Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2024 Jul 1.
Published in final edited form as: Curr Opin Gastroenterol. 2023 May 23;39(4):268–273. doi: 10.1097/MOG.0000000000000943

Managing the Older Adult with Inflammatory Bowel Disease: Is Age Just a Number?

Helen Bermudez 1, Adam S Faye 2,3, Bharati Kochar 4,5,6
PMCID: PMC10275506  NIHMSID: NIHMS1894141  PMID: 37265181

Abstract

Purpose of review

This review summarizes the most recent literature on older adults with inflammatory bowel diseases (IBD). Additionally, we review geriatric syndromes that may be pertinent to the management of older adults with IBD.

Recent findings

Traditionally chronological age has been used to risk stratify older adults with IBD, however physiologic status, including comorbidities, frailty, and sarcopenia, are more closely associated with clinical outcomes for older adults. Delaying care for and undertreating older adults with IBD based upon advanced chronologic age alone is associated with worse outcomes, including increased mortality. Treatment decisions should be made considering physiologic status, with an understanding of the differential risks associated with both ongoing disease and treatment. As such, there is an increasing recognition of the impact geriatric syndromes have on older adults with IBD, which need to be further explored.

Summary

Older adults with IBD are less likely to receive advanced therapies and timely surgery. They are also more likely to have adverse outcomes despite having similar disease courses to younger adults with IBD. Focusing on biological age as opposed to chronological age can shift this trajectory and improve quality of care for this growing population of patients with IBD.

Keywords: Aging, Crohn’s disease, ulcerative colitis, geriatric, frailty, sarcopenia

Introduction

There is an exponential growth of older patients with inflammatory bowel diseases (IBD) in recent times; estimates from the Western hemisphere note that anywhere between one quarter and one third of patients with IBD are 60 years or older. This growth can be explained by a rising incidence, but also by an improvement in treatment and life-expectancy (1,2*). Patients 65 years and older now constitute the fastest growing age group of individuals with IBD in the Western world (3*). While traditional teaching suggested that thymic involution and immunosenescence, among other processes of decline, may result in a milder course of IBD at older ages, recent literature has suggested otherwise. In a prospective cohort study in the United States (U.S.), after accounting for disease duration, there was no significant difference in Crohn’s disease behavior and extent of ulcerative colitis between older and younger individuals (4,5). Other studies reveal a high risk for surgery among individuals with older-onset IBD, suggesting aggressive IBD disease at older ages as well (6,7). Despite the similarities in disease courses, treatment often differs between older and younger adults with IBD.

Older adults with IBD may be newly diagnosed (older-onset) or have aged with longstanding disease. Beyond IBD disease duration, older adults are a heterogeneous population, making unifying management guidelines challenging. Increasingly, it is recognized that older adults require individualized care given shifting physiology, functional capacity, and goals. As the projected number of geriatricians per capita is declining, sub-specialists will increasingly be required to provide geriatric tailored care for older patients in their practice. This is a challenge we must be prepared to face and address in this decade (8,9*). In this review, we will summarize the existing literature on management of IBD in older adults, present geriatric risk-stratification constructs, and highlight avenues to think beyond chronologic age as a consideration in the care of an older adult with IBD.

IBD-Related Disease Management

Overall, older adults with IBD are more likely to have an adverse outcome as compared to younger adults with IBD (10*). This has led to a historic reluctance to use advanced therapies or surgical interventions in the management of older adults with IBD, despite similar consequences of under treatment in both younger and older adults (5). More recently, there is a proliferation of comparative effectiveness and safety literature evaluating newer therapeutic agents in the treatment of IBD, as well as about surgical management for older adults with IBD (10*). In a pooled analysis of randomized trials of anti-tumor necrosis factor (TNF) agents, there was no increased risk of infection when comparing older adults who received treatment as compared to placebo, suggesting that disease activity rather than treatment effects, may be more closely associated with adverse events (11**). Further, in a single-centered retrospective analysis, severe disease was the second most common cause of inpatient IBD-related mortality in older adults (12*).

Despite the mounting evidence of the importance of steroid-sparing effective immunosuppression in patients with IBD, older patients with IBD are less likely to be treated with advanced therapies including biologic agents, as compared to younger adults, and conversely are more likely to be treated with prolonged courses of corticosteroids (5). Corticosteroid use has several well-known short term and long term systemic detrimental effects that are amplified at older ages.

