Inflammatory bowel disease in the elderly

Burden of inflammatory bowel disease among elderly, 1990-2019: A systematic analysis based on the global burden of disease study 2019

AIM

The number of elderly patients with inflammatory bowel disease (IBD) has increased dramatically over the past few decades. Understanding the global burden of IBD in the elderly can provide a valuable basis for formulating future healthcare policies. This study aimed to comprehensively assess the global burden of IBD in the elderly from 1990 to 2019.

METHODS

We extracted prevalence, incidence, disability-adjusted life-years (DALYs), and mortality data of older adults (60-89 years old) with IBD from 2010 to 2019 from the Global Burden of Disease (GBD) Study 2019, and analyzed in subgroups according to region, country, Socio-demographic Index (SDI), age group, and gender. Additionally, Trends in the global burden of IBD in old age from 1990 to 2019 were analyzed by calculating the estimated annual percentage change (EAPC) in the age-standardized rates (ASDs).

RESULTS

From 1990 to 2019, the number of prevalent cases, incident cases, DALYs, and deaths of IBD in older adults increased significantly. Age-standardized rates of incidence, prevalence, DALYs, and mortality all trended downward. Americas, European regions, and high SDI countries had consistently high burdens. Middle SDI countries had the fastest growth in prevalence, incidence, and the fastest decline in DALYs, and mortality. The age-standardized rates of prevalence, incidence, and DALYs for IBD in the elderly were highest in the 60-64 age group, and age-standardized rates of mortality were highest in the 80-84 and 85-89 age groups. No gender differences were observed when stratified by gender.

CONCLUSIONS

IBD in older adults has become a global public health burden due to significant increases in the number of prevalent cases, incident cases, DALYs, and deaths. There are marked differences among regions, countries, and between different age groups. Public health practitioners should develop targeted policies to effectively reduce the disease burden of IBD in older adults.

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.

Vedolizumab Is Associated With a Lower Risk of Serious Infections Than Anti-Tumor Necrosis Factor Agents in Older Adults

BACKGROUND & AIMS

Despite the increased numbers of older adults with inflammatory bowel diseases (IBDs), there are few studies regarding the safety and effectiveness of IBD treatments in older adults. The aim of this study was to compare the safety and effectiveness of anti-tumor necrosis factor (TNF)-α agents and vedolizumab in older adults with IBD.

METHODS

We conducted a retrospective cohort study using an active comparator, new-user design for adults age 65 years and older with IBD initiating anti-TNF-α agents and vedolizumab in the Medicare claims database from 2014 to 2017. The primary safety outcome was infection-related hospitalization (excluding intra-abdominal and perianal abscesses). Co-primary outcomes to estimate effectiveness were IBD-related hospitalization, IBD-related surgery, and new corticosteroid use 60 days or more after biologic initiation. We performed propensity score weighting to control for confounding and estimated adjusted hazard ratios and 95% confidence intervals using standardized morbidity ratio-weighted variables.

RESULTS

We identified 1152 anti-TNF-α new users and 480 vedolizumab new users. The median age was 71 years in both cohorts and 11% were age 80 years or older. Crohn's disease patients comprised 54% of the anti-TNF-α cohort and 57% of the vedolizumab cohort. There was no significant difference in demographics, health care utilization, or frailty in both cohorts. More than half of both cohorts had a Charlson comorbidity index of 2 or higher. Vedolizumab users had a decreased risk of infection-related hospitalization (adjusted hazard ratio, 0.47; 95% confidence interval, 0.25-0.86). There was no significant difference in the outcomes approximating effectiveness.

CONCLUSIONS

Older IBD patients treated with vedolizumab had a lower risk of infection-related hospitalization compared with those initiating anti-TNFs. We observed no difference in effectiveness defined by hospitalizations, surgery, or new corticosteroid use.

Frailty in inflammatory bowel diseases: an emerging concept

Inflammatory bowel diseases (IBD), consisting of Crohn's disease and ulcerative colitis, are chronic remitting, relapsing inflammatory conditions of the gastrointestinal tract. While traditionally a disease of younger ages, the number of older adults with IBD is rising rapidly. Patients with IBD often experience geriatric syndromes at earlier ages. Older adults with IBD have poorer disease and treatment-related outcomes compared with younger adults with IBD. Applying the principles of geriatrics to understanding a chronic disease in older adults may improve health span. Better tools are needed to stratify IBD patients who are at high risk for adverse events. Frailty is a geriatric construct that may approximate biologic age. Frailty is a complex, multi-dimensional syndrome that leads to increased vulnerability to stress and decline of reserve across multiple physiologic systems. In this review, we present the leading conceptual models of frailty and discuss the applications of frailty in immune-mediated diseases. We also review chronic conditions where frailty has been applied successfully as a tool for risk stratification. Finally, we discuss in the detail the growing body of literature highlighting the relationship between frailty and IBD, the epidemiology of frailty in IBD, and ramifications of frailty in IBD.

Short-Term Outcomes for Restorative and Non-Restorative Proctocolectomy in Older Adults

BACKGROUND

Curative surgery for ulcerative colitis can be subdivided into restorative (with pouch and anastomosis) and non-restorative operations. Restorative surgery in older adults is controversial, due to concerns about surgical risk and long-term functional outcome. The goal of this study is to compare 30-day outcomes for restorative and non-restorative surgery in older adults with ulcerative colitis.

METHODS

Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from 2012-2018. Patients were included if they were >65 years old and had ulcerative colitis. Restorative and non-restorative surgeries were defined with procedure codes. Patient characteristics and adverse surgical outcomes were compared between restorative and non-restorative surgeries utilizing chi-square tests and Fisher's exact tests. Multivariate logistic regression models were constructed to evaluate the association of restorative versus non-restorative surgery with adverse surgical outcomes while adjusting for potential confounders.

