In this podcast Dr Afzali discusses the special concerns that should be addressed when caring for elderly patients with inflammatory bowel disease, which she spoke about at the Advances in Inflammatory Bowel Diseases virtual regional meeting on August 7.

Anita Afzali, MD, is a professor of medicine at The Ohio State University Wexner Medical Center and medical director of The Ohio State University Inflammatory Bowel Disease Center.

TRANSCRIPT:

Welcome to another podcast from the Gastroenterology Learning Network. I'm your moderator, Rebecca Mashaw.

Today, I'm speaking with Dr. Anita Afzali, medical director of the Ohio State University Inflammatory Bowel Disease Center, about her presentation at the regional meeting for Advances in Inflammatory Bowel Disease on caring for elderly patients with IBD. Thank you for taking the time to talk with us, Dr. Afzali.

Dr. Anita Afzali:  Thank you, Rebecca. Happy to be here.

Gastroenterology Learning Network:  Among elderly patients with IBD, there are, of course, those who've had IBD for years after a diagnosis at a younger age, but there are also cases of patients who were diagnosed with IBD at a later age than is usual. Have these patients often had symptoms for years and just not received the right diagnosis? Or do some just not develop the condition until they're already in their 50s, or 60s, or even beyond?

Dr. Afzali:  Yeah, that's a great question. What we do know with the elderly onset of disease or a diagnosis of the disease, there are certainly some patients as you're describing where they have not had any symptoms and at a later onset of age and life, they now present with symptoms and then get the diagnosis of inflammatory bowel disease.

In fact, what we know is that this second rise, if you will, in regards to those who are diagnosed with inflammatory bowel disease, oftentimes what we're seeing is this rise is quite common. In fact, 20% of patients have a diagnosis of inflammatory bowel disease after the age of 60, so we are seeing a rise in inflammatory bowel disease at a later onset of life and age.

Now, with that said, Rebecca, what we also have seen is that, oftentimes, some patients may have a delay in diagnosis. They are symptomatic, may have some symptoms that may suggest inflammatory bowel disease, but the diagnosis has not been made. Delay in diagnosis has been reported to be about 6 years for patients with elderly onset inflammatory bowel disease.

This also falls under the category of the risk for misdiagnosis. Where we see this risk 4-fold higher in elderly onset of IBD compared to the younger patient with a diagnosis or a new diagnosis of inflammatory bowel disease being made.

GLN:  One particular form of IBD, and it's not one that we talk about very much, is microscopic colitis. That's much more common amongst older patients, is it not, than younger? Also, more among women?

Dr. Afzali:  Great question. Absolutely, microscopic colitis is different than the macroscopic, meaning we're visibly seeing the inflammation, the ulcerations, the colitis, or the enteritis that we see with inflammatory bowel disease. Certainly, microscopic colitis falls under the types of colitis or inflammation we see, but it's on the microlevel, meaning on biopsies that we evaluate.

Then under the microscope, we see and are making the diagnosis of microscopic colitis, whether it's collagenous colitis or lymphocytic colitis. Now, these patients, again, the diagnosis of microscopic colitis does more commonly occur at a later onset or age of life. That is a subtype of the colidity is what we call our diagnosis.

GLN:  Patients older than 65 are often excluded from many clinical trials, not just for IBD drugs, but for drugs in particular. How does that complicate the choices in positioning of therapeutic agents for these patients?

Dr. Afzali:  It's tough. It certainly is challenging. I'm a PI of many clinical trials and do not commonly see our elderly patients enrolled into the clinical trials. Certainly, not having an equal or good representation of older patients in these trials can impact our decisions and our understanding.

Overall, when we're thinking of treatments and selection of therapies, what I say is, find the appropriate therapy for the right patient, whatever that appropriate therapy may be, and whoever that right patient may be, based off the factors. Whether, sure, age is just a number so it's not necessarily age, but is there medical comorbidities? Are they fit or are they frail elderly? What other components do we need to consider when we're reaching into that medicine cabinet for each respective patient?

We do not have clinical trials representation, but we certainly understand the background in regards to our current therapies, knowing that some of our therapies are certainly safer with a lesser risk for infections, less risk for malignancy or cancer, and these are the therapeutic agents we should consider for our patients with inflammatory bowel disease who are older and at risk for infection.

