fashioned from the end of the small intestine (the ileum) to hold waste. This procedure is often successful, but older adults face long-term complications such as fecal incontinence or pouchitis (inflammation of the pouch). Limited data were available for other procedures.
Surgery outcomes for older Crohn’s patients were less promising than those for ulcerative colitis patients. After bowel resection, which involves removing the intestine’s affected portions, disease recurrence is frequent. Some studies reported recurrence was five times more likely in older adults than in younger patients.
IBD treatment can be and often is effective for older adults, and age alone should not disqualify a patient from effective therapies. In fact, IBD patients of all ages reportedly have an overall survival rate that’s the same as or just slightly lower than the general population without IBD.
More research is needed to determine whether there’s any difference between early- and late-onset IBD in older adults. Some studies suggest that late-onset IBD is milder and progresses more slowly than long-standing IBD, which could affect treatment decisions. Meanwhile, it’s important for IBD patients to carefully discuss—and understand—the pros and cons of treatment with their doctor when deciding on a drug regimen.