IBD has been viewed as a condition of adult middle age or young adults. The chronic illness—which includes Crohn’s disease and ulcerative colitis, and can cause abdominal pain, diarrhea, bleeding, and decreased quality of life—impacts about 3.1 million people in the U.S. It is not a condition that affects only the middle-aged and young. A 2021 study found that more than 25% of IBD sufferers are older. Gastroenterology & Hepatology article.
It is becoming more common for IBD to be diagnosed after the age of 60. This makes it even less well-known. Whereas IBD was once taught as a disease with two spikes in onset—20s to 30s, and 40s to 50s—doctors are learning there is a third spike that begins later in life. “Now we know you can be 75 and get IBD,” says Dr. Simon Hong, a gastroenterologist and IBD specialist at NYU Langone Health.
Regardless of when the disease starts, however, understanding—and treating—IBD in older adults comes with its own set of challenges and intricacies.
IBD is different for older adults
People with IBD diagnosed early in life are still living with it in later years. This means many people are living with the effects of IBD on their digestive tracts and the altered impacts that surgery has had to deal with it. The disease can flare up again.
There was a common belief that disease activity declines as we age. However, some individuals find their IBD less active later on in life. But that isn’t always the case, says Cleveland Clinic gastroenterologist Dr. Jessica Philpott. “I certainly see some patients who develop more aggressive disease as they advance in age,” she says.
IBD may look different in people with IBD who are 60 or older than it is for patients who have been suffering from IBS for years. Whereas younger Crohn’s patients can have damage in any part of their intestinal tract, in older-onset cases it more often primarily affects the colon.
Diagnosing IBD becomes harder as we age. Bloody diarrhea is one of the more frequent symptoms that an older person may experience. IBD assessment should begin immediately if this alarming sign is present in younger people. But for someone in their 60s or older, doctors often need to rule out a host of other conditions—including infection, ischemia of the colon, other forms of colitis, diverticulitis, and cancer—before they look into IBD as a potential cause.
Older adults may not be as proactive in seeking medical attention because they have already experienced more serious health problems. Crohn’s in particular can be trickier to pinpoint than ulcerative colitis, as it might present as intermittent abdominal pain and weight loss, which aren’t uncommon in older adults generally. Sometimes, these factors may delay effective treatment and a proper diagnosis by several years.
Dr. Gil Melmed (director of inflammation bowel disease clinical Research at Cedars-Sinai Medical Center, Los Angeles) recounts the tale of a patient, now age 84. The patient had previously been admitted for bloody diarrhea, abdominal pain and other issues. Her symptoms were repeatedly confirmed by doctors. She was treated with antibiotics. The symptoms would gradually improve over time and then return. The antibiotics caused additional problems, such as a potentially fatal condition. C. difficile infection. When Melmed first saw her, after yet another hospital admission, he realized she wasn’t suffering from diverticulitis at all but Crohn’s disease.
Hong has experienced this misdiagnosis cycle many times. “Doctors do have to always remember to have IBD on their list” for people who are older, he says.
Late-onset IBD is increasing at an alarming rate, probably due to environmental triggers such as air pollution. This makes it even more crucial that people be vigilant.
Menopause and inflammation, among other complications
IBD is fundamentally a condition of chronic inflammation. Increased inflammation is linked to aging, which has led to IBD being called such. inflammaging.IBD sufferers who age with IBD have an increased risk of many inflammation-related diseases, such as heart disease, diabetes, cancer, obesity and skin conditions.
Experts warn that while some health problems may seem similar to older adults with IBD, in fact the IBD is causing a completely different problem. While it might seem that joint pain is caused by osteoarthritis in older patients, IBD can cause a completely different type of arthritis.
IBD sufferers over 50 are at greater risk for developing bone and skin diseases.
There are many health risks that could arise, so it is important to take preventative measures, such as good nutrition, exercise and routine vaccinations. Many vaccines meant for seniors contained live virus. This made them more difficult to combine with IBD treatments. This is no longer the case, he says, and in fact, because so many IBD treatments suppress the immune system—and aging itself is associated with an increased risk of infections—it is especially important for these patients to get regular vaccines for things like pneumonia.
Many details about IBD and the effects it has on the body of aging remain a mystery. For example, we don’t yet know much about how aging with IBD looks different for women going through menopause and afterward, and what role menopause treatments might play in the disease course. Some small studies have found a modest protective role for estrogen-replacement therapies for IBD disease activity, but the answers aren’t yet definitive. “We really need more data in this area,” says Dr. Sunanda Kane, who specializes in IBD and women’s health at Mayo Clinic in Rochester, Minn.
