Elderly Inflammatory Bowel Disease Research Articles

963 Sources of Concern Over Time in IBD: A Prospective Study of the Complex Relationship Between Symptomatic Disease Activity and Perceived Stress

Background: The incidence of Crohn's disease (CD) and ulcerative colitis (UC) in the elderly population is reported to be increasing. Comorbid diseases, which are more prevalent with advanced age, may impact the natural history of inflammatory bowel disease (IBD) and treatments. We sought to characterize the population-based burden and outcomes of elderlyonset CD and UC in comparison to IBD of younger onset. Methods: We identified incident cases of IBD in Ontario, Canada between 1999 and 2008 from health administrative databases at the Institute for Clinical Evaluative Sciences using algorithms that were validated specifically in Ontario. The primary outcomes were hospitalizations and first IBD-related surgery. We compared groups defined by age at diagnosis: young adult (18-44y); middle-adult (45-64y); and elderly (≥65y) in univariate and regression analysis. Comorbidity was assessed using the validated Johns Hopkins Adjusted Clinical Group (ACG) case-mix system. Results: There were 8,985 incident cases of CD and 12,233 incident cases of UC during the study period. Of these, 725 new cases of CD and 1,749 new cases of UC occurred in the elderly. There was a slightly greater female predominance among the elderly group. More than a quarter of elderly IBD patients (29% of CD; 26% of UC) were in the top quartile for ACG comorbidity score, which was about twice as frequent as the middle-adult group. The incidence of IBDrelated hospitalization adjusted for sex, ACG comorbidity, and geographic region was lower for elderly IBD subjects when compared with young adults in both CD (incidence rate ratio [IRR], 0.76; 95% CI: 0.69 0.83) and UC (IRR, 0.88; 95% CI: 0.82 0.96). The KaplanMeier survival curves for bowel surgery for UC and CD stratified by age at diagnosis are shown in Figure 1. The cumulative risk of CD-related bowel resection at 2, 5, and 10 years were 18%, 24%, and 31%, respectively for elderly CD patients which were similar to the 15%, 23%, and 30% cumulative risks observed in young adults with CD. In contrast, the cumulative risk of colectomy among elderly UC patients at 2, 5, and 10 years (9%, 14%, and 18%, respectively) was higher than that of middle-age adults (8%, 11%, and 15%, respectively) and young adults (7%, 10%, and 13%, respectively). The adjusted hazard ratio for colectomy among elderly UC patients compared with their young adult counterparts was 1.36 (95% CI: 1.18 1.57). Conclusion: In this population-based study, UC patients who were diagnosed after age 65 years incurred increased risk of colectomy compared to those diagnosed as young, or middle-age adults. It is unclear whether this was due to more a more aggressive disease course or a lower threshold for colectomy due to the potential adverse effects of immunosuppressive medical therapy.

Systematic review with meta‐analysis: inflammatory bowel disease in the elderly

Elderly patients represent an increasing proportion of the inflammatory bowel disease (IBD) population. To critically review available data regarding the care of elderly IBD patients. Bibliographic searches (MEDLINE) up to June 2013. Approximately 10-15% of cases of IBD are diagnosed in patients aged >60 years, and 10-30% of the IBD population are aged >60 years. In the elderly, IBD is easily confused with other more common diseases, mainly diverticular disease and ischaemic colitis. The clinical features of IBD in older patients are generally similar to those in younger patients. Crohn's disease (CD) in elderly patients is characterised by its predominantly colonic localisation and uncomplicated course. Proctitis and left-sided ulcerative colitis are more common in patients aged >60 years. Infections are associated with age and account for significant mortality in IBD patients. The treatment of IBD in the elderly is generally similar. However, the therapeutic approach in the elderly should be 'start low-go slow'. The benefit of thiopurines in older CD patients remains debatable. Although the indications for anti-tumour necrosis factors in the elderly are generally similar to those for younger patients, lower response and higher adverse events have been reported in the elderly. Surgery in elderly patients does not generally differ. Ileal pouch-anal anastomosis can be successful, provided the patient retains good anal sphincter function. Management of the older IBD patient differs from that of younger patients; therefore, conventional practice algorithms may have to be modified to account for advanced age.

