Therapeutic Needs of Older Adults with Inflammatory Bowel Disease (IBD): A Systematic Review

Abstract

Background/Objective: Inflammatory bowel disease (IBD) diagnosis in the elderly falls under two categories: those diagnosed at a younger age and transitioning to the elderly group (>60 years) and those diagnosed at ≥60 years of age. Although it is difficult to calculate the incidence of IBD among elderly adults precisely, it is estimated that around 10–15% of IBD in the US are diagnosed after 60 years, and approximately 13% of IBD cases are diagnosed after the age of 65 globally. The objective of this systematic review is to assess the therapeutic needs of elderly adults with IBD, focusing on quality of life (QOL), symptom presentation, mental health management, IBD medication utilization patterns, surgical outcomes, and healthcare utilization to identify gaps in IBD management. Methods: We identified 42 published articles through a database search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses from October 2023 to June 2024. We conducted the quality appraisal of the selected studies using the Joanna Briggs Institute (JBI) critical appraisal tools. Results: Our findings indicate decreased health-related QOL, more colonic and less penetrating disease in elderly Crohn’s disease patients, and comparable symptoms between elderly and younger ulcerative colitis patients. Despite an increased trend in prescribing biologics, the elderly show decreased response rates and poor remission. Higher healthcare utilization is noted among elderly IBD patients, alongside insufficient attention to their mental health concerns. Conclusions: The findings from this systematic review offer a comprehensive synthesis of the management of elderly adults with IBD and highlight several unmet needs that warrant attention in future research and clinical practice considerations.

1. Introduction

Inflammatory bowel disease (IBD) is an incurable illness affecting the gastrointestinal (GI) tract characterized by diarrhea, abdominal cramps, weight loss, rectal bleeding, and other extra-intestinal manifestations [1]. Crohn’s disease (CD) and ulcerative colitis (UC) represent the primary forms of IBD. According to recent data, approximately 3.1 million adults in the United States are affected by IBD [1]. The prevalence of IBD is increasing by 5.2% annually among elderly adults [2]. IBD diagnosis among elderly adults can be categorized into two groups: 1) those diagnosed with IBD at a younger age and then transitioned to the elderly group (>60 years of age) and adults diagnosed with IBD at 60 years of age or older [3]. Based on a 2019 global study, there has been a significant rise in the incidence rate of IBD among older adults worldwide, with the highest rates observed in the Western Pacific area and the greatest burden found in the US [4]. Although it is difficult to calculate the incidence of IBD among elderly adults precisely, it is estimated that around 10–15% of IBD in the US are diagnosed after 60 years, and approximately 13% of IBD cases are diagnosed after the age of 65 globally [4,5].

The dysbiosis of intestinal microbial flora is a major contributing factor to the diagnosis of IBD among elderly adults. The intestinal microbiota is altered in the elderly due to several reasons. Physiological changes associated with normal aging, such as decreased intestinal motility, fecal retention, altered nutrition due to decreased taste and smell, and decreased resistance to stressors, may disrupt the balance of gut bacteria in elderly adults and increase their risk for IBD [3]. In addition to the unique pathophysiology of IBD among elderly adults, elderly patients face multiple challenges associated with its treatment. Elderly adults with IBD are often excluded from clinical trials due to factors such as age, multiple comorbid conditions, and a history of dysplasia or cancer [5,6]. As a result, determining the best drug therapy for this population to manage their IBD-related symptoms remains difficult. To address these challenges, the American Gastroenterology Association (AGA) updated its clinical practice guidelines on the management of IBD in elderly patients [2]. However, these recommendations heavily focused on diagnosis and medical management, with little or no attention to the management of mental health, symptom management, evaluation of the cost of illness, and other unmet needs of elderly adults with IBD [2].

Any chronic illness significantly affects the quality of life (QOL) of the affected population. This is also true for IBD, which impairs the QOL of elderly adults [7]. Moreover, little is known about the other unmet needs and burdens perceived by elderly adults with IBD. These individuals are at risk for mental health concerns due to both disease-related and treatment-related factors [8]. Older adults with IBD tend to have a higher geriatric deficit [9] and experience negative health outcomes due to frailty [10]. IBD patients generally face many unplanned healthcare utilization needs [11]; however, the situation varies greatly among elderly adults with IBD due to aging and related co-morbid conditions. Therefore, the purpose of this systematic review is to assess the therapeutic needs of elderly adults with IBD, with a specific focus on their QOL, symptom presentation, mental health management, IBD medication utilization patterns, surgical outcomes, and healthcare utilization, to identify the gaps in their IBD management.

2. Methods

We utilized a systematic review methodology to achieve the purpose of this study, conducting a literature review from October 2023 to June 2024 to select published manuscripts focused on the management of elderly adults with IBD. We adhered to the Joanna Briggs Institute (JBI) guidelines for systematic reviews to guide our study [12].

2.1. Search Method

Using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we conducted a literature search to identify the eligible articles for this systematic review [13]. In partnership with a research librarian, we developed a search plan and conducted a database search of PubMed, Embase, CINAHL, and Cochrane Central Register of Controlled Trials using the following keywords: “inflammatory bowel disease, Crohn’s disease, ulcerative colitis, older adults, elderly IBD, frailty, quality of life, symptoms, cost of illness, medication outcomes, mental health, social support, burden, and unmet needs”. These keywords were customized based on the prerequisites of each database to identify the articles.

The second author refined the search process by uploading the articles identified via the database search to Covidence, a software program designed to streamline the review process and facilitate collaboration among multiple authors [14]. Covidence helped remove duplicates. The second author then screened the titles and abstracts of the articles, retaining those that met the inclusion criteria. The first author verified the screening process, and no discrepancies were noted between the first and the second author during title and abstract screening, as we have well-defined inclusion criteria. Subsequently, the first, second, third, and fourth authors read all the full-text articles retained for this review based on the inclusion criteria. Lastly, the first author manually reviewed the references of the selected studies to figure out any additional research articles that matched the criteria. All authors agreed to the final list of full-text articles selected for this review.

2.2. Study Selection Criteria

We defined older adults with IBD as those diagnosed with IBD at a younger age and then transitioned to the elderly group (>60 years of age) and adults diagnosed with IBD ≥60 years of age [3]. The inclusion criteria were: (1) studies published in English; (2) quantitative (randomized or non-randomized studies), qualitative, or mixed-method studies that focused on elderly adults with IBD; and (3) studies published from 2012 to 2024.

The concept of addressing the concerns of elderly adults with IBD emerged as the baby boomers reached the elderly category [15]. Since then, more research has focused on addressing the needs of the elderly, particularly evaluating the effectiveness of pharmacological therapies among elderly adults with IBD. Subsequently, several other studies have explored additional healthcare dimensions, such as quality of life (QOL), mental health, healthcare utilization, and causes of hospitalization among elderly adults with IBD [16,17,18,19]. Therefore, we decided to select the timeframe of 2012–2024 to synthesize evidence from the most recently published literature.

We based our definition of elderly adults by age on the United Nations’ criteria of individuals aged 60 years or above [20]. The exclusion criteria were: (1) any type of review or conference abstract; (2) studies that focused on adult (18–59 years old) and pediatric (<18 years old) IBD patients; and (3) studies published before 2012. The search process is summarized in the PRISMA diagram in Figure 1.

Figure 1. PRISMA flow diagram.

2.3. Quality Appraisal

The authors conducted the quality appraisal of the selected studies using the Joanna Briggs Institute (JBI) critical appraisal tools [21]. We utilized four JBI quality assessment tools that matched the study designs of the selected articles: the JBI analytical cross-sectional quality assessment tool, the JBI case-control quality assessment tool, the JBI qualitative research quality assessment tool, and the JBI cohort quality assessment tool. These included 8–11 questions based on the study design, with responses of “yes”, “no”, “not applicable”, or “unclear” for each given question. The first author independently conducted the quality appraisal, which was then verified by the second author. Any disagreements were resolved through discussion. The majority of questions for each study were answered with “yes”. The quality appraisal results are summarized in Supplementary Table S1.

2.4. Data Abstraction

The authors extracted data from the articles that met the inclusion criteria. The first author began the data extraction process, and subsequently, the third and fourth authors validated the extracted data. We extracted the following information based on the aims of the study: author details, study setting, study type, age of elderly participants as defined in the studies, the purpose of the study, variables measured, and major findings. Refer to Table 1 for data abstraction results. Because of the diverse study designs, we opted to qualitatively synthesize the findings.

Table 1. Data Abstraction Table (n = 42). Therapeutic needs of older adults with IBD: A Systematic Review.

