Does ulcerative colitis behave differently in the elderly?

Comparison of Disease Phenotype and Course among Elderly- and Early-Onset Inflammatory Bowel Diseases in the Middle East

BACKGROUND

It is unknown if the clinical manifestations and phenotype of disease are comparable between early- and elderly-onset inflammatory bowel disease (IBD). We aimed to seek differences in disease phenotype, course, complications, and treatment between early- and elderly-onset IBD patients.

METHODS

This retrospective cohort study on registered IBD patients in the Iranian Registry of Crohn's and Colitis (IRCC) compared demographics, disease phenotype, disease activity, IBD-related surgery and medications between early- and elderly-onset IBD. A generalized linear regression model was used to investigate the relative risk of age at diagnosis adjusted for gender and disease duration for the outcomes.

RESULTS

From 10048 IBD patients, 749 with early-onset (7.5%), and 472 (4.7%) elderly-onset IBD were enrolled: 855 (63.1%) ulcerative colitis (UC) and 366 (26.9%) Crohn's disease (CD). Left-sided colitis was more frequent among elderly-onset UC patients (P<0.001). Ileum and ileocolonic locations were the most common types in elderly-onset and early-onset CD patients, respectively. In comparison with elderly-onset UC, early-onset cases more often used prednisolone (22.1% vs. 11.4%, P=0.001), immunomodulators (44.9% vs 25.2%, P<0.001) and anti-tumor necrosis factors (TNF) (20.1% vs 11.9%, P=0.002). Elderly-onset UC patients had 0.7 times lower risk of aggressive phenotype (95%CI:0.6‒0.9, P=0.005). Early-onset CD was associated with higher use of prednisolone (27.7% vs 8.1%, P<0.001), immunomodulators (58.7% vs 41.8%, P=0.005) and anti-TNF (49.6% vs 35.4%, P=0.006).

CONCLUSION

Early-onset IBD was associated with a more aggressive phenotype and higher prednisolone, immunomodulators, and anti-TNF use.

Clinical results following colonic resection for ulcerative colitis in elderly individuals (elderly-onset vs. nonelderly onset)

BACKGROUND

The incidence of ulcerative colitis (UC) is increasing, but there are few reports comparing elderly UC patients undergoing colectomy for elderly-onset UC (EO) and nonelderly-onset UC (NEO). The aim of this study was to analyze the differences between EO and NEO patients who underwent UC-related surgery.

METHODS

We identified 1973 patients with UC who underwent colectomy at Hyogo College of Medicine between January 1, 1984, and December 31, 2018. Only patients aged 65 years old and older who underwent colectomy were enrolled in this study (n = 221, 11.2%), and their clinical records were retrospectively reviewed. Patients were divided into two groups according to their age at disease onset: those with onset at younger than 60 years old (NEO) and at 60 years old or older (EO).

RESULTS

In the 221 UC patients who underwent colectomy at 65 years old or older, there were 155 cases of EO and 66 cases of NEO. The main surgical indication in NEO patients was colitis-associated cancer/dysplasia (32/66, 47%). In contrast, refractory to medical treatment was the leading cause of surgery in EO patients (80/155, 52%). The distributions of surgical indications were different between the two groups (p < 0.01). The preoperative daily dose of steroids was significantly higher in the EO group than in the NEOgroup (0 mg vs. 10 mg, p < 0.01). The rates of immunosuppressant, infliximab (IFX) and adalimumab use did not differ significantly between the groups. Significantly more patients underwent emergency surgery in the EO group than in the NEO group (14% vs. 35%, p < 0.01). The proportions of patients with postoperative morbidity (Clavien-Dindo grade III or higher) were 17.4% (27/155) in the EO group and 13.6% (9/66) in the NEO group. There was no significant difference between the two groups (p = 0.48). The prognosis of the EO patients who underwent UC-related emergency surgery was worse than that of the NEO patients (p < 0.01). In the EO group, 8 (14.8%) of 54 patients died within 30 postoperative days, while there were no deaths in the NEO group.

