Intest Res.  2023 Apr;21(2):216-225. 10.5217/ir.2021.00177.

Clinical spectrum of elderly-onset inflammatory bowel disease in India

• Gupta YK
• Singh A
• Narang V
• Midha V
• Mahajan R
• Mehta V
• Singh D
• Bansal N
• Durairaj MVB
• Dutta AK
• Sood A

• KMID: 2541894
• DOI: http://doi.org/10.5217/ir.2021.00177

Abstract

Background/Aims
Inflammatory bowel disease (IBD) is increasingly being recognized in elderly patients. Data on clinical spectrum of elderly-onset IBD patients is lacking from India.
Methods
A cross-sectional retrospective analysis of a prospectively maintained database of patients diagnosed with IBD was conducted at 2 centers in India. The clinical spectrum of elderly-onset IBD including demographic profile (age and sex), clinical presentation, disease characteristics (disease behavior and severity, extent of disease), and treatment were recorded and compared with adult-onset IBD.
Results
During the study period, 3,922 (3,172 ulcerative colitis [UC] and 750 Crohn’s disease [CD]) patients with IBD were recorded in the database. A total of 186 patients (4.74%; 116 males [62.36%]) had elderly-onset IBD (69.35% UC and 30.64% CD). Diarrhea, blood in stools, nocturnal frequency and pain abdomen were the commonest presentations for UC, whereas pain abdomen, weight loss and diarrhea were the most frequent symptoms in CD. For both elderly onset UC and CD, majority of the patients had moderately severe disease. Left-sided colitis was the commonest disease location in UC. Isolated ileal disease and inflammatory behavior were the most common disease location and behavior, respectively in CD. 5-Aminosalicylates were the commonest prescribed drug for both elderly onset UC and CD. Thiopurines and biologics were used infrequently. Prevalence of colorectal cancer was higher in elderly onset IBD.
Conclusions
Elderly onset IBD is not uncommon in India. Both the elderly onset UC and CD were milder, with no significant differences in disease characteristics (disease extent, location and behavior) when compared to adult-onset IBD. Colorectal cancer was more common in elderly onset IBD.

Keyword

Crohn disease; Colitis, ulcerative; Inflammatory bowel diseases; Elderly; Aged

Figure

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  Fig. 1. Flow of patients in the current study. DMCH, Dayanand Medical College and Hospital; CMCH, Christian Medical College and Hospital; IBD, inflammatory bowel disease.

Reference

1. Jairath V, Feagan BG. Global burden of inflammatory bowel disease. Lancet Gastroenterol Hepatol. 2020; 5:2–3.

2. Charpentier C, Salleron J, Savoye G, et al. Natural history of elderly-onset inflammatory bowel disease: a population-based cohort study. Gut. 2014; 63:423–432.

3. Sturm A, Maaser C, Mendall M, et al. European Crohn’s and Colitis Organisation topical review on IBD in the elderly. J Crohns Colitis. 2017; 11:263–273.

4. Tran V, Limketkai BN, Sauk JS. IBD in the elderly: management challenges and therapeutic considerations. Curr Gastroenterol Rep. 2019; 21:60.

5. Travis S. Is IBD different in the elderly? Inflamm Bowel Dis. 2008; 14 Suppl 2:S12–S13.

6. Ruel J, Ruane D, Mehandru S, Gower-Rousseau C, Colombel JF. IBD across the age spectrum: is it the same disease? Nat Rev Gastroenterol Hepatol. 2014; 11:88–98.

7. Song EM, Lee HS, Park SH, et al. Clinical characteristics and long-term prognosis of elderly onset ulcerative colitis. J Gastroenterol Hepatol. 2018; 33:172–179.

8. Mak J, Lok Tung Ho C, Wong K, et al. Epidemiology and natural history of elderly-onset inflammatory bowel disease: results from a territory-wide Hong Kong IBD registry. J Crohns Colitis. 2021; 15:401–408.