The management of older adults with IBD therefore falls into a classic risk paradox: those who are most likely to benefit from high-risk treatments are the ones who are least likely to receive it. Delays in treatment may result in decisions made in urgent and emergent situations where outcomes may be worse due to limited planning. For example, an analysis of outcomes after emergent colectomy in older adults revealed a higher postoperative mortality rate, compared with planned interventions in patients with older-onset UC (13*).

Perhaps, the reluctance to use effective treatment strategies in older adults with IBD stems from the lack of high-quality data. High quality, prospective data on the medical and surgical management of older adults are limited, but acutely needed. Older patients with IBD are also disproportionately under-represented in clinical trials of approved IBD medications: fewer than 1% of randomized controlled trials studying medications approved to treat IBD included patients who are 65 or older (14*). Additionally, there has been no consideration of constructs beyond chronologic age, either as inclusion criteria or outcomes in the majority of IBD clinical trials (14*,15*). This is a significant limitation, as thinking beyond chronological age and considering factors such as functional status is critical for optimizing care decisions for older adults with IBD (16*).

Frailty: A Measure of “Biologic” Age

Frailty is a state of decreased physiological reserve that is associated with adverse health outcomes. While there is no universally accepted measure of frailty, there are prevalent constructs based on the suitability of the population and question (17). One model describes frailty as a phenotype of 3–5 characteristics: fatigue, unintentional weight loss, slow gait speed, weakness, and reduced functional capacity (18). Another model of frailty postulates that it is an accumulation of deficits spanning domains of morbidity, function, sensation, and cognition (19). A comprehensive geriatric assessment measures aspects that contribute to frailty. In a cross-sectional European cohort of older adults with IBD, disease activity was associated with an increasing number of geriatric deficits identified by a comprehensive geriatric assessment that includes activities of daily living, instrumental activities of daily living, physical capacity, comorbidities, polypharmacy, malnutrition, depression, cognitive function, and a social domain (20**).

In a population-based cohort, older adults with IBD were more likely to be frail than matched comparators (21*). Further retrospective studies demonstrate that in patients of all ages with IBD, frailty is independently associated with adverse outcomes such as hospital readmission and mortality (22*). Another study demonstrated that patients with IBD who were frail, prior to initiation of an anti-TNF agent or immunomodulator, had a significant greater risk of frailty after treatment than those who were not frail. These studies suggest that frailty is a relevant risk stratification concept in patients with IBD, particularly among older patients in whom there is a higher prevalence of frailty (21*,22*).

Increasingly, it is recognized that frailty is a dynamic state that can be modulated and perhaps even prevented through various multi-modal interventions, although there is no universally accepted approach (23*). Phenotypic frailty, which has been the most responsive to intervention and change in other chronic disease states, shares many features with IBD: fatigue, unintentional weight loss, sarcopenia, and anorexia just to name a few features (24*). Therefore, to better understand which features of frailty are most pertinent in patients with IBD, it will be critical to disentangle frailty conferred by active inflammation from intrinsic frailty. Eventually, an understanding of which components of frailty in patients of all ages with IBD are preventable, reversible, or amenable to intervention will be most beneficial to patients (25*). Frailty may be ameliorated by IBD treatment, but frailty also confers an increased risk for adverse events with treatments (22*,23*,25*,26). Understanding that risk-benefit ratio and learning how to identify the patient who will most benefit from that intervention remains unknown. Current studies on frailty in IBD are largely retrospective, and most often focus on deficit models (27*). Robust and prospective studies are needed to elucidate the most pertinent definition of frailty and the role of frailty as a risk stratification modality in patients with IBD (28). Therefore, at this time, beyond a consideration of the overlap between IBD and frailty, there is no practical application for frailty in routine practice. Further research is needed before incorporating measures of frailty into the clinical practice of IBD.

Sarcopenia

Sarcopenia is a progressive and generalized loss of skeletal muscle mass, strength, and function that is also associated with adverse outcomes among several different patient populations (8). Although sarcopenia is often associated with advancing age, more recent data suggests that it begins earlier in life and is closely associated with ongoing inflammation (29,30*). As such, sarcopenia is common in patients with IBD, with some estimates noting a prevalence of more than 60% (31*), although variations exist between studies (32*). This likely stems from the heterogeneity of sarcopenia assessments used, as studies use different imaging-based measures of muscle mass and use differing cutoffs to define the presence or absence of sarcopenia (29–31*,33*). Additionally, most studies exclude measures of muscle strength and function, limiting their applicability.