RESULTS

Of 392 total patients, 95 had restorative and 297 had non-restorative surgery. Patients undergoing restorative surgery, compared to non-restorative surgery, were significantly younger (P<0.01), had lower incidences of steroid usage (P<0.001) and higher rates of readmission (P = 0.02). There were no differences in post-operative complications between the groups in both unadjusted analyses and covariate-adjusted regression analysis (P > 0.05).

CONCLUSION

In carefully selected older patients with ulcerative colitis, restorative surgery is associated with increased readmission, but otherwise similar rates of morbidity or mortality compared to non-restorative surgery. Data regarding postoperative functional outcome and quality of life are also needed to help select the most appropriate curative option for older adults.

Crohn's Disease is Associated with Longer In-Hospital Lengths of Stay and Higher Rates of Complications and Costs after Primary Total Hip Arthroplasty

BACKGROUND

As the incidence and prevalence of Crohn's disease continues to change worldwide, rates within North America have been increasing. The objective of this study was to evaluate whether patients who have Crohn's disease undergoing primary total hip arthroplasties have worse outcomes compared with matched cohorts. Specifically, we evaluated 1) medical complications, 2) in-hospital lengths of stay (LOS), and 3) costs of care.

METHODS

Two cohorts of patients who underwent primary total hip arthroplasties from January 1, 2005 to March 31, 2014 were identified from the Medicare claims of the PearlDiver platform. Cohorts were matched by age, sex, and following comorbidities-anemia, diabetes, hyperlipidemia, hypertension, malnutrition, pulmonary disease, and renal failure, yielding 55,361 patients within the study (n = 9229) and matching cohorts (n = 46,132). Outcomes assessed included 90-day medical complications, in-hospital LOS, and costs of care. A P-value less than .005 was considered statistically significant.

RESULTS

Patients with Crohn's disease were found to have significantly higher incidences and odds ratios of 90-day medical complications (30.2 vs 13.8; odds ratios: 2.2, P < .0001). They were also found to have significantly longer LOS (3.8- vs 3.6-days, P < .0001) and higher day of surgery ($12,662.00 vs 12,271.15, P < .0001) and 90-day episode costs ($16,933.18 vs $15,670.32, P < .0001).

CONCLUSION

Crohn's disease is associated with higher rates of medical complications, longer in-hospital LOS, and increased costs of care. This study may aid physicians to perform appropriate risk adjustment for adverse outcomes and to educate these patients about potential postoperative complications in these patients.

The Present Status of Fecal Microbiota Transplantation and Its Value in the Elderly

OPINION STATEMENT

PURPOSE OF REVIEW: This article will review current literature describing fecal microbiota transplantation (FMT) in the treatment of various diseases, and its potential role in elderly patients (age ≥ 65 years).

RECENT FINDINGS

Research on FMT has blossomed in the last decade and its pivotal role in the treatment of recurrent Clostridium difficile infection (CDI) has been recognized by the American College of Gastroenterology in the latest guidelines. There is also emerging evidence that FMT may be beneficial in the treatment of severe and/or complicated CDI refractory to medical therapy, resulting in decreased rates of colectomy and mortality. In the elderly, CDI is associated with markedly higher rates of mortality and colectomy; outcomes are even worse when patients have underlying inflammatory bowel disease (IBD). While the majority of patients who receive FMT for CDI are older, only a handful of studies focused specifically on FMT treatment outcomes and safety in this age group. Current data corroborate the efficacy and safety profile of FMT, while also supporting its use for recurrent, severe, and/or complicated CDI in the elderly population. FMT is recommended for the treatment of recurrent, severe, and/or complicated CDI in patients older than 65 years of age. It may be prudent to offer FMT earlier in the disease course, possibly after just the second recurrence and for the first episode of severe CDI to avert complications including colectomy and end-organ failure that elderly patients are more prone to developing.

Inflammatory Bowel Disease is Similar in Patients with Older Onset and Younger Onset

BACKGROUND

As the American population is aging, the number of older people with inflammatory bowel disease is increasing. We used clinical data from the Sinai-Helmsley Alliance for Research Excellence (SHARE), a prospective cohort, to examine disease and treatment differences in older adults.

METHODS

We performed a cross-sectional study assessing demographics and disease behavior by age at diagnosis with univariate, bivariate, and multivariate analyses. "Older-onset" patients were diagnosed after age 60, "younger-onset" patients were diagnosed before age 60 but are older than 60 years, and the remainder were "young."

RESULTS

There were 91 older-onset, 389 younger-onset, and 3431 young patients with Crohn's disease. Older-onset patients had more ileal (37%) and colonic (27%) disease compared with younger-onset and young patients. There were no differences in disease behavior, location, or surgeries between older-onset and young patients with Crohn's disease within 5 years of diagnosis. Older-onset patients with inflammatory disease had a higher odds of being in remission. Young patients reported more anti-tumor necrosis factor and thiopurine use compared with younger-onset and older-onset patients (P < 0.01). There were 98 older-onset, 218 younger-onset, and 1702 young patients with ulcerative colitis. There were no differences in disease extent, activity index, or surgeries. Young patients with ulcerative colitis reported more anti-tumor necrosis factor use (26%) compared with younger-onset patients (17%, P < 0.01).

CONCLUSIONS

Disease behavior or location was not different between younger and older adults with inflammatory bowel disease. Older patients were less likely to be treated with immunosuppression. If older patients have similar disease behavior, less frequent treatment with immunosuppressives may risk suboptimally controlled disease.