Effect of Aging on Healthcare Costs of Inflammatory Bowel Disease

Population aging is expected to result in a substantial additional burden on healthcare resources in the near future. We aimed to assess the current and future impact of aging on direct healthcare costs (DHC) attributed to inflammatory bowel disease (IBD). Patients with IBD from a Dutch multicenter cohort filled out 3-monthly questionnaires for 2 years. Elderly (≥60 yr) and younger patients (18-60 yr) IBD were analyzed for differences in 3-monthly DHC, productivity losses, and out-of-pocket costs. Prevalence rates were obtained from a health insurance database. Estimates of annual DHC and prevalence rates were applied to the total Dutch adult population in 2011 and then projected to 2040, using predicted changes in population demography, prices, and volume. IBD-attributable DHC were lower in elderly than in younger patients with IBD with respect to 3-monthly DHC (&OV0556;359 versus &OV0556;978, P < 0.01), productivity losses (&OV0556;108 versus &OV0556;456, P < 0.01), and out-of-pocket costs (&OV0556;40 versus &OV0556;57, P < 0.01). Between 2011 and 2040, the percentage of elderly IBD patients in the Netherlands has been projected to rise from 24% to 35%. Between 2011 and 2040, DHC of the total IBD population in the Netherlands are projected to increase from &OV0556;161 to &OV0556;661 million. Population aging accounted for 1% of this increase, next to rising prices (29%), and volume growth (70%). Population aging has a negligible effect on IBD-attributable DHC of the IBD population in the near future, because the average costs incurred by elderly patients with IBD are considerably lower than those incurred by younger patients with IBD.

Risk factors for depression in the elderly inflammatory bowel disease population

Risk factors for depression in the elderly inflammatory bowel disease population

P-111 Geriatric Patients with Inflammatory Bowel Disease are Less Likely to be Treated with Immunomodulating Agents

Inflammatory bowel disease (IBD) is a lifelong illness that affects approximately 1.4 million in the United States. While there is an increasing geriatric population in the nation, there is limited published data on older IBD patients. The effect of aging physiology on IBD manifestations is unknown. Small prior studies have shown decreased use of immunomodulating agents in elderly IBD patients. However, the effect of age upon treatment regimens in elderly IBD patients is unknown. This study evaluated the use of immunomodulator therapy in geriatric IBD patients. A retrospective chart review of inflammatory bowel disease patients cared for in a 18-month period at a university medical center was performed. There were no exclusion criteria. Patient age, gender, race, disease type and treatment regimen were obtained. Geriatric age was defined as ≥65 years. A database, maintaining patient confidentiality, was created. Statistical analysis was performed using Fisher’s exact test with statistical significance set at P < 0.05. The study was approved by the university institutional review board. 293 medical records of IBD patients were reviewed. There were 175 women and 118 men. One hundred fifty-six patients had Crohn’s disease, 135 had ulcerative colitis and 2 had indeterminate colitis. The mean age was 41.04. Two hundred seventy-one (163 women, 108 men) were <65 years. Twenty-two (14 women, 8 men) were ≥65 years. One hundred sixty-one of the 293 (55%) patients were on immunomodulating therapy. One hundred fifty-six of the 271 (57.6%) patients <65 and 5 of 22 (22.7%) of geriatric patients were on immunomodulating therapy. Geriatric IBD patients were found to be significantly less likely (P = 0.0029) to be treated with immunomodulating agents than non-geriatric patients. There was no significant difference in the use of immunomodulating therapy in women <65 and women ≥65 or (P = 0.0847) or in men <65 and men ≥65 (P = 0.1503). The importance of recognizing disease presentation and prescribing patterns in elderly IBD patients is increasingly important. This study revealed that immunomodulating agents are used less frequently in geriatric IBD patients. The decreased utilization of immunomodulator therapy in geriatric patients may reflect less severe disease, patient preference or prescriber caution due to co-morbidities and the potential for adverse medication reactions. Further study should be performed to evaluate the influence of aging upon inflammatory bowel disease management.

