There is a growing number of people diagnosed with IBD who are defined as “elderly”. This varies in definition but can be considered those who have IBD older than 50 or older than 60 or 65. I prefer the World Health Organization definition of >65.
The two different groups are those with IBD who age and those who are diagnosed at an older age with “new” IBD, either with truly new onset IBD or due to IBD that was subclinical or minimally symptomatic for many years that reached a threshold of symptoms or a complication (like a bowel obstruction).
The diagnosis of IBD in older patients can be challenging, since there are other possible diagnoses that can look like IBD that are more likely in older individuals, including ischemic colitis (reduced blood flow), diverticulitis, or sigmoid colitis associated with diverticula (so-called “SCAD”). In addition, it is possible that an older person may be taking ibuprofen which can cause erosions or ulcers in the bowel and be confused for Crohn’s disease. Therefore, in making the diagnosis, we need to make sure these other things are carefully considered, including biopsies and in some cases, following over time to see the natural history or progression of the condition.
The earlier reports of new onset “elderly IBD” said that in general these patients were likely to have less aggressive IBD, a milder course, but this is being questioned now- there are definitely examples of IBD that is severe in older individuals. I am unaware of a difference in extra-intestinal manifestations among older patients with IBD.
The considerations for treatment are important, since we know that patients who are older may undergo immune senescence. This is the condition in which the immune system becomes weaker as we age. Remembering that IBD is a condition of an overactive immune system, it is paradoxical to recognize that IBD is active in such patients. There are certainly anecdotes (and I have patients) of IBD quieting down or “burning out” as patients get older. However, there is also the consideration regarding treatment in older patients. It has been reported, for example, that older patients have a higher incidence of opportunistic infections with anti-TNF therapies. In this consideration, a non-TNF inhibitor therapy would be preferable. In the case of an elderly patient who may have had subclinical or mild, slowly progressive disease, a limited surgery or even no treatment may be a reasonable option.
For those who were diagnosed at a young age, as they age or go through changes in life, it is possible to consider whether the disease has changed, and whether a de-escalation strategy or elective treatment change may be helpful. However, this is an untested management approach and must be considered carefully. See our article about approaches and challenges to de-escalation.
I haven’t sensed a difference in coping or resilience in my older patients. In my experience, they can have the same challenges in understanding and adherence as patients diagnosed at a younger age.
Thoughts and comments are welcome.
David T. Rubin, MD
Professor of Medicine, University of Chicago Medicine