Restorative Proctocolectomy in Elderly IBD Patients: A Multicentre Comparative Study on Safety and Efficacy

BACKGROUND AND AIMS

Restorative proctocolectomy in elderly inflammatory bowel disease [ IBD] patients is controversial and limited data are available on the outcomes of surgery. The aim of this study was to evaluate the safety, efficacy, and long-term results of ileal-pouch-anal anastomosis in elderly patients, in a multicentre survey from European referral centres.

METHODS

The International Pouch Database [IPD] combined 101 variables. Patients aged ≥ 65 years were matched on the basis of open versus laparoscopic surgery with a control group of consecutive younger unselected patients with a ratio of 1:2. Statistical analysis was performed using two-tailed t test, chi square and Fisher's exact tests, Kaplan-Meier function, and log-rank tests where appropriate.

RESULTS

In the IPD, 77 patients aged ≥ 65 years [Group A] and 154 control patients [Group B] were identified. Elderly patients had more comorbidities [p = 0.0001], longer disease duration [p = 0.001], less extensive disease [p = 0.006], more previous abdominal operations [p = 0.0006], surgery for cancer or dysplasia more frequently [p = 0.0001], fewer single-stage procedures [p = 0.03], more diversions after ileal pouch-anal anastomosis [IPAA] [p = 0.05], and a higher laparoscopic conversion rate [p = 0.04]. Postoperative complications and pouch failure were similar between the groups, but Group A had more Clavien-Dindo IV-V complications [p = 0.04], and longer length of stay [p = 0.007]. Laparoscopy was associated with a shorter duration of surgery [p = 0.0001], and length of stay [p = 0.0001], and the same complication rate as open surgery.

CONCLUSIONS

Restorative proctocolectomy can be performed in selected elderly patients, but there is a higher risk of postoperative complications and longer length of stay in this group. Laparoscopy is associated with shorter operating time and length of stay.

Analysis of Hospital-Based Emergency Department Visits for Inflammatory Bowel Disease in the USA

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, debilitating condition with high emergency department (ED) utilization. We aimed to investigate the utilization patterns of ED by IBD patients and measure hospitalization and surgical rates following ED visits.

METHODS

We conducted a cross-sectional study of adults with IBD listed as the primary ED diagnosis from the 2009 to 2011 Nationwide Emergency Department Sample. The characteristics of the IBD-related ED visits in relation to following hospitalizations and surgeries were analyzed.

RESULTS

Adult IBD patients constitute 0.09 % of the total ED visits. Crohn's disease (CD) contributed to 69 % of the IBD-ED visits. The hospitalization rate from ED was 59.9 % nationally, ranging from 56 % in west to 69 % in northeast. The most significant factors associated with hospitalization were intra-abdominal abscess [odds ratio (OR) 24.22], bowel obstruction (OR 17.77), anemia (OR 7.54), malnutrition (OR 6.29), hypovolemia/electrolyte abnormalities (OR 5.57), and fever/abnormal white cell count (OR 3.18). Patients with CD (OR 0.66), low-income group (OR 0.90), and female gender (OR 0.87) have a lower odds of getting hospitalized. Age above 65 years (OR 1.63), CD (OR 1.89), bowel obstruction (OR 9.24), and intra-abdominal abscess (OR 18.41) were significantly associated with surgical intervention.

CONCLUSION

The IBD-related ED visits have remained relatively stable from 2009 to 2011. The presence of anemia, malnutrition, hypovolemia, electrolyte abnormalities, fever, abnormal white cell count, bowel obstruction, or intra-abdominal abscess during the ED visit was associated with hospitalization. The presence of bowel obstruction and intra-abdominal abscess was strongly associated with surgical intervention.

Medical and surgical complications of inflammatory bowel disease in the elderly: a systematic review

BACKGROUND/AIMS

The complications of therapy, hospitalization, and surgery related to inflammatory bowel disease (IBD) in the elderly are not well described. While multiple reviews have described the management and complications of elderly patients with IBD, none have been performed in a systematic fashion.

METHODS

We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to evaluate the association between elderly patients with IBD and complications from therapy, hospitalizations, and surgery. Eligible studies were identified via structured keyword searches in PubMed and manual literature searches.

RESULTS

A total of 5,644 publications were identified. Of these, fourteen studies met inclusion criteria, encompassing 963 elderly IBD patients (113 Crohn's disease and 850 ulcerative colitis patients), over 37,000 hospitalizations of elderly IBD patients and over 4,500 controls. Consistent associations were observed between increased age and higher nocturnal stool frequency post-ileal pouch anal anastomosis. Only two studies met inclusion criteria for medication-related complications, one observed an increased mortality and infection risk among elderly patients treated with tumor necrosis factor antagonists and the other observed increased hospital-related complications among elderly patients treated with steroids.

CONCLUSIONS

Elderly patients with IBD are at an increased risk of hospital- and therapy-related complications. We found a paucity of high-quality studies evaluating outcomes in elderly patients with IBD. Further studies of elderly patients with IBD are needed to further evaluate the effect of age on medical and surgical complications.

Inflammatory bowel disease cause-specific mortality: a primer for clinicians

BACKGROUND

Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC) is perceived to harbor significant morbidity but limited excess mortality, thought to be driven by colon cancer, compared with the general population. Recent studies suggest mortality rates seem higher than previously understood, and there are emerging threats to mortality. Clinicians must be up to date and able to clearly convey the causes of mortality to arm individual patients with information to meaningfully participate in decisions regarding IBD treatment and maintenance of health.

METHODS

A MEDLINE search was conducted to capture all relevant articles. Keyword search included: "inflammatory bowel disease," "Crohn's disease," "ulcerative colitis," and "mortality."