9. Shi HY, Chan FK, Leung WK, et al. Natural history of elderlyonset ulcerative colitis: results from a territory-wide inflammatory bowel disease registry. J Crohns Colitis. 2016; 10:176–185.

10. Komoto S, Higashiyama M, Watanabe C, et al. Clinical differences between elderly-onset ulcerative colitis and non-elderly-onset ulcerative colitis: a nationwide survey data in Japan. J Gastroenterol Hepatol. 2018; 33:1839–1843.

11. Langholz E. Ulcerative colitis: an epidemiological study based on a regional inception cohort, with special reference to disease course and prognosis. Dan Med Bull. 1999; 46:400–415.

12. Munkholm P. Crohn’s disease: occurrence, course and prognosis: an epidemiologic cohort-study. Dan Med Bull. 1997; 44:287–302.

13. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut. 2006; 55:749–753.

14. Best WR, Becktel JM, Singleton JW, Kern F Jr. Development of a Crohn’s disease activity index. National Cooperative Crohn’s Disease Study. Gastroenterology. 1976; 70:439–444.

15. Schroeder KW, Tremaine WJ, Ilstrup DM. Coated oral 5-aminosalicylic acid therapy for mildly to moderately active ulcerative colitis: a randomized study. N Engl J Med. 1987; 317:1625–1629.

16. Kedia S, Limdi JK, Ahuja V. Management of inflammatory bowel disease in older persons: evolving paradigms. Intest Res. 2018; 16:194–208.

17. Loftus EV Jr, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Crohn’s disease in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gastroenterology. 1998; 114:1161–1168.

18. Loftus EV Jr, Silverstein MD, Sandborn WJ, Tremaine WJ, Harmsen WS, Zinsmeister AR. Ulcerative colitis in Olmsted County, Minnesota, 1940-1993: incidence, prevalence, and survival. Gut. 2000; 46:336–343.

19. Zhao J, Ng SC, Lei Y, et al. First prospective, population-based inflammatory bowel disease incidence study in mainland of China: the emergence of “western” disease. Inflamm Bowel Dis. 2013; 19:1839–1845.

20. Wei SC, Lin MH, Tung CC, et al. A nationwide populationbased study of the inflammatory bowel diseases between 1998 and 2008 in Taiwan. BMC Gastroenterol. 2013; 13:166.

21. Piront P, Louis E, Latour P, Plomteux O, Belaiche J. Epidemiology of inflammatory bowel diseases in the elderly in the province of Liège. Gastroenterol Clin Biol. 2002; 26:157–161.

22. Loftus CG, Loftus EV Jr, Harmsen WS, et al. Update on the incidence and prevalence of Crohn’s disease and ulcerative colitis in Olmsted County, Minnesota, 1940-2000. Inflamm Bowel Dis. 2007; 13:254–261.

23. Lakatos PL, David G, Pandur T, et al. IBD in the elderly population: results from a population-based study in Western Hungary, 1977-2008. J Crohns Colitis. 2011; 5:5–13.

24. Kaplan GG, Windsor JW. The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol. 2021; 18:56–66.

25. Hou JK, Kramer JR, Richardson P, Mei M, El-Serag HB. The incidence and prevalence of inflammatory bowel disease among U.S. veterans: a national cohort study. Inflamm Bowel Dis. 2013; 19:1059–1064.

26. Ng SC, Tang W, Ching JY, et al. Incidence and phenotype of inflammatory bowel disease based on results from the AsiaPacific Crohn’s and Colitis Epidemiology Study. Gastroenterology. 2013; 145:158–165.

27. Makharia GK, Ramakrishna BS, Abraham P, et al. Survey of inflammatory bowel diseases in India. Indian J Gastroenterol. 2012; 31:299–306.

28. Shivananda S, Lennard-Jones J, Logan R, et al. Incidence of inflammatory bowel disease across Europe: is there a difference between north and south? Results of the European Collaborative Study on Inflammatory Bowel Disease (EC-IBD). Gut. 1996; 39:690–697.

