[00:30]
Hello, I’m Dr. Adam Faye, and welcome to IBDIQ, part of The IBD Project by Takeda, where we’re coming together to help enhance expertise in IBD care—right from the start.
I’m delighted today to speak to you on the topic of managing older adults with inflammatory bowel disease (or IBD). In this presentation, we will review the 5Ms of geriatric care and how each of them can help us approach the care of older patients. We will also review therapeutic management for older adults with IBD, in addition to considerations for surgery. And finally, we will review health maintenance to ensure continued care for this patient population.
[01:11]
When it comes to management of the older patient with IBD, we should consider the 5Ms of geriatric care.1 What matters most to the patient? What multicomplexities or comorbidities should be considered? How is the patient’s mind, or psychological well-being? What medications is the patient taking? And how is the patient’s mobility and dexterity? Let’s take a closer look at each.
First, what matters most to the patient with regard to their quality of life?1 Is it that bowel urgency is limiting their ability to go out and do the social things that they enjoy? Symptoms like bowel urgency may cause patients to limit their physical activity and social interactions.2 It’s important to be cognizant of what matters most to your older adult patients, taking individual preferences and preservation of functional status into account.1
[02:04]
Second, I think about multicomplexity, or comorbidities that may push me away from or towards a treatment.1 While comorbidities may help determine the choice of appropriate medical therapy, multicomplexities of patients’ lives should also be considered. An understanding of a patient’s living conditions, social support, and ability to adapt to changes in their disease status are important to managing older adults with IBD.
The third M, mind, involves assessing patients’ cognitive abilities and psychological well-being.1 This includes evaluating their ability to understand treatment instructions and adhere to the prescribed regimen. It also includes an understanding of how certain medications may have a greater impact on mood, sleep quality, and mental status in older adults than in younger patients.3,4
[02:58]
Next, we assess the patient’s current medications. This medication review is to assess for possible drug interactions as well as identify polypharmacy, and to consider the most suitable route of administration based on the patient’s treatment history and medical background.1 Polypharmacy, which is commonly defined as the regular use of 5 or more medications, has been associated with increased adverse events, especially in older adults, so medication review is important in this patient population.1,5
Lastly, when developing a care plan for older adults, I assess mobility, dexterity, and access to healthcare facilities. I also consider their ability to self-administer medications and the availability of care partners.1
[03:48]
Do they have the manual dexterity to do the injections? Do they have significant osteoarthritis that may limit that ability? If so, is there a care partner around them to be able to help them with the injections versus an infusion? If they do not have a care partner at home and are unable to self-inject, are they able to travel back and forth to receive an infusion-based therapy?6
Another element of the fifth M, mobility, is frailty.7 Frailty is often described as a complex syndrome leading to increased vulnerability to stress and decreased reserve across multiple physiologic systems, which can increase the risk of adverse health outcomes.8 Frailty is a dynamic process in which patients can transition between being non-frail, pre-frail, and frail over time.
[04:39]
Ongoing inflammation drives frailty, which can occur over time as a result of repeated stressors.1 To explore the impact of ongoing inflammation on frailty, let’s review the different variables that can affect patient fitness in older adults with IBD in relation to stressors and response to treatment.
IBD-related inflammation and repeated stressors, like disease flares or illness, cause temporary decreases in wellness over time.1,9 It has been hypothesized that despite treatment, a patient with ongoing IBD-related inflammation is more likely to become frail and respond poorly to stressors. This leads to increased frailty, which has been shown in 4 retrospective cohort studies to be associated with more risk of hospitalizations, serious adverse events, and mortality.1,10-13
In contrast, treating IBD-related inflammation may improve frailty in older adults with IBD.1
[05:42]
Frailty can also be impacted by treatment response, as demonstrated by a 2022 US-based retrospective study of 1,210 patients with IBD who initiated anti-tumor necrosis factor (or anti-TNF) therapy between 1996 and 2010.14 Of this patient population, two-thirds of patients had Crohn’s disease (or CD). The median age at anti-TNF treatment initiation was 30 years old with 20% being 50 years or older.
Patients’ frailty index scores were calculated 1 year before treatment and 1 year following treatment with an anti-TNF agent.14 Among the patients who were older than 60 years at anti-TNF initiation, the 42 patients who had pre-treatment frailty scores above the median the year prior experienced a mean improvement in frailty index of 8 points, with a mean improvement of 12 points noted in those patients who responded to therapy.
[06:46]
Now for those who develop IBD later in life, do we think that the disease has a different overall clinical course compared to adults who develop IBD younger in life?
