Elderly-onset IBD Research Articles

P607 Increased rates of fractures and malignancy in elderly onset IBD in Singapore

Abstract Background Elderly onset inflammatory bowel disease (EOIBD) has variable characteristics in the published literature. We performed this study to report the disease characteristics, treatment exposure, and clinical outcomes of EOIBD compared to adult onset IBD (AOIBD) in Singapore. Methods This is a retrospective study involving IBD patients seen at two tertiary hospitals in Singapore from January 2020 to September 2023. Patients were identified from the Singapore National IBD registry. Those with missing data on age of IBD diagnosis were excluded. Data on baseline demographics, disease characteristics, treatment and disease-related complications were collected. EOIBD is defined as age of diagnosis ≥ 60 years old and AOIBD as those diagnosed from age 18 to 59 years old. The characteristics was compared between these two groups. Data was analysed using SPSS version 27.0. Results 1116 patients were included in the final analysis, 10.6% (n =118) were EOIBD as shown in Figure 1. 50% were male with a mean age of diagnosis at 68 years old. The comparison between EOIBD and AOIBD are shown in Figure 1 and Table 1. There is a higher proportion of Crohn’s disease (CD) (45.7% vs 37.4%) in EOIBD. In terms of treatment, there is significantly lower use of thiopurines amongst EOIBD (34.5% vs 46.8%, p = 0.012). There was a trend of higher use of methotrexate among EIOBD (19.6% vs 10.6%, p = 0.067) although this was not statistically significant and this is similarly observed in the use of biologics (32.8% in EOIBD vs 27.1% in AOIBD, p = 0.205). There were no significant differences in corticosteroids (CS) exposure, CS dependence and mean number of CS courses used. There was a lower proportion of IBD-related surgery in EOIBD (12.1 vs 18.5%, p = 0.094) with EOID having a significantly lower mean number of IBD-related surgery (1.1 vs 1.6, p <0.001). Among EOIBD, there were significantly higher rates of malignancy (17% vs 6%, p <0.001) and fractures (18.1% vs 9.2%, p = 0.02); the latter despite a statistically higher mean level of vitamin D (20.9 ng/ml vs 18.3 ng/ml, p = 0.026). There were no differences in IBD-related hospitalization. Conclusion EOIBD is associated with increased rates of fractures and malignancy compared to AOIBD. Therefore, bone health and malignancy screening should be regularly performed in this group of patients to clinical outcomes.

Frailty and pre-frailty with long-term risk of elderly-onset inflammatory bowel disease: A large-scale prospective cohort study

PurposeTo investigate the prospective association of frailty status with the long-term risk of elderly-onset IBD in a large prospective cohort. MethodsParticipants free of IBD and cancer at enrollment from the UK Biobank cohort were included. Baseline pre-frail and frail status was measured by Fried phenotype including weight loss, exhaustion, low grip strength, low physical activity and slow walking pace, defined as meeting one or two criteria and meeting three or more criteria. Primary outcome was elderly-onset IBD, including elderly-onset ulcerative colitis (UC) and Crohn’s disease (CD). Multivariable Cox regression was conducted to examine the related associations. ResultsOverall, 417,253 participants (aged 56.18 ± 8.09 years) were included. Of whom, 19,243 (4.6 %) and 188,219 (45.1 %) were considered frail and pre-frail, respectively. During a median of 12.4 years follow-up, 1503 elderly-onset IBD cases (1001 UC, 413 CD, and 89 IBD-Unclassified) were identified. Compared with non-frail, individuals with frail (HR=1.40, 95 %CI: 1.13–1.73) and pre-frail (HR=1.15, 1.03–1.28) showed significantly higher risk of elderly-onset IBD after multivariable adjustment (Ptrend<0.001). The positive association was more evident regarding risk of elderly-onset CD (HR=2.16, 1.49–3.13 for frail; HR=1.49,1.20–1.85 for pre-frail; Ptrend<0.001). Sensitivity analyses and subgroup analyses according to age, gender and body mass index (BMI) demonstrated similar results. ConclusionsFrailty and pre-frailty are associated with increased risk of elderly-onset IBD, particularly elderly-onset CD.

Microbial-Immune Crosstalk in Elderly-Onset Inflammatory Bowel Disease: Unchartered Territory.