Author, Year, and Setting	Study Type/Design	Age of Elderly	Study Purpose	Variables and Measures	Major Findings
Adar et al., 2019 [22] USA	Retrospective cohort study using EMR data from three hospitals	>60 years of age	To evaluate the effectiveness of two groups of biologics (anti-TNF vs. Vedolizumab) as well as to evaluate their risk of malignancy and infection in in adults >60 years of age	Any infection that occurred within 1-year of anti-TNFα and Vedolizumab initiation Type of infection Assessed if the biologic therapy stopped due to infection? Information on hematological or skin cancer within 1 yr of medication initiation Clinical characteristics of IBD (remission status, inflammatory markers, radiologic findings) Charlson comorbidity index IBD location and behavior (Montreal classification	n = 234 patients (131 on anti-TNF and 103 on VDZ) The average age of starting biologics therapy was 68 years The mean Charlson comorbidity index was comparable between two groups at the beginning of the therapy The infection risk was comparable between two groups within 1-year of beginning of the therapy. Infusion reaction and infection (20%) were the number one reasons for stopping anti-TNF therapy, whereas, infection (14%) was the sole reason for stopping VDZ. 3% patients from anti-TNF group and 1% from VDZ group developed a new onset of cancer excluding skin cancer or recurrence of their previous cancer after initiating the therapy The extent of colonic involvement did not differ between CD or UC The clinical characteristics of IBD did not differ between two groups during the course of the therapy.
Alexakis et al., 2017 [23] UK	Retrospective cohort study using a national database	>60 years of age	To compare the surgical risk between elderly and adult onset IBD and to analyze the effect of thiopurines on surgical outcomes	Surgical history: Colectomy in UC and first intestinal surgery in CD patients Medication history History of corticosteroid dependency (corticosteroid for >3 months) History of thiopurine use (<12 months vs. >12 months	n = 4107 No difference noted on the colectomy risk between adult onset and elderly UC on 1, 5 and 10-year risk analysis Higher risk for colectomy was linked to the use of thiopurine, early use of steroids, and steroid dependency in elderly onset UC ↓ risk for first intestinal resection in elderly onset CD compared to adult-onset CD on 1, 5 and 10-year risk analysis ↓ colectomy risk among elderly onset UC patients who were on thiopurines >12 months
Amano et al., 2022 [24] Japan	Retrospective cohort study study	>60 years of age	To evaluate the effectiveness and safety of anti-TNF therapy and analyzed the factors that influenced anti-TNF’s effectiveness among the elderly onset IBD patients who never received biologics in the past	IBD characteristics Concurrent drugs used with anti-TNF therapy Steroid free and clinical remission short term (at 8 weeks) at long term (52 weeks) Severe adverse events	432 bio-naive elderly IBD patients were included ↑ proportion of UC patients noted among the elderly group (p = 0.021) Concurrent use of corticosteroids and immunomodulators were comparable between both groups The clinical remission and steroid free remission rates were significantly lower among bio-naïve elderly onset IBD patients at 8 and 52 weeks. Among bio-naïve elderly onset IBD patients, the rates of remission (both steroid free and clinical) were notably lower at 8 and 52 weeks. The IBD- type (UC), >1 year of disease duration, concurrent use of corticosteroid use were the major factors that determined the steroid free and clinical remission with the use of anti-TNF at 52 weeks of therapy Although SAE and cumulative cessation rate were comparable between older adults with IBD patients and non-elderly patients, elderly older adults with IBD frequently experienced cardiovascular events, infection, cancer diagnosis and death
Asscher et al., 2022 [25] Netherlands	Prospective cohort study	>65 years Old	To evaluate the geriatric deficits in older patients with IBD and to match these deficits with disease characteristics	Demographic (age, sex, height and weight) IBD characteristics (type, duration, behavior and location) of IBD [based on Montreal classification], hospitalization 3 years prior to the study Disease activity: measured for CD patients using HBI and partial Mayo score for UC patients Labs- CRP, Hgb, FCP Disability related to IBD- assessed using IBD disability index QOL- SIBDQ Geriatric assessment (CCI, MNA, KIIADL, LIADL, hand grip strength, 4-m gait speed, geriatric depression scale, cognitive impairment test	n = 405 Median age = 70 + clinical disease activity noted for 21.7% patients ↑ CRP or FCP noted among 26.7% patients 39.9% of patients with severe geriatric deficits had active disease 51.6% of patients have geriatric deficits in somatic domain (comorbidity, polypharmacy, and nutrition) 43% of patients have deficits in ADLs, 22.7% have deficits in physical capacity, 16.5% have deficits in mental domain, and 23.7% have deficits in social domain. ↓ HRQOL noted with positive of biochemical and clinical disease activity and geriatric deficits Individuals with elderly onset IBD were found to have more impairment in the mental domain, primarily as a cognitive impairment (16.9% vs. 6.7%; p < 0.001
Benchimol et al., 2013 [26] UK, Canada, US, and Denmark	Retrospective study using health administrative databases from 2004 to 2009	≥65 years of age	To identify the prescription variations among elderly adults with IBD	The rate of prescription was assessed for each of the IBD medications (ASA, SASP, systemic and topical steroids, immunosuppressives, and biologics)	The total number of patients varied in each quarter of the year in all four countries from 2004 to 2009 Canada range of patients: 9742–13361 Denmark range of patients-: 1481–2150 UK range of patients: 8067–8860 USA range of patient: 171–4033 ≥1 IBD medication prescribed for 54.7–73% of US patients, 47.2–57.7% UK patients, 34.1–38% Denmark patients, and 43.2–47.7% of Canadian patients ↑ trend in the rate of prescription for immunosuppressive and biologics noted among elderly adults (U.S) ↑ usage of 5-ASA (Canada) and Sulfasalazine (UK) for both CD and UC Higher usage of rectal therapy (topical corticosteroids or 5-ASA) in Denmark and Canada ↑ prescription rates noted for systemic steroids by mouth for CD patients in Denmark and similar pattern noted for UC patients in US: (15–20%) in Denmark vs. US at (7–10%)
Bollegala et al., 2016 [27] USA	Case-control study using ACS-NSQIP database from 2005 to 2012	≥65 years	To compare the post-operative complications and death between elderly IBD patients vs. IBD patients who were <65 years of age	cases of mortality within 30 days of surgery Post-operative complications VTE (DVT and PE) Renal dysfunction (ARF vs. PRF) Infection (wound, sepsis, shock, pneumonia and UTI), and Ventilator dependence >48 h Neurological conditions: nerve injury, coma and stroke Complications of the CVS: MI and cardiac arrest Bleeding that needed blood transfusion BMI, Diabetes, Smoking, anemia, health status, and the year in which surgery was performed	Out of 15,495 patients with IBD who had surgery from 2005 to 2012, only 11% (n = 1707) were more than 65 years of age Post-operative mortality (within 30 days) was higher for both elderly UC (p < 0.001) and CD (p < 0.001) patients compared to non-elderly patients Higher risk for DVT (p < 0.001) among elderly CD patients ↑ risk of renal dysfunction post-surgery among elderly IBD patients (p < 0.001) ↑ rates of infectious complications after surgery among older IBD patients: ↑ risk for wound dehiscence, ventilator dependence, pneumonia, shock and UTI (p < 0.001 for all) ↑ risk of MI and cardiac arrest post-surgery among elderly IBD patients (p < 0.001) Four times higher risk for neurological complications among elderly IBD patients (p < 0.001) ↑ need for blood transfusion due to bleeding among elderly IBD patients (p < 0.001)
Bozon et al., 2023 [28] France	Prospective, multicenter, cohort observational study	>65 years of age	To identify the infection risk among older adults with IBD who have been placed on biologics (anti-tNF vs. Vedolizumab [VDZ], vs. Ustekinumab [UST])	IBD clinical characteristics (type, duration of the disease and Montreal classification) Disease activity—active disease vs. remission IBD treatment—Biologics, immunomodulators, steroids Patient comorbidity- collected from the medical records and via Charlson comorbidity index	207 older adults with IBD were included and were followed up for 1-year No differences in comorbidity noted between anti-TNF vs. VDZ or UST group. It was noted that 29% of the older IBD patients experienced at least one type of infection during a one-year follow-up The prevalence of infection was comparable among the three groups (anti-TNF vs. VDZ vs. UST) Digestive tract infection was the common one among the anti-TNF group, whereas, pulmonary infections were higher among the VDZ-UST group. Hospitalization due to infection did not differ between both groups (anti-TNF vs. VDZ-UST group). IBD flare occurred among a comparable number of patients (27%) among anti-TNF group and VDZ-UST group (32%).
Casas-Deza et al., 2023 [29] Spain	Observational multicenter prospective study using registry data	>60 years of age	To evaluate the safety and effectiveness of Ustekinumab (UST)among elderly vs. non-elderly CD patients	Charlson’s comorbidity index IBD characteristics- disease activity, phenotype, location, perianal disease, biological markers (CRP and fecal calprotectin) IBD medications MRI and endoscopy results Effectiveness of Ustekinumab (as steroid free remission)	212 older adults with CD Higher proportion of complicated disease noted among the elderly CD patients CRP and fecal calprotectin levels were comparable between two groups Effectiveness of Ustekinumab (measured as steroid free remission) was comparable between two age groups Sustained use of UST for maintaining IBD symptoms was comparable between two age groups No difference in adverse effects noted due to Ustekinumab between two age groups in the elderly group was found to have ↑ incidence of IBD with ↑ percentage of complicated IBD disease [54.7% vs. 47.2%, p = 0.01]
Charpentier et al., 2014 [30] France	Retrospective population based study	>60 years of age	To determine the natural history of IBD in individuals who are >60 years of age versus <60 years	Gender, age, family history, years of having the disease since diagnosis, the gap between diagnosis and onset of symptoms, endoscopic, clinical, radiological and histological details.	1058 older adults were diagnosed with IBD among this cohort Less GI (abdominal pain, diarrhea) and general symptoms, but more anal fistula and bleeding via rectum were noted among elderly onset CD patients compared to younger patients. Less abdominal pain and rectal bleeding were noted among elderly onset UC patients 5-ASA was widely used for both CD and UC patients. Only a small portion of IBD patients (n = 30) received biologics therapy ↓ surgical risk noted among elderly IBD patients who received treatment with systemic steroids
Cheng et al., 2022 [31] USA	Retrospective cohort study using national administrative claims database	Patients with IBD who are >60 years of age	To assess the infection risk of different biologics such as anti-TNF agents, Vedolizumab (VDZ)and Ustekinumab (UST) in older adults with IBD	time taken from the beginning of the treatment (anti-TNF vs. VDZ vs. UST) to hospitalization due to infection type infections Age IBD subtype (CD vs. UC) Charlson Comorbidity index	2369 patients were on anti-TNF; 972 on Vedolizumab; and 352 on Ustekinumab Mean age of all the participants varied from 67 to 68 years of age During follow up, the incidence rate for any infection was comparable among the three cohorts (anti-TNF vs. Vedolizumab vs. Ustekinumab) Pneumonia followed by septicemia were the most common reasons for in-patient hospitalization. Among the three groups (those who used Vedolizumab vs. Ustekinumab vs.anti-TNF), decreased rate of infection related hospitalization noted among those who used Vedolizumab and Ustekinumab than the anti-TNF.