A common perception is that IBD tends to burn out over time.1
To examine this perception, we will discuss a 2020 systematic review and meta-analysis of pooled population-based cohort data from 1977 to 2011 of more than 70,000 patients with IBD from Europe and Canada.15
[07:21]
Results comparing older- and younger adult-onset IBD showed that the risks of needing surgery, hospitalization, and corticosteroid use at 1, 5, and 10 years were fairly similar.15 These results suggest that patients with older-onset IBD had a similar trajectory compared to patients with younger adult-onset IBD in terms of needing surgery, hospitalization, and corticosteroid use. It was also noted that immunomodulators and biologics were used less frequently in patients with older-onset IBD compared to patients with younger adult-onset IBD.
Although there are generally not a lot of data on this, research suggests disease does not burn out over time, particularly for those with Crohn’s disease.1 This emphasizes the importance of treating ongoing disease activity and casting aside the expectation that disease activity will eventually fade.
[08:23]
Given that research suggests the disease course may be similar between older- and younger adult-onset IBD, the next question is, are they being treated similarly?
A 2023 nationwide cohort study from Denmark of approximately 69,000 newly diagnosed patients with IBD treated between 1995 and 2020 demonstrated that these 2 age cohorts were not treated the same.16
That study compared approximately 19,000 older adults aged 60 years or older with approximately 50,000 younger adults, and results showed the use of corticosteroids within 1 and 5 years of IBD diagnosis was the same between older and younger adults, whereas there was lower use of 5-aminosalicylic acid (or 5-ASA), thiopurines, and biologics among individuals who had older-onset IBD.16
[09:22]
There are some additional considerations for older adults with IBD that may influence how their care is managed. Older adults are at an increased risk for adverse effects from medical therapies.4 Older adults are often excluded from clinical trials, and increased comorbidity in this population is also a concern.4,17 Higher frequency of malignancy and age-related decline of immunity may also inform decisions about safety considerations.4
However, despite these concerns, the treatment of IBD does not seem to increase the risk of certain adverse events among older adults, as demonstrated in a 2021 pooled analysis of data from 4 randomized controlled trials by Cheng and colleagues.18
[10:13]
In this pooled analysis, older adults, who made up about 10% of the total study population, who received anti-TNF therapy had a lower rate of serious adverse events, hospitalizations, and severe infections compared with older adults who received placebo.18
Now, let's talk about the management of older adults with IBD and important considerations for assessing therapy options.
We will discuss the American Gastroenterological Association (or AGA) Clinical Practice Update on Management of Inflammatory Bowel Disease in Elderly Patients, with elderly being defined as age 60 years and older in this publication.4 We will be referring to this as the AGA Older Adult Expert Review going forward. This overview may inform treatment selection based on disease severity and patient fitness, some of which we've discussed already during our review of the 5Ms.
[11:15]
To determine disease severity, there should be an assessment of disease presentation, prognostic factors, and psychosocial needs.4 Additionally, fitness and frailty should be assessed along with chronological age when making management decisions, as pre-treatment frailty may suggest an increased risk of infections after immunomodulator or anti-TNF treatment, or after surgery, as was observed in a retrospective cohort study of patients with IBD in New England.4,12
As for treatment options, for induction therapy, older adults can use certain corticosteroids, anti-TNF therapy, anti-integrin therapy, interleukin inhibitors, or Janus kinase (or JAK) inhibitors.4 In my practice, I use corticosteroids as a bridge to corticosteroid-sparing therapy rather than as the sole induction therapy in my older adult patients to help mitigate long-term complications of use.
[12:16]
Maintenance treatment options have similar recommendations.4 Although corticosteroids are not recommended for maintenance therapy, thiopurines are included. Thiopurine use in older adults should be assessed on a case-by-case basis due to a higher risk of certain malignancies in this patient population.
Another class of medication developed since the publication of the AGA Older Adult Expert Review is the sphingosine-1-phosphate receptor modulators, or S1P receptor modulators.19 These agents have been studied for use in both induction and maintenance therapy in certain patients with ulcerative colitis (or UC).19-21 Data on the use of these agents in older adults is limited.20,21
[13:02]
Management of IBD in older adults can often be hindered by misconceptions of a milder disease course at this age and fear of medication adverse events.3 Older patient populations with IBD are often managed with the frequent use of corticosteroids, due to a misperception that corticosteroids are safe and convenient when compared to alternative corticosteroid-sparing therapies. This could result in delayed treatment escalation and underuse of possibly more effective therapies.
According to the AGA Older Adult Expert Review, systemic corticosteroids are not recommended for maintenance therapy.4 If used for induction therapy, nonsystemic corticosteroids are preferred when possible based on disease phenotype. In my clinical practice, I use nonsystemic when possible but, when needed, will use systemic corticosteroids as a bridge to corticosteroid-sparing therapy.