Although the data on sarcopenia in IBD are limited and heterogenous, the majority of studies report that sarcopenia is associated with increased postoperative morbidity, mortality, and readmission after intestinal resection (34). In a recent retrospective study, sarcopenia was independently associated with increased risk of anastomotic leak in IBD patients undergoing colorectal surgery (32*). In a separate prospective study, sarcopenia, measured by grip strength and muscle mass in patients with IBD who were 18–60 years-old, was associated with worse clinical outcomes as compared to controls and individuals defined as pre-sarcopenic (35*). Future research should expand upon this using uniform diagnostic criteria, and include measures of muscle strength and function to comprehensively evaluate the impact of sarcopenia on operative and clinical outcomes in IBD. Additionally, research on sarcopenia and its intersection with frailty should work toward identifying potentially modifiable interventions, such as strength training and nutrition, paving the way for future research evaluating the impact of such interventions (34).

Polypharmacy

Polypharmacy, most commonly defined as the regular use of 5 or more medications, is noted in least 39% of older adults in the U.S. (36). Polypharmacy is associated with adverse outcomes including hospitalizations, drug interactions, poor drug compliance, undertreatment, and increased mortality (37). However, polypharmacy is not widely studied in older patients with IBD. In one recent retrospective study, polypharmacy was present in 48% of patients with IBD aged 62 years and older and was associated with a higher risk of IBD therapy nonadherence (38*).

While numerical definitions of polypharmacy are easier to use in studies, there is an increasing role for therapeutic polypharmacy in multi-morbid patients, where each medication is indicated for the appropriate treatment of the morbidity. In patients with IBD, not surprisingly, polypharmacy is associated with comorbidities such as colon cancer, ischemic heart disease, and diabetes mellitus (39*). However, regular reconciliation of gastrointestinal medications should be performed in IBD clinic to ensure that medications are being used for the appropriate indications (40). As an example, in older adults with IBD, diarrhea symptoms may be treated with high anti-cholinergic burden medications. This not only augments polypharmacy but can lead to undesirable anti-cholinergic effects in older individuals, including falls and cognitive decline (9*,41). Instead, it is important to utilize more effective treatments for inflammation or inflammation-associated motility and nerve disturbances (41).

Treatment and Disease Attributed Malignancy Risk

Risk for malignancies is a significant consideration in the treatment of older adults with IBD, who have a higher baseline risk for malignancies. Thiopurines, a mainstay of IBD treatment in previous decades, are associated with increased risks for malignancy, including non-melanoma skin cancer, myeloid leukemia, myelodysplastic syndromes, and lymphoma (42*). While anti-TNF therapy may confer an increased risk for certain malignancies, the risk is greatest with combination therapy with thiopurines (43,44). Similarly, advanced therapies are thought to be associated with augmented risk of cancer, yet recent studies suggest that this risk may not be purely attributable to the medications themselves (45,46*). In patients with IBD with a prior history of cancer, immunosuppression exposure including anti-TNF did not result in higher incidences of malignancy, either new or recurrent (47). Furthermore, in IBD patients with cancer, exposure to anti-TNF and other biologics did not influence the risk of cancer progression-free survival (48*). This further exemplifies the importance of properly treating all older adults with IBD and highlights the need for more studies in this area.

Patients with chronic colonic inflammation from IBD have a ~2–3-fold increased risk of developing colorectal cancer (CRC), even without concomitant PSC (primary sclerosing cholangitis). In the absence of concurrent PSC, the recommendation is to start a routine surveillance colonoscopy program 8–10 years after symptoms onset for patients with colitis, with subsequent colonoscopies occurring every 1–3 years (49*). Further, it should be noted that the risk of CRC increases as duration of disease increases, making older adults with longstanding disease at potentially higher risk for CRC (50). Akin to colon cancer screening for the general population, there is a paucity of data evaluating when routine surveillance colonoscopies should be stopped among older adults with IBD.