Cohen et al., 2020 [32] Israel and UK	Retrospective multicenter cohort study using patient’s electronic medical records	>60 years of age	To evaluate the effectiveness and adverse effects of Vedolizumab between individuals diagnosed with IBD who are >60 years of age versus <60 years	Age of disease onset, duration of disease, disease phenotype, smoking hx, medications, surgical hx, EIM, and disease activity HBI score for individuals with CD Partial Mayo score for individuals with UC Endoscopic response and remission were assessed for both CD and UC patients Corticosteroid free remission	284 IBD patients who completed 14 weeks of Vedolizumab therapy were included 144 patients were >60 years of age Clinical, endoscopic and corticosteroid free remission after Vedolizumab use was found to be similar between individuals diagnosed with IBD who are >60 years of age versus <60 years Older patients with IBD who were on anti-TNFα previously demonstrated poor response to Vedolizumab with poor remission rates. Although not fatal, the infection rate was higher among elderly IBD patients who were on Vedolizumab. Elderly IBD patients had significantly greater CV, metabolic, and respiratory comorbidities in both CD and UC
de Jong et al., 2020 [33] Netherlands	Retrospective cohort study using data from an IBD registry	>60 years of age	To analyze the rates of failure and safety of the initial anti-TNF treatment among individuals with IBD who belong to three different age categories (<40, 40–59, and ≥ 60 years of age)	Rate of anti-TNF failure: number of years on anti-TNF therapy until discontinuation Severe Adverse Events (SAE) rates: infections require hospitalization	895 IBD patients (81 were > 60 yrs old) Higher anti-TNF failure rates noted among the first-time users of 40–59 and ≥ 60 years of age group (p = 0.03) Concurrent use of thiopurine ↓ the anti-TNF failure rates (p = 0.031) Higher incidence of SAE were associated with anti-TNF therapy among older (≥60 years) patients with IBD (p < 0.001) ↑ risk for serious infection rate noted among older (≥60 years) patients with IBD (p < 0.001) due to anti-TNF therapy
Desai et al., 2013 [34] USA	Retrospective Case-control study at a single center using medical data	>60 years of age	To evaluate the safety and durability of anti-TNF α (Inflimab, Adalimumab, Certolizumab) among elderly IBD patients	Comorbidity assessed by Charlson comorbidity index Start and end date of anti-TNF therapy and its potential overlap with immunomodulators and steroids Reason for stopping anti-TNF therapy and adverse effects experienced by individuals due to anti-TNF α therapy	54 elderly patients on anti-TNF therapy ↓ rate of older patients with IBD who were simultaneously on anti-TNF α therapy with AZA in comparison to younger individuals with IBD 70% of elderly IBD patients stopped anti-TNF α therapy after 24 months of initiation. After six months of anti-TNF α therapy, older IBD patients responded less to the therapy compared to their younger counter parts. Higher comorbidity was associated with higher chance of anti-TNF α treatment cessation Four older patients with IBD developed infections and needed hospitalization
Everhov et al., 2018 [35] Sweden	Retrospective cohort study using national data	≥60 years of age	To analyze the clinical characteristic and treatment of IBD among elderly adults with IBD and to match surgical rate and healthcare utilization to general population.	IBD characteristics: type, location, extent and behavior IBD medication history Extraintestinal manifestations of IBD IBD-related surgical history	6443 elderly adults with IBD were included This cohort was followed up for a medium duration of 4.2 years stricturing was more common among elderly CD patients, however, less proctitis was noted among elderly UC patients compared to their counter parts Elderly IBD patients received ↓ outpatient care and ↑ hospitalizations due to IBD and ↑ general health care compared to adult IBD patients ↓ use of biologics and immunomodulators among older patients with IBD, but they used more steroids compared to adults Extraintestinal manifestation occurrences were comparable between elderly and adult patients Higher absolute risk for intestinal surgery noted among older patients with IBD (p < 0.001)
Fumery et al., 2016 [36] France	Retrospective study using a population-based registry (1988–2006)	>60 years of age	To evaluate the natural history of CD for those who were diagnosed at the age of 70 vs. who were diagnosed between 60 and 70 years of age	Date of CD diagnosis Montreal classification to describe the disease characteristics (non-stricturing/non-penetrating vs. structuring/penetrating Extra intestinal manifestations Current IBD medications ((5-ASA, corticosteroids, IS, and anti-TNF) Surgical history Time between symptoms and CD diagnosis	447 patients above the age of 60 and 370 patients with elderly onset CD No difference in clinical presentation of CD and extra-intestinal manifestations noted between two groups Pure colonic involvement was frequently noted both at the diagnostic phase and at later among older patients with IBD who were >70 years of old Non-stricturing/non-penetrating disease type was the most frequently noted disease characteristic among both groups (>70 years vs. between 60 and 69 years) ↓ use of immunosuppressants in patients > 70-year-old (p = 0.003) The rate of surgery did not differ between those who are >70 vs. those who are between 60 and 69. Median time from when symptoms developed until the CD diagnosis was 2 months
Garg et al., 2022 [37] USA	Retrospective cohort study	>65 years of age	To evaluate the adverse effects and effectiveness of Ustekinumab (UST) in older vs. younger CD patients	Patients diagnosed with CD who were administered at least one dose of UST were included Age at which UST was initiated, disease duration, gender, prior hospitalization, prior surgeries, prior medication history and concurrent use of immunomodulatory and steroid history was collected Disease severity assessed by the clinician and most recent endoscopic result.	117 patients participated in the study; 39 were elderly CD patients Elderly CD patients had longer disease duration, more colonic involvement of the disease and less perianal involvement (p < 0.001 for all) compared to non-elderly group Less chance of achieving complete clinical remission after the initiation of UST among older patients with CD in comparison to their peers (p = 0.01) Complications related to infusion and other risks (infection, post-operative complications) were comparable between older patients with CD versus their younger counterparts Compared to their peers, older patients with CD frequently exhibited moderate form of the disease ((87.2% vs. 52.6%) and were less prone to have severe form of the disease (12.8% vs. 44.9%) (p < 0.001). Post-operative complications were comparable between patients who had a surgical resection while on Ustekinumab versus who were not on Ustekinumab
Gebeyehu et al., 2023 [38] UK	Multicenter Prospective cohort study	≥60 years	To evaluate the adverse effects and effectiveness of Ustekinumab and Vedolizumab among older patients with CD	Concurrent use of other IBD patients IBD characteristics: Disease extent and duration, HBI index, CRP and fecal calprotectin Details of Ustekinumab and Vedolizumab (adverse events, serious infection that require hospitalization, dose escalation and cessation) Effectiveness was assessed by sustained use of the medication, clinical response rate and steroid free remission	83 patients who were on Ustekinumab and 42 on Vedolizumab were included Sustained use and serious infection rate were similar among patients who were on Ustekinumab and Vedolizumab Disease activity (as measured by HBI) significantly reduced after the use of Ustekinumab and Vedolizumab at 6 months and at 1 year in both groups Penetrating nature of CD was positively associated with persistent use of Ustekinumab and Vedolizumab
Hahn et al., 2022 [39] Canada	Retrospective study using EMR data	≥60 years	To assess adverse effects and effectiveness of of biologics (vedolizumab, Adalimumab, Infliximab, and Ustekinumab)among elderly adults with IBD to evaluate the sustainable use of biologics	Disease activity/clinical remission: HBI was used for patients with CD and partial Mayo score for patients with UC Disease related variables: Labs- CRP, Hgb, FCP; endoscopic reports; cormobidity, hospitalizations, adverse effects (infection, hospitalizations, maligancy and IBD-related surgery) Demographic data: comorbidities, disease duration, and disease extent	n = 147 patients 75.5% of them received the IBD diagnosis before the age of 60 The rates of remission did not show a statistical difference among the 4 biologics (vedolizumab, Adalimumab, Infliximab, and Ustekinumab) No statistical difference noted between sustainability of the medication, time to adverse event and infection rates between the biologics (vedolizumab, Adalimumab, Infliximab, and Ustekinumab). Infection, infusion reaction, and loss of response were the common unfavorable events which resulted in the termination of biologics.
Hou et al., 2016 [40] USA	Retrospective cohort study at multiple centers	>65 years of age	To compare the nature of the disease behavior and characteristics of IBD among those who were diagnosed after the age of 65 vs. those who were diagnosed between 18 and 64 years of age	IBD type, behavior, characteristics (utilized Montreal classification), age at diagnosis, location of the disease, gender and ethnicity Clinical, endoscopic and radiographic evaluation of IBD Medication history (5-ASA, systemic glucocorticoids, immunomodulators, anti-TNF, budesonide) IBD-related surgery (bowel resection vs. perianal surgery) Smoking status (never, former, current)	1665 patients were eligible for the study 272 patients had elderly (≥65) onset IBD and 1393 patients had adult onset (<65 years) IBD 92% was male; 83% were non-Hispanic white Majority of the elderly onset CD was located at the colon in an isolated form compared to adult-onset CD (p = 0.048) No differences in disease location noted between elderly and adult onset UC Non structuring and non-penetrating behavior was the prominent one noted among both elderly and adult onset CD ↓ rate of perianal disease (p = 0.018) and penetrating disease (p = 0.023) were noted among elderly onset CD Higher chance for bowel resection and perianal surgery among non-elderly CD patients; however, no such difference was noted among UC patients.
Huguet et al., 2018 [41] Spain	Cross sectional study using retrospective data from hospital medical records	>70 Years of age	To evaluate the clinical course, adverse effects of treatment, and the surgical need for elderly IBD patients	Demographic data: age, sex, DOB IBD characteristics (Montreal classification) Medical therapies used and its adverse effects Comorbidities Surgical Mx, its complications, IBD related hospitalizations, cancers, infection and deaths	n = 314 The average age of the IBD diagnosis was approximately s 63.4 years in this cohort Mesalamine was used by 100% of patients with UC, however, only 52% of those with CD was on it. 66% of the patients were on corticosteroids Immunosuppressive medications: 34.4% were on Thiopurines and 5% was on methotrexate Biologics- 10.5% was on Infliximab and 6% on Adalimumab More immunosuppressive medications have been used with longer disease progression (p = 0.052) The probability of the use of biologics and corticosteroids were found to be lower among elderly IBD patients (p = 0.06 for steroids; p ≤ 0.006 for biologics) Majority of the adverse effects were related to Thiopurines (50% of patients who were on it) followed by Infliximab (33.3% of patients who were on it). Leukopenia was the most common adverse effect seen in patients. Bowel resections was the most frequent performed surgical intervention (90%). Cancer was reported in 37 patients after the diagnosis of IBD Most frequent comorbidity in elderly IBD patients was HTN (n = 157).