Risk factors for depression in the elderly inflammatory bowel disease population

Background and aimsLittle is known about depression in elderly individuals with inflammatory bowel diseases (IBD). We assessed the point prevalence of depression and determined associations with disease activity, quality of life, and medication adherence in elderly patients with IBD. MethodsWe identified elderly (≥65years) individuals within Crohn's and Colitis Foundation of America Partners, an online IBD cohort. Individuals completed the short geriatric depression scale (GDS). We used bivariate statistics to determine whether demographic or disease-related factors, disease activity, quality of life or medication adherence was associated with depression. We used logistic regression to estimate independent effects of depression on medication adherence. ResultsA total of 359 elderly individuals with IBD completed the GDS. The mean age was 70.2years (SD 4.7); mean disease duration was 25.6years (SD 17.6), and 62.6% had Crohn's disease (CD). The point prevalence of depression was 22.6%. Lower education levels (p=0.001), higher corticosteroid use (<0.01) and lower exercise levels (<0.001) were associated with depression. For both CD and ulcerative colitis (UC), those with depression had increased disease activity (short Crohn's disease activity index 52.5 versus 29, p=0.005, and simple clinical colitis activity index 5 versus 2, p=0.003). Depressed patients had lower quality of life (short IBD questionnaire 4.6 versus 5.7, p<0.001). Depressed individuals had reduced medication adherence (adjusted OR 2.18; 95% CI 1.04–4.57). ConclusionsDepression is common in this geriatric IBD cohort. Depression is independently associated with reduced medication adherence. Recognition and treatment of depression in elderly patients with IBD could improve outcomes.

Surgical Outcomes in the Elderly with Inflammatory Bowel Disease are Similar to Those in the Younger Population

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

6-Mercaptopurine Side Effect Profile in the Elderly Inflammatory Bowel Disease Patient

A total of 77 million baby boomers will join the category of elderly over the next 19 years, at a rate of 4 million per year. The elderly inflammatory bowel disease patient is under represented in clinical trials and often clinicians make decisions using data from such trials involving a much younger patient populations. We set out to investigate the safety of 6-Mercaptopurine in our elderly patient population. Using an electronic search database we identified 41 patients with Inflammatory Bowel disease on 6-Mercaptopurine/Azathioprine with either Ulcerative colitis (UC) or Crohn's disease (CD). A comparison of the dosage, side effect profile, and duration of therapy was examined. Of 41 patients with inflammatory bowel disease, 26 were female and 25 were male. The mean age of the patient population was 70.4 years old. Twenty-five patients were diagnosed with CD and 16 with UC. The dosage of 6-MP ranged from 25 mg to 150 mg. The average duration of therapy was 48.5 months. Thirty patients experienced a single side effect, whereas 8 had multiple occurrences. Four patients had to discontinue therapy (1 rash, 1 hepatitis & rash, 1 pancytopenia, 1 infection) secondary to a severe side effect. The other 26 patients continued their therapy at the current dose, or tolerated therapy after lowering dosage. Two patients developed malignancies while on 6-MP(1 Basal Cell Carcinoma& Squamous Cell Skin Cancer, 1 Bladder Cancer & Prostate Cancer). Our experience demonstrates of 41 patients with inflammatory bowel disease 37/41 (90.2%) were able to tolerate the medication without having to discontinue treatment. Of those with side effects 26/30 (86.7%) were able to continue 6-MP/Azathioprine In our elderly IBD patient population taking immunomodulators that with periodic measurement of CBC, creatinine, and hepatic profile long-term therapy remained beneficial.

Risk Factors for Depression in the Elderly Inflammatory Bowel Disease Population

Purpose: Depression is common among patients with inflammatory bowel disease (IBD). Less is known about depression in the elderly population with IBD. Within an elderly IBD population, we aimed to 1) assess factors associated with depression and 2) determine whether depression is associated with disease activity, quality of life, or medication adherence. Methods: We identified elderly (≥65 years) individuals within Crohn's and Colitis Foundation of America (CCFA) Partners, an online cohort of over 10,000 patients living with self-reported IBD. Individuals were asked to complete the short- geriatric depression scale (GDS), a 15 question validated tool used to assess depression in the elderly population. A score of ≥5 on this scale suggests depression. We used bivariate statistics to determine whether demographic or disease related factors, disease activity (as measured by the short Crohn's disease activity index (sCDAI) or simple clinical colitis activity index (SCCAI), quality of life (measured by the short inflammatory bowel disease questionnaire (SIBDQ) and medication adherence (measured by the Morisky medication adherence scale (MMAS)) were associated with depression. We then used logistic regression to estimate the independent effects of depression on medication adherence. Results: A total of 359 elderly individuals with IBD completed the GDS. The mean age was 70.2 years (sd 4.7), with a mean disease duration of 25.6 years (sd 17.6). The prevalence of depression was 22.6%. Neither age, disease duration, nor gender differed by depression status. Lower education levels were significantly associated with depression (p=0.001). For both Crohn's disease (CD) and ulcerative colitis (UC), those with depression had significantly increased disease activity when compared to those without (sCDAI 52.5 versus 29, p=0.005 and SCCAI 5 versus 2, p=0.003). Depressed patients also had significantly lower health related quality of life (SIBDQ 4.6 versus 5.7, p<0.001) and lower medication adherence (p=0.01). Those with depression were more likely to have reduced medication adherence, even after controlling for disease activity (OR 2.49; 95% CI 1.26-4.92). Conclusion: Depression is common in this geriatric IBD cohort. Traditional risk factors for depression in the elderly, such as female gender and advancing age, are not associated with depression in geriatric IBD. Depression is independently associated with reduced medication adherence. The short GDS is a feasible tool for depression screening in the elderly IBD population that may allow for improved recognition and outcomes.