Elderly-onset inflammatory bowel disease [IBD] patients exhibit a distinct natural history compared to younger IBD patients, with unique disease phenotypes, differential responses to therapy, and increased surgical morbidity and mortality. Despite the foreseeable high demand for personalized medicine and specialized IBD care in the elderly, current paradigms of IBD management fail to capture the required nuances of care for elderly-onset IBD patients. Our review postulates the roles of systemic and mucosal immunosenescence, inflammageing and a dysbiotic microbial ecosystem in the pathophysiology of elderly-onset IBD. Ultimately, a better understanding of elderly-onset IBD can lead to improved patient outcomes and the tailoring of future preventative and treatment strategies.

Association Between Inflammatory Bowel Disease and Psychiatric Morbidity and Suicide: A Swedish Nationwide Population-Based Cohort Study With Sibling Comparisons.

Background and AimsInflammatory bowel disease [IBD] is linked to psychiatric morbidity, but few studies have assessed general population comparators. We aimed to investigate the risk of psychiatric morbidity and suicide in adult-onset IBD patients.MethodsWe used a nationwide population-based cohort study in Sweden [1973–2013]. We studied the risk of psychiatric disorders and suicide in 69,865 adult-onset IBD patients [ulcerative colitis, UC: n = 43,557; Crohn’s disease, CD: n = 21,245; and IBD-unclassified: n = 5063] compared to 3,472,913 general population references and 66 292 siblings.ResultsDuring a median follow-up of 11 years, we found 7465 [10.7%] first psychiatric disorders in IBD [incidence rate, IR/1000 person-years 8.4] and 306 911 [9.9%] in the general population [IR 6.6], resulting in 1.8 extra psychiatric morbidity per 100 patients followed-up for 10 years and a hazard ratio [HR] of 1.3 [95% confidence interval, 95%CI = 1.2–1.3]. The highest risk of overall psychiatric morbidity was seen in the first year after IBD diagnosis [HR = 1.4, 95%CI = 1.2–1.6] and in patients with extraintestinal manifestations [HR = 1.6, 95%CI = 1.5–1.7]. Psychiatric morbidity was more common in all IBD subtypes [HR 1.3–1.5]. An increased risk of suicide attempts was observed among all IBD types [HR = 1.2–1.4], whereas completed suicide was explicitly associated with CD [HR = 1.5] and elderly-onset [diagnosed at the age of > 60 years] IBD [HR = 1.7].ConclusionAdult-onset IBD was associated with an increased risk of psychiatric disorders and suicide attempts. Psychological follow-up should be provided to patients with IBD, especially those with extraintestinal manifestations and elderly-onset IBD. This follow-up should be within the first year after IBD diagnosis.

Biologic Therapy in Elderly Patients with IBD: Current Trends and Special Management Considerations

With the aging IBD population and increasing incidence of elderly-onset IBD, the overall prevalence of IBD in the elderly is rising. The elderly have unique medical, psychosocial, and other age-related comorbidities and disabilities that need to be taken into account when assessing the impact of IBD on the patient’s overall health and quality of life, and choosing an effective therapy. There is a general reluctance among physicians to prescribe biologic therapies out of concerns of their potential side effects, in favor of mesalamine, steroids, and surgery. Although there is an overall paucity of robust data on biologic use in the elderly from randomized clinical trials, recent retrospective and real-world studies provide insight on the safety and efficacy of anti-TNF and other biologics in this population. This review analyzes and highlights the most recent data on biologic therapies in the elderly, so physicians can make informed decisions and judiciously use biologics in the elderly with moderate to severe IBD, keeping in mind the goals of care in this population, i.e., effectively and safely control IBD symptoms, minimize steroid use, prevent short-term disease complications and hospitalization, restore the patient’s quality of life and functionality, and prevent further frailty and disability.

Epidemiology and Natural History of Elderly-onset Inflammatory Bowel Disease: Results From a Territory-wide Hong Kong IBD Registry.