Jeuring et al., 2016 [42] Netherlands	Retrospective cohort study	>60 years of age	To determine the incidence and long term effects of IBD on those who have had an IBD diagnosis at 60 years or older and to compare it with those who have had an IBD diagnosis as an adult	Disease progression CD- based on Montreal classification (non-structuring/non-penetration/structuring/penetrating) UC- proctictis to left sided disease to extensive disease Hospitalization (first time/flare/surgery for IBD) Surgery (bowel resection or for IBD related complications) Medication use (failure of the treatment/cessation of the medication)	1162IBD patients above the age of 60 ↑ incidence of IBD diagnosis at 60 years or older from 11.71 to 23.66/100,000 from 1991 to 2010 (p < 0.01) ↓ utilization of corticosteroid and biological therapy among those who have had an IBD diagnosis at 60 years or older in comparison to with those who have had an IBD diagnosis as an adult The most common reason to stop anti-TNF therapy was due to loss of response Ileum was most commonly affected area in elderly onset CD and more left side disease and less rectal involvement in elderly onset UC Higher risk for hospitalization noted among EO UC at the diagnosis phase and at the later stage (5 and 10 year) The rate of IBD surgery was comparable between EO vs. AO IBD in this cohort over the time; however, more patients with EO CD had undergone surgery at diagnosis.
Juneja et al., 2012 [43] USA	Retrospective observational study using EMR data	≥65 years of age	To identify the clinical presentation, treatment models, patient outcomes, comorbidity and nutritional status in older adults with IBD	Comorbidity assessed by modified Charlson comorbidity index IBD type (CD vs. UC), location of IBD, history of surgery, duration of the hospital stay, medication history, age of the patients, nutritional status (iron, Vitamin 12 and Vitamin D deficiency)	n = 393 older IBD patients (193 males 49.1%, 200 females 50.9%) 61% of older UC patients have undergone proctocolectomy with ileostomy and 38% of older CD patients have undergone small bowel surgery 5ASA agents were the common ones used for maintenance therapy 31.6% of the older IBD patients were on chronic steroid therapy Less use of biologics and immunomodulators among older IBD patients Multiple drug therapy use was highly prevalent among this group (94.3% of the patients were ≥3 medications The length of disease duration of CD was significantly correlated in older CD patients with iron (p = 0.03), Vitamin B12 (p = 0.02) and Vitamin D deficiency (p = 0.003; no such correlation observed among elderly UC patients Cardiovascular, pulmonary and diabetes were the prevailing comorbid conditions among older iBD patients.
Khan et al., 2022 [44] USA	Retrospective study using national data from Veterans Health System	>60 years of age	To assess the efficacy of Vedolizumab among older IBD patients and to compare it with younger IBD patients	Course of the disease after Vedoluzumab initiation: steroid free remission; IBD-related hospitalization and need for IBD-related surgery within 1 year of Vedolizumab initiation; endoscopic improvements (only for those who had a colonoscopy before beginning the therapy and had a later colonoscopy after initiation); lab values- CRP, ESR and calprotectin	n = 279 older adults with IBD Higher comorbidity and cancer history among the elderly before initiating the VDL therapy The rate of steroid free remission was similar compared to older adults with IBD versus their younger counterparts Hospitalization and IBD-related surgery rates, and endoscopic improvement were similar compared to older adults with IBD versus their younger counterparts The reason for Vedolizumab discontinuation differed between both groups; the elderly patients had “loss of response” as the reason, whereas, younger patients had “no response” documented as the reason (p = 0.006)
Kuenzig et al., 2020 [45] Canada	Retrospective cohort study	≥65 years of age n =4806	To identify if care variation existed among elderly onset IBD patients and to evaluate the outcomes based on care provided by the specialists (gastroenterologists) vs. primary care providers	What was measured was use of gastroenterologist care, IBD hospitalization within 1 month before or after dx, ED visit r/t IBD 1 month before or after IBD dx, hospitalization r/t IBD dx during the first and five years of IBD diagnosis, ED visit r/t IBD dx during the first and five years of IBD diagnosis, surgical resection of the intestine, use of IBD medications (biologics, systemic corticosteroids and immunomodulators), and persistent use of opioids during the first and five years of IBD diagnosis	72.5% patients had a gastroenterologist Those who were under the care of gastroenterologist were founds to have ↓ risk for hospitalization and colectomy ↑ use of immunomodulators among patients whose primary care providers are not gastroenterologists Those who were under the care of gastroenterologist were founds to have ↑ use of biologics (within 5 years of IBD diagnosis) and systemic steroids (during the first and five years of IBD diagnosis) Geographic disparities (urban vs. rural) noted about gastroenterologist care among older patients with IBD. Older patients with IBD residing in rural areas were less likely to receive treatment from gastroenterologists compared to their younger counterparts living in rural areas
Kim et al., 2022 [46] Korea	Prospective study using the data from Crohn’s Disease Clinical Network and Cohort study	>60 years of age	To describe the outcomes and nature of the disease of EO- CD and to compare it with AO- CD	IBD clinical characteristics: Disease location, behavior (nonstricturing/nonpenetrating), structuring, and penetrating), symptoms, BMI, CDAI at diagnosis, Lab values: hemoglobin, ESR, CRP, and albumin IBD medications	n = 94 patients total (26 were elderly onset; 68 had onset as a late adult) n = 26 for elderly patients with CD Similar results noted on disease behavior, location and perianal disease at diagnosis between EO- CD and AO- CD Elderly onset CD patients tended to have ↑BMI (p = 0.079), ↓ CRP (p = 0.080), and ↓CDAI (p = 0.023) compared to the adult onset group Similar aggregate probability noted on the use of systemic steroids among both groups The aggregate probability of thiopurine (p = 0.003) and anti-TNF medications (p = 0.047) were significantly lower among the EO- CD patients ↓ risk for bowel resection in the EO-CD patients in comparison to AO-CD (p = 0.067)
Kochar et al., 2022 [47] Sweden	Retrospective study using national data from a Swedish registry	≥60 years of age	To assess the frailty rate of older adults who have a diagnosis of IBD and to compare it with younger IBD patients	IBD details: Nature of IBD, medication usage and healthcare utilization Mortality and its causes Hospitalizations: Both IBD related hospitalization and all-cause hospitalization Frailty: Assessed using hospital frailty risk score	10,590 older adults with IBD (27% CD, 59% UC, 13% IBD-U) Mean age: 71 yrs old Only 12% of elderly adults with IBD were found to be at high risk for frailty Elderly adults with IBD who were on immunosuppression was found to be in the category of low risk for frailty Strong association noted between frailty and mortality risk among elderly adults with IBD High frailty risk ↑ the mortality risk of systemic disorders (alimentary tract, hematological, respiratory, circulatory, nervous system, nutrition and metabolic disorders), trauma and infections
Long et al., 2014 [17] USA	Prospective study	≥65 years of age	To determine the association of depression with QOL, disease activity, and medication adherence	Depression—Assessed via shorter version of the geriatric depression scale QOL—assessed by SIBDQ Disease activity assessed by self of report of sCDAI for CD patients and SCCAI for UC patients Medication Adherence: by MMAS Exercise- measured by Godin Leisure Time Index	A total of 359 individuals participated in this study Mean age of the participants = 70.2 years 62.6% of the individuals had CD among this group 22.6% (n = 81) had a score that matched with the diagnosis of major depression. Use of corticosteroids was significantly associated with depression (p < 0.01) Exercise levels were significantly reduced among depressed patients (p < 0.001) Higher levels of disease activity was significantly associated with depression for older adults with both CD (p = 0.005) and UC (p = 0.003) Significant reduction in QOL (p < 0.001) and medication adherence (p = 0.01) noted among depressed older adults with IBD Older adults with IBD who were depressed were less likely to adhere to their medications compared to the individuals who were not depressed Duration of the disease had an average of 25.6 years
Lobaton et al., 2015 [48] Belgium	Retrospective observational case- control study	>65 years of age	To assess the effectiveness and adverse effects of anti-TNF among older adults with IBD (>65 years of age) vs. controls (<65 years of age)	IBD type Comorbidity (assessed by Charlson Comorbidity index) Disease characteristics (duration, location, and behavior) Extra intestinal manifestations Concurrent use of immunomodulators Anti-TNF treatment with Infliximab and Adalimumab evaluated at 10 weeks and at 6 months after initiating the therapy	66 patients with elderly IBD diagnosis and 112 patients as controls Worse outcomes to anti-TNF therapy noted among older adults with IBD at short term; however, such differences were not found between elderly vs. adult IBD patients on continued monitoring Older adults with IBD tend to have a higher chance to stop the anti-TNF treatment Higher chance for severe adverse events among older adults with IBD who were on anti-TNF therapy (p < 0.001); this risk differed (based on the type of severe adverse event) among elderly adults who were concurrently on anti-TNF medications and other therapies Elderly individuals who received anti-TNF therapy faced an ↑ risk of hospitalization and surgery. Simultaneous administration of anti-TNF therapy and immunomodulators or corticosteroids led to ↑ risk of malignancy and death among older adults with IBD Higher risk of malignancy and death among elderly who had an increased comorbidity score
Mosli et al. 2023 [49] Saudi Arabia	Retrospective study	>60 Years of age	To assess the clinical characteristics, demograogic and treatment plans of elderly adults with IBD	Age of onset Disease characteristics of CD and UC using Montreal classification Comorbidities Medications to treat IBD Family hx Smoking hx EIMs IBD complications	n = 76 Majority of them developed IBD (either CD or UC) after 40 years of age; 23.6% developed IBD after 60 years of age The most common form of disease location in CD was ileocolic disease, whereas patients with UC presented with left colon involvement Patients were presented with common comorbidities such as hypertension, diabetes and malignant neoplasms. 5-ASAs were the common (56.58% of patients were on it) medications used to treat IBD
Nguyen et al., 2015 [18] Canada	Retrospective cohort study using health administrative database	≥65 years of age	To compare the health services use (hospitalizations, emergency department visits and outpatient visits) among IBD patients with three age groups: 18–40 years old, 41–64 years old and ≥65 years old	comorbidity assessed by Johns Hopkins ACG case-mix system Health services specific to IBD: specialist, GP and ED visits, endoscopic and diagnostic procedures, and hospitalizations Medication history (steroids, immunomodulators and biologics)	2474 cases of elderly IBD patients participated in this study; (725 CD and 1749 UC); ↑ morbidity rate noted among these elderly IBD patients. Slightly increase of female dominance in the older individuals with IBD Incidence of comorbidity was higher in the older individuals with IBD Elderly IBD patients tend to have a lower chance of gastroenterology visits within 1 year of diagnosis and at 5 year compared to their younger counter parts (p < 0.001) ↑ diagnostic imaging utilization among elderly UC patients compared to young adults (p < 0.001) Fewer ED visits noted among elderly IBD patients within 1 year of diagnosis and at 3rd year compared to their younger counter partners (p < 0.001) Higher hospitalization rates noted among elderly IBD patients within 1 year of diagnosis, but this rate ↓ in the subsequent years. Majority of elderly IBD patients received steroids within 5 years of diagnosis Lower incidence of biologic use (5% for CD and 2% for UC) among elderly IBD patients