Screening colonoscopies are routinely recommended until age 75, however this is a sporadic adenoma associated colorectal adenocarcinoma, which has a nearly 10-year latency period (51*). Colon carcinogenesis in patients with IBD follows a more aggressive pathway (52) and therefore, it may be inappropriate to stop screening based on chronologic age alone. In a retrospective study aimed to assess yield of surveillance colonoscopies in older patients with IBD, a major risk factor for the development of dysplasia in IBD patients ≥75 years-old was a prior diagnosis of dysplasia or CRC. This suggests that a prior history of dysplasia could be used to risk stratify patients with IBD who might benefit from ongoing colonoscopies beyond the age of 75. However, this should be considered in the context of a patients’ functional status, comorbidities, and life expectancy (51*). Beyond increased procedural risk at advanced ages, it is important to recognize the impact that bowel preparation and sedation can have on older adults. However, there are many adults in their late 70s and early 80s who will benefit from an ongoing surveillance program as they would be excellent candidates for endoscopic resection of limited foci of dysplasia or even a colectomy for persistent multi-focal dysplasia. History with IBD and findings from surveillance colonoscopies should be considered when making decisions on the need for future surveillance colonoscopies. Consequently, there should not be one chronologic age at which a patient should stop having surveillance colonoscopies for IBD. Given the nascent stages of current evidence, an ongoing conversation engaging in shared-decision making should be employed to make a mutually acceptable decision on continuing surveillance colonoscopies and an age to stop (53).

Our Practice

We strive to provide evidence-based care for our patients. However, as with other diseases, in IBD those who are most vulnerable are least likely to be included in the studies that provide practice-guiding evidence. In our practice, we aim to provide tailored care based on the patient in front of us, taking into consideration how our recommendations may impact their overall life beyond just their disease. For our older adults specifically, we discuss aspects of their IBD that impact the 5Ms of age-friendly healthcare: Mind, Mobility, Medications, Multi-complexity, and what Matters most (9*). We use this knowledge to craft an IBD treatment plan that will help ameliorate their overall life beyond just their IBD. We emphasize that advanced chronologic age alone should not limit their treatment options, and that untreated disease may lead to larger decrements in quality of life than the treatments themselves (11**,54). However, we do recognize that the U.S. insurance system may often limit and dictate treatment options and strategies. We share with our patients that in the current decade, IBD should not be a condition that limits their life expectancy, but it is important to be thoughtful about treating IBD because of the significant impact it has on quality of life, which may be equally, if not, more important for our older adults. As in all aspects of providing medical care, especially for those who are most vulnerable, humility and collaboration is critical: we admit what we know and what we don’t know. We draw upon our experience, but also discuss challenging cases with colleagues. Open communication with patients and their caregivers is especially important for older adults since the patient-caregiver dynamic can change with age.

Conclusion

As the population continues to age, there will an increasing number of older adults living with IBD. Currently, there is limited understanding of the optimal management of IBD at older age given the shifting risk-benefit paradigms based on variable physiologic and immunologic processes, as well as changes in functional status that accompany advanced chronological age. This creates disparities in the degree of evidence-based treatment that we provide to our older patient with IBD. Geriatric constructs such as frailty and sarcopenia should be better studied prospectively to determine their role as an objective risk stratification tool for treatment decision making. Furthermore, efforts to ensure that studies and clinical trials are more representative of our real-world patient population should be made. Ultimately, accepting that age is just a number and there are other, more objective, measures of vulnerability is important for optimizing the care of our aging IBD patient population.

Key Points.

  • Older adults with IBD can have similar disease courses as compared to their younger counterparts

  • Older adults have a higher baseline risk for adverse events; adequate disease control can minimize this risk

  • Physiologic status, including frailty and sarcopenia, should be considered in treatment decisions for older adult with IBD

  • Gastroenterologists should be aware of geriatric constructs, such frailty and polypharmacy, which can have significant impacts on the older adults

Financial support and sponsorship

R03AG074059 (BK) and R03AG078927 (ASF)

Footnotes

Conflicts of interest No relevant financial conflicts of interest

References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:

