Clinical Presentation and Disease Course
The clinical features of older IBD patients are generally similar to those of younger patients, with notable exceptions. Furthermore, some reports have found no difference in disease location. Nevertheless, elderly patients may have worse outcomes because of factors such as comorbid conditions and delayed presentation.
Genetic factors seem to play a more prevalent role in paediatric patients with IBD than in older individuals. In this respect, older patients are less likely to have a family history of IBD, perhaps reflecting greater environmental influence than in younger patients.
The clinical manifestations of the first disease flare, both in UC and in CD, are generally similar in patients aged >60 years and in younger age groups. Unexplained diarrhoea, weight loss and perianal disease in the elderly should arouse suspicions regarding CD. Reports of a more serious clinical course in older patients were not substantiated in some studies. In fact, some authors suggested that elderly IBD patients are less likely to present with symptoms of abdominal pain, diarrhoea and anaemia.
With respect to extra-intestinal manifestations of IBD, no significant differences have been observed between elderly and younger patients in several studies, although one report concluded that patients aged >40 years were more likely to have uveitis/iritis than younger patients. As an example, 17% of patients aged >60 years of age were reported to have extra-intestinal manifestations in a recent sludy, which, in order of frequency, were peripheral arthritis, uveitis, spondylitis and erythema nodosum.
The main differences between elderly patients and young patients with IBD are summarised in Table 2. In the following sections, the clinical presentation and disease course will be analysed separately for CD and UC.
Crohn's Disease
Several authors have reported that CD in elderly patients generally follows the same clinical pattern as in young people, with some exceptions, which are mainly related to the type of clinical onset and disease course. In this respect, some researchers have suggested that clinical symptoms on diagnosis are more subtle in elderly patients than in younger patients, with less diarrhoea, abdominal pain, weight loss, fever and extra-intestinal manifestations in CD. In a recent study, at the end of follow-up, only 30% of the elderly patients had complications (stricturing or penetrating) compared with more than 50% of the children; nevertheless, exceptions, such as CD presenting as toxic megacolon, are reported in elderly patients.
With respect to the location, colon disease is the most common form in elderly CD patients, whereas extensive colon and diffuse small bowel disease is rare, although this has not been confirmed in all reports. Thus, the proportion of patients with colonic involvement seems to increase with age at diagnosis. In a recent study, 48% of patients diagnosed after age 40 had isolated colonic involvement compared with 28% and 20% for those diagnosed at 20 and 40 years and before age 20 years, respectively. In a French population-based cohort (EPIMAD registry) comprising 841 IBD patients aged >60 years at diagnosis, the most frequent phenotype at diagnosis in patients with CD was pure colonic disease (65%). Because of the higher proportion with isolated colitis, elderly patients are less likely to present with abdominal pain and more likely to have diarrhoea and bleeding.
In the case of CD, the Montreal classification considers three age groups, with age >40 years as the most advanced age group, although the proportion of patients with inflammatory (nonstricturing, nonpenetrating) behaviour also increases in patients after 40 years. Furthermore, no differences were found regardless of whether age was higher or lower than 60 years. In the aforementioned EPIMAD registry (IBD patients aged >60 at diagnosis), inflammatory disease (78%) was the most frequent phenotype. Consequently, the stricturing pattern (B2) and penetrating pattern (B3) are less common than in patients aged 18–60 years. A change in the behaviour of CD is exceptional in the elderly, whereas in the paediatric and adult CD population, it is quite frequent after 5 years. In the study by Charpentier et al., only 30% of patients had B2/B3 behaviour at the end of follow-up as compared with more than 50% in younger patients.
Regarding medical treatment, the cumulative probability of receiving corticosteroids, immunosuppressants and anti-tumour necrosis factor (TNF) α therapy in CD was, respectively, 47%, 27% and 9% at 10 years in the largest population-based study of late-onset IBD reported to date (see 'Medical treatment' section). Finally, several studies have reported a lower frequency of surgery in elderly patients with CD than in younger patients.
Ulcerative Colitis
The clinical course of UC in elderly patients is similar to or more favourable than that observed in younger patients. As was the case with CD, clinical symptoms on diagnosis seem to be more subtle in elderly than in younger patients, with less rectal bleeding, diarrhoea and abdominal pain in UC. However, initial UC attacks in the elderly may be more severe.
As for location, according to the Montreal classification, proctitis and left-sided UC are more common in patients aged >60 years than in younger patients. A World Gastroenterology Organisation survey reported proctitis in 42% of UC patients aged >60 years, compared to 33% in those aged <60 years. The most frequent symptoms in this age group include diarrhoea, and, sometimes, paradoxical constipation. Furthermore, the incidence of proximal extension over time is lower in elderly patients with UC. In the French EPIMAD registry (including UC patients aged >60 years at diagnosis), 29% of patients had proctitis, 45% left-sided colitis and 26% extensive colitis, with no extension during follow-up in most cases (84%). Thus, in UC, location tends to remain stable, with only about 15% of patients showing progression over time; this observation is in sharp contrast with the 50% rate of extension reported in the paediatric population.
An inverse correlation was found between age at onset of UC and the risk of relapse (i.e. a lower incidence of relapse among older patients). However, some authors have reported that severity of recurrence is usually higher in elderly patients.
Paediatric and adult patients more often require systemic corticosteroids during follow-up than elderly patients (17%) (see 'Medical treatment' section). Finally, as for surgery, colectomy rates in UC seem to be lower in the elderly. In the EPIMAD registry, only 16% of elderly onset patients were operated on at 10 years from diagnosis.