Experiences with elderly onset IBD

Introduction and Aims: Inflammatory Bowel Diseases (IBD) are considered to have a bimodal presentation: one peak at the second or third and another peak at the fifth or sixth decade of life. Elderly onset IBD is considered to show different disease characteristics as compared to young age onset. Therefore, the aim of this study was to analyze disease characteristics in elderly onset IBD in comparison to literature data.

Geriatric Inflammatory Bowel Disease: Phenotypic Presentation, Treatment Patterns, Nutritional Status, Outcomes, and Comorbidity

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

The Elderly Inflammatory Bowel Disease Patient and Osteoporosis

Inflammatory bowel disease increases the risk of osteoporosis by multiple mechanisms. The risk of osteoporosis-related fractures weighs heavily on the elderly inflammatory bowel disease population, due to the combination of aging and menopause on the underlying disease-associated risk. Risk factors are reviewed, as well as pathophysiologic mechanisms including inflammation, malabsorption and nutritional deficiencies, and use of glucocorticoid therapy. New data concerning vitamin D and the inflammatory disease is highlighted. Current recommendations concerning screening for bone disease in inflammatory bowel disease patients are reviewed. Therapy with vitamin D, calcium and bone-specific agents such as bisphosphonates, hormone replacement therapy, calcitonin and teriparatide are discussed, as well as potential benefits of direct treatment of the inflammation.

Clinical features of elderly Inflammatory bowel disease patients in Japan

Clinical features of elderly Inflammatory bowel disease patients in Japan

Clostridium difficile Infection in Geriatric IBD Admissions: 20 Year Tertiary Referral Experience

Purpose: The elderly with inflammatory bowel disease (IBD) have been affected by Clostridium difficile infection (CDI) at disproportionate rates and with worse clinical outcomes. We evaluated a 20 year hospital discharge database to characterize patterns of CDI among geriatric IBD patients requiring hospitalization and to describe outcomes in this cohort. Methods: Retrospective review of all geriatric (age > 65yr) admissions with a diagnosis of IBD [Crohn's disease (CD), ulcerative colitis (UC)] admitted from 1/1991-12/2010 extracted from a comprehensive electronic medical record based using ICD-9 coding and indexed terms. Co-morbidity was determined using Charlson's index. Results: Total geriatric IBD admissions (including repeated admissions) over 20 years were 1297 (UC: 703; CD: 594) and 6.1%, n=79 (UC: 55; CD: 24; F=40; M=39) involved CDI. Total number of geriatric IBD patients were 270 (UC:139; CD:131). Number of elderly IBD admissions with CDI rose from 0 in 1991 to 10 in 2010. Among the primary admissions for geriatric IBD (n = 319), 6.9% (n = 22) had CDI. Average Length of Stay for primary geriatric IBD admissions was 8.3 ± 10.1, which increased to 16.8 ± 28.8 days in patients with CDI; p <0.005. CDI occurred more commonly in UC (7.8%), compared with CD (4.0%) admissions (p = 0.006) and both conditions demonstrated a rise in CDI over the 20 year time period. Elderly UC patients with repeat admissions were diagnosed with CDI at higher rate (30.1%) compared to those without repeat admissions (4.4%; p<0.005). A similar pattern was seen for geriatric CD patients with repeat admissions, had CDI at higher rate (15.8%) compared to those without repeat admissions (2.1%; p <0.005). IBD therapy in elderly CDI patients included: corticosteroids (41.2%); 5ASA agents (33.8%); immunomodulators (1.5%); immunosuppressants (10.3%) and biologics (1.5%). CDI was treated with metronidazole alone in 33.7%, oral vancomycin alone 5.9% or a combination of both in 60.4%. 30.9% of patients with CDI required colectomy. Predisposing factors associated with geriatric IBD admissions with CDI included antibiotic therapy: 91.2%; recurrent hospitalizations: 79.4%; nursing home admissions: 7.4%. 2.46 % (n=32) of the geriatric IBD hospitalizations ended in death and 25% of these had CDI. Mortality with CDI was 10.1% (mortality without CDI: 1.8%; p < 0.005). There was no difference in the Charlson Co-morbid index for expired patients with CDI (5.9± 5.3) and without CDI (6.5± 2.9; p= NS). Conclusion: Geriatric IBD patients admitted with CDI experienced longer hospital stays and higher mortality. Elderly with repeat admissions had a higher rate of CDI. CDI in geriatric IBD patients requiring hospitalization is an important harbinger of poor clinical outcome.