Nguyen et al., 2017 [50] Canada	Retrospective cohort study using administrative data	≥65 years	To compare the dangers of IBD-related surgery and mortality between elderly onset vs. younger-onset IBD	Stratified IBD patients into three groups: elderly (≥65 years); young adults (18–40); and middle age adults (41–64) Comorbidity: assessed via Johns Hopkins ACG case-mix system IBD-related surgery IBD related deaths	n = 2474 11.6% of newly diagnosed patients with IBD were aged 65 years or older Elderly adults with UC were found to have a higher 5-year aggregate surgery risk compared to young and middle aged IBD patients 5-year aggregate surgery risk was comparable between older adults with CD vs. young and middle aged IBD patients Individuals with elderly onset CD demonstrated higher IBD-specific mortality compared to CD patients who were middle aged and young adults (p < 0.0001) Malignancies were accounted for the major cause of death in elderly onset UC and CD
Nguyen et al., 2018 [19] USA	Retrospective cohort study using nationwide readmissions database	>64 years of age	To compare the costs, annual burden, and causes for hospitalization between older (>64 years) and younger (<64 years) IBD patients	Total days spend in hospital as the primary measure Comorbidity index: measured using Charlson’s comorbidity index Clinical work-up: Bowel surgeries, colonoscopy, endoscopy, paracentesis, blood transfusions and parenteral nutrition Causes for hospitalization Measured the avoidable hospital admission reasons using prevention quality indicators	15,428 elderly adults were included in this cohort Elderly adults with IBD had a ↑ length of stay in hospital compared to middle-aged and younger patients (p < 0.01) with ↑ hospitalization related costs (p < 0.01) Higher comorbid conditions noted among older patients compared to their younger counter partners (p < 0.01) Older IBD patients have less chance to undergo IBD-related procedures and GI surgery compared to younger IBD patients (p < 0.01) Serious infections (bacteremia, c.diff and pneumonia) were the primary cause of hospitalization among older patients (p < 0.01) followed by cardiovascular complications (p < 0.01) Older adults aged 64 years or older were more prone to receiving blood transfusions while hospitalized
Perera et al., 2018 [51] Canada	Retrospective study of a single center	≥65 years	To assess the relationship between age of IBD diagnosis, advanced age, and HRQOL in elderly adults with IBD and to examine the health predictors of the HRQoL among all age groups	Demographic variables: age, age of IBD diagnosis Disease variables: extent, severity and length of the disease duration IBD phenotype (Montreal classification) Disease activity by HBI and UCDAI Collected comorbid data on cardiovascular disease, pulmonary disease, diabetes and psychiatric disease HRQOL- Measured using SIBDQ	n = 92 elderly CD patients and 47 elderly UC patients HRQOL was not influenced by age ≥65 years or advanced age at diagnosis No association noted between HRQOL and other co-existing conditions such as CV, diabetes, and pulmonary diseases HRQOL was strongly linked to psychological disorder in CD patients (p < 0.001). Diagnosis age and duration of disease were highest in adults >65 yrs old
Pugliese et al., 2022 [52] Italy	Matched cohort l retrospective prospective study	≥65 years	Compared the effectiveness of Vedolizumab among older vs. younger IBD patients	Sustained benefit of Vedolizumab (whether the patient discontinued it or not) and clinical and endoscopic remission (measured via endoscopic result, HBI and SFCR data)	n = 198 elderly (108 UC; 90 CD ↑ presence of peri-anal disease, previous use of immunosuppressant agents and anti-TNF use among younger IBD patients ↑ presence of cancer among older IBD patients Elderly IBD patients had ↑ rate of withdrawal due to the lack of effectiveness of Vedolizumab Elderly IBD patients had ↑ risk of cancer diagnosis while on Vedolizumab Elderly UC patients had ↓ clinical remission in response to Vedolizumab, but no difference in endoscopic remission or no such difference noted among elderly CD patients
Rozich, et al. 2021 [53] USA	Retrospective EMR cohort study	>60 years of age	Comparative study to assess the complications related to IBD and its treatment in older adults with elderly vs. adult onset IBD	Comorbidities- history of: Smoking BMI Prior IBD medications Prior GI surgery Current remission Prior serious infection Prior hospitalizations	n = 356 (191 AO-IBD; 165 EO-IBD) ↑ risk of complications noted in elderly onset (EO-IBD) in comparison to adult onset (AO- IBD) (p = 0.03) as a result of the IBD treatment No differences noted on complications due to IBD b/w AO-IBD and EO-IBD In individuals with AO-IBD, the use of corticosteroid therapy and a history of prior surgical procedure have been linked to an increased risk of complications with IBD treatment ↑ risk of complications noted due to IBD in EO-IBD patients with multiple co-morbidities.
Rusher et al., 2024 [54] USA	Qualitative study	>60 years of age	Qualitative study to evaluate the lived experiences of older adults with IBD	Semi-structured interviews were conducted using patient priorities care conceptual model as a framework The interview questions were designed to explore the following information from an older adult with IBD such as decisions related to IBD treatment, their health perceptions and the influence of IBD on their life	n = 22 Major identified themes were Age related challenges of having IBD at an older age Co-morbidity considerations with IBD Impact of aging on disease, medications and loss of independence Financial implications of IBD as an older adult in relation to retirement, challenges with insurance coverage, cost of the medication as a major factor to make the treatment choices Older adult’s perceptions about quality of life, what is most important factor in their life and a sense of gratitude with their life achievements Debilitating effect of social isolation, more support from providers on guidelines to maintain their health
Shashi et al., 2019 [55] USA	Retrospective case-control study using electronic medical record data	≥65 years of age	To compare the effectiveness (based on healing of the intestinal mucosa and the necessity to have surgical management for IBD) and the toxicities of Vedolizumab among individuals with IBD who were ≥ 65 years vs. who were ≤ 65 years	Healing of the intestinal mucosa- evaluated by endoscopy or CT or MRI follow up Surgical history while on Vedolizumab Monitored the most common adverse effects of Vedolizumab: Infusion reaction, infection, arthralgia, dyspnea, and rash	25 elderly adults were included in the study Endoscopic assessment revealed similar mucosal healing among both elderly and adult IBD patients who were on Vedolizumab No significant difference noted on IBD-related surgery between elderly and adult IBD patients who were on Vedolizumab The adverse effects of Vedolizumab were comparable between elderly and adult IBD patients
Schwartz et al., 2022 [56] USA	Retrospective study using a national data	≥65	To assess the in-patient mortality, length of stay and total expenditure among elderly adults with IBD	Patient stratification into two groups: above 65 and below 65 Comorbidity- measured by Elixhauser comorbidity index Discharge details to assess mortality during admission Resource utilization- total in-patient expenditure and length of stay	Older CD patients = 32,635 Older UC patients = 29,150 ↑ comorbidities, mortality rates, longer hospital stays, and more female among geriatric IBD patients Clostridium difficile was the most common complication found among geriatric IBD patients ↓ rate of surgery among geriatric IBD patients Inpatient mortality was inversely associated with geriatric IBD diagnosis for both CD and UC (p < 0.001 for both) Sepsis was the major cause of death among both geriatric and non-geriatric IBD patients (and for both UC and CD) Age over 65 was associated with higher odds of death among elderly IBD patients (p < 0.001). An increased inpatient mortality was noted for patients older than 65 with IBD regardless of their comorbidities and disease type
Tao et al., 2014 [16]	Case-control design	>60 years	To assess the QOL of life of older adults with IBD to identify its influencing factors	QOL—assessed using SF-36 scale IBD Diagnosis- based on the criteria set by Asia Pacific conference on Digestive Disease	n = 68 (UC = 24; CD = 44) Significantly lower QOL in elderly adults with IBD compared to controls (p < 0.05) QOL has been negatively influenced by disease activity and age
Velonias et al., 2017 [7] USA	Prospective cohort study at a single center	>60 years of age	To describe the HRQOL in older patients and to compare it between older vs. younger populations (<60 years)	IBD-specific QOL: Measured using SIBDQ General QOL: SF-12 Disease related information: collected via Montreal classification: age of onset, location and behavior (CD) and extent (UC) of the disease Labs: CRP, ESR and hemoglobin within 2 weeks of enrollment Disease activity: HBI in CD and SCCAI in UC	186 participants were older than 60 (99 CD; 87 UC) IBD diagnosis was made after 60 years for 34% of elderly IBD patients Elderly adults with CD were found to have less penetrating disease and perianal involvement Usage of immunomodulators (p < 0.001) and anti-TNF biologics (p = 0.027) were less among elderly IBD patients Older IBD patients have higher IBD-related QOL (measured via SIBDQ) and mental component of QOL (measured via SF-12), but lower physical QOL Did not screen elderly adults for depression, or assessed their frailty and social support
Wang et al., 2021 [57] China	Retrospective cohort study using cancer registry database, telephone follow-up records, and medical documents	≥60 years of age	To compare incidence trends of malignancy among E-O vs. A-O IBD	IBD characteristics: type of IBD, disease behavior, intestinal complications, extra intestinal manifestations, comorbidities, history of smoking and alcohol IBD medications Cancer diagnosis details: age of cancer diagnosis, cause of death, type of cancer	1480 had adult onset (966 with UC and 514 with CD). n = 129 elderly onset IBD patients ↑ comorbidity rate among E-O IBD patients (p < 0.0001) ↑ incidence of cancer among E-O IBD compared to A-O IBD with a higher cancer related mortality rate. ↑ incidence of colorectal cancer among E-O IBD compared to A-O IBD ↑ incidence of cancer outside the GI system among E-O IBD compared to A-O IBD with an upward trend since 2016 Diabetes was found to be risk factor for malignancy and the use of steroids was a protective factor The older IBD patients who were diagnosed with cancer in this cohort were only on 5-ASA and steroids; none of them were on Biologics
Wang et al., 2022 [58] USA	Case–control study using Medicare data	>66 years	To evaluate the association between IBD and cancer in older adults	Cancer diagnosis CRC screening data IBD medications: Biologics, Immunomodulators, corticosteroids, and 5-ASAs	16,000 cancer patients with a prior diagnosis of iBD An IBD diagnosis did not increase the overall cancer risk Statistically significant association noted between an IBD diagnosis and colorectal cancer, small intestinal cancer, intra and extra-hepatic bile duct cancer After adjusting IBD-medications, an IBD diagnosis was not related to the risk for extra intestinal cancers Could not evaluate the IBD clinical details (severity of the disease, disease duration, anatomical location etc.) with cancer risk

