Inflammatory bowel disease (IBD) has long been considered a disease of middle age, or even young, adulthood. The chronic illness — which includes Crohn’s disease and ulcerative colitis, and can cause abdominal pain, diarrhea, bleeding and reduced quality of life — affects about 3.1 million people in the United States. -Page. More than a quarter of people with IBD are elderly, number expected to rise to 30% by 2030, by 2021 Digestive System & Liver thing.
Even more underestimated is the growing population of people who are diagnosed with the condition after they turn 60. While IBD was once thought of as a disease with two onsets – ages 20 through 30s and 40s to 50s – doctors are learning that there’s a third of spikes that start later in life. “We now know you can be 75 years old and have IBD,” said Dr. Simon Hong, a gastroenterologist and IBD specialist at NYU Langone Health.
However, no matter when the illness begins, understanding — and treating—IBD in the elderly comes with its own set of challenges and complexities.
IBD looks different in older people
Hundreds of thousands of people with IBD diagnosed earlier in life are now living with the disease into adulthood. For many people, that means living with the damage the disease has done to their gut, and sometimes with the changing effects of surgery done to control it, such as such as anal sacs or increased fecal incontinence. Not to mention the outbreaks continue.
It is generally assumed that disease activity declines with age, and some people find their IBD becomes dormant later in life. But that’s not always the case, says Dr. Jessica Philpott, a Cleveland Clinic gastroenterologist. “I certainly see some patients who develop more severe disease as they get older,” she said.
For people who develop IBD after turning 60, the disease may look a little different than it does for people who have had it for decades. While younger Crohn’s patients can have lesions in any part of the intestinal tract, in older-onset cases it usually affects primarily the colon.
As people get older, it also becomes more difficult to diagnose a new case of IBD. There are many more common reasons that an elderly person may experience, such as bloody diarrhea. This alarming symptom is one of the first reasons to evaluate for IBD in a young person. But for people age 60 and older, doctors often need to rule out a host of other conditions — including infection, ischemia in the colon, other forms of colitis, diverticulitis. and cancer — before they considered IBD as a potential cause.
And because older adults often face more health problems, they may not seek prompt medical help. Crohn’s in particular can be more difficult to pinpoint than ulcerative colitis, as it can present as intermittent abdominal pain and weight loss, which is not uncommon in older adults. These factors can sometimes delay the proper diagnosis and thus effective treatment, by years.
Dr. Gil Melmed, director of inflammatory bowel disease clinical research at Cedars-Sinai Medical Center in Los Angeles, tells the story of a patient now 84 years old. She was hospitalized several times because of abdominal pain and bloody diarrhea. Doctors repeatedly diagnosed her with diverticulitis and treated her with antibiotics. Her symptoms will go into remission for a while and then return. Then antibiotics lead to other complications, including dangerous C. difficile infection. When Melmed saw her for the first time, after another hospitalization, he realized that she did not have diverticulitis but Crohn’s disease.
Hong has seen this cycle of misdiagnosis countless times. “Doctors should always keep IBD on their list” for older adults, he says.
The percentage of people with late-onset IBD appears to be increasing, possibly due to environmental triggers such as air pollution, which makes it all the more important to be vigilant.
Inflammation, menopause and other complications
Essentially, IBD is a chronic inflammatory disease. Aging itself is also associated with increased inflammation, a connection that gave rise to the term Explosion. Thus, elderly patients with IBD are at even greater risk for many of the health outcomes associated with classical inflammation, including cardiovascular disease, cancer, fatskin problems, arthritisand loss of skeletal muscle.
Experts warn that some common health complaints may look like the health complaints of older adults who don’t have IBD, but in reality, IBD poses a different problem. For example, joint pain in an older patient may first present as osteoarthritis, but if they have IBD, it may be a different form of arthritis altogether.
Older IBD patients also have an increased risk of other conditions including osteoporosis, colon and skin cancers, blood clots, and general physical decline.
The long list of potential health problems increases the importance of standard preventive care, including good nutrition and exercise, as well as simple things like routine immunizations, Melmed saves. idea. Until recently, many vaccines for older adults contained live virus, putting them at risk of mixing with some IBD therapies. This is no longer the case, he says, and in fact, because so many IBD treatments suppress the immune system — and aging itself is associated with an increased risk of infection — which is particularly important. It’s especially important for these patients to get vaccinated regularly for things like pneumonia.