Prevalence of metabolic syndrome is comparable between inflammatory bowel disease patients and the general population

Metabolic syndrome (MS) is associated with an increased risk of cardiovascular disease. However, its prevalence in inflammatory bowel disease (IBD) patients remains largely unknown. This study was planned to determine the prevalence of MS in Japanese IBD patients. The prevalence of MS among outpatients with IBD aged 18 or older was studied using the modified National Cholesterol Education Program Adult Treatment Panel III definition. A total of 107 quiescent IBD patients, including 76 ulcerative colitis (UC) patients and 31 Crohn's disease (CD) patients, were studied. Sufficient data were collected from a total of 102 patients. Prevalence of MS was significantly higher in UC (23.0%) patients compared to CD patients (7.1%). MS prevalence was substantially higher among male IBD patients (21.1%) compared to female IBD patients (12.9%), particularly in patients over 30 years of age. No difference was observed in the prevalence of MS between our IBD cohort and the general population in both males and females aged 40 years and older (P = 0.707 in males, P = 0.328 in females). IBD patients with MS were also older than those without (50.2 ± 15.0 vs. 38.0 ± 11.9 years, P = 0.013). In a logistic regression analysis, age was the statistically significant predictor of MS among IBD patients. The odds ratio (95% confidence interval) was 1.064 (1.017-1.114). Prevalence of metabolic syndrome in our IBD patients was comparable to that of the general population. Because age was the independent risk factor for developing MS, evaluation for MS is needed for elderly IBD patients.

Safety of 6-mercaptopurine Use in the Elderly Inflammatory Bowel Disease Population

Purpose: The population of elderly patients with inflammatory bowel disease (IBD) is increasing in part to the aging population as well as newly diagnosed IBD patients at an older age. Elderly patients are under-represented in clinical trials that investigate medical and surgical therapy for IBD. The aim of this study was to investigate long term safety with the use of the immunomodulator, 6-mercaptopurine.TableMethods: Thirty two patients above the age of 60 with either a diagnosis of Ulcerative Colitis (UC) or Crohn's disease (CD) were reviewed for demographics, dosage and most common adverse events. The study defined patient's aged 60 years or older as “elderly”. A comparison of the dosage, side effect profile and duration of therapy was examined. Results: Of the twenty nine patients (20 female, 9 male; mean age 70.3 years), 14 had CD and 15 had UC. All were on 6-MP at dosages ranging from 50mg to 150 mg. Of the twenty nine patients, 11 had a single documented side effect, 5 had more than one side effect and 13 were without side effects. Only one patient became pancytopenic. The average duration of therapy was 44 months. None exhibited newly diagnosed malignancies or episodes of pancreatitis. The most common adverse event was anemia (34%), whereby 70% of cases were with dosages greater than 50 mg. Leukopenia and elevated liver enzymes were the next most common side effects. All the patients were managed appropriately with individual side effects and none of the patients were discontinued from therapy. Conclusion: This is the first study reporting the safety profile of long-term 6-MP usage in the elderly IBD population (> 60 years). Our experience of 29 elderly patients on immunomodulator therapy revealed that elderly patients tolerated their medications reasonably well with a side effect profile that can be managed conservatively. Periodic monitoring of CBC, serum creatinine and hepatic profile is still warranted in this population with comorbid diseases and on multiple medications. Disclosure: Dr Seymour Katz - Speaker's Bureau: Proctor & Gamble, Abbott, UCB; Consultant/Scientific Advisor: Proctor & Gamble, Abbott, UCB; Research/Clinical Trial Support: Abbott, Proctor & Gamble, Pfizer, Élan, Bristol Meyers, Hutchison, Otsuka, Prometheus, Eisai, Millenium.