CONCLUSION

Among elderly UC patients undergoing UC-related surgery, EO patients undergoing emergency surgery had very poor outcomes, and the mortality rate was 14.8%. In such cases, it is important for physicians and surgeons to begin communication at an early stage so that the optimal surgical timeframe is not missed.

Relation of geriatric nutritional risk index with clinical risks in elderly-onset ulcerative colitis

BACKGROUND AND AIM

Worldwide increasing aging societies have many elderlies with intractable diseases including ulcerative colitis (UC). Reportedly, each patients' frailty as well as chronological age is a clinical risk factor of elderly-onset UC (EOUC). Because malnutrition is one of the major manifestations of frailty, we aimed to investigate the effect of malnutrition on the prognosis of EOUC with geriatric nutritional risk index (GNRI), a prognostic tool for several diseases in the elderly to estimate malnutrition, and to evaluate clinical risks among EOUC patients in Japan, the world-leading aging society.

METHODS

The EOUC patients (≥ 65 years at diagnosis, n = 2778) in the previous nationwide survey were classified by age and GNRI, and odds ratios (ORs) of hospitalization and UC-related surgery were determined to evaluate the effects of malnutrition on the EOUC patients as well as aging.

RESULTS

The risks of hospitalization and surgery were elevated as age advanced. The value of GNRI, negatively correlated with disease activity (r = -0.53), could distinguish severe activity (cutoff ≤ 86.82, sensitivity = 0.79, and specificity = 0.77) and discriminate the EOUC patients suffering from surgery and hospitalization. In a multivariate analysis, GNRI ≤ 86.82 was a higher risk of hospitalization (OR: 4.0, 95% CI, 2.5-6.5) and surgery (OR: 2.7, 95% CI, 0.98-7.4) than cutoff age ≥ 75 years old (OR of hospitalization and surgery were 1.4 [95% CI, 0.99-2.0] and 2.3 [95% CI, 0.8-6.3], respectively).

CONCLUSION

Malnutrition estimated by GNRI was significantly related with poor clinical courses of the EOUC patients, suggesting that evaluation of nutritional status at the onset might be useful for predicting risks of clinical courses.

Clinical differences between elderly-onset ulcerative colitis and non-elderly-onset ulcerative colitis: A nationwide survey data in Japan

BACKGROUND AND AIM

Studies on the characteristics of elderly-onset ulcerative colitis (EOUC) and non-elderly-onset ulcerative colitis (NEOUC) have reported conflicting findings. The aim of this study was to compare disease characteristics of EOUC and NEOUC by analyzing the database of the Japanese nationwide inflammatory bowel disease (IBD) registry.

METHODS

We analyzed the age of disease onset, sex, disease severity, and disease extent in patients with ulcerative colitis that were newly diagnosed and registered within 1 year between 2004 and 2009 (n = 28 179). We also analyzed the medical treatment, rate of IBD-related surgery, and postoperative complications. We compared them between younger than 65 years old (NEOUC group) and 65 years old or older (EOUC group) patients.

RESULTS

A total of 25 401 (90.1%) and 2778 (9.9%) patients were included in the NEOUC and EOUC groups, respectively. In the EOUC group, disease activity was significantly higher, and extent of pathological changes in the colon more extended significantly. Laboratory findings showed that inflammatory markers were elevated significantly in the EOUC group. The proportion of those with IBD-related hospitalization was significantly higher in the EOUC group (54.2% vs 35.7%, P < 0.001). The proportion of patients who were treated with corticosteroids was significantly higher in the EOUC group (36.7% vs 30.8%, P < 0.001). Significantly more number of patients underwent IBD-related surgery in the EOUC group (0.68% vs 0.27%, P < 0.001).