EMR—electronic medical record; 5ASA—5 Aminosalicylic acid; QOL—the quality of life; HRQOL—Health-related quality of life; SIBDQ—Short IBD questionnaire; sCDAI—short Crohn’s Disease Activity Index; SCCAI—Simple Clinical Colitis Activity Index; MMAS—Morisky Medication Adherence Scale; HBI—Harvey Bradshaw Index; CRP—C-reactive Protein; FCP—fecal calprotectin; CCI—Charlson comorbidity index; MNA—Mini nutritional assessment; KIADL—Katz index of independence in activities of daily living; LIADL—Lawton Instrumental activities of daily living; SAE—severe adverse effects; ESR—erythrocyte sedimentation rate; Short Form Survey—12 item; EO—elderly onset; AO—adult onset; ACG—Adjusted Clinical Group: ↑ = increased; ↓ = decreased.

3.1. Study Characteristics

We included 42 studies that met the inclusion criteria in this systematic review. The study settings varied across countries, with the US dominating with 13 studies, followed by Canada with five studies. Two studies were multinational [26,32]. More than 75% of the studies (n = 25) employed a retrospective design, with investigators using various types of databases (administrative, claims, or electronic medical records) to conduct their research. Only one of the reviewed studies utilized a qualitative design to elicit the perceptions of elderly adults with IBD [54]. The age of elderly adults was predominantly defined by the United Nations definition as >60 years in the majority (n = 23) of the reviewed studies, followed by >65 years in 16 studies. In other studies, the participants’ ages varied from >64, >66, and >70 years. Refer to Table 1 for further study details, which exposes the results of the included studies, mentioning the type of the study, the age of the included patients, the purpose of the study, variables and measures, and major findings.

3.2. Quality of Life

Of the 42 studies selected for this review, only six addressed the QOL of older adults with IBD [7,16,17,25,51]. Three of these studies were prospective [7,17,25], while the others were case-control [16], retrospective [51], and qualitative [54] studies. Except for one study [16], QOL was measured using the short IBD questionnaire [7,17,25,51]. A Chinese-based study used the Short-Form Questionnaire Version 12, while a US-based study employed the Short-Form Questionnaire (SF) Version 14 in addition to the short IBD questionnaire [7,16]. QOL in elderly adults with IBD was found to be lower in four of the reviewed studies [16,17,25,51], with significantly lower QOL noted in two of the findings (p < 0.05–p < 0.001) [17,51]. A Canadian study revealed that health-related QOL was not influenced by age, but a statistically significant association was noted between health-related QOL and psychological disorders in elderly CD patients (p < 0.001) [51]. Decreased health-related QOL was observed in elderly adults with IBD in the Netherlands who had positive clinical (measured via partial Mayo score for patients with UC and the Harvey Bradshaw Index [HBI] for patients with CD) and biochemical disease activity (measured via positive fecal calprotectin and C-reactive protein) [25]. Conversely, a US-based study indicated that older IBD patients have higher IBD-related QOL (measured via a short IBD questionnaire) and mental component of QOL but lower physical QOL; both were measured via the Short-Form Questionnaire Version 12 [7]. The qualitative study did not directly measure the QOL of elderly adults with IBD. Instead, it asked the participants to define QOL. The participants reported that QOL meant their ability to engage in activities they enjoyed, such as traveling and spending time with family [54]. However, the participants also expressed concerns related to loss of independence, mobility, and sensory loss due to aging, which they viewed as barriers to healthcare access [54].

3.3. Symptom Presentation

3.3.1. IBD-Related Symptoms

In general, the symptom presentation of IBD among elderly adults varied in many of the reviewed studies compared to non-elderly adults. Elderly-onset CD patients exhibited fewer GI (abdominal pain, diarrhea) and systemic symptoms but had higher instances of anal fistula and rectal bleeding compared to younger patients. However, elderly-onset UC patients experienced less abdominal pain and rectal bleeding [30]. A retrospective study in France revealed that non-struicturing/non-penetrating disease types were the most frequently noted among both groups of CD patients (those who were diagnosed at the age of 70 years vs. between 60 and 69 years) [36]. Colonic involvement was commonly observed among elderly CD patients [4,36,37], with moderate clinical disease activity [37]. These findings were mirrored in a US-based retrospective cohort study, which noted that the majority of elderly-onset CD was isolated to the colon compared to adult-onset CD (p = 0.048); moreover, non-stricturing/non-penetrating behavior was prominent among both elderly- and adult-onset CD [40]. However, elderly-onset CD had a decreased rate of perianal disease (p = 0.018) and penetrating disease (p = 0.023) compared to adult-onset CD, as confirmed in a later US retrospective study [7]. Conversely, no such differences in disease location were observed between elderly and adult-onset UC [50]. A retrospective cohort study using a Swedish registry showed that stricturing was more common among elderly CD patients [47], while a similar study from Spain reported a higher proportion of complicated disease (p = 0.01) among elderly IBD patients [29]. Less proctitis was noted among elderly UC patients compared to their younger counterparts [35]. Additionally, elderly CD patients presented with nutritional deficiencies, such as iron (p = 0.03), vitamin B12 (p = 0.02), and vitamin D deficiency (p = 0.003), correlated with the duration of CD. No such correlation was observed among elderly UC patients [43].

3.3.2. Geriatric Concerns

Several of the reviewed studies addressed concerns related to older age, such as co-morbidity, geriatric deficit, frailty, and risk of complications [19,25,32,41,43,44,47,49,50,53,54,56,57]. Findings from a prospective study in the Netherlands indicated that 39.9% (n = 405) of patients with severe geriatric deficits had active disease [25]. Of these, 51.6% had deficits in the somatic domain, such as comorbidity, polypharmacy, and nutrition; 43% had deficits in activities of daily living; 22.7% had deficits in physical capacity; 16.5% had deficits in the mental domain; and 23.7% had deficits in the social domain [25]. Similar findings were noted in a large retrospective study in Sweden, where frailty was strongly linked to an increased risk for mortality among elderly adults with IBD. Additionally, a high frailty risk increases the mortality risk from digestive diseases, infections, hematological conditions, respiratory disease, nutrition and metabolic diseases, circulatory disorders, nervous system disorders, and trauma [47].

The reviewed studies highlighted several common co-morbidities among elderly adults with IBD. Findings from multiple studies revealed higher comorbidity rates among older patients compared to their younger counterparts (p < 0.01) [19,56,57]. Elderly IBD patients had significantly greater cardiovascular, metabolic (diabetes), and respiratory comorbidities in both CD and UC [17,36,42,49]. Consistent with the previous studies, higher comorbidity rates were noted among elderly adults with IBD before initiating the Vedolizumab in a retrospective study in the US [44]. Polypharmacy was highly prevalent among elderly adults with IBD; a retrospective study in the US indicated that out of 393 older patients, 94.3% were on ≥3 medications [43]. Participants from a qualitative study reported that their IBD symptoms were the most bothersome than their comorbid conditions [54].

Higher cancer prevalence among elderly adults with IBD was a concern in many of the reviewed studies [44,49,57]. Further analysis of a retrospective study in China indicated a higher cancer incidence rate in general, as well as colorectal cancer, among elderly-onset IBD compared to adult-onset IBD, with a higher cancer-related mortality rate [57]. Additionally, there was an increased incidence of extra-intestinal cancer among elderly-onset IBD patients, with an upward trend since 2016. Diabetes was found to be a risk factor for malignancy, while the use of steroids was a protective factor [57]. Malignancies accounted for the major cause of death in elderly-onset IBD in Canada [38]. Results from a recent case-control study showed that an IBD diagnosis did not increase the overall cancer risk in older adults with IBD [58]. However, a statistically significant association was noted between an IBD diagnosis and colorectal cancer, small intestinal cancer, and intra- and extra-hepatic bile duct cancer. After adjusting for IBD medications, an IBD diagnosis was not related to the risk of extra-intestinal cancers in older adults with IBD [58].

Analysis of treatment-related complications revealed no differences between older patients with adult-onset IBD (AO-IBD) compared to elderly-onset IBD (EO-IBD; p = 0.03) in a retrospective study in the US [53]. The same study showed an increased risk of treatment-related complications in EO-IBD patients with multiple co-morbidities, while improved functional status and better biological reserve predicted worse health outcomes [53]. A retrospective study based on a large national sample showed increased mortality rates, longer hospital stays, and a higher proportion of females among elderly IBD patients [56]. Clostridium difficile was the most common complication found among elderly IBD patients. Sepsis was the major cause of death among both geriatric and non-geriatric IBD patients, according to this national data [56]. Furthermore, being over 65 was associated with higher odds of death among elderly IBD patients (p < 0.001). Increased inpatient mortality was noted for patients older than 65 with IBD, regardless of their comorbidities and disease type [56].