Demographics of Inflammatory Bowel Disease in Elderly in Outpatient Setting

Demographics of Inflammatory Bowel Disease in Elderly in Outpatient Setting

W1236 Safety of Chronic 5-ASA Use in the Elderly Inflammatory Bowel Disease Population

W1236 Safety of Chronic 5-ASA Use in the Elderly Inflammatory Bowel Disease Population

Therapy Insight: osteoporosis in inflammatory bowel disease—advances and retreats

There is a discrepancy between the high rates of reduced bone mineral density (BMD) reported in patients with inflammatory bowel disease (IBD) and the relatively low fracture rates observed in population-based studies. When fractures occur, they are most common among the elderly IBD population. It has become clear that BMD is but one of several important factors to be considered when assessing fracture risk. Ideally, BMD should be assessed selectively, as opposed to assessing this measure in all IBD patients simply because they carry an IBD diagnosis. Preventing bone loss should begin with an attempt to limit corticosteroid-induced bone loss. This can be done by using the minimum effective prednisolone dose, substituting budesonide when appropriate, administering other steroid-sparing immunomodulators, or by prescribing additional agents that enhance bone health. The administration of calcium and vitamin D appears to maintain or enhance bone mass. Bisphosphonates are of unclear additional benefit to the majority of patients who are at low fracture risk. Although more data are required to understand the best strategy to prevent fractures, a greater appreciation of the role of selective BMD testing and the utility of simple therapeutic strategies (such as calcium and vitamin D supplements) is emerging.

Factors Affecting Surgical Risk in Elderly Patients With Inflammatory Bowel Disease

The operative treatment of elderly patients with inflammatory bowel disease (IBD) has often been avoided in favor of medical management because of a perceived increase in surgical risk. This study sought to define the following in the elderly IBD patient population: (1) the risk of surgical management and (2) those factors affecting risk. Thirty patients with IBD, aged 60 years or more, who were surgically managed by a single surgeon over a 10-year period, were retrospectively matched to 75 patients with IBD who were less than 60 years of age; patients were matched according to sex, date of surgery, and type of surgery performed. Regression analysis using generalized estimating equation methodology to account for the matched clusters of patients was performed to evaluate the effect of age group on the complication rate, operating room time, and length of hospital stay. Presence of comorbid conditions, surgical indications, prior surgery for IBD, and the use of immunosuppressive medications were studied in multivariate models, adjusting for age group. By means of univariate analysis, the odds of complications in elderly IBD patients were shown to be statistically higher than the odds seen in younger patients (47% vs. 20%, P = 0.01). Also observed in the elderly group were a longer length of hospital stay (11.5 days vs. 7.1 days, P = 0.001) and longer operating room time (249 minutes vs. 212 minutes, P = 0.02). Multivariate analysis revealed that the effect of age remained statistically significant, even when adjusted for potential confounding variables such as comorbidity, medications, date of diagnosis of IBD, and indications for surgery. The complication outcome was significantly associated with the surgical indication, with obstruction, fistula, and bleeding having increased odds of complications as compared with other indications (odds ratio = 1.7 vs. 4.2 vs. 7.2, respectively, P = 0.02). The length of hospital stay similarly was significantly associated with the surgical indication (fistula, 10.5 days vs. bleeding, 9.8 days vs. obstruction, 7.4 days vs. other, 9.3 days; P = 0.04) and a history of prior surgery. A significant interaction for length of hospital stay was present between age group and prior surgery status (with prior surgery: old, 18 days vs. young, 6.4 days, P = 0.0001; without prior surgery: old, 9.5 days vs. young 7.3 days, P = 0.10). Elderly patients with IBD have an increased rate of postoperative complications along with an increased length of hospital stay and increased operating room time. This effect of age persists when adjusted for comorbidity and immunosuppressive therapy. Complications are most dependent on surgical indications, with obstruction being the least and bleeding the worst predictive factors. The longest hospital stay is associated with patients who require surgery for fistulous disease and patients who have undergone previous surgery. The fact that the higher complication rate seen in older patients with IBD is associated with disease-defined surgical indications suggests that IBD in elderly patients may be more aggressive than what is observed in younger individuals. ( J Gastrointest Surg 2002;6:606–613.)