* of special interest

** of outstanding interest

  • 1.Zammarchi I, Lanzarotto F, Cannatelli R, et al. Elderly-onset vs adult-onset ulcerative colitis: A different natural history? BMC Gastroenterol. 2020. May 12;20(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2. Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Vol. 18, Nature Reviews Gastroenterology and Hepatology. Nature Research; 2021. p. 56–66. * Perspective piece that describes the 4 epidemiologic phases of IBD: Emergence, Acceleration, Compounding and Equilibrium.
  • 3. Kuenzig ME, Stukel TA, Kaplan GG, et al. Variation in care of patients with elderly-onset inflammatory bowel disease in Ontario, Canada: A population-based cohort study. J Can Assoc Gastroenterol. 2021. Apr 6;4(2):e16–30. * Using population-based health administrative claims data, this analysis describes the wide variation in care experienced by patients diagnosed with IBD ≥65 years and identifies that older patients with IBD who are treated by gastroenterologists have better outcomes.
  • 4.Kochar B, Long MD, Galanko J, et al. Inflammatory Bowel Disease is Similar in Patients with Older Onset and Younger Onset. Inflamm Bowel Dis. 2017. Jul 1;23(7):1187–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Rozich JJ, Dulai PS, Fumery M, et al. Progression of Elderly Onset Inflammatory Bowel Diseases: A Systematic Review and Meta-Analysis of Population-Based Cohort Studies. Clinical Gastroenterology and Hepatology. 2020. Oct 1;18(11):2437–2447.e6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Bewtra M, Newcomb CW, Wu Q, et al. Mortality associated with medical therapy versus elective colectomy in ulcerative colitis a cohort study. Ann Intern Med. 2015. Aug 18;163(4):262–70. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Everhov ÅH, Halfvarson J, Myrelid P, et al. Incidence and Treatment of Patients Diagnosed With Inflammatory Bowel Diseases at 60 Years or Older in Sweden. Gastroenterology. 2018. Feb 1;154(3):518–528.e15. [DOI] [PubMed] [Google Scholar]
  • 8.Kotsani M, Kravvariti E, Avgerinou C, et al. The relevance and added value of geriatric medicine (Gm): Introducing gm to non-geriatricians. Vol. 10, Journal of Clinical Medicine. MDPI; 2021. Jul 7;10(14):3018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9. Kochar B, Ufere NN, Ritchie CS, Lai JC. The 5Ms of Geriatrics in Gastroenterology: The Path to Creating Age-Friendly Care for Older Adults with Inflammatory Bowel Diseases and Cirrhosis. Vol. 13, Clinical and Translational Gastroenterology. Lippincott Williams and Wilkins; 2022. p. E00445. * This concept model proposes applications for the 5M model of geriatric health care to older adults with IBD.
  • 10. Rozich JJ, Luo J, Dulai PS, et al. Disease-and Treatment-related Complications in Older Patients with Inflammatory Bowel Diseases: Comparison of Adult-onset vs Elderly-onset Disease. Inflamm Bowel Dis. 2021. Aug 1;27(8):1215–23. * In a retrospective cohort study, they identified that IBD patients ≥60 years old who age with the disease, had a lower risk of treatment-related complications than patients with elderly onset (≥60 years) IBD without a significant difference in risk of disease-related complications.
  • 11. Cheng D, Cushing KC, Cai T, Ananthakrishnan AN. Safety and Efficacy of Tumor Necrosis Factor Antagonists in Older Patients With Ulcerative Colitis: Patient-Level Pooled Analysis of Data From Randomized Trials. Clinical Gastroenterology and Hepatology. 2021. May 1;19(5):939–946.e4. ** In a post-hoc analysis of pooled data from ulcerative colitis clinical trials, they found that adults ≥60 years with UC had a greater baseline risk for serious adverse events compared with younger adults. Yet, there was no increase in risk in older adults treated with an anti-TNF agent compared with older adults treated with placebo.
  • 12. Schwartz J, Stein DJ, Lipcsey M, et al. High rates of mortality in geriatric patients admitted for inflammatory bowel disease management. J Clin Gastroenterol. 2021. Jan 1;56(1):E20–6. * In an analysis of National Inpatient Sample, they found that age ≥65 years was independently associated with greater odds of death after controlling for comorbidities, type of admission, surgery, hospital type, and IBD type.
  • 13. Kuwahara R, Ikeuchi H, Bando T, et al. Clinical results following colonic resection for ulcerative colitis in elderly individuals (elderly-onset vs. nonelderly onset). BMC Surg. 2022. Dec 1;22(1). * In a single-center retrospective analysis, they concluded that older adults who required emergent colectomy for ulcerative colitis had poorer outcomes, including nearly 15% rate of mortality, compared with younger adults undergoing emergent colectomy.
