Is IBD different in the elderly?

The inflammatory bowel diseases (IBDs) ulcerative colitis (UC) and Crohn's disease (CD) in the elderly are characterized more by features in common with younger patients than any differences. Physiological changes, however, do make older people less able to withstand dehydration due to diarrhea. Special factors need to be taken into account, including comorbid disease, which influences the differential diagnosis and approach to investigations. Age-related changes in pharmacokinetics influence the choice of treatment. Matters such as home circumstances or the influence of impaired mobility on the ability to cope with otherwise mild symptoms always need consideration. Six population-based studies on 1917 patients found a median 12% (range 8%–20%) with late-onset (age >60) UC (see Ref.1 for a review). In a large cohort of 2509 patients the age-adjusted annual incidence was 8 per 105 person years for UC at age 65, compared to a peak of 22 per 105 person years at age 25.2 For CD, population-based studies indicate an incidence of 4/105 person years at age 65 in 1469 patients with CD.3 From 1965 the mean age at diagnosis for UC increased from 34.2 years to 39.8 years (P < 0.0001), while that for CD remained largely unchanged. After age 65, UC affects about twice as many men as women, but CD is equally prevalent.3 Presentation is no different than younger patients, but may be delayed through access to specialist healthcare, or the older person's disinclination to seek medical advice. This has implications for the severity of disease and the need for decisive treatment. There is a trend toward more distal colonic disease in the elderly. An OMGE survey reported proctitis in 42% of UC patients over age 60, compared to 33% under age 60.4 Disease extension appears to be less common in older patients. Clinical features of CD differ little from younger patients. Extraintestinal manifestations are unaffected by the age of onset.5,6 Nevertheless, the diagnosis of CD may more often be missed in older persons. The mean time of diagnosis at age 64–85 years was 6.4 years, compared to 2.4 years in those age 20–61,7 probably because the differential diagnosis is wider in older patients. Just like UC, distal colonic CD is commoner in older persons. Small bowel involvement may be less common (57% versus 88%) in the elderly. The prevalence of fistulizing disease is not influenced by the person's age. Unlike UC, there is a tendency for CD to “burn out,” with the risk of relapse appearing to halve after 15 years' disease. Diagnostic rigor should be greater in the elderly because multiple pathology is more common and the patient has a tendency of rapid deterioration. Thought should be given to the impact of invasive investigations on elderly people. Much depends on their biological rather than chronological age. Flexible sigmoidoscopy with biopsies in elderly patients with chronic diarrhea gives far more information than barium enema, and an abdominal computed tomography (CT) scan should be the initial investigation of suspected large bowel pathology. Evidence-based drug therapy should not replace common sense. Sorting out practical problems such as access to a lavatory or commode on the same level, a district nurse to administer topical therapy, or somebody to do the shopping when housebound by unpredictable urgency may do much to improve the IBD sufferer's quality of life. Sensitive clinicians talking to someone much older than themselves recognize the potential cultural divide, which may regard discussion of bowel function as anathema. More time is required with elderly patients, who may be deaf or suffer from memory impairment. A detailed account of a person's social circumstances, their physical environment at home, and community support is essential. Memory impairment as well as multiple medications affect the elderly IBD patient's adherence to the predisposed therapeutic regimen. Simple solutions such as written instructions and pill counters are used by clinicians with a sense of caring for the elderly. The response to medical therapy of UC in the elderly is no different than younger patients, but the time to response may be slower. Speed of response matters because of the tendency to rapid deterioration, so decisive treatment with systemic steroids is often appropriate. Although topical therapy appeals to the elderly because of limited systemic toxicity, this is usually outweighed by difficulties in administering enemas. Also, impaired anorectal sphincter function may make it difficult for the IBD patient to retain an enema. Suppositories are better tolerated, and should be the first choice for topical therapy in the elderly. The timing of surgery is always difficult. Disincentives to operate on the elderly IBD patient include the presence of comorbidity, concerns about the ability to cope with a stoma, or the disinclination of older patients to have surgery. Nevertheless, the key principle when considering colectomy in an elderly patient is that the decision should not be delayed. Decisions have to be as objective as possible. In general, patients over 60 years experience twice as many drug-related adverse events, but the risk of steroid-associated complications is similar to those under 65 years.8 A low threshold for using azathioprine or 6-mercaptopurine as steroid-sparing agents is justified because myelosuppression is unrelated to age.9 Infliximab has been associated with a higher mortality in IBD patients over the age of 60.10 It can be used safely if appropriate caution to exclude sepsis, cardiac failure, and tuberculosis are taken. Surgery for CD is technically no different than younger patients, but unlike UC the risk of surgery is curiously lower when CD presents in older patients.11 Active physiotherapy is appropriate to reduce the risk of postoperative pulmonary complications, with careful fluid and electrolyte balance to reduce the risk of cardiac complications. Take-home messages are to consider the diagnosis so that there is no delay and to recognize the limited physiological reserve of elderly patients. Treat as if the disease was proportionately more severe than in a younger patient and make decisions early. Account should be taken of cultural sensitivities, the influence of memory or other conditions on the ability to comply with treatment, and the need for practical support such as pads or commodes. This means an empathetic approach and astute clinical judgment.