CONCLUSION

Elderly patients show higher disease activity, with a higher proportion requiring IBD-related hospitalization and IBD-related surgery, according to the nationwide registry in Japan.

Characteristics and Behavior of Elderly-onset Inflammatory Bowel Disease: A Multi-center US Study

BACKGROUND

Existing data conflict regarding differences in inflammatory bowel disease (IBD) characteristics between adult-onset and elderly-onset IBD. IBD extent and behavior are strong predictors of IBD-related surgery and complications. The aim of this study was to compare disease characteristics and behavior of adult- and elderly-onset IBD in a multi-center US study.

METHODS

We performed a multi-center retrospective cohort study of patients with IBD. Chart review was performed to confirm IBD diagnoses and extract data regarding IBD characteristics, medications, surgery, cancer, and death. Patients were classified based on age at IBD diagnosis as adult onset (18-64 years) or elderly onset (≥65 years).

RESULTS

A total of 1665 patients were confirmed to have IBD; 272 patients were ≥65 years at IBD diagnosis. Whites were more likely than non-whites to have elderly-onset IBD (adjusted odds ratio 2.26, 95% confidence interval 1.36-3.76). Patients with ulcerative colitis were more likely than CD patients to have elderly-onset IBD (aOR 1.50, 95% confidence interval 1.11-2.03). Compared with patients with adult-onset CD, patients with elderly-onset CD were more likely to have isolated colonic disease and nonstricturing, nonpenetrating phenotype, but less likely to have perianal complications or receive immunosuppressants. Rates of bowel resection, and both colonic and extra-colonic malignancies did not differ based on age of IBD onset.

CONCLUSIONS

There are several significant differences in the disease characteristics between adult- and late-onset IBD; these differences may reflect differences in natural history of IBD and influence approaches to management among patients with elderly-onset IBD.

Epidemiology and Long-term Outcome of Inflammatory Bowel Disease Diagnosed at Elderly Age-An Increasing Distinct Entity?

BACKGROUND

Elderly onset (EO) inflammatory bowel disease (IBD) may become a more common entity as a result of population aging and the rising IBD incidence. Its management is challenging, because of multimorbidity, polypharmacy, and frailty. Insight into the long-term outcome is essential for optimal patient counseling and treatment. We studied the incidence and disease outcome of elderly-onset IBD in direct comparison to adult-onset (AO) IBD.

METHODS

All 2823 cases with IBD from the Dutch population-based IBD South Limburg cohort, diagnosed between 1991 and 2011, were included. Long-term outcome (hospitalization, surgery, and disease phenotype) was compared between AO (<60 years at diagnosis) and EO (≥60 years at diagnosis) disease, for Crohn's disease (CD) and ulcerative colitis (UC) separately.

RESULTS

In total, 1162 patients with CD (136 EO/1026 AO) and 1661 patients with UC (373 EO/1288 AO) were included. The EO IBD incidence increased from 11.71 per 100,000 persons in 1991 to 23.66 per 100,000 persons in 2010, P < 0.01. Immunomodulators were less often used in EO CD (61.8% versus 77.1%, P = 0.03) and EO UC (22.8% versus 35.4%, P < 0.01), even as biologicals (25.1% versus 55.1%, P = 0.03 and 7.8% versus 18.0%, P < 0.01, respectively). No differences were observed in surgery risk (CD: hazard ratio [HR] 1.19; 95% confidence interval [CI], 0.85-1.67 and UC: HR, 0.88; 95% CI, 0.53-1.46), or in CD phenotype progression (HR, 0.81; 95% CI, 0.52-1.25), but more patients with EO UC required hospitalization (HR, 1.29; 95% CI, 1.01-1.63).

CONCLUSIONS

EO IBD is rising, warranting physicians' alertness for IBD in elderly patients. The long-term outcome was not different from AO disease, despite a less frequent use of immunomodulators and biologicals.

Systematic review with meta-analysis: 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.

