The Impact of Inflammatory Bowel Disease in Canada 2018: IBD in Seniors

Approximately one in every 160 seniors live with IBD. Due to the fact that IBD has no known cure, and thus patients diagnosed at younger ages will carry their disease with them into their senior years, the number of senior IBD patients is rising significantly in Canada. Seniors with IBD present unique challenges for care. Patients with IBD will experience greater comorbid conditions resulting from their advancing age and longer disease duration. Risks associated with IBD-related surgeries and complications from other illnesses associated with age and their medications further complicate treatment options and may lead to higher healthcare utilization. Healthcare providers need to be prepared to work in multidisciplinary teams with other specialists in order to address the complexity and comorbidities of seniors with IBD.

Highlights: 1. Approximately one out of every 160 individuals over the age of 65 in Canada is living with IBD.2. The rising prevalence of IBD in seniors results from new diagnoses and advancing age of previously diagnosed patients with IBD.3. Patients with IBD will experience greater comorbid conditions resulting from their advancing age and longer disease duration.4. As the IBD population ages, the proportion of seniors with IBD will increase in gastroenterology clinics.5. The care of seniors with IBD brings unique challenges with respect to therapeutic decision-making.

Key summary points: 1. Approximately 0.6% of seniors in Canada live with IBD.2. In Ontario, the prevalence of IBD among seniors increased by 5.2% per year, which outpaced the 3.9% per year rise observed in nonseniors.3. Approximately 15% of IBD patients are newly diagnosed after the age of 65 years.4. The incidence of IBD in seniors ranged from 16.5 to 18.9 per 100,000 in Canada.5. In Ontario, the diagnosis of ulcerative colitis in seniors was double that of Crohn's disease.6. Clinical presentation of seniors with Crohn's disease is unique with a higher likelihood to present with isolated colonic disease without fistulizing disease or extra-intestinal manifestations as compared with those diagnosed at a younger age.7. Seniors with IBD are less likely to have outpatient visits relating to their IBD as compared with younger patients with IBD.8. Among individuals diagnosed over the age of 65, the 10-year risk of intestinal surgery was 7% to 19% for ulcerative colitis and 31% for Crohn's disease.9. Seniors who undergo intestinal resections for their IBD have significantly higher postoperative complications and mortality as compared with younger IBD patients undergoing surgery.10. The use of anti-TNF agents in seniors is lower for Crohn's disease (4.0%) and ulcerative colitis (2.3%) as compared with younger individuals with IBD. However, the rate of use of biologics is increasing over time.11. Therapeutic decision-making in seniors with IBD is challenging due to their comorbid conditions.12. Seniors who use thiopurines have a higher risk of lymphoma (5.4 per 1000 person-years) as compared with IBD patients younger than 50 (0.37 per 1000 person-years) exposed to thiopurines.13. Newer gut-selective α4β7 integrin inhibitors may be a safer choice for seniors due to potentially lower risk of infection and cancer.14. Due to multiple comorbidities, seniors with IBD may struggle with polypharmacy that can lead to drug interactions and reduced medication adherence.15. Persons between 65 and 79 of age with IBD on average cost the healthcare system $5298 per year, which is higher than age-matched controls.

Gaps in knowledge and future directions: 1. Administrative healthcare databases are more likely to misclassify senior patients with IBD. Future research is necessary to improve the identification of senior patients with IBD in databases.2. Gastroenterologists will need to contend with an older IBD population with greater comorbidities. Research focusing on defining the burden of comorbidities in senior IBD patients is needed for healthcare resource utilization planning.3. The use of anti-TNF in senior patients is lower than in younger individuals with IBD. Future research should evaluate trends in using biologics in the senior population with the advent of newer biologics such as integrin and other cellular adhesion molecule inhibitors.4. Polypharmacy is a challenge for senior IBD patients. Future research should focus on interventions to simplify drug regimens and administration for senior patients.5. Senior individuals with IBD cost the healthcare system more than age-matched controls. However, research is necessary to establish the IBD-attributable cost to the healthcare system and the indirect cost to society.