Editorial: Optimal Treatment for Older Patients With Inflammatory Bowel Disease: How to Detect and Manage Frailty?

There is an increasing prevalence of older patients with IBD and the management of those over 60 years of age can be challenging [1]. An exaggerated perception of risk should not lead clinicians to undertreat fit, older patients, but we must also be aware that patients with frailty are at higher risk of adverse outcomes with immunosuppressive therapy [1-4]. We therefore need to be able to differentiate between the approximately 65% of IBD patients over the age of 60 years without frailty and the 35% with frailty [2]. Fons et al. used a comprehensive geriatric assessment (CGA) to prospectively assess frailty in a cohort of outpatients with IBD aged ≥ 65 years [5]. The CGA comprised five domains: somatic (comorbidities, polypharmacy, malnutrition), activities of daily living (ADL), physical capacity (hand grip strength, 4-m gait speed), mental (Geriatric Depression Scale, cognitive function) and social domains [5]. The study found that 160 (39.5%) had 2–3 geriatric deficits and 32 (7.9%) had 4–5 geriatric deficits [5]. Unfortunately, the exact number of deficits required to define frailty was not outlined. However, the consequences of frailty were examined by investigating primarily hospital admissions. Out of 136 all-cause hospitalisations in 96 patients (23.7%), only 41 admissions, in 28 patients, were related to IBD [5]. Patients with severe deficits in CGA were at higher risk of all-cause hospitalisations (aHR 3.46, 95% CI 1.67–7.16, p < 0.001) and acute hospitalisations (aHR 3.45, 95% CI 1.59–7.51, p = 0.002). There was no association with severe CGA deficits and IBD-related hospitalisations (aHR 3.16, 95% CI 0.90–11.08, p = 0.072), which may reflect a small sample size rather than lack of biological effect. The effects of frailty on hospital admission are in keeping with results from a recent meta-analysis [2]. It is important to note that age was not associated with increased risk of hospital admission, whereas biochemical disease activity, comorbidity, polypharmacy and malnutrition were [5]. By now it should be clear to most clinicians that making IBD treatment decisions based on age alone is inappropriate. We now have a better understanding of the consequences of frailty in IBD, but what is less clear is how we can incorporate frailty considerations into IBD clinics. The first problem arises when trying to identify IBD patients with frailty. A multitude of frailty assessments have been used in recent studies, with many not feasible for routine clinical use or overly simplistic [2]. The CGA is comprehensive, but is probably too time-intensive for routine use in IBD clinics. Perhaps a more practical approach could be to screen all older patients for frailty with a simple tool such as the Clinical Frailty Scale (CFS), saving a more detailed assessment for those with a high CFS score [6]. A recent IBD Frailty score has been developed, but only validated against established frailty scores [7]. Whether this IBD-specific score can predict the risk of IBD-related frailty outcomes is yet to be established. Future studies should examine the risk of adverse outcomes of different IBD treatments in patients with and without frailty to facilitate evidence-based choices for older patients with IBD. Isabel Carbery: writing – review and editing, conceptualization. Christian P. Selinger: conceptualization, writing – original draft. The authors have nothing to report. I.C. has received speaker honoraria from Celltrion and Lilly, research grants from Celltrion and has received meeting support fees from Celltrion, Lilly, Johnson & Johnson and Galapagos. C.P.S. has received unrestricted research grants from Warner Chilcott, Janssen and AbbVie, has provided consultancy to Warner Chilcott, Dr. Falk, AbbVie, Takeda, Fresenius Kabi, Galapagos, Ferring, Arena and Janssen, and had speaker arrangements with Warner Chilcott, Dr. Falk, AbbVie, MSD, Pfizer, Celltrion and Takeda. This article is linked to Fons et al. paper. To view this article, visit https://doi.org/10.1111/apt.70594. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.