Much is still unknown about the complexities of the aging body caused by the effects of IBD and vice versa. For example, we still don’t know much about how aging with IBD looks different for women going through and beyond, and how menopause treatments may play a role. in the course of the disease. Several small studies have found a modest protective role for estrogen replacement therapies on IBD activity, but the answer remains uncertain. “We really need more data in this area,” said Dr. Sunanda Kane, who specializes in IBD and women’s health at the Mayo Clinic in Rochester, Minn.
But even something as big as menopause can be missed – or misunderstood – when doctors focus too much on a patient’s IBD and its treatments. Kane recalls a 57-year-old patient receiving newer monoclonal antibody therapy for her ulcerative colitis. One day, the patient told her primary care physician that she was running a “fever” and was “confusion”. The doctor concluded she likely had a rare brain infection from taking the IBD medication, ordered her to stop the medication and referred her to a neurologist. While the patient anxiously awaited her neurologic appointment, she called Kane to ask if she could take another IBD medication instead. Kane listened to the patient’s story and realized that her symptoms were those of menopause. Returning to her previous IBD treatment and estrogen replacement therapy, the patient ended well, Kane reported. But it serves as a reminder that the presence of IBD can blur a patient’s overall picture assessment, especially when there are major health changes, as they often occur during pregnancy. old.
One thing that has become clear as more and more people live with IBD into an older age is when assessing IBD patients and their outlook for treatment, not just based on age. Experts now favor decisions based on a person’s weaknesses over time. And like inflammation, the combination of aging and IBD increases the odds of illness, putting someone at risk for poorer health outcomes.
Confusion surrounding IBD treatment for the elderly
As people age, it tends to become more difficult to treat illnesses. There are more comorbidities, a lengthy list of medications, and a person’s overall health to take into account. These factors become even more important when considering IBD therapies. “Whatever we do, from the procedure to the treatment, is different for older people,” says Philpott of the Cleveland Clinic.
Once the disease progresses to a specific state, doctors often turn to surgery to remove the damaged part of the intestine. However, this is not always an option for extremely frail patients with IBD, regardless of their age.
Of course, the disease can often be well controlled with medication. But there are some common pitfalls, warn experts who work with elderly IBD patients.
One of the biggest concerns in pharmaceutical treatments for older IBD patients is the susceptibility to infection, because nearly all IBD medications will in some way affect the immune system. The immune system, which declines with age. However, according to experts, this concern could lead to widespread treatment of the condition — or treatments with even more dangerous forms of drugs.
For decades, corticosteroids have been considered the prophylactic IBD . Therapy. And they are still indicated for the short-term treatment of mild to moderate flare-ups, especially in young people. But long-term use, especially for older adults, is less effective than other options and may actually carry higher risks, including high blood pressure, diabetes, bone loss, infections. , osteoporosis and overall mortality.
However, about 30% of elderly IBD patients were prescribed steroids for more than six months at a time, according to a 2015 study in Inflammatory bowel disease. According to NYU’s Hong, part of the reason is because of the long history of these drugs, “they are considered a ‘safe’ option.” Instead, he says, “I would argue that instead because of taking steroids for a long time, it would be much better to use one of the new biologics.”
Over the past few decades, small molecule “biology” has entered the newly established field of IBD treatment. Particularly effective are drugs such as anti-tumor necrosis factor agents. However, some doctors are reluctant to prescribe these drugs because they are known to increase the risk of cancers, such as lymphoma, especially in older adults. Some doctors even recommend surgery — which comes with negligible risks for older people — before trying biologics.
Melmed’s 84-year-old patient was finally diagnosed with the disease Crohn’s disease was started biologically immediately, and there have been no other outbreaks yet. Melmed acknowledges that there are risks with these drugs for older patients. But he’s looking at the bigger picture of “how to best benefit the patient,” he says. “There are no risk-free options. Just because someone is older, we certainly don’t want to deny them the potential benefits of an effective therapy. “
As part of that approach, Melmed advocates assessing not only a patient’s gut health, but also their environment and health.
Young people with IBD are known to have higher rates of depression and greater challenges in navigating normal lives, because of the unpredictability of attacks. And there’s no reason to think this will be different for everyone just because they’re wiser in a few years – or decades. But depression can be more difficult to detect in elderly patients if it is not screened and living fairly in the home country or without social support can be accepted as normal. However, experts agree that is not necessarily the case.
“As doctors, we always focus on inflammation,” said Hong. “But in reality, the important thing is: What does this elderly patient want to do? Do they want to travel? Or bike around the park? And that’s where experts say the conversation around the risks and benefits of treatment should focus. “Just because they’re older doesn’t mean they don’t deserve the same quality of life,” Hong said. “Don’t settle for less.”
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