RESULTS

CD and UC have slightly different causes of mortality; however, malignancy and colorectal cancer-associated mortality remains controversial in IBD. CD mortality seems to be driven by gastrointestinal disease, infection, and respiratory diseases. UC mortality was primarily attributable to gastrointestinal disease and infection. Clostridium difficile infection is an emerging cause of mortality in IBD. UC and CD patients have a marked increase in risk of thromboembolic disease. With advances in medical and surgical interventions, the exploration of treatment-associated mortality must continue to be evaluated.

CONCLUSIONS

Clinicians should be aware that conventional causes of death such as malignancy do not seem to be as significant a burden as originally perceived. However, emerging threats such as infection including C. difficile are noteworthy. Although CD and UC share similar causes of death, there seems to be some differences in cause-specific mortality.

Gastrointestinal drug interactions affecting the elderly

With the burgeoning elderly population in the United States, drug interactions are an increasing concern because of altered drug metabolism associated with age and polypharmacy. This article describes interactions between drugs used in common gastrointestinal diseases, including acid peptic disease, diarrhea, constipation, endoscopic procedural sedation, and inflammatory bowel disease, and those used to treat 5 common geriatric primary care diseases: hypertension, diabetes, hyperlipidemia, arthritis, and psychiatric illnesses.

Comparative outcomes of younger and older hospitalized patients with inflammatory bowel disease treated with corticosteroids

BACKGROUND

Data on the differences in inpatient treatment approaches and outcomes between younger and older patients with inflammatory bowel disease (IBD) are limited. Therefore, we used a parallel cohort study design to compare outcomes between younger and older patients with IBD.

METHODS

All anti-tumor necrosis factor (TNF)-naive patients aged 60 years and older hospitalized at our institution between 2003 and 2011 and treated with corticosteroids for an IBD flare were matched 1:1 to younger patients aged 18 to 50 years. Rates of corticosteroid response, colectomy, and initiation of anti-TNF therapy were compared.

RESULTS

Sixty-five patients were identified in each cohort. Median ages were 70 years (range, 60-94) and 30 years (range, 18-50) for the older and younger groups, respectively. Twenty-three percent of older patients were refractory to corticosteroids compared with 38% of the younger cohort (odds ratio, 0.5; 95% confidence intervals, 0.2-1.1). Older corticosteroid-refractory patients had surgery (80% versus 72%) and were started on anti-TNF therapy (20% versus 12%; P = 0.71), at a similar frequency as younger patients. Older steroid-responsive patients were less likely to start an anti-TNF agent during the first year of follow-up than younger patients (7% versus 31%, P = 0.006), but there was no difference in 1-year colectomy rates (27% versus 28%, P = 0.63).

CONCLUSIONS

Corticosteroid response was similar in older and younger patients hospitalized for IBD. Inpatient treatment for corticosteroid-refractory patients was similar between cohorts. Older corticosteroid-responsive patients were less likely to be treated with an anti-TNF than younger patients.

Surgical outcomes in the elderly with inflammatory bowel disease are similar to those in the younger population

BACKGROUND

Inflammatory bowel disease (IBD) has a bimodal distribution with approximately 15 % of patients manifesting after age 65. Previous reports suggest an increased risk of surgical complications in the elderly.

AIM

To compare surgical outcomes in elderly IBD patients (≥ 65 years at the time of surgery) to matched younger IBD cohorts.

METHODS

This was a retrospective cohort study at a single academic center of patients who underwent surgery for IBD. Forty-two elderly patients (≥ 65 years) were matched at least 1:1 (median 1:5) to patients in each of three control groups [18-35 years (n = 71); 36-49 years (n = 62); 50-64 years (n = 58)] according to gender, disease type/location, and type of surgery. Postoperative complications were compared. Patient characteristics were used in multivariate risk models. Analysis was performed using ordinary logistic regression.

RESULTS

Twenty ileal or ileocolonic resections, 12 partial or total colectomies, four stricturoplasties, and six laparoscopic partial or total colectomies were performed in the elderly group. The post-operative complication rate was not statistically different between the elderly and younger cohorts (38 % vs. 39 % vs. 40 % vs. 48 % in the 18-35, 36-49, 50-64, and ≥ 65 years groups, respectively, p = 0.26). The only significant risk factors for complication were Charlson comorbidity index (p = 0.0002), preoperative hemoglobin (p = 0.0065), total parenteral nutrition use (p = 0.024), and failed medical therapy (as the indication for surgery) (p = <0.0001).

CONCLUSIONS

The surgical complication rate among elderly and younger IBD patients was similar. Advanced age by itself should not be considered a risk factor for adverse operative outcome.

A clinical review of recent findings in the epidemiology of inflammatory bowel disease

Inflammatory bowel diseases (IBD), including both Crohn's disease and ulcerative colitis, are disorders of chronic inflammation of the gastrointestinal tract marked by episodes of relapse and remission. Over the past several decades, advances have been made in understanding the epidemiology of IBD. The incidence and prevalence of both Crohn's disease and ulcerative colitis have been increasing worldwide across pediatric and adult populations. As IBD is thought to be related to a combination of individual genetic susceptibility, environmental triggers, and alterations in the gut microbiome that stimulate an inflammatory response, understanding the potentially modifiable environmental risk factors associated with the development or the course of IBD could impact disease rates or management in the future. Current hypotheses as to the development of IBD are reviewed, as are a host of environmental cofactors that have been investigated as both protective and inciting factors for IBD onset. Such environmental factors include breast feeding, gastrointestinal infections, urban versus rural lifestyle, medication exposures, stress, smoking, and diet. The role of these factors in disease course is also reviewed. Looking forward, there is still much to be learned about the etiology of IBD and how specific environmental exposures intimately impact the development of disease and also the potential for relapse.