But even something as big as menopause can be missed—or misinterpreted—when doctors are overly focused on a patient’s IBD and its treatments. Kane remembers the case of a patient aged 57 who had recently been given a new monoclonal anti-inflammatory therapy to treat her ulcerative collitis. One day the patient told her primary-care doctor that she was having “fevers” and “confusion.” The doctor concluded she was likely suffering from a rare brain infection as a result of her IBD medication, told her to discontinue her medication, and referred her to a neurologist. The patient was anxiously waiting for her appointment at the neurology. She called Kane to inquire about other IBD medications she might be able to take. Kane listened to the patient’s story and realized that her symptoms were those of menopause. Kane says that she was able to report back on the IBD treatment as well as estrogen-replacement therapy. But it served as a reminder that the presence of IBD can cloud the assessments of a patient’s full picture, especially when big health changes come up, as they so often do during the aging process.
One thing that has become clear as more people live with IBD into older age is that when evaluating patients for IBD and their treatment prospects, it’s not just about age. Experts now advocate basing decisions on one’s frailty score over chronological age. The combination of IBD and aging can increase the likelihood of frailty. This puts people at higher risk of poor outcomes.
IBD treatment for the elderly: Confusion
The challenges of treating illnesses as we age tend to increase. There are more comorbidities, a lengthening list of medications, and a person’s overall health to take into account. Consider these important factors when looking at IBD therapies. “Anything we do, from procedures to treatment, it’s different for someone that’s older,” says Cleveland Clinic’s Philpott.
Doctors often consider surgery to repair damaged parts of the intestinal tract when the disease progresses to an advanced stage. IBD is a serious condition that can lead to death.
The majority of the time, IBD can be treated with medication. Specialists who treat IBD patients with older people warn of some potential pitfalls.
The susceptibility of IBD patients over 65 is one of their greatest concerns. IBD drugs almost all weaken the immune system. But this concern, say experts, can lead to vast undertreatment of the condition—or treatments with even riskier forms of drugs.
Corticosteroids were a staple of IBD treatment for decades. Corticosteroids are used to treat mild and moderate flare-ups of IBD. They’re especially useful for younger patients. However, their effectiveness over the long term is lower than that of other treatments and they can pose a greater risk to older people, such as hypertension, diabetes and bone loss.
According to 2015 research, 30% of IBD patients over 60 have received steroids for longer than 6 months.Inflammatory Bowel Diseases Part of the reason, NYU’s Hong says, is that because of these drugs’ long history, “they’re seen as sort of the ‘safe’ option.” Instead, he says, “I would argue that rather than being on steroids for a long period of time, it would be much better to be on one of the new biologics.”
In the past couple of decades, small molecule “biologics” have entered the scene as a newly established treatment for IBD. Drugs like antitumor neoplastic factor agent agents can be particularly beneficial. These medications are often not prescribed by doctors because of their potential to raise the risk for cancer (e.g. lymphoma) in elderly patients. Some doctors even recommend surgery—which comes with its own not insubstantial risks for older individuals—before trying biologics.
Melmed’s 84-year-old patient who was finally diagnosed with Crohn’s disease was immediately started on biologics, and has yet to have another flare-up. Melmed admits to the risks of these drugs for patients older than 84. But he looks at the larger picture of “how to best benefit a patient,” he says. “There’s no risk-free option. Just because somebody’s older, we certainly don’t want to deny them the potential benefits of an effective therapy.”
As part of that approach, Melmed advocates assessing not just patients’ intestinal health but also their environment and well-being.
Because of IBD’s unpredictable nature, IBD sufferers are more likely to experience depression in their younger years. And there’s no reason to think this would be different for people just because they are a few years—or decades—wiser. But depression can be more difficult to spot in an elderly patient if it isn’t screened for, and being fairly homebound or lacking social support might be accepted as normal. Yet it doesn’t have to be that way, experts agree.
“As doctors, we’re always focused on inflammation,” NYU’s Hong says. “But in reality, what matters is: What does this older patient want to do? Are they looking to travel? Or ride a bike around the park?” And that’s where experts say the conversation around treatment risks and benefits should focus. “Just because they’re older doesn’t mean that they don’t deserve the same quality of life,” Hong says. “Don’t settle for less.”
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