  • 14. Kochar B, Kalasapudi L, Ufere NN, et al. Systematic Review of Inclusion and Analysis of Older Adults in Randomized Controlled Trials of Medications Used to Treat Inflammatory Bowel Diseases. Vol. 27, Inflammatory Bowel Diseases. Oxford University Press; 2021. p. 1541–3. * This review highlights the disproportionate under-representation of older adults in clinical trials of approved IBD medications in the modern era.
  • 15. Vieujean S, Caron B, Jairath V, et al. Is it time to include older adults in inflammatory bowel disease trials? A call for action. Vol. 3, The Lancet Healthy Longevity. Elsevier Ltd; 2022. p. e356–66. * This review highlights that older adults with IBD are often excluded from clinical trials and describes approaches that can be taken to ensure that they are included.
  • 16. Cheng D, Kochar B, Cai T, et al. Comorbidity Influences the Comparative Safety of Biologic Therapy in Older Adults With Inflammatory Bowel Diseases. American Journal of Gastroenterology. 2022. Nov;117(11):1845–50. * In an analysis of insurance claims databases, this analysis found that adults ≥60 years are less likely to be treated with effective and indicated therapies including immunosuppression for moderate-severe IBD. In addition, they demonstrated that comorbidities, not chronologic age alone, mediated adverse outcomes after immunosuppression.
  • 17.Hollinghurst J, Housley G, Watkins A, et al. A comparison of two national frailty scoring systems. Age Ageing. 2021. Jul 1;50(4):1208–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. J Gerontol A Biol Sci Med Sci. 2001. Mar;56(3):M146–56. [DOI] [PubMed] [Google Scholar]
  • 19.Roberts S, Collins P, Rattray M. Identifying and managing malnutrition, frailty and sarcopenia in the community: A narrative review. Vol. 13, Nutrients. MDPI AG; 2021. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20. Asscher VER, Waars SN, van der Meulen-de Jong AE, et al. Deficits in Geriatric Assessment Associate With Disease Activity and Burden in Older Patients With Inflammatory Bowel Disease. Clinical Gastroenterology and Hepatology. 2022. May 1;20(5):e1006–21. ** In a cross-sectional cohort of patients ≥60 years with IBD, they demonstrated that patients with IBD who had more deficits on a geriatric assessment had a higher burden of disease. Furthermore, active disease was associated with more geriatric deficits pointing to the importance of improving treatment approaches.
  • 21. Kochar B, Jylhävä J, Söderling J, et al. Prevalence and Implications of Frailty in Older Adults With Incident Inflammatory Bowel Diseases: A Nationwide Cohort Study. Clinical Gastroenterology and Hepatology. 2022. Oct;20(10):2358–2365.e11. * In a population-based cohort, this analysis demonstrated that adults ≥60 years were more likely to be higher risk for frailty than matched non-IBD comparators.
  • 22. Faye AS, Wen T, Soroush A, et al. Increasing Prevalence of Frailty and Its Association with Readmission and Mortality Among Hospitalized Patients with IBD. Dig Dis Sci. 2021. Dec 1;66(12):4178–90. * In an analysis of 4 years of data from the National Readmissions Database, this study identified that frailty is associated with a higher risk of readmissions and mortality among patients with IBD independent of age, comorbidities, and severity of admission.
  • 23. Qian AS, Nguyen NH, Elia J, et al. Frailty Is Independently Associated with Mortality and Readmission in Hospitalized Patients with Inflammatory Bowel Diseases. Clinical Gastroenterology and Hepatology. 2021. Oct 1;19(10):2054–2063.e14. * In an analysis of the National Readmissions Database in 2013, they found that infections, not IBD, were the leading cause of hospitalization for older adults with IBD and frailty was independently associated with higher risk for mortality and hospitalizations.
  • 24. Kochar B, Orkaby AR, Ananthakrishnan AN, Ritchie CS. Frailty in inflammatory bowel diseases: an emerging concept. Vol. 14, Therapeutic Advances in Gastroenterology. SAGE Publications Ltd; 2021. * This review outlines the construct of frailty as it is applicable to IBD.
  • 25. Kochar BD, Cai W, Ananthakrishnan AN. Inflammatory Bowel Disease Patients Who Respond to Treatment with Anti-tumor Necrosis Factor Agents Demonstrate Improvement in Pre-treatment Frailty. Dig Dis Sci. 2022. Feb 1;67(2):622–8. * In a retrospective analysis, frailty is shown to be modifiable with anti-TNF treatment.