Elderly-onset inflammatory bowel disease [IBD], defined as age ≥60 at diagnosis, is increasing worldwide. We aimed to compare clinical characteristics and natural history of elderly-onset IBD patients with those of adult-onset IBD patients. Patients with a confirmed diagnosis of IBD from 1981 to 2016 were identified from a territory-wide Hong Kong IBD registry involving 13 hospitals. Demographics, comorbidities, clinical features, and outcomes of elderly-onset IBD patients were compared with those of adult-onset IBD patients. A total of 2413 patients were identified, of whom 270 [11.2%] had elderly-onset IBD. Median follow-up duration was 111 months (interquartile range [IQR]: 68-165 months). Ratio of ulcerative colitis [UC]: Crohn's disease [CD] was higher in elderly-onset IBD than in adult-onset IBD patients [3.82:1 vs 1.39:1; p <0.001]. Elderly-onset CD had less perianal involvement [5.4% vs 25.4%; p <0.001] than adult-onset CD. Elderly-onset IBD patients had significantly lower cumulative use of immunomodulators [p = 0.001] and biologics [p = 0.04]. Elderly-onset IBD was associated with higher risks of: cytomegalovirus colitis (odds ratio [OR]: 3.07; 95% confidence interval [CI] 1.92-4.89; p <0.001); herpes zoster [OR: 2.42; 95% CI 1.22-4.80; p = 0.12]; and all cancer development [hazard ratio: 2.97; 95% CI 1.84-4.79; p <0.001]. They also had increased number of overall hospitalisations [OR: 1.14; 95% CI 1.09-1.20; p <0.001], infections-related hospitalisation [OR: 1.87; 95% CI 1.47-2.38; p <0.001], and IBD-related hospitalisation [OR: 1.09; 95% CI 1.04- 1.15; p = 0.001] compared with adult-onset IBD patients. Elderly-onset IBD was associated with increased risk of infections and cancer development, and increased infection- and IBD-related hospitalisations. Specific therapeutic strategies to target this special population are needed.

Mortality in adult-onset and elderly-onset IBD: a nationwide register-based cohort study 1964–2014

ObjectivesTo examine all-cause and cause-specific mortality in adult-onset and elderly-onset IBD and to describe time trends in mortality over the past 50 years.DesignSwedish nationwide register-based cohort study 1964–2014, comparing mortality...

Variation in Access to Specialist Care and Risk of Surgery in Patients with Inflammatory Bowel Disease: A Population-Based Cohort Study

IntroductionInflammatory bowel disease (IBD; subtypes: Crohn’s disease (CD) and ulcerative colitis (UC)) is a chronic disease of the gastrointestinal tract with rising prevalence among people ≥65y. Rural residents, especially those ≥65y, have decreased access to specialist care. Specialist care is associated with lower risk of hospitalization and surgery.&#x0D; Objectives and ApproachWe evaluated variation across physician networks in access to specialist care and surgery among incident patients ≥65y in Ontario health administrative data. Access to specialist care was defined as: ≥1 outpatient visit to gastroenterologists or the majority of IBD-specific outpatient care by gastroenterologists. Variation was assessed with multilevel logistic regression and median odds ratios (MOR), adjusting for age, sex, distance from IBD physician, comorbidities, neighbourhood income, and rural/urban. Models evaluating surgical risk also adjusted for specialist care use, emergency department visits, and hospitalization at diagnosis. Network-level variables included rurality (RIO score), population colonoscopy and gastroenterologist supply.&#x0D; ResultsThere was significant variation in having ≥1 gastroenterologist visit (CD p=0.0001, MOR 3.3; UC p&lt;0.0001, MOR 3.1) and gastroenterologist providing the majority of care (CD p=0.0001, MOR 3.0; UC p&lt;0.0001, MOR 3.7) within 12 months of diagnosis. Variation remained significant after accounting for network-level characteristics (≥1 gastroenterologist visit: CD p=0.0002, MOR 2.6, UC p&lt;0.0001, MOR 2.2; majority of care: CD p=0.0002, MOR 2.4; UC p&lt;0.0001, MOR 2.4). In CD, there was no variation in the five-year risk of surgery (p=0.07, MOR 1.3) and was unchanged by network-level factors (p=0.13, MOR 1.3). Variation in the risk of colectomy exists for patients with UC (p=0.016, MOR 1.3) and was not reduced when accounting for network-level characteristics (p=0.019, MOR 1.3).&#x0D; Conclusion/ImplicationsAccess to specialist care among patients with elderly-onset IBD is varies greatly between networks but this variation cannot be explained by differing provision of gastroenterological services across physician networks. Further research is needed to understand the factors that influence access to care and outcomes in elderly patients with IBD.

Post-operative complications in elderly onset inflammatory bowel disease: a population-based study.