[14:00]
Corticosteroids also have safety considerations we should keep in mind for older adults.4 Older adults have a greater prevalence of comorbidities like diabetes, hypertension, glaucoma, cataracts, osteoporosis, and cognitive impairment compared to younger patients, which can all be exacerbated by corticosteroid use.
The AGA Older Adult Expert Review suggests that initiating biologic or small molecule therapies with rapid onset of action could reduce the need for corticosteroids.4
[14:39]
When selecting immunosuppressive therapy for older adults with IBD, several things should be considered. Some of these considerations overlap with the 5Ms of geriatric care we reviewed earlier.1 For example, the patient’s age, functional status, comorbidities, and frailty should be evaluated prior to initiating immunosuppressive therapy.4 This is similar to the Ms multicomplexity and mobility. Additionally, the choice of therapy should be based on the patient’s disease severity and phenotype, the drug’s onset of action, and potential to achieve corticosteroid-free remission.
The AGA Older Adult Expert Review also suggests that older adults’ increased risk of fracture, venous thromboembolism, infections, and cancer be incorporated in management decisions.4 With that in mind, medications with lower overall infection or malignancy risk may be preferred in the older population when indicated. My approach, including which agent I am selecting, is informed by the patient’s circumstance and my clinical judgment.
[15:49]
I would also consider combination therapy in patients with certain disease phenotypes.4
Aside from medications, surgery can also be an option for older adults with IBD.4 When to perform surgery and the type of surgery should take into consideration several factors, including disease severity, risks and effectiveness of medical therapy, candidacy for surgery, how surgery may impact patients’ independence and functional status, and the risk of postoperative complications.
There was a study that looked at the risk of postoperative adverse events within the American College of Surgeons National Surgical Quality Improvement Program database.22 Data from more than 9,000 IBD-related intestinal resections in adults 60 years of age or older and about 40,000 surgeries in adults 18 to 60 years old between 2005 and 2019 were analyzed.
[16:49]
As you can see from the results on screen, dependent functional status, malnutrition, preoperative sepsis, and emergent surgery all increased the risk of an adverse postoperative event, with similar results observed in both the older and younger adult groups.22
Among the 9,390 older adults and more than 40,000 younger adults who underwent IBD-related intestinal resection, 37% of older adults experienced a postoperative adverse outcome within 30 days of surgery compared to 28% of younger adults.22
[17:29]
If indicated, surgery should not be delayed in appropriate older adult patients.4,23 For example, in 1 population-based cohort study of 139 patients with older-onset IBD who underwent surgery in France, surgery 3 months or more after diagnosis was associated with more long-term adverse effects than surgery within 3 months of diagnosis.23
Health maintenance is another aspect of IBD management in the older population. Older adults are at a higher risk for vaccine preventable illnesses, especially while receiving systemic immunosuppression.4 Based on the AGA Older Adult Expert Review, older adult patients should adhere to recommended vaccination schedules, ideally vaccinating before the start of immunosuppression therapy. Please remember to check the Centers for Disease Control and Prevention (or CDC) website for evolving guidance and information on vaccine recommendations for your older adult or immunocompromised patients.
[18:35]
Older adults should also be up to date with cancer screenings.4 Patients with chronic colitis related to CD or UC are at increased risk of developing colorectal cancer, underlining the importance of surveillance colonoscopies. However, as patients age, the decision to perform surveillance colonoscopy should take into consideration anesthesia and perforation risks associated with the procedure, the patient’s life expectancy, comorbidity, and eligibility for colon resection surgery.
Osteoporosis preventative measures are another important aspect of health maintenance. Older patients with IBD may have an increased risk of osteoporosis for several reasons besides age-related bone loss.24 These include malnutrition, reduced physical activity, vitamin D deficiency, and corticosteroid use. It is important to take preventative measures such as having adequate vitamin D and calcium supplementation, managing underlying disease, and monitoring with osteodensitometry.
[19:44]
In summary, as the patient population with IBD continues to age, it is important to understand the unique considerations involved in caring for older patients.
The 5Ms of geriatric care, Matters Most, Multicomplexity, Mind, Medications, and Mobility can help guide management of this patient population.1
There are also age-specific considerations for older adults with IBD, like their increased risk for adverse effects and comorbidities, though we must remember that undertreatment of disease activity itself can be a driver of adverse clinical outcomes in this patient population.1,4
For medical management, we discussed which therapeutic options are available for both induction and maintenance, including considerations for selecting a therapy. Besides pharmacological therapy, surgery is also a treatment option for older patients when appropriate.4
[20:44]
Of course, disease management does not end there. We must also practice health maintenance such as vaccinations, cancer screening, and osteoporosis preventative measures to continue to care for our patients.4,24
Thank you for your interest and for spending some time with IBDIQ today to help adapt to the evolving care needs of all patients with IBD.