GLN:  That gets into my next question, which is about balancing those risks and benefits of various drug therapies in older patients. You addressed infection and malignancy. What about drug-drug interactions, because very often, older patients have comorbidities and they are taking other medications. How complicating a factor can that be?

Dr. Afzali:  Polypharmacy is what we call that, Rebecca. That's what you're alluding to. That's absolutely something we need to be cognizant of, and our patients are at risk for, whether they have inflammatory bowel disease or multiple other medical comorbidities.

We know that far too commonly, and often, we're seeing our patients are on many medications, so recognizing the drug-drug interactions, accidentally taking one over the other, the timing, the complicated issues that comes with polypharmacy aside from the safety concerns, is something we absolutely need to consider for our patients, especially the elderly onset of disease patients.

GLN:  What about risks for diagnostic and screening procedures like colonoscopies? Are there specific things that you need to keep in mind if you're a gastroenterologist and you have a 70-year-old patient coming in for a colonoscopy, whether it's for diagnosis or screening?

Dr. Afzali: Colonoscopy certainly has the potential risk associated with this as a modality. It's an invasive procedure. There are risks associated with a colonoscopy for any age, but certainly, for elderly patients, there is the sedation risk, there is the risk once you're performing the colonoscopy in regards to the potential complications that can happen at the time of colonoscopy—which can happen at any age, but certainly, when we worry about elderly onset, if a complication happens, their ability to recover from that complication may also be an issue. There is risk, and this is exactly why, even as an example, for colon cancer screening, at a certain age, after about 70, 72, 75, we say maybe we don't need to do any more colon cancer routine screening.

So, that concern comes with inflammatory bowel disease as well, where we say the risks are there, the risks are low if I control your bowel inflammation. This is a shared decision-making discussion we need to have with our patients in regard to at what point do we say we don't need to do as much of some of these invasive procedures.

Again, weighing risk-benefit, knowing what our treatment goals are, knowing what our concerns are, and ensuring that this is a shared decision-making model with all of our patients.

GLN:  What would you say the key take-aways are from your talk on this subject? For your colleagues in the gastroenterology who are dealing with older patients, and the population is aging so that population of patients is probably growing.

Dr. Afzali:  Again, as we talked about, Rebecca, recognizing exactly what you said—the population is aging, elderly onset of inflammatory bowel disease is accounting for at least, again, 20% of newly diagnosed patients. Recognizing and including inflammatory bowel disease in our differentials, so that we're not having a delayed diagnosis, should be the first step.

Keep that in your differential and make sure that you're considering the potential that your patient may have a new diagnosis of inflammatory bowel disease. Once you've made the diagnosis, recognizing that there is age-associated factors for our older IBD patients such as sarcopenia, decreased anal sphincter tone, cognitive impairment.

We spoke about polypharmacy and the underlying cognitive impairment that happens with age and time. The baseline risks as an independent risk factor for cancer that we know is associated for our patients in general, but then, as an independent risk, we know the risk for cancer increases with age.

Keep these factors in mind when you're reaching into the medicine cabinet for which treatment strategies to choose for your patient. Unfortunately, we know that nearly 30% of our older patients are still maintained on steroids, on corticosteroids. This is a big number and it's not good. This is not how we should be managing and caring for our patients.

Recognizing that age is just a number, and we should not be under-treating our patients with the appropriate therapy or therapies based simply off of age. Then lastly, Rebecca, I want to highlight that we need to recognize that there is modifiable factors and there is nonmodifiable factors. The majority of factors, despite age, is modifiable.

Nutrition status, making sure we've optimized nutrition. Helping make sure that all of our patients, and especially our older patients, are receiving their appropriate immunizations and vaccinations, keeping that up to date. Doing the appropriate colon cancer, skin cancer screenings as an example. The polypharmacy, again, that we talked about, medication side effects, interactions, but then also, again, keep them off of the steroids and the narcotics if you can.

In the disease-related factors, if we improve nutrition, if we control the inflammation, if we control their other medical comorbidities, overall our patients could continue to do well on the right therapy that's safe for them that's managing their bowel disease and that's allowing each of them to continue their regular day-to-day activities and have the good quality of life that they should.

GLN:  Thanks very much for spending this time with us. It's been enjoyable and interesting to hear your insights on this subject. Thank you.

Dr. Afzali: Thank you for having me.