IBD diagnosed after the age of 60 is increasing. Data on post-operative complications in elderly onset IBD are scarce. To describe the incidence of and factors associated with post-operative complications in elderly onset IBD, diagnosed after the age of 60. Using EPIMAD Cohort (1988-2006), among 841 incident IBD patients, 139 (17%) underwent intestinal surgery, including 100 Crohn's disease (CD) and 39 ulcerative colitis (UC). After a median post-operative follow-up of 6years (2-10), 50 (36%) patients experienced at least 1 complication with a total of 69. During the first 30 post-operative days, the mortality rate was 4%. Thirty-two early complications (<30days) were observed in 23 patients (17%), with 15 infectious, without significant difference between CD and UC. More than half early post-operative complications (n=19, 59%) were severe (>grade 2) without significant difference between CD and UC (P=0.28). Thirty-seven long-term adverse effects of surgical therapy (≥30days) were observed in 33 patients (24%). Multivariate analysis found (1) acute severe colitis (OR=7.84 [2.15-28.52]) and emergency surgery (OR=4.46 [1.75-11.36]) were associated with early post-operative complications, and (2) Female gender (HR=2.10 [1.01-4.37]) and delay before surgery >3months (HR=2.09 [1.01-4.31]) with long-term adverse effects of surgical therapy. One-third of elderly IBD patients experienced at least 1 post-operative complication. Half of the early complications were severe, and infectious. Emergency surgery was the key driver for post-operative complication.

PTU-052 The Impact of Thiopurines on Risk of Intestinal Surgery in Elderly-Onset IBD: Abstract PTU-052 Table 1

Introduction Thiopurines (TP) have an established role in the maintenance of steroid-free remission in IBD. Their role in reducing the need for surgery in younger populations has been recently highlighed. 1 TPs are associated with an increased risk of lymphoma in the elderly but their role in reducing the risk of surgery in patients with elderly-onset IBD (EO-IBD) is not established. We therefore aimed to evaluate the impact of TPs on the risk of surgery in EO-IBD, using a nationally representative research database. Methods This was a retrospective descriptive study using data from the Clinical Practice Research Datalink (CPRD). Incident cases of IBD were isolated using previously validated Read codes. Patients were included if they had codes for ulcerative colitis (UC) or Crohn’s disease (CD), and their date of diagnosis was on/after their 60 th birthday. Information extracted included sex, age at diagnosis, smoking status, and prescription data for IBD medications. Finally, we obtained data on our main outcomes: colectomy in UC and first intestinal surgery in CD. A multivariate Cox proportional hazard model was generated to deduce the risk of surgery according to TP use. The model was adjusted for potential confounders including sex, smoking, 5 ASA use and early steroid use (corticosteroid within 3 months of diagnosis). In a subgroup of TP users, a second proportional hazard model was used to define the impact of duration of TP treatment on the risk of surgery. Results 2758 and 1349 were identified with EO-UC and EO-CD respectively, with a mean follow up of 4.9 years. Mean age at diagnosis was 71.8 years. Table 1 demonstrates the summary demographic and prescription data for both groups. TP use was associated with an increased risk of colectomy in EO-UC (HR 3.5, CI 2.28–5.35, p Conclusion TP use for longer than 12 months is associated with a reduced risk of colectomy in EO-UC but in contrast does not appear appear to impact on the risk of first intestinal surgery in EO-CD. This is an important observation since the risk of TP-associated lymphoma is substantially increased in this age group. Further work is needed to evaluate the role of TPs in EO-IBD. Reference 1 Chhaya V, et al . Impact of early thiopurines in 2770 children and young people diagnosed with IBD: a national population-based study. Aliment Pharmacol Ther . 2015 Oct; 42 (8). Disclosure of Interest C. Alexakis: None Declared, S. Saxena Grant/research support from: SS is funded by a National Institute for Health Research Career Development Fellowship (NIHR CDF-2011-04-048). The views expressed are not necessarily those of the NHS, NIHR, or Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript, V. Chhaya: None Declared, E. Cecil Grant/research support from: EC is funded by a National Institute for Health Research Career Development Fellowship (NIHR CDF-2011-04-048). The views expressed are not necessarily those of the NHS, NIHR, or Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript, R. Pollok: None Declared