Ulcerative colitis: comparison between elderly and young adult patients and between elderly patients with late-onset and long-standing disease

BACKGROUND AND AIM

We examined the pathologies, treatment characteristics, and clinical course of elderly ulcerative colitis (UC) patients.

METHODS

Among 222 UC patients (127 men, 95 women; average age, 34 ± 16 years), we selected 109 with UC diagnosed between 20 and 39 years of age (young adult group) and 23 diagnosed at ≥ 60 years of age (elderly group). Moreover, 12 patients diagnosed between 60 and 64 years of age (late-onset group) and 6 patients aged ≥ 60 years diagnosed under 50 years old (long-standing group) were also extracted for sub-analysis. The clinical characteristics and course were compared among the groups.

RESULTS

The average age at onset was 29 ± 6 years in the young adult group and 66 ± 5 years in the elderly group. The frequency of immunomodulator or steroid use did not differ between the two groups. The comorbidity rate was 14.7 % in the young adult group and 69.6 % in the elderly group (P < .0001). Seven patients (58.3 %) in the late-onset UC group and none of the patients in the long-standing UC group were on steroid treatment. None of the patients in the long-standing UC group required hospitalization/surgery for UC exacerbation, while 3 (25.0 %) and 2 patients (16.7 %) in the late-onset group required hospitalization and surgery, respectively.

CONCLUSIONS

The comorbidity rate was significantly higher in the elderly group. Treatments did not differ significantly between the young adult and elderly groups. Therefore, it appears that the inflammation tends to subside with age in elderly patients with long-standing UC.

Comparison of demographic and clinical characteristics of patients with early vs. adult vs. late onset ulcerative colitis

BACKGROUND & AIMS

There is limited data comparing influence of age on the presentation, clinical course, and therapeutic response of patients with ulcerative colitis. We aimed to compare the demographic and clinical characteristics of patients diagnosed with UC in older age vs. adulthood vs. early age.

METHODS

Five-hundred sixty one patients with UC seen at our center from 1995 to 2011 were categorized into early onset (EO), adult onset (AO) and late onset (LO) due to age at date of initial diagnosis. Patients diagnosed younger than age 17 were defined as EO, while those diagnosed between 17 and 60 were defined as AO and older than age 60 as LO. All patients were analyzed for demographic and clinical characteristics.

RESULTS

There was a male predominancy among LO patients (50% vs. 57.7% vs. 78.6%, p=0.004). Patients with EO UC were more likely to be non-smokers (p<0.001), and had higher family history of UC (p=0.02). Patients with EO UC had more steroid use (p=0.03), total colectomy (p=0.04), presence of chronic active disease (p=0.04) rates when compared with AO and LO groups. Patients in EO group had higher overall probability of surgery in 1, 5 and 10 years, when compared with patients in LO group (p=0.02), but it wasn't different between EO and AO groups (p=0.09).

CONCLUSIONS

Our study showed that clinical course of UC was more aggressive in younger ages. Also the difference between the demographic characteristics suggests that different age groups have different risk factors for the disease development.

Association of age at diagnosis and ulcerative colitis phenotype

BACKGROUND

Ulcerative colitis (UC) primarily affects young adults; however, 12% of patients are diagnosed at an advanced age. Previous studies report that older patients are less likely to have pancolitis and more likely to have distal disease location.

AIMS

Our objective was to compare UC phenotype by age of diagnosis in a tertiary referral cohort.

METHODS

Retrospective database analysis. Demographics, disease extent, and EIM were compared by the following age of diagnosis groups: <17 years, 17-40 years, and >40 years.

