Providing care for elderly patients with inflammatory bowel disease (IBD) involves unique challenges in diagnosis and therapeutic decision making, according to a clinical practice update from the American Gastroenterological Association (AGA) published in Gastroenterology.
“Clinicians must be prepared to newly diagnose IBD in the elderly and initiate therapy in the context of other health issues experienced by the elderly,” the research group noted. The group developed the best practice advice statements for the diagnosis, treatment, and health maintenance of elderly patients with IBD.
“Most clinical data to inform these practices are based on observational data or indirect evidence as elderly IBD patients comprise a very small proportion of subjects enrolled in IBD clinical trials or long-term pharmacovigilance initiatives,” the study authors wrote.
Diagnosing IBD in Older Patients
For older patients who present with symptoms including diarrhea, rectal bleeding, abdominal pain, and weight loss, providers should have a strong clinical suspicion for IBD, according to the study group.
Compared with patients younger than 40 years, those older than 60 years are more likely to have other diagnoses that may mimic symptoms of IBD, including colorectal cancer, ischemic colitis, segmental colitis associated with diverticulosis, nonsteroidal anti-inflammatory drug-induced pathology, radiation enteritis or colitis, or microscopic colitis.
“Because the medical and surgical management of these conditions varies substantially, a vigorous approach to confirming the diagnosis of IBD is important in the elderly population,” stated the researchers.
Initial diagnostic steps should involve laboratory investigations that include complete blood count, serum albumin, serum ferritin, and C-reactive protein. Stool testing for Clostridioides difficile in new cases of diarrhea may be appropriate, as well as computed tomography in elderly patients who present with acute symptoms especially when abdominal pain is prominent.
Colonoscopy with histologic confirmation is a “cornerstone of diagnosis,” although additional consideration is needed regarding procedural risks and tolerance for anesthesia in the presence of comorbidities and polypharmacy in elderly patients, according to the investigators.
“In patients for whom the indication for colonoscopy is equivocal or is associated with relatively high risk, the use of noninvasive stool markers of inflammation such as fecal calprotectin and imaging may aid in decision-making,” the study group wrote.
In addition, the initial presenting phenotype of IBD may differ between elderly onset and younger onset of the disease.
“Presenting with more benign phenotypes may suggest patients with elderly-onset IBD may have more favorable outcomes compared with their younger counterparts,” wrote the researchers. “While some initial epidemiological studies may support this notion, others have suggested that those with elderly-onset ulcerative colitis were more likely than younger IBD patients to undergo colectomy. Thus, in attempting to predict disease course, it may be more prudent to consider specific disease characteristics rather than chronologic age.”
Managing older patients with IBD requires a multidisciplinary approach. The National Social Life, Health, and Aging Project, for example, found that 29% of persons aged 57 to 85 years were using at least 5 prescription drugs, and 4% were at risk of major drug-drug interactions. Effective care may involve pharmacist support, a geriatrician, mental health providers, social workers, and healthcare navigators.
The research group advises that clinicians should assess patients’ overall fitness and frailty when considering treatment options, in addition to age, as pretreatment frailty is associated with an increased risk of infections after immunomodulator or anti-tumor necrosis factor (TNF) treatment or postsurgery.
“Interventions aimed to ameliorate physical and nutritional frailty including physical therapy and nutritional support may thus be an important part of care of the older IBD patient,” the researchers wrote.
Aminosalicylates are efficacious for the induction and maintenance of remission in patients with mild to moderate ulcerative colitis, noted the study authors. More than two-thirds of older patients with ulcerative colitis and Crohn disease receive 5-ASA therapy, and the rare complication of interstitial nephritis may be especially relevant in older patients owing to a decline in renal function.
Corticosteroids appear to have similar efficacy in elderly IBD patients compared with younger patients, despite the limited evidence-based data available. Budesonide may be preferred, compared with conventional corticosteroids in older patients who have ileocolonic or right-sided luminal Crohn disease or left-sided ulcerative colitis.
“Any use of systemic corticosteroids should prompt consideration for corticosteroid-sparing therapy and measures to mitigate risk for osteoporosis should a prolonged course be required,” the researchers advised.
Systemic corticosteroids for IBD maintenance therapy should be avoided, owing to the potentially higher risk for adverse effects, the study group recommended.
Thiopurines are effective in maintaining remission in Crohn disease and ulcerative colitis, although the data are limited, particularly in the elderly, noted the investigators.
“On balance, thiopurines by virtue of their oral administration are convenient and inexpensive options for many older patients with IBD,” the authors noted. “However, their inferior efficacy when compared to other therapies, their delayed efficacy (thereby potentially prolonging corticosteroid exposure), and the higher absolute risk of potentially serious treatment-related malignancies in older IBD patients makes prudence about new initiation of thiopurines important.”
Methotrexate is another option in older patients with Crohn disease, with data supporting its role in inducing and maintaining remission. It can also be an alternative to thiopurines when used as combination therapy in patients at high risk for thiopurine-related adverse effects including malignancy.
The effectiveness of anti-TNF therapy in elderly patients with IBD has had mixed results, and evidence for the safety of the combination of an immunomodulator with anti-TNF biologic therapy in older patients is also mixed.
Some clinical trials have suggested that the effectiveness of vedolizumab in Crohn disease and ulcerative colitis is similar between older and younger patients, and most of the safety data regarding tofacitinib are based on indirect studies in rheumatology.
“While there is a higher frequency of serious infections in older patients on tofacitinib compared with those on placebo, it was similar to risks observed in younger individuals,” noted the investigators. “Pooled analysis of clinical trials in rheumatoid arthritis has been informative regarding the safety of this therapy in older patients.”
