Management of Inflammatory Bowel Disease in the Elderly Patient: Challenges and Opportunities

Abstract

The population of older patients with inflammatory bowel disease (IBD) continues to grow, partly reflecting the aging global population in general. The debilitating effects of IBD compound age-related decrements in health and functional capacity, and make the medical management of older patients with Crohn's disease and ulcerative colitis distinctly challenging to clinicians. Here, we review the recent literature describing the pharmacologic management of IBD in this population, with focus on the safety, tolerability, and efficacy of common treatment options, such as steroids, immunomodulators, tumor necrosis factor-α antagonists, and integrin antagonists; surgical interventions in older patients are also discussed. Few studies have systematically and prospectively evaluated the clinical challenges in the medical management of IBD in this patient population, leaving a limited evidence base to which clinicians can turn to for guidance. Treatment patterns may thus be suboptimal. For example, prolonged steroid use in the elderly was found to be common, causing significant morbidity from side effects in a particularly vulnerable population. Finally, within the context of a limited evidence base, we discuss common treatment scenarios to define the parameters within which physicians can individualize care for older patients with IBD. Overall, older patients with IBD are at higher risk of adverse events and less treatment responsiveness compared with younger patients, underscoring the need for future studies to fully characterize appropriate treatment courses for this population.

Figure 1. Rise in the IBD over the years

(A) Incidence rates of UC and (B) CD in Olmsted County, Minnesota between 1940 and 2000.(4) Unadjusted incidence rates for males and females were added to give the total cases per 100,000 person-years (PY). For comparison, the total age- and sex- adjusted rate between 1990 and 2000 was 8.8 per 100,000 PY for UC and 7.9 per 100,000 PY for CD. (C) General population of the United States by age group according to the United States Census Bureau.^a Projected numbers are reported in the millions. ^a2014 National population projections: Summary tables.

Figure 2. Utilization of different therapeutic agents in patients aged 65 years or older.(27)

In a retrospective observational study, electronic medical records from a 20-hospital setting were reviewed from January 1, 1991 through December 31, 2010. Patterns for IBD medication in a total of 383 IBD patients aged ≥65 years were summarized.