29. Das K, Ghoshal UC, Dhali GK, Benjamin J, Ahuja V, Makharia GK. Crohn’s disease in India: a multicenter study from a country where tuberculosis is endemic. Dig Dis Sci. 2009; 54:1099–1107.

30. Tiihonen K, Ouwehand AC, Rautonen N. Human intestinal microbiota and healthy ageing. Ageing Res Rev. 2010; 9:107–116.

31. Ananthakrishnan AN, Donaldson T, Lasch K, Yajnik V. Management of inflammatory bowel disease in the elderly patient: challenges and opportunities. Inflamm Bowel Dis. 2017; 23:882–893.

32. Foxworthy DM, Wilson JA. Crohn’s disease in the elderly: prolonged delay in diagnosis. J Am Geriatr Soc. 1985; 33:492–495.

33. Taleban S, Colombel JF, Mohler MJ, Fain MJ. Inflammatory bowel disease and the elderly: a review. J Crohns Colitis. 2015; 9:507–515.

34. Polito JM 2nd, Childs B, Mellits ED, Tokayer AZ, Harris ML, Bayless TM. Crohn’s disease: influence of age at diagnosis on site and clinical type of disease. Gastroenterology. 1996; 111:580–586.

35. Harper PC, McAuliffe TL, Beeken WL. Crohn’s disease in the elderly: a statistical comparison with younger patients matched for sex and duration of disease. Arch Intern Med. 1986; 146:753–755.

36. Viola A, Monterubbianesi R, Scalisi G, et al. Late-onset Crohn’s disease: a comparison of disease behaviour and therapy with younger adult patients. The Italian Group for the Study of Inflammatory Bowel Disease ‘AGED’ study. Eur J Gastroenterol Hepatol. 2019; 31:1361–1369.

37. Gower-Rousseau C, Vasseur F, Fumery M, et al. Epidemiology of inflammatory bowel diseases: new insights from a French population-based registry (EPIMAD). Dig Liver Dis. 2013; 45:89–94.

38. Juneja M, Baidoo L, Schwartz MB, et al. Geriatric inflammatory bowel disease: phenotypic presentation, treatment patterns, nutritional status, outcomes, and comorbidity. Dig Dis Sci. 2012; 57:2408–2415.

39. Johnson SL, Bartels CM, Palta M, Thorpe CT, Weiss JM, Smith MA. Biological and steroid use in relationship to quality measures in older patients with inflammatory bowel disease: a US Medicare cohort study. BMJ Open. 2015; 5:e008597.

40. Kaplan GG, Hubbard J, Panaccione R, et al. Risk of comorbidities on postoperative outcomes in patients with inflammatory bowel disease. Arch Surg. 2011; 146:959–964.

41. Pellino G, Sciaudone G, Candilio G, et al. Complications and functional outcomes of restorative proctocolectomy for ulcerative colitis in the elderly. BMC Surg. 2013; 13(Suppl 2):S9.

42. Nguyen GC, Bernstein CN, Benchimol EI. Risk of surgery and mortality in elderly-onset inflammatory bowel disease: a population-based cohort study. Inflamm Bowel Dis. 2017; 23:218–223.

43. Ananthakrishnan AN, Shi HY, Tang W, et al. Systematic review and meta-analysis: phenotype and clinical outcomes of older-onset inflammatory bowel disease. J Crohns Colitis. 2016; 10:1224–1236.

44. Hou JK, Feagins LA, Waljee AK. Characteristics and behavior of elderly-onset inflammatory bowel disease: a multi-center US study. Inflamm Bowel Dis. 2016; 22:2200–2205.

45. Cheddani H, Dauchet L, Fumery M, et al. Cancer in elderly onset inflammatory bowel disease: a population-based study. Am J Gastroenterol. 2016; 111:1428–1436.

46. Fries W, Viola A, Manetti N, et al. Disease patterns in late-onset ulcerative colitis: results from the IG-IBD “AGED study”. Dig Liver Dis. 2017; 49:17–23.