3.4. IBD Medication Utilization Patterns

3.4.1. Biologics

Most of the reviewed studies focused on the safety and efficacy of different IBD medications, comparing elderly IBD patients to non-elderly IBD patients. Biologics were the most commonly analyzed medication group in these reviewed studies [7,29,32,33,34,35,41,42,48,52]. Although anti-TNF groups were the most frequently addressed biologics, integrin receptor antagonists (Vedolizumab) and anti-IL-12 and -23 blockers (Ustekinumab) were also examined [28,29,31,32,37,38,39,44,52,55].

Regarding the use and efficacy of biologics, several studies reported decreased usage and response rates for anti-TNF among elderly IBD patients [7,30,35,41,42,43,46,50]. Additionally, some studies noted increased failure rates with anti-TNF, higher discontinuation rates, and decreased rate of remission also noted in elderly adults [24,33,34,42,48]. Infection and infusion reactions were the most common reasons for stopping anti-TNF therapy [22,33,34]. However, a multinational study based on health administrative databases from 2004 to 2009 revealed an increasing trend in prescribing biologics for elderly adults with IBD [26].

Most recent studies evaluated the effectiveness of other biologics, such as integrin receptor antagonists (Vedolizumab) and anti-IL-12 and anti-23 blockers (Ustekinumab), with varied results [22,26,28,29,31,32,37,38,39,44,52,55]. Four studies compared the effectiveness of Vedolizumab between elderly and non-elderly IBD patients [32,44,52,55]. Clinical, endoscopic, and corticosteroid-free remission after Vedolizumab use was found to be similar between both elderly and non-elderly IBD patients in a multinational study [32], and endoscopic assessment revealed similar mucosal healing in both elderly and adult IBD patients who were on Vedolizumab in a US-based study [55]. However, elderly IBD patients treated with anti-TNFα demonstrated poor response and remission rates to Vedolizumab compared to their younger counterparts [32,52]. Elderly UC patients had decreased clinical remission in response to Vedolizumab, but no difference in endoscopic remission was noted among elderly CD patients [52]. Some studies reported discontinuation of Vedolizumab due to a lack of response among elderly IBD patients [44,52] Although not fatal, the infection rate was higher among elderly IBD patients on Vedolizumab compared to non-elderly IBD patients [32]. Additionally, findings from a matched cohort study in Italy indicated an increased risk of cancer diagnosis among elderly IBD patients who were on Vedolizumab compared to non-elderly patients [52]. Two studies compared the effectiveness of Ustekinumab among elderly versus non-elderly CD patients, yielding mixed results [29,37], The effectiveness of Ustekinumab (measured as steroid-free remission) was comparable between the two age groups, and no difference in adverse effects was observed in a multicenter study in Spain [29]. However, a retrospective cohort study in the US highlighted a significantly lower chance of achieving complete clinical remission after initiating Ustekinumab among elderly CD patients compared to their peers (p = 0.01) [37]. The rate of infusion reaction and other complications (infection, postoperative complications) did not differ between elderly and non-elderly CD patients [37].

Five recent studies compared the effectiveness of three biological groups, namely, anti-TNF, Ustekinumab, and Vedolizumab, among elderly adults with IBD [22,28,31,38,39]. Findings from a UK study indicated that sustained use and serious infection rates were similar among patients who were on Ustekinumab and Vedolizumab. The penetrating nature of CD was positively associated with persistent use of Ustekinumab and Vedolizumab, and disease activity (measured by HBI) significantly reduced after 6 months and at 1 year in both groups [38]. Similarly, a Canada-based study showed no statistical difference in the remission rates among the use of four biologics (Vedolizumab, Adalimumab, Infliximab, and Ustekinumab) among elderly adults with IBD [39]. The risk of infection among elderly IBD patients was comparable between the biologics (Vedolizumab, anti-TNF, and Ustekinumab) in three studies [28,31,39] Pneumonia followed by septicemia were the most common reasons for in-patient hospitalization among the three groups (Vedolizumab vs. Ustekinumab vs. anti-TNF) in a US-based study [31]. Meanwhile, digestive tract infection was the most common among the anti-TNF group, while pulmonary infections were common among elderly IBD patients who used Vedolizumab and Ustekinumab in France [28]. A retrospective US study comparing the safety of anti-TNF versus Vedolizumab indicated that infusion reactions and infection (20%) were the most common reasons for stopping anti-TNF therapy, whereas infection (14%) was the sole reason for stopping Vedolizumab [22]. Additionally, 3% of patients from the anti-TNF group and 1% from the Vedolizumab group developed a new onset of cancer (excluding skin cancer) or recurrence of their previous cancer after initiating the therapy [22].

3.4.2. Immunosuppressant Medications

Contrasting findings were noted regarding the use and outcomes of immunosuppressant medications among elderly IBD patients. The findings of a few studies reported increased use of these medications among elderly adults with IBD [26,41], with one study highlighting that this use was associated with a longer disease course [41]. Conversely, many studies reported decreased use of immunosuppressant medications among elderly IBD patients [7,34,35,36], and one study noted a low cumulative probability of immunosuppressant use among elderly CD patients in Korea [46]. Interestingly, elderly adults with IBD who were on immunosuppressants were found to be at low risk for frailty [47].

3.4.3. 5-Aminosalicylic Acids (5-ASA) and Steroids

Only four of the reviewed studies addressed the use of 5-ASA agents, which are commonly used for maintenance therapy among adults with IBD [26,30,43,49] The findings from a multi-national study indicated that 5-ASA was more commonly used in Canada, while Sulfasalazine was more commonly used in the UK by elderly adults with IBD.

Similarly, a few studies addressed corticosteroid therapy in older adults with IBD [17,41,42,43,53]. In a US-based study, out of 393 participants [50], 0.6% of the older IBD patients were on chronic steroid therapy [43], while a study from Spain showed that more than half (66%) out of 314 patients were on steroids [41]. The use of corticosteroids was significantly associated with depression among elderly adults with IBD (p < 0.01) [17]. Additionally, corticosteroid therapy and prior surgery were associated with an increased risk of treatment-related complications in adult-onset IBD patients in the US [53]. However, findings from a retrospective cohort study in Canada indicated that the majority of elderly IBD patients received steroids within five years of diagnosis [18]. Higher usage of rectal therapy with 5-ASA and topical corticosteroids was noted in Denmark and Canada in a multi-national study [26].

3.5. Surgical Outcomes

Nine of the reviewed studies evaluated the surgical outcomes of elderly adults with IBD, yielding mixed results. Findings from a retrospective cohort study in Canada indicated that elderly adults with UC had a higher five-year cumulative risk of surgery compared to young and middle-aged IBD patients [50]. Similar findings were noted in a retrospective study from Sweden, which reported a higher absolute risk for bowel surgery in elderly adults with IBD (p < 0.001) [35]. However, a UK-based study comparing the surgical risk between elderly- and adult-onset IBD and analyzing the effect of thiopurines on surgical outcomes showed a comparable risk for colectomy between elderly and adult-onset UC in 1, 5, and 10-year risk analyses. Notably, decreased surgical risk (colectomy) was observed among elderly-onset UC patients who were on thiopurines for more than 12 months [23]. Further analyses among elderly adults with CD showed a comparable cumulative risk of surgery between elderly adults with CD and young and middle-aged IBD patients in Canada [50]. By contrast, a UK-based study noted a decreased risk for first intestinal resection in elderly-onset CD compared to adult-onset CD in 1, 5, and 10-year risk analyses [39]. Similar results were observed in a Korean study, which reported a decreased risk for bowel resection in elderly-onset CD patients compared to the adult group (p = 0.067) [46]. A retrospective study based on large US national data also confirmed decreased surgical rates among elderly IBD patients [56]. Out of 314 study participants in a retrospective study in Spain, bowel resections were the most frequently performed surgical intervention (90%) [41]. A case-control study based on a national database from the US compared post-operative complications and death between elderly IBD patients and non-elderly IBD patients [27]. Out of 1707 elderly IBD patients, post-operative mortality (within 30 days) was higher for both elderly UC (p < 0.001) and CD (p < 0.001) patients compared to non-elderly patients. Additionally, longer lengths of stay, increased risk of renal dysfunction post-surgery (p < 0.001), higher rates of infectious complications after surgery (wound dehiscence, shock, pneumonia, ventilator dependence, and urinary tract infections; p < 0.001 for all), increased risk of myocardial infarction and cardiac arrest post-surgery (p < 0.001), and increased need for blood transfusion (p < 0.001) were noted among elderly IBD patients [27]. However, a higher risk for DVT (p < 0.001) was only noted among elderly CD patients [27].

Few studies evaluated the surgical outcomes of IBD medication therapy. Interestingly, a retrospective study from France showed that treatment with systemic steroids reduced the risk of surgery among elderly IBD patients [30]. Post-operative complications were comparable among elderly CD patients who had a surgical resection while on Ustekinumab versus those who were not on Ustekinumab in a retrospective study in the US [37]. Further analysis revealed that the rate of surgery did not differ between those who are more than 70 years old versus those who are between 60 and 69 years old in France [36].

3.6. Healthcare Utilization

Hospitalization rates, ED visits, care provided by a gastroenterologist, and diagnostic imaging rates were compared between elderly and non-elderly IBD patients. In the Netherlands, a higher risk for hospitalization was noted among elderly onset UC at the time of diagnosis and during follow-up at 5 and 10 years [42]. Similar findings were observed in a retrospective study in Canada, where higher hospitalization rates were noted among elderly IBD patients within one year of diagnosis, although this rate decreased in subsequent years [40]. Furthermore, this study reported decreased healthcare utilization among elderly IBD patients compared to their younger counterparts, including a lower chance of gastroenterology visits within one year of diagnosis and at five years post-diagnosis (p < 0.001) [40]. Additionally, diagnostic imaging utilization was significantly higher among elderly UC patients compared to young adults (p < 0.001), with fewer ED visits noted among elderly IBD patients within the first and third years compared to their younger counterparts (p < 0.001) [40]. Compared to previous studies that were older [40,42], findings from a recent retrospective study in Canada indicated decreased colectomy and hospitalization risk among elderly adults with IBD who received care from a gastroenterologist [45]. Another benefit observed with gastroenterologist care included increased use of biologics (within five years of IBD diagnosis) and systemic steroids (within 1 and 5 years of IBD diagnosis), whereas decreased use of immunomodulators was noted among elderly IBD patients whose primary care providers were not gastroenterologists [45]. However, disparities exist in gastroenterologist care among IBD patients living in rural versus urban areas; elderly IBD patients in rural areas were less likely to receive gastroenterology care compared to younger patients across all age groups living in rural areas [45].