RESULTS

A total of 260 patients evaluated between July 1, 2004 and April 19, 2010 were included. Race, smoking history, extraintestinal manifestations of disease, and disease duration were significantly associated with age of diagnosis. As age of diagnosis increased, the proportion of non-white patients increased (p = 0.04), former smoking history increased (p < 0.001), extraintestinal manifestations of disease decreased (p < 0.017), and disease duration decreased (p < 0.0001). As age of diagnosis increased, there was a trend for a higher proportion of patients with proctitis and a decreased proportion of patients with pancolitis. Multivariable analysis adjusting for sex, race, smoking history, family history, and disease duration demonstrated that diagnosis at >40 years was associated with a decreased likelihood for pancolitis compared to younger cohorts (OR 0.43, 95% CI 0.24, 0.76).

CONCLUSIONS

Diagnosis of ulcerative colitis after age 40 years was associated with decreased disease extent compared to younger age groups, even after adjustment for sex, race, smoking history, family history, and disease duration. Our results suggest that older patients have distinct clinical phenotypes.

Inflammatory bowel disease of the elderly: frequently asked questions (FAQs)

The growing recognition of the older inflammatory bowel disease (IBD) patient is heightened by the entry of the 77.2 million baby boomers who will turn 65 beginning of 2011. It is anticipated that this will occur at a rate of 10,000 per day or 4 million per year for the next 19 years. The management of IBD in this population is complex because of problems with co-morbidities, polypharmacy, impaired mobility, and cognition, as well as difficult social and financial issues. This review focuses on the older IBD patient's unique concerns and provides guidance in their diagnosis and management.

Old-age inflammatory bowel disease onset: A different problem?

Inflammatory bowel disease (IBD) in patients aged > 60 accounts for 10%-15% of cases of the disease. Diganostic methods are the same as for other age groups. Care has to be taken to distinguish an IBD colitis from other forms of colitis that can mimick clinically, endoscopically and even histologically the IBD entity. The clinical pattern in ulcerative colitis (UC) is proctitis and left-sided UC, while granulomatous colitis with an inflammatory pattern is more common in Crohn’s disease (CD). The treatment options are those used in younger patients, but a series of considerations related to potential pharmacological interactions and side effects of the drugs must be taken into account. The safety profile of conventional immunomodulators and biological therapy is acceptable but more data are required on the safety of use of these drugs in the elderly population. Biological therapy has risen question on the possibility of increased side effects, however this needs to be confirmed. Adherence to performing all the test prior to biologic treatment administration is very important. The overall response to treatment is similar in the different patient age groups but elderly patients have fewer recurrences. The number of hospitalizations in patients > 65 years is greater than in younger group, accounting for 25% of all admissions for IBD. Mortality is similar in UC and slightly higher in CD, but significantly increased in hospitalized patients. Failure of medical treatment continues to be the most common indication for surgery in patients aged > 60 years. Age is not considered a contraindication for performing restorative proctocolectomy with an ileal pouch-anal anastomosis. However, incontinence evaluation should be taken into account an individualized options should be considered

Patients with late-adult-onset ulcerative colitis have better outcomes than those with early onset disease

BACKGROUND & AIMS

The influence of age on the presentation, clinical course, and therapeutic response of patients with adult-onset ulcerative colitis (UC) is understudied. Given potential age-related differences in risk factors and immune function, we sought to determine if disease behavior or clinical outcomes differed between patients diagnosed with UC in later versus earlier stages of adulthood.

METHODS

We performed a retrospective cohort study of 295 patients with UC seen at a tertiary care center from 2001 to 2008. Adult subjects newly diagnosed with UC between the ages of 18 and 30 years were defined as early onset, those newly diagnosed at age 50 or older were defined as late onset. The 2 groups were analyzed for differences in medication use and clinical end points, including disease extent, severity at the time of diagnosis, and steroid-free clinical remission at 1 year after disease onset.

RESULTS

Disease extent and symptom severity were similar between groups at the time of diagnosis. One year after diagnosis, more patients in the late-onset group achieved steroid-free clinical remission (64% vs 49%; P = .01). Among those who required systemic steroid therapy, more late-onset patients achieved steroid-free remission by 1 year (50% vs 32%; P = .01). Former smoking status was a more common risk factor in the late-onset cohort (P < .001), whereas more early onset patients had a positive family history (P = .008).