Elderly-onset IBD: a milder disease?

Patients with elderly-onset IBD are more likely to have marked comorbidities and polypharmacy than those diagnosed at a younger age, which might affect therapeutic decision-making. Increased knowledge of this higher-risk group might guide patient management. Data from a large population-based study evaluating the clinical presentation and course of elderly-onset IBD are discussed.

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.

Geriatric inflammatory bowel disease: phenotypic presentation, treatment patterns, nutritional status, outcomes, and comorbidity

BACKGROUND AND AIMS

The U.S. population is aging and the burden of geriatric inflammatory bowel disease (IBD) patients has increased. Systematic data describing phenotypic presentation, treatment regimens, outcomes and comorbidities in elderly IBD patients is limited. We performed a retrospective observational study of IBD patients age ≥65 followed in a 20-hospital system to determine patterns of phenotypic presentation, treatment, polypharmacy, nutritional status and comorbidity.

METHODS

Data were extracted from electronic medical record based on ICD-9 coding/indexed terms on Crohn's disease (CD) and ulcerative colitis (UC) patients.

RESULTS

A total of 393 geriatric IBD patients were identified (49.1% males; 50.9% females; 61.8% UC; 38.2% CD; 73.4 ± 6.6 years old). Younger age at diagnosis of CD (≤64) was associated with greater prevalence of small bowel surgeries (63.6%) compared with those diagnosed after age ≥65 (20.9%) (p < 0.005). Fistulizing/penetrating disease was frequent in patients diagnosed with CD at a younger age (43.6% compared to 7%) (p < 0.005). IBD maintenance treatment included: 44% 5-ASA agents; 31.6% maintenance prednisone (defined as ≥6 months treatment duration); 4.8% steroid suppositories; 5.6% 6MP/azathioprine; 1.3% methotrexate; 1.3% adalimumab; 1.3% infliximab; 9.4% loperamide/diphenoxylate/atropine; 0.5% had no IBD medications. Longer duration of CD disease correlated with vitamin B12, vitamin D and iron deficiency.

CONCLUSION

Geriatric patients diagnosed with CD earlier in life had greater small bowel involvement compared with new onset geriatric CD. There is low utilization of immunomodulator and biologic agents in geriatric IBD patients. Duration of CD correlates with nutrient deficiency. Prospective studies are warranted in this respect.

Medical and surgical therapy of inflammatory bowel disease in the elderly - prospects and complications

Population ageing is a global phenomenon. People aged 65 years and older comprise approximately 16% of the population of Europe. The medical management of elderly patients with inflammatory bowel disease (IBD) is challenging with respect to diagnosis, pharmaceutical and surgical treatment, and complications. IBD has a late onset in 10%-15% of patients, with the first flare occurring at 60 to 70 years of age; others suffer from the disease for several decades. Even though the natural course of the disease in geriatric populations and the diagnostic options may not differ much from those in younger patients, distinct problems exist in the choice of medical therapy. Recommended clinical practise has been rapidly evolving towards an intensified initial treatment in IBD. However, in patients older than 65 years, a gentler approach should be used, and a combination of immunosuppressive agents should be avoided because of increased risk of infectious and neoplastic complications. Furthermore, elderly patients with severe IBD show prolonged, complicated post-operative clinical courses with worse hospital outcomes, so early surgical intervention for elderly patients is recommended. This article provides an overview of elderly IBD patient care, including medical and surgical therapeutic considerations and emphasises the necessity of close collaborations between gastroenterologists and surgeons.

Potentiation of Th17 cytokines in aging process contributes to the development of colitis

Th17 cells, which produce IL-17 and IL-22, promote autoimmunity in mice and have been implicated in the pathogenesis of autoimmune/inflammatory diseases in humans. However, the Th17 immune response in the aging process is still not clear. In the present study, we found that the induction of IL-17-producing CD4(+) T cells was significantly increased in aged individuals compared with young healthy ones. The mRNA expression of IL-17, IL-17F, IL-22, and RORC2 was also significantly increased in aged people. Similar to humans, Th17 cells as well as mRNAs encoding IL-17, IL-22 and RORγt were dramatically elevated in naïve T cells from aged mouse compared to young ones. In addition, CD44 positive IL-17-producing CD4(+) T cells were significantly higher in aged mice, suggesting that memory T cells are an important source of IL-17 production. Furthermore, the percentage of IL-17-producing CD4(+) T cells generated in co-culture with dendritic cells from either aged or young mice did not show significant differences, suggesting that dendritic cells do not play a primary role in the elevation of Th17 cytokines in aged mouse cells. Importantly, transfer of CD4(+)CD45Rb(hi) cells from aged mice induced more severe colitis in RAG(-/-) mice compared to cells from young mice, Taken together, these results suggest that Th17 immune responses are elevated in aging humans and mice and may contribute to the increased development of inflammatory disorders in the elderly.

Validation of ICD-9-CM diagnostic codes for inflammatory bowel disease among veterans

BACKGROUND

Inflammatory bowel disease (IBD) is well described among young whites and less so among the elderly and non-whites. Population-level data is required to assess outcomes among minority groups.

AIM

To validate diagnostic codes for IBD from the Department of Veterans Affairs.

METHODS

National databases were used to identify local patients with Crohn's disease (CD) and ulcerative colitis (UC), the extra-intestinal manifestations and surgical procedures associated with IBD. Diagnosis was confirmed by manual chart abstraction. Multivariable logistic regression was used to derive diagnostic algorithms for CD and UC, which were then validated in an independent cohort.