  • 26.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. Jun 1;158(8):2104–2111.e2. [DOI] [PubMed] [Google Scholar]
  • 27. Faye AS, Colombel JF. Aging and IBD: A New Challenge for Clinicians and Researchers. Inflamm Bowel Dis. 2022. Jan 1;28(1):126–32. * This review article emphasizes that frailty is associated with adverse clinical outcomes in patients with IBD and explores directions to take to integrate frailty into clinical practice.
  • 28.Ananthakrishnan AN. Frailty in Patients With Inflammatory Bowel Disease. Vol. 17, Gastroenterology & Hepatology. 2021. [PMC free article] [PubMed] [Google Scholar]
  • 29.Erős A, Soós A, Hegyi P, et al. Sarcopenia as an independent predictor of the surgical outcomes of patients with inflammatory bowel disease: a meta-analysis. Vol. 50, Surgery Today. Springer; 2020. p. 1138–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30. Faye AS, Dodson JA, Shaukat A. Sarcopenia as a Risk Prediction Tool in Inflammatory Bowel Disease. Inflamm Bowel Dis. 2022. Dec 1; 28(12):1932–1933. * An editorial highlighting the potential for sarcopenia to be a risk stratification tool in patients with IBD.
  • 31. Campbell JP, Teigen L, Manski S, et al. Sarcopenia Is More Prevalent Among Inflammatory Bowel Disease Patients Undergoing Surgery and Predicts Progression to Surgery Among Medically Treated Patients. Inflamm Bowel Dis. 2022. Dec 1; 28(12):1844–1850. * A multi-centered retrospective cohort study which concluded that sarcopenia, measured radiographically, was associated with need for future surgery in patients with IBD initiating a biologic.
  • 32. Trinder MW, Clifford M, Jones AL, et al. The impact of sarcopenia on outcomes in patients with inflammatory bowel disease undergoing colorectal surgery. ANZ J Surg. 2022. Mar 1;92(3):397–402. * A single-centered retrospective study concluding that sarcopenia in patients with IBD is associated with a significantly increased risk for major post-operative complications after colorectal surgery.
  • 33. Bedard K, Rajabali N, Tandon P, et al. Association Between Frailty or Sarcopenia and Adverse Outcomes in Inflammatory Bowel Disease: A Systematic Review. Gastro Hep Advances. 2022;1(2):241–50. * A systemic review of 16 studies which concluded that frailty indices can be used to predict hospitalization and mortality related outcomes in adult patients with IBD.
  • 34.Faye AS, Khan T, Cautha S, Kochar B. Sarcopenia in Inflammatory Bowel Diseases: Reviewing Past Work to Pave the Path for the Future. Curr Treat Options Gastroenterol. 2022. Jun 17;20(3):250–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35. Liu S, Ding X, Maggiore G, et al. Sarcopenia is associated with poor clinical outcomes in patients with inflammatory bowel disease: a prospective cohort study. Ann Transl Med. 2022. Mar;10(6):367–367. * A prospective cohort study of Asian adults 18–60 years with IBD which revealed that sarcopenia, defined by skeletal muscle function and mass, and pre-sarcopenia are prevalent and associated with greater odds for surgery, hospitalization, or death than those who are not sarcopenic.
  • 36.Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL. Trends in prescription drug use among adults in the United States from 1999–2012. JAMA - Journal of the American Medical Association. 2015. Nov 3;314(17):1818–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Mehta RS, Kochar BD, Kennelty K, Ernst ME, Chan AT. Emerging approaches to polypharmacy among older adults. Vol. 1, Nature Aging. Springer; 2021. p. 347–56. [DOI] [PubMed] [Google Scholar]
  • 38. Mesonero F, Fernández C, Sánchez-Rodríguez E, et al. Polypharmacy in Patients with Inflammatory Bowel Disease: Prevalence and Outcomes in a Single-center Series. J Clin Gastroenterol. 2022. Mar 1;56(3):189–95. * A retrospective single-centered study which found that polypharmacy, defined as ≥5 concomitant medications, was present in 20% of patients with IBD.
  • 39. Mosli MH, Alsahafi M, Alsanea MN, et al. Multimorbidity among inflammatory bowel disease patients in a tertiary care center: a retrospective study. BMC Gastroenterol. 2022. Dec 1;22(1). * A retrospective web-based registry study which found that multi-morbidity, having ≥2 comorbidities, was present in 10% of adult patients with IBD.
  • 40.Pravodelov V Thoughtful Prescribing and Deprescribing. Vol. 104, Medical Clinics of North America. W.B. Saunders; 2020. p. 751–65. [DOI] [PubMed] [Google Scholar]