A large (n = 15,428) retrospective study in the US that analyzed the costs, annual burden, and reasons for hospitalization among elderly adults with IBD indicated that they had an increased length of stay in hospitals compared to middle-aged and younger patients (p < 0.01), along with increased hospitalization-related costs (p < 0.01) [19] Older IBD patients have less chance to undergo IBD-related procedures and GI surgeries compared to younger IBD patients (p < 0.01). Serious infections (bacteremia, Clostridium difficile, and pneumonia) were the primary cause of hospitalization among older patients (p < 0.01), followed by cardiovascular complications (p < 0.01) in this cohort. Adults >64 years of age were more likely to receive a blood transfusion during hospitalization [19] Interestingly, only one of the reviewed studies addressed the financial concerns of elderly adults with IBD. Participants in this qualitative study raised concerns related to medication costs as a major factor influencing treatment choices, challenges with insurance coverage, and the impact of spending retirement income to manage their IBD [54].

3.7. Mental Health Concerns

Only two of the reviewed studies addressed the mental health concerns of adults with IBD [17,25] One study evaluated the geriatric deficits of 405 elderly adults with IBD and found that 16.5% of them had deficits in the mental domain. Patients with older-onset IBD were more often impaired in the mental domain, including cognitive impairment (16.9% vs. 6.7%; p < 0.001) [25]. Another prospective study in the US indicated that higher levels of disease activity were significantly associated with depression among older adults with both CD (p = 0.005) and UC (p = 0.003). It was also noted that medication adherence was significantly decreased in patients with depression compared to patients without depression [17]. Although not directly related to mental health, participants of a qualitative study expressed the profound impact of social isolation due to their bowel urgency and other IBD symptoms [54]. This social isolation can significantly influence the mental health of older adults with IBD, exacerbating feelings of loneliness and affecting overall well-being.

4. Discussion

This systematic review aimed to assess the therapeutic needs of elderly adults with IBD, focusing on their QOL, symptom presentation, mental health management, IBD medication utilization patterns, surgical outcomes, and healthcare utilization to identify gaps in their IBD management. Findings from this systematic review highlighted several key points: elderly adults with IBD generally experience decreased health-related QOL, more frequently presenting with colonic involvement and less frequently with penetrating disease in the case of CD. Symptom presentations were comparable between elderly versus younger UC patients. Despite an observed trend toward increased biologic prescriptions for the elderly, there was a noted decrease in response rates and poorer rates of remission. The use of immunomodulators and corticosteroids remains prevalent, with mixed results in surgical outcomes among elderly adults with IBD. Healthcare utilization was higher among elderly adults with IBD.; however, affiliation with a gastroenterologist correlated with a decreased risk of hospitalization and surgery. Notably, mental health concerns of elderly IBD patients received insufficient attention in the reviewed studies.

These findings have significant implications for the care of elderly adults with IBD. Four of the reviewed studies reported decreased QOL among elderly adults with IBD. Managing a chronic illness poses numerous challenges for elderly adults, which can compromise their independence and QOL [59]. As a GI tract disorder, IBD significantly impairs QOL due to persistent GI symptoms, such as diarrhea, abdominal pain, nutritional deficits, bowel urgency, and other general symptoms related to fatigue [60]. Coupled with the effects of aging, these chronic symptoms can be particularly difficult for elderly adults to manage, a consideration often overlooked in clinical practice. Healthcare providers should consider and discuss interventions to maintain QOL, including ensuring family and social support and promoting activities that enhance physical functioning.

The expert review by the American Gastroenterological Association (AGA) recommends a comprehensive laboratory analysis of elderly adults with IBD, including blood tests for nutritional factors, such as serum albumin and serum ferritin, and stool testing for pathogens like Clostridium difficile, as needed [2]. Interestingly, only one of the reviewed studies reported nutritional blood profiles [43], and nutritional deficiencies are common factors contributing to geriatric deficits and frailty among older adults with IBD [25,47]. Therefore, dietary management is a key intervention to consider for maintaining functional status and addressing geriatric deficits and frailty among these patients. More research is warranted in this area to address the gaps in the literature and provide optimum nutritional support to adults with IBD.

The IBD medication utilization patterns differed across the reviewed studies, probably due to differences in study settings across the world where healthcare policies and clinical practice guidelines vary. The reviewed studies evaluated the safety and efficacy of different groups of biologics, such as anti-TNF agents (Infliximab and Adalimumab), integrin receptor antagonists (Vedolizumab), and interleukin inhibitors (Ustekinumab), in managing symptoms in older adults with IBD. All these biologics are included in the induction and maintenance algorithm for managing IBD in elderly patients as recommended by the American Gastroenterological Association (AGA) expert review, which suggests that faster-acting biologics may minimize risks associated with corticosteroid therapy in elderly IBD patients [2]. Although Tofacitinib as a Janus kinase inhibitor (JAS) was recommended by the AGA expert review for both induction and maintenance of IBD symptoms in elderly IBD patients, none of the reviewed studies evaluated the safety and efficacy of this medication.

Although biologics have been recommended for managing IBD symptoms in elderly IBD patients, healthcare providers cannot ignore their adverse effects, including the risk of malignancy and infection. The AGA expert review recommends considering the suitability of an elderly adult for the medications recommended in the treatment algorithm by evaluating the risks associated with the therapy, geriatric deficits, and higher comorbid status of the elderly, as well as evaluating renal and hepatic functions, tuberculosis, and hepatitis B status [2]. Additionally, screening the status of thiopurine methyl transferase is recommended before starting thiopurine for elderly IBD patients [2].

Only a few of the studies addressed corticosteroid therapy in this systematic review. The AGA expert review committee recommends the use of Budesonide due to its high first-pass metabolism [2]. Although higher use of rectal steroid therapy was noted in one of the reviewed studies [26], a clinician needs to consider the self-administering ability and mobility status of elderly IBD patients or the ability of their available support system to administer the medication, as well as the strength of their rectal sphincter to retain the rectal forms of corticosteroid therapy [2].

The findings from this review shed light on several unmet needs of elderly adults with IBD. Studies addressing healthcare utilization consistently reported increased hospitalization rates, emergency room visits, and diagnostic imaging among elderly adults with IBD [18,42,45]. However, no one explored the financial concerns related to the increase in healthcare utilization or the costs of the medications. Many elderly adults with IBD may have retired and used their retirement funds to manage IBD-related expenses [54]. Others may be relying on governmental aid or a family member to meet their expenses as they are unable to work due to their declining functional status. In a previously published study, both groups of elderly adults (who acquired IBD at an early age and acquired old versus those who acquired IBD at a later stage) expressed fears and concerns about meeting their financial needs [54]. These financial concerns necessitate more exploration in future research to identify cost-effective strategies and options for support from government and non-government agencies to meet the financial struggles of elderly adults with IBD.

Only two studies among those reviewed addressed the mental health needs of elderly adults with IBD [17,25]. As a chronic illness affecting the GI tract, many older patients with IBD are at risk for developing mental health disorders, including depression, due to a number of reasons. First, they may be socially withdrawn due to their bowel urgency and the associated stigma [54]. Second, some IBD medications, such as corticosteroid use, put an individual at risk for depression [2,17]. Previously published data support the association between depression and medication adherence [25]. Given that medication adherence is vital in managing IBD symptoms, clinical practices need to consider assessment and depression screening of elderly adults with IBD for prompt referral to a mental healthcare team. Social support is another factor directly connected to the mental health status of an individual. Published literature reiterates that social support promotes well-being, improves health outcomes and self-management of IBD, as well as facilitates the management of loneliness and depression [61,62]. Additionally, social support can significantly influence health maintenance, such as adhering to appointments and medications. Therefore, support needs to be promoted not only to manage mental health concerns but also to treat IBD as a disease.

Although AGA experts recommend health maintenance practices such as annual influenza, pneumococcal, and herpes zoster vaccinations [2], none of the reviewed studies evaluated their effectiveness in elderly adults with IBD. Future research should address this gap. Findings from a recent qualitative study reported that elderly adults with IBD verbalized gaps related to informational needs to maintain their routines [54].

Considering the insufficient evidence on any special dietary practices to support the clinical course of IBD and the physiology of aging, recommendations have been made to include vitamin D, protein, and adequate water consumption based on the body weight of older adults with IBD as well as oral nutrition supplements [63,64]. The published literature is inconclusive in support of low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) and anti-inflammatory diet (IBD-AID) for older adults with IBD. A personalized approach to nutrition, considering the IBD disease characteristics and co-morbidity of the individual, has been recommended for older adults with IBD [63,64]. Additionally, there have been recommendations to consider a DASH or Mediterranean diet due to their potential benefits for comorbidities, although empirical evidence on these interventions is lacking among older adults with IBD [63,64]. The AGA recommends including a nutritionist in the multidisciplinary team when managing the care of elderly adults with IBD [2]. Although the dysbiosis of intestinal microbial flora is a major contributing factor to the diagnosis of IBD among elderly adults, no empirical studies have evaluated the effectiveness of probiotics in alleviating symptoms or preventing the onset of IBD in this population. Future studies are warranted to explore the effectiveness of probiotics among older adults with IBD.

The strengths of this review include pooling information from 42 empirical studies that provided data from a large number of elderly adults with IBD. Additionally, we have included studies across the world, such as the US, Canada, Spain, France, and the UK, and provided a worldwide perspective on the management of elderly adults with IBD. The limitations of this review are that the majority of the studies were retrospective studies that focused on electronic medical records or administrative claims, which can probably contribute to errors related to data abstraction. Few observational or prospective studies and limited qualitative studies addressed the perceptions of elderly adults with IBD, highlighting areas for further investigation.

5. Conclusions

This systematic review focused on assessing the therapeutic needs of elderly adults with IBD, focusing on their QOL, symptom presentation, mental health management, IBD medication utilization patterns, surgical outcomes, and healthcare utilization to identify gaps in their IBD management. The findings from this systematic review offer a comprehensive synthesis of the management of elderly adults with IBD and highlight several unmet needs that warrant attention in future research and clinical practice considerations.