RESULTS

The test cohort of 3,827 patients (1,316 potential cases, 2,511 random controls) was predominantly male (94%), white (56%), and of age of 58 (standard deviation 15). The positive predictive value (PPV) of CD codes was superior (88-100%) to UC (50-93%). The accuracy of extra-intestinal manifestations and surgeries was poor (PPV 0-29%). ICD-9-CM code 555.x without 560.9 had a PPV of 91% for CD in the validation cohort. Code 556.x with age, gender, and race factors was highly predictive of UC (c-statistic 0.9, PPV of 81%).

CONCLUSION

VA administrative data can diagnose elderly and non-white patients with IBD.

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.

Lower gastrointestinal bleeding in the elderly

Lower gastrointestinal bleeding (LGIB) is an important worldwide cause of morbidity and mortality in the elderly. The incidence of LGIB increases with age and corresponds to the increased incidence of specific gastrointestinal diseases that have worldwide regional variation, co-morbid diseases and polypharmacy. The evaluation and treatment of patients is adjusted to the rate and severity of hemorrhage and the clinical status of the patient and may be complicated by the presence of visual, auditory and cognitive impairment due to age and co-morbid disease. Bleeding may be chronic and mild or severe and life threatening, requiring endoscopic, radiologic or surgical intervention. Colonoscopy provides the best method for evaluation and treatment of patients with LGIB. There will be a successful outcome of LGIB in the majority of elderly patients with appropriate evaluation and management.

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.

Inflammatory bowel disease in the elderly is associated with worse outcomes: a national study of hospitalizations

BACKGROUND

Inflammatory bowel disease (IBD) has a bimodal peak of incidence with approximately 15% of the cases manifesting after 65 years. Previous reports on the outcomes of IBD in the elderly have been single-center studies or have predated the use of biologics. The aim of our study was to compare outcomes of IBD-related hospitalizations in a nationwide representative cohort of patients 65 years and older with younger patients.

METHODS

This was a cross-sectional study utilizing data from the Nationwide Inpatient Sample (NIS) for the year 2004. We identified all IBD-related hospitalizations through the presence of the appropriate ICD-9-CM codes for Crohn's disease, ulcerative colitis, or associated complications. We compared the differences in disease presentation as well the frequency of utilization of different interventions. We calculated the adjusted odds of mortality in older compared to the younger IBD patients using multivariate logistic regression.

RESULTS

Patients older than 65 years accounted for approximately 25% of all IBD-related hospitalizations in 2004. They were less likely to be hospitalized with fistulizing (4.0 versus 8.8%, P < 0.001) or stricturing disease (4.0 versus 5.8%, P = 0.001). Even after adjusting for comorbidity, they had higher in-hospital mortality (odds ratio [OR] 3.91, 95% confidence interval [CI] 2.50-6.11). Older patients with fistulizing disease are more likely to undergo surgery (OR 1.55, 95% CI 1.00-2.40). Among IBD patients who underwent surgery, older patients also had a longer postoperative stay (1.73 days, 95% CI 1.04-2.21).

CONCLUSIONS

Older patients with IBD-related hospitalizations have substantial morbidity and higher mortality than younger patients. Further research is needed to better characterize the natural history and treatment outcomes in this cohort.

[Epidemiology of inflammatory bowel disease in the elderly]

INTRODUCTION

Inflammatory bowel disease has classically been considered a disorder with onset in young people. However, between 5 and 15% of patients are diagnosed when aged more than 60 years old. Epidemiological studies comparing these two age groups are controversial and consequently new studies are required to define the characteristics in each group.

OBJECTIVES

To determine the epidemiological characteristics specific to Crohn's disease and ulcerative colitis in the elderly and to compare these characteristics with the form of presentation in young people in Spain.

METHOD

We performed a case-control, descriptive study. Patients with inflammatory bowel disease registered in the database of the Crohn-Colitis Unit were included. The patients were stratified in two groups according to age at symptom onset: the first group consisted of patients with onset at age 60 years or above and the second group was a control group consisting of patients aged less than 60 years old. The control group was composed of two patients for each case matched by sex and diagnosis.

RESULTS

Thirty-three cases aged more than 60 years old (4.1%) were included, eight with Crohn's disease and 25 with ulcerative colitis. The control group included 66 patients (16 with Crohn's disease and 50 with ulcerative colitis). Statistically significant differences were observed between the two groups both in the form of presentation (tenesmus and occlusive symptoms were more frequent and abdominal pain was less frequent in the group aged more than 60 years than in the control group) and in treatment response (corticosteroid dependency and refractoriness and requirement for immunosuppressive treatment were more frequent in the elderly).

CONCLUSION

The results of the present study suggest that there are epidemiological differences in inflammatory bowel disease among the elderly, notably a lower frequency of abdominal pain and a lower rate of refractoriness to steroid treatment.

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.

Diarrheal diseases in the elderly

Diarrhea in the elderly population is one disease that needs special attention in treatment and management, especially in acute- and long-term care residents, because of their multiple comorbidities, immunosenescence, frailty, and poor nutritional status. Close follow-up to ensure adequate hydration and electrolyte replacement and infection control measures to contain outbreaks should be emphasized to caregivers and nursing staff in acute- and long-term care facilities. Although C difficile colitis causes significant morbidity and mortality in this population, judicious use of antibiotics is important to decrease the incidence and recurrence of the disease. When the diarrhea is chronic and all stool testings and serologies have been performed, the patient may benefit from endoscopy and colonoscopy for biopsy. Attentive and vigilant nursing staff is crucial in the timely diagnosis and treatment of diarrheal diseases to improve quality of life and reduce mortality.