There is conflicting evidence on whether older age is associated with a higher risk of postoperative complications after surgery in patients with IBD.
“Pharmacologic thromboprophylaxis is important in older patients undergoing surgery due to higher risk for venous thromboembolism,” the researchers commented. “In addition, assessment and optimization of nutritional status prior to surgery may be important in reducing postoperative morbidity and facilitating recovery.”
Clinicians should discuss health maintenance issues with older patients soon after a diagnosis of IBD. Older patients have a higher risk for vaccine-preventable illnesses, especially regarding systemic immunosuppression.
“Clinicians should facilitate adherence to recommended vaccination schedules including influenza, pneumococcal, and herpes zoster vaccines, as the risk for serious sequelae of these infections is increased among elderly patients,” wrote the research group. “While gastroenterologists often defer routine health maintenance such as vaccinations to primary care providers, it is not uncommon for IBD patients of any age to find themselves without a primary care provider, and for primary care providers to have some uncertainty regarding the safety and timing of certain vaccines in persons on immunomodulatory drugs. It is also important to ensure the older IBD patient is up to date with age-appropriate cancer screening recommended for the general population.”
Patients with chronic colitis related to ulcerative colitis or Crohn disease have about a 2-fold risk of developing colorectal cancer, compared with age-matched individuals. Although the relative risk is higher in younger patients with IBD, the absolute risk is higher in the elderly as colorectal cancer becomes increasingly common.
“[V]igilance is needed toward ongoing surveillance colonoscopies and clinicians should be prepared to adequately address dysplastic lesions in these patients,” the researchers advised.
“As with all decisions in medicine and the decisions regarding therapy choice in the elderly, the persistence with surveillance colonoscopy with advancing age should consider anesthesia and perforation risks associated with the procedure itself, comorbidity, overall life-expectancy, and candidacy for colon resection surgery,” the study group advised.
The review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board and underwent internal peer review by the Clinical Practice Updates Committee as well as external peer review.
The AGA’s best practice guidelines for the management of IBD in older patients are summarized below.
Diagnosis: IBD diagnosis should be considered in older patients (60 years and older) who present with diarrhea, rectal bleeding, urgency, abdominal pain, or weight loss. Fecal calprotectin or lactoferrin may help clinicians prioritize patients with low IBD probability for endoscopic evaluation. Certain presentations — hematochezia or chronic diarrhea — should be viewed with intermediate to high suspicion of underlying IBD, microscopic colitis, or colorectal neoplasia; these patients should undergo colonoscopy.
A diagnosis of segmental colitis associated with diverticulosis should be considered in elderly patients with segmental left-sided colitis, in addition to the possibility of Crohn disease or IBD-unclassified.
General Treatment Principles: A comprehensive initial assessment is important to determine both short- and long-term treatment goals; patients should be risk stratified based on the likelihood of severe clinical course.
The use of systemic corticosteroids is not indicated for maintenance therapy. Nonsystemic corticosteroids, such as budesonide, should be used when corticosteroid induction therapy is needed. The use of immunosuppression should be based on patient’s age, functional status, comorbidities, and frailty. Immunomodulary treatments with lower overall risk for infection or malignancy — vedolizumab or ustekinumab — may be preferred if appropriate in the clinical context. When considered, thiopurine monotherapy for maintenance of remission should balance the convenience of admission and cost with lower efficacy and slow onset of action, as well as increased risk for nonmelanoma skin cancers and lymphoma.
Comorbidity optimization is important to minimize risks associated with IBD, as well as its treatment and the selection of the appropriate treatment agent. Any decisions regarding timing and type of surgery should take into account disease severity, functional status and independence, risks and efficacy of medical therapies, and the potential risk for complications. Therapeutic decisions should also consider the risk of complications, including fracture, venous thromboembolism, pneumonia or other opportunistic infections, herpes zoster, and both skin and nonskin cancers.
Overall, care for older patients with IBD should be multidisciplinary and must engage gastrointestinal specialists, primary care providers, appropriate subspecialists, mental health professionals, surgeons, nutritionists, and pharmacists.
Health Maintenance: Clinicians should work with patients to facilitate adherence to vaccination schedules, including influenza, pneumococcal, and herpes zoster. Vaccines should be scheduled prior to initiation of immunosuppression, if possible. When deciding to continue or stop colorectal cancer surveillance in this population, clinicians should incorporate the patient’s age, comorbidities, overall life expectancy, likelihood of endoscopic resectability of the lesion, and surgical candidacy.
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
1. Ananthakrishnan AN, Nguyen GC, Bernstein CN. AGA clinical practice update on management of inflammatory bowel disease in the elderly: Expert review. Published online September 30, 2020. Gastroenterology. doi: 10.1053/j.gastro.2020.08.060
2. Kochar B, Cai W, Cagan A, Ananthakrishnan AN. Pretreatment frailty is independently associated with increased risk of infections after immunosuppression in patients with inflammatory bowel diseases. Gastroenterology. 2020;158(8):2104-2111.e2.
3. Nugent Z, Singh H, Targownik LE, Bernstein CN. Herpes zoster infection and herpes zoster vaccination in a population-based sample of persons with IBD: is there still an unmet need? Inflamm Bowel Dis. 2019;25(3):532-540.
4. University of Chicago. National Social Life, Health, and Aging Project (NSHAP). https://www.norc.org/Research/Projects/Pages/national-social-life-health-and-aging-project.aspx. Accessed October 13, 2020.