P622 Health care consumption and treatment of Crohn's disease in Stockholm County

conducted using chi-square test for categorical variables. P value <0.05 was considered for statistical significance. Results: In our study group there were 157 patients with elderly onset IBD (14.7%), with similar sex distribution as in non-elderly IBD patients. There were significantly less active smokers among elderly-onset IBD patients (5.9% vs 18.3%, p = 0.0007) and patients resided rural areas more frequently (33.8% vs 25.4% p = 0.02). Ulcerative colitis (UC) is more frequently encountered in elderly IBD patients (67.1% vs 57.5% p = 0.02). Colonic Crohn’s Disease (CD) L2 is more prevalent in our elderly cohort (61.2% vs 39.1% p = 0.003) whereas extensive ileocolonic CD (L3) was less frequent (24.5% vs 41.4%, p = 0.02). No significant association with extent of colonic involvement for elderly UC patients was identified. Malignization occurred 6 times more frequently in elderly IBD patients (1.9% vs 0.3% p = 0.01). With regard to therapeutic management, a significantly higher number of elderly-onset patients were treated with 5ASA (77.6% vs 49.9% p = 0.0002) whereas no significant differences were identified for corticosteroids or azathioprine treatments. There was no difference with regard to severity of disease flare in elderly vs. non-elderly IBD patients. Conclusions: In Romania elderly IBD patients have distinct epidemiological and phenotypical characteristics: higher frequency of UC and colonic CD phenotype and higher risk of malignization that requires active surveillance.

P621 Health care consumption and treatment of ulcerative colitis in Stockholm County

conducted using chi-square test for categorical variables. P value <0.05 was considered for statistical significance. Results: In our study group there were 157 patients with elderly onset IBD (14.7%), with similar sex distribution as in non-elderly IBD patients. There were significantly less active smokers among elderly-onset IBD patients (5.9% vs 18.3%, p = 0.0007) and patients resided rural areas more frequently (33.8% vs 25.4% p = 0.02). Ulcerative colitis (UC) is more frequently encountered in elderly IBD patients (67.1% vs 57.5% p = 0.02). Colonic Crohn’s Disease (CD) L2 is more prevalent in our elderly cohort (61.2% vs 39.1% p = 0.003) whereas extensive ileocolonic CD (L3) was less frequent (24.5% vs 41.4%, p = 0.02). No significant association with extent of colonic involvement for elderly UC patients was identified. Malignization occurred 6 times more frequently in elderly IBD patients (1.9% vs 0.3% p = 0.01). With regard to therapeutic management, a significantly higher number of elderly-onset patients were treated with 5ASA (77.6% vs 49.9% p = 0.0002) whereas no significant differences were identified for corticosteroids or azathioprine treatments. There was no difference with regard to severity of disease flare in elderly vs. non-elderly IBD patients. Conclusions: In Romania elderly IBD patients have distinct epidemiological and phenotypical characteristics: higher frequency of UC and colonic CD phenotype and higher risk of malignization that requires active surveillance.

IBD across the age spectrum—is it the same disease?

IBD is a chronic disorder with disease onset ranging from early childhood to beyond the sixth decade of life. The factors that determine the age of onset currently remain unexplained. Is timing of occurrence a random event or is it indicative of different pathophysiological pathways leading to different phenotypes across the age spectrum? Over the past decade, several studies have suggested that the characteristics and natural history of IBD seem to be different according to age of onset. This heterogeneity suggests that the respective contributions of genetics, host immune system and environment to the aetiology and phenotype of Crohn's disease and ulcerative colitis are different across ages. Critical reviews that focus on differences characterizing IBD between age groups are scarce. Therefore, this Review updates the knowledge of the differences in epidemiology, clinical characteristics, and natural history of paediatric, adult and elderly-onset IBD. In addition, potential differences in host-gene-microbial interactions according to age are highlighted.

Elderly-onset IBD: a milder disease?

Patients with elderly-onset IBD are more likely to have marked comorbidities and polypharmacy than those diagnosed at a younger age, which might affect therapeutic decision-making. Increased knowledge of this higher-risk group might guide patient management. Data from a large population-based study evaluating the clinical presentation and course of elderly-onset IBD are discussed.

PMO-226 Differing phenotype in elderly IBD; should Montreal include an A4 category

IntroductionThe phenotype of elderly-onset IBD is poorly described and knowledge lags behind that of other age-groups. While not the dominant age-group in the disease population, those diagnosed over 60 will...