  • 41.Buckley JP, Kappelman MD, Allen JK, et al. The burden of comedication among patients with inflammatory bowel disease. Inflamm Bowel Dis. 2013. Dec;19(13):2725–36. [DOI] [PubMed] [Google Scholar]
  • 42. Hong SJ, Katz S. The elderly IBD patient in the modern era: changing paradigms in risk stratification and therapeutic management. Vol. 14, Therapeutic Advances in Gastroenterology. SAGE Publications Ltd; 2021. * A review of changes in disease characterization, risk stratification, and the unique biology of IBD in older adults.
  • 43.Hong SJ, Galati J, Katz S. Crohn’s Disease of the Elderly: Unique Biology and Therapeutic Efficacy and Safety. Vol. 51, Gastroenterology Clinics of North America. W.B. Saunders; 2022. p. 425–40. [DOI] [PubMed] [Google Scholar]
  • 44.Lemaitre M, Kirchgesner J, Rudnichi A, et al. Association between use of thiopurines or tumor necrosis factor antagonists alone or in combination and risk of lymphoma in patients with inflammatory bowel disease. JAMA - Journal of the American Medical Association. 2017. Nov 7;318(17):1679–86. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Piovani D, Danese S, Peyrin-Biroulet L, et al. Systematic review with meta-analysis: biologics and risk of infection or cancer in elderly patients with inflammatory bowel disease. Vol. 51, Alimentary Pharmacology and Therapeutics. Blackwell Publishing Ltd; 2020. p. 820–30. [DOI] [PubMed] [Google Scholar]
  • 46. Ytterberg SR, Bhatt DL, Mikuls TR, et al. Cardiovascular and Cancer Risk with Tofacitinib in Rheumatoid Arthritis. New England Journal of Medicine. 2022. Jan 27;386(4):316–26. * A post-marketing randomized controlled trial of adults ≥50 years with rheumatoid arthritis who have ≥1 cardiovascular risk factor to assess for risk of adverse events with tofacitinib and adalimumab treatment. They found that tofacitinib was inferior to adalimumab with regards to major cardiovascular events and malignancy.
  • 47.Axelrad J, Bernheim O, Colombel JF, et al. Risk of New or Recurrent Cancer in Patients With Inflammatory Bowel Disease and Previous Cancer Exposed to Immunosuppressive and Anti-Tumor Necrosis Factor Agents. Clinical Gastroenterology and Hepatology. 2016. Jan 1;14(1):58–64. [DOI] [PubMed] [Google Scholar]
  • 48. Holmer AK, Luo J, Russ KB, et al. Comparative Safety of Biologic Agents in Patients with Inflammatory Bowel Disease with Active or Recent Malignancy: A Multi-Center Cohort Study. Clin Gastroenterol Hepatol. 2023. Jan 12:S1542-3565(23)00029-0. * A multi-centered retrospective cohort study of patients with IBD with active cancer or prior cancer which demonstrated that treatment with anti-TNF agents was comparable to non-TNF biologics with regards to cancer recurrence.
  • 49. Shah SC, Itzkowitz SH. Colorectal Cancer in Inflammatory Bowel Disease: Mechanisms and Management. Vol. 162, Gastroenterology. W.B. Saunders; 2022. p. 715–730.e3. * An updated review on colorectal cancer in patients with IBD covering chronic inflammation as a risk factor for neoplastic progression, dysplasia, and potential chemopreventive properties of IBD treatments.
  • 50.Everhov ÅH, Erichsen R, Järås J, et al. Colorectal cancer in elderly-onset inflammatory bowel disease: a 1969–2017 Scandinavian register-based cohort study. Aliment Pharmacol Ther. 2022. Oct 1;56(7):1168–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51. Sasson AN, Sheehan G, Yu A, et al. Yield and Predictors of Surveillance Colonoscopies in Older Adults With Long-standing Ulcerative Colitis. Clinical Gastroenterology and Hepatology. 2022. Jun 1;20(6):e1353–64. * A multi-centered retrospective cohort study including patients ≥75 years with UC who underwent at least 1 surveillance colonoscopy which concluded that patients without a history of dysplasia may have a low yield to continue endoscopic surveillance past 75 years.
  • 52.Danese S, Mantovani A. Inflammatory bowel disease and intestinal cancer: A paradigm of the Yin-Yang interplay between inflammation and cancer. Vol. 29, Oncogene. 2010. p. 3313–23. [DOI] [PubMed] [Google Scholar]
  • 53.Betesh AL, Schnoll-Sussman FH. Colorectal Cancer Screening in the Elderly. Vol. 37, Clinics in Geriatric Medicine. W.B. Saunders; 2021. p. 173–83. [DOI] [PubMed] [Google Scholar]
  • 54.Faye AS, Dodson JA, Shaukat A. Safety and Efficacy of Anti-TNF Therapy in Older Adults With Ulcerative Colitis: A New Path Forward. Gastroenterology. 2022. May;162(6):1762–4. [DOI] [PubMed] [Google Scholar]

RESOURCES