Age at onset of inflammatory bowel disease and the risk of surgery for non-neoplastic bowel disease

BACKGROUND

There is conflicting data regarding the response to medical and surgical therapy for inflammatory bowel disease with respect to age at disease onset.

AIM

To determine if the age at onset of Crohn's disease and ulcerative colitis is a risk factor for surgery for non-neoplastic bowel disease.

METHODS

This was a case-control study of patients evaluated between 1998 and 2001. Cases had undergone an initial operation for bowel disease. Controls were matched 1:1 for gender, disease subtype, date of first visit (+/-2 years), time from diagnosis prior to first visit (+/-3 years) and duration of follow-up. Association with age, disease extent, smoking history, medication use and co-morbidities vs. case/control status was assessed using multiple variable conditional logistic regression to estimate the odds ratio (OR) and 95% confidence intervals (CI) for undergoing surgery.

RESULTS

Among 132 Crohn's patients, older patients had lower odds for surgery (OR per 5 years, 0.86; 95% CI: 0.75-0.98). The rate of surgery for non-neoplastic bowel disease was not significantly associated with disease distribution, co-morbidities or cigarette smoking. Among 234 ulcerative colitis patients, the rate of surgery was unrelated to age, disease extent, co-morbidities or cigarette smoking,

CONCLUSIONS

For Crohn's disease, but not ulcerative colitis, the risk of surgery for non-neoplastic bowel disease decreases with increasing age at diagnosis, irrespective of disease distribution and history of cigarette smoking.

Crohn's disease runs a more aggressive course in young Asian patients

BACKGROUND

Crohn's disease is a heterogeneous inflammatory bowel disease. The impact of age at diagnosis on the clinical course of patients varies widely as reported in the Western literature. Using the Vienna Classification, we seek to determine whether young Crohn's disease patients in an Asian population followed a different clinical course than old patients.

METHODS

The case records of 100 Crohn's disease patients who were treated at the Inflammatory Bowel Disease Center, Singapore General Hospital, were studied retrospectively. The age group and location of disease and behavior according to the Vienna classification were determined at diagnosis.

RESULTS

A1 group (age <40 years) defined as "young" and A2 group (age > or =40) defined as "old" contained 65 and 35 patients, respectively. Median age for the young group was 27.4 years and that for the old group was 52.6 years. Of the young patients, 66.7% flared at least once compared with 28.6% of the old patients, odds ratio of 5.0 (P < 0.001). Young patients were more likely to be steroid dependent (20.0% of A1 versus 8.6% of A2, P = 0.14), received azathioprine (38.5% of A1 versus 5.7% of A2, P < 0.001) and experienced complications (31% of A1 versus 20% of A2, P = 0.25)-numerically higher rates that did not reach statistical significance. There was no significant difference between the age groups for the location and behavior of disease as well as requirement for surgery.

CONCLUSION

In this first Asian study looking specifically at the impact of age at diagnosis of Crohn's disease, we found that young patients underwent a more aggressive clinical course.

Disease location, anti-Saccharomyces cerevisiae antibody, and NOD2/CARD15 genotype influence the progression of disease behavior in Crohn's disease

BACKGROUND

Crohn's disease (CD) is characterized by heterogeneity of phenotype. The Vienna classification can be used to classify CD, and recent data illustrate that behavior evolves over the course of the disease. Clinical and biological influences on disease progression remain unclear. We examined the associations of CD disease progression at diagnosis and for up to 20 years of follow-up.

METHODS

Two hundred thirty-one well-characterized CD patients were studied. Demographic, clinical, and NOD2/CARD15 data were collected. Disease behavior according to the Vienna classification was assessed at diagnosis and for up to 20 years following diagnosis.

RESULTS

At diagnosis, 70% of patients had inflammatory disease, 9% stricturing, and 21% penetrating. Early age at diagnosis was associated with ileocolonic and upper GI disease (p = 0.015), and positive anti-Saccharomyces cerevisiae antibody (ASCA) was associated with ileal involvement (p = 0.008). Smoking was relatively protective against colonic, rather than ileal involvement at diagnosis (p < 0.02). At 20 years, 92% had progressed to a more severe disease type. Patients who progress to a more severe disease type require more frequent surgery (p < 0.00001). Multivariate analysis found disease progression to be associated with ileal disease location (p = 0.001) and positive ASCA (p = 0.003). Variant NOD2/CARD15 alleles were protective against rapid progression of disease phenotype (p = 0.04). The presence of perianal disease was independent of intestinal penetrating disease.

CONCLUSIONS

The progression of disease type in CD is associated with the need for more frequent surgery. Rapid progression is associated with ileal disease and positive ASCA, and delayed progression is associated with variant NOD2/CARD15 alleles. Consideration should be given to a separate Vienna classification for perianal disease.

Crohn's disease in the over-60 age group: a population based study

OBJECTIVES

Late-onset Crohn's disease (CD) may show a distinctive pattern of expression. The aim of our study was to describe the incidence or presentation of CD in the elderly and compare the outcomes in patients < 60 years or > or = 60 years at diagnosis.

METHODS

The study included a population based inception cohort of all incident CD cases diagnosed in Brittany (France) between 1994 and 1997. Sixty-three patients were > or = 60 years and 201 were < 60 years at diagnosis. The physicians managing the patients used standardized questionnaires to collect the study data. The questionnaires on outcomes and treatments were completed in 2002.

RESULTS

In patients > or = 60 years, the annual incidence was 2.5 per 10 persons and clinical features were similar to those in younger patients, except for a higher rate of colon involvement. Among older patients, those with diverticula (29/63, 46%) were more likely to have granulomas (58% vs 33% of patients without diverticula, P < 0.04), but the diagnosis of CD was confirmed by lesions remote from the diverticula in most cases (23/29). Early resection rates were not higher in older patients, who were less likely to require immunosuppressants or re-admission for CD flares, as compared to younger patients. Five year mortality in older patients was 16% but was unrelated to CD.

CONCLUSIONS

In Brittany, the age specific incidence, clinical features, and prognosis of CD among the elderly are comparable to those in younger individuals. Colon involvement is more common. Concomitant diverticular disease is common and should prompt a search for CD lesions at other sites to confirm the diagnosis. Older patients are less likely to require immunosuppressants or admission for flares.

Lower gastrointestinal bleeding in elderly patients

Lower gastrointestinal bleeding (LGIB) is one of the common medical emergencies that can become life-threatening in elderly patients. Increased prevalence of cerebrovascular and cardiovascular diseases, malignancy, polypharmacy, and the use of nonsteroidal anti-inflammatory drugs in elderly patients adversely affects the outcome of LGIB. Diverticular bleeding, vascular ectasia, polyps and hemorrhoids are among the common causes of LGIB in the elderly. In a majority of cases, LGIB stops spontaneously with resuscitation and supportive therapy. In those elderly patients in whom LGIB continues, benefits of endoscopic, angiographic, or surgical intervention should not be withheld because of age alone. However, the timing of tests and the type of intervention should be custom tailored for frail elderly patients. Such a decision should depend upon functional status, its impact on outcome, and the consent process.

Advances in clinical laboratory tests for inflammatory bowel disease

Inflammatory bowel disease (IBD) is a generic term that refers to Crohn's disease and chronic ulcerative colitis (UC). The CD and UC are considered to be distinct forms of IBD; but there is a subgroup of CD with a UC-like presentation. The genetic factors play a significant role in IBD. IBD is associated with a strong familial pattern. Recent studies support the hypothesis that IBD patients have a dysregulated immune response to endogenous bacteria in the gastrointestinal tract. The serologic responses seen in Crohn's disease include antibodies to Saccharomyces cerevisiae, mycobacteria, bacteroides and E. coli. The pANCA antibody seen in UC and CD has been demonstrated to react with epitopes of H1 histone, Bacteroides caccae (Ton-B linked outer membrane protein), Pseudomonas fluorescens-associated bacterial protein I-2, mycobacterial histone 1 homologue called Hup B. In recent years, several serologic markers have been found to be useful for the diagnosis and differentiation of CD and UC. These markers include the following antibodies: (a) pANCA, (b) ASCA, (c) anti-pancreatic antibody, (d) OmpC antibody and (e) I-2 antibody and antibodies to anaerobic coccoid rods. The application of a panel of markers with the use of an algorithm (i.e. IBD First Step) can identify specific subtypes of IBD that have different clinical courses and progression of the diseases. The serologic markers are useful for the diagnosis and management of CD and UC patients.

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.

Gastrointestinal diseases in the elderly

PURPOSE OF REVIEW

The subject of gastrointestinal disorders in the elderly is timely and important because of the demographic reality that soon over 20% of our population will be older than 65 years of age, utilizing perhaps 50% of our total healthcare costs. The purpose of this review is to draw attention to some areas of clinical information that point in the direction of better clinical care for the elderly. Medicine is finally advancing from the era when most symptoms in older patients were ascribed to the aging process itself. Indeed, within gastroenterology there are few changes that occur inevitably as part of aging.

RECENT FINDINGS

Progress has been made in several areas of gastrointestinal pathophysiology. These include: the pathophysiology of swallowing and evacuation disorders and the beginning of the application of techniques derived from physiological studies to improve function; recognizing the importance of reflux esophagitis and its complications and improving treatment; understanding the importance of disorders of malabsorption and their impact upon nutrition in the elderly; major issues in the diagnosis and management of inflammatory bowel disease in this age group; and approaches to the prevention and treatment of gastrointestinal cancer, particularly colorectal cancer.

SUMMARY

As we pay more attention to these areas and encourage clinical research we expect to improve the treatment of older patients with these diseases and to reduce the burden of morbidity in this population.

Treatment of inflammatory bowel disease in the elderly: an update

Inflammatory bowel disease (IBD) is most common in young adults, but it can also present in the elderly. Furthermore, with the aging of the population, the number of elderly patients with IBD is expected to grow. Other conditions, such as diverticulitis and ischaemic colitis, may be more common in the elderly and need to be considered in the differential diagnosis. Management of elderly patients with IBD follows the same principles as in younger patients, with a few exceptions. For patients with mild-to-moderate colitis, a 5-aminosalicylate drug is often used (sulfasalazine, olsalazine, mesalazine, balsalazide). Topical therapy may be sufficient for those with distal colitis, whereas an oral preparation is used for more extensive disease. In those with more severe or refractory symptoms, corticosteroids are used, although the elderly appear to be at increased risk for corticosteroid-associated complications. For patients with corticosteroid-dependent or corticosteroid-refractory disease, immunosuppression with azathioprine or mercaptopurine may help avoid surgery. In patients with Crohn's disease, a similar approach is followed, with the additional consideration that the formulation of drug used must ensure delivery of drug to the site of inflammation. In fistulising Crohn's disease, antibacterials, immunosuppressive drugs, infliximab and surgery are often used in combination. Controlled trials and clinical experience have shown that infliximab is a significant addition to the therapeutic armamentarium for patients with Crohn's disease.

Diagnosis and misdiagnosis of inflammatory bowel disease

Several diseases can mimic IBD clinically, but careful and repeated evaluations, if necessary, will dramatically decrease the likelihood of misdiagnosis. A careful consideration of patient's clinical, radiographic, endoscopic, and histopathologic features will establish the correct diagnosis in the majority of cases.