CONCLUSIONS

Patients with early and late-adult-onset UC have similar initial clinical presentations, but differ in disease risk factors. Late-onset patients have better responses to therapy 1 year after diagnosis.

Inflammatory bowel disease in the elderly

This article reviews the epidemiology, clinical manifestations, diagnosis, prognosis, and treatment of inflammatory bowel disease (IBD), which will grow in prevalence as the population ages. Prognosis of late-onset ulcerative colitis (UC) is generally similar to that of early-onset UC, whereas in Crohn disease it is probably better because of a tendency for colonic involvement. Disease complications are related more to the duration of the inflammatory bowel disease than the subject's current age. The diagnosis in elderly patients can be challenging due to the large number of conditions that mimic IBD on radiologic, endoscopic, and histologic testing. Distinguishing these conditions from IBD will significantly alter prognosis and treatment. Complications related to IBD and its treatment are common and must be recognized early to limit their impact in a vulnerable elderly population.

Retrospective analysis of old-age colitis in the Dutch inflammatory bowel disease population

AIM: To describe the characteristics of Dutch patients with chronic inflammatory bowel disease (IBD) first diagnosed above 60 years of age-a disease also known as old-age colitis (OAC) and to highlight a condition that has a similar appearance to IBD, namely segmental colitis associated with diverticular disease (SCAD).

METHODS: A retrospective longitudinal survey of patient demographic and clinical characteristics, disease characteristics, diagnostic methods, management and course of disease was performed. The median follow-up period was 10 years.

RESULTS: Of a total of 1100 IBD patients attending the Department of Gastroenterology, 59 (5%) [median age 82 years (range 64-101); 25 male (42%)] were identified. These patients were diagnosed with ulcerative colitis (n = 37, 61%), Crohn’s disease (n = 14, 24%), and indeterminate colitis (n = 8, 15%). Remission was induced in 40 (68%) patients within a median interval of 6 mo (range 1-21) and immunosuppressive therapy was well tolerated. Histological evaluation based on many biopsy samples and the course of the disease led to other diagnosis, namely SCAD instead of IBD in five (8%) patients.

CONCLUSION: OAC is not an infrequent problem for the gastroenterologist, and should be considered in the evaluation of older patients with clinical features suggestive of IBD. Extra awareness and extensive biopsy sampling are required in order to avoid an erroneous diagnosis purely based on histological mimicry of changes seen in SCAD, when diagnosing IBD in the presence of diverticulosis coli.

Inflammatory Bowel Disease After Age 60

New-onset idiopathic inflammatory bowel disease (IBD) is not uncommon among the elderly, although more common are colonic infection, ischemia, or neoplasia, all of which may mimic IBD. Although the clinical presentation of IBD in the elderly often resembles that of younger subjects, atypical manifestations are common and may lead to difficulty in diagnosis. Much progress has been made in both medical and surgical therapy for IBD, but such therapy poses additional challenges in the elderly, who are more likely to experience adverse effects of medications or complications of surgery. The elderly generally have a favorable outcome to both medical and surgical therapy for IBD. Although concern about possible untoward effects of therapy is warranted, treatment should not be withheld because of fear of complications.

Inflammatory bowel disease in the elderly

Approximately 15% of all patients with IBD first develop symptoms after age 65. As the number of elderly in the population continues to grow, clinicians should expect to see a greater number of elderly IBD patients. In general, the presenting features of IBD are similar to those encountered in younger patients, but the broad differential diagnosis of colitis in the elderly can make definitive diagnosis more challenging. Although most therapies for IBD have not been studied specifically in the elderly, as a general rule, medical and surgical treatment options are the same regardless of age. Osteoporosis, a condition generally associated with aging, should be managed aggressively in patients with IBD because many older persons already have a substantial baseline risk for accelerated bone loss.