IBD Drive Time: Bharati Kochar, on Frailty Among Older Patients with IBD

In this episode of IBD Drive Time, Dr Bharati Kochar, an expert in studying frailty in older patients, speaks about inflammatory bowel disease among older patients. Dr Kochar, Dr Ray Cross and Dr Millie Long also discuss considerations in medication to manage IBD in times of the ongoing COVID-19 pandemic.

Millie Long, MD, is professor of medicine, vice-chief for Education and Fellowship Program director in the division of Gastroenterology and Hepatology at the University of North Carolina at Chapel Hill. Raymond Cross, MD, is professor of medicine and director of the Inflammatory Bowel Disease Program at the University of Maryland School of Medicine in Baltimore, Maryland. Bharati Kochar, MD, is a gastroenterologist and IBD specialist at Massachusetts General Hospital in Boston.

TRANSCRIPT:

Millie Long:
Hi, this is Millie Long from University of North Carolina. One of the co-hosts of IBD Drive Time. And I'm here along with my good friend and colleague, Ray Cross, who helps to cohost this podcast. And we have an outstanding guest today, Dr. Bharati Kochar from Mass General, who's going to be speaking to us about one of her main topics of interest, which is IBD in older individuals. So Bharati, welcome to our podcast.

Dr. Bharati Kochar:
Thank you so much for having me. It's such an honor to be here.

Millie Long:
Well, this is a really important topic. Not only are we seeing new diagnosis and diagnoses in older individuals, but certainly our patients are living throughout their lives. And so there are a lot of things we need to address as gastroenterologists for our older patient population. So let me just start with a simple question. Can you describe IBD in older individuals? I mean is it similar in terms of disease severity? Talk us through kind of older IBD.

Dr. Bharati Kochar:
That's a great question and I'll start by saying, thank you for using the word older because I think it's always important to kind of talk about who we're referring to when we discuss this. And so I like the word older because it talks about relative age. And so we're talking about a group of people in the IBD world who are maybe 60 and 65 years and older. So not really older, elderly, or geriatric, but older than the traditionally discussed population in the field. This is one of the big issues I do feel like is that a lot of our literature about people 60 and 65 years and older are talking about geriatric IBD or elderly IBD, and it doesn't really relate to the patients that we see in front of us. Back to your question, so IBD in older adults, I think traditionally, was very much thought to burn out by an older age.

And so it was thought that as you have thymic involution, and immune senescence, and things like that, you just don't have as much of a chance of having such severe inflammatory conditions. So across all of the inflammatory conditions, including in rheumatology and such. But more and more, we know that you can have very robust inflammation at older ages. Sort of simplistically, even though your number of immune cells decrease with age, their function could be more pro-inflammatory. And so there's a lot of research going on and try to figuring out who are these people who have more proinflammatory aging?
So I think we all see patients in their 60s, but even their 80s and 90s, who present with new severe disease. So including penetrating fistulizing Crohn's disease, severe ulcerative colitis that requires rescue therapy and colectomy. And there's also people who've aged with the disease, and maybe they've had quiescent disease for 30 or 40 years and all of a sudden had an older age, so as young as 60, but even as old as 80 or 90, have a really severe flare. So I think just like in younger adults, IBD in older adults can range this gamut and it's not something that we should not be thinking about as a condition that could be serious at older ages.

Millie Long:
No, I totally agree with you. I've seen some really severe IBD in my older patients. And I feel like sometimes we do them in disservice by kind of thinking in our heads, "Well this is milder." Or maybe giving them steroids and not escalating their underlying therapy. And so I think it's really important for us to recognize that these older epidemiological trends may not be applicable in today's age. What do you think about, in terms of treatment, when you're selecting treatments in older individuals with inflammatory bowel disease? What are the main things you're considering?

Dr. Bharati Kochar:
That's a great question. I'd love to hear what both of you have to think as well. But I think one of the things that is one of my biggest pet peeves is we picked a treatment because it is the "safest option." And so what I always tell people is, what's safest for the patient is effectively treating their IBD. So even if that sounds aggressive, and I will say again in air quotes, "aggressive," I don't think it's aggressive if that's the one strategy that is required to get them in at least clinical remission. If not some of the more objective targets that we like to aim for in all of our patients. And so I think you just have to match their treatment to their disease. And so if you see deep punched-out ulcers in someone with terrible, terrible colitis and you just want to put them on some mesalamine because it feels safer to you and they're... You're sort of thinking, "Well, they're 80 years old, how bad can things get?"

I mean, I think things can get very bad. And we've all have had the patient that's gone to a colectomy within a few months because we just didn't treat them upfront aggressively enough. And I think the important thing to recognize is that some older adults may have maybe less reserve to tolerate your trials of treatment. So it feels like it's really important to get it right the first time that you're trying. And so I don't have a go-to drug for older people. And I will say that we all know that older adults are underrepresented in clinical trials of IBD medications, and so it's not that we have a huge body of literature to turn to. And it does involve a long risk-benefit conversation often, but it's worth having and worth being upfront with good effective therapy.

Millie Long:
Totally agree with you. And obviously I do the same in my clinical practice. I thought, one, there was a nice study that Sid Singh did in his California IBD cohort recently that looked at Crohn's disease comparative use of TNFs as compared to ustekinumab, as compared to vedolizumab. But I think in many instances people may have been starting vedolizumab thinking, "I want to start the safest drug." But in reality with complications of Crohn's disease, they did much worse because of not as well controlling the Crohn's disease. So I think we need to match the patient to the drug just as you mentioned. I want to ask one more question, which is that we're in the midst of this never-ending COVID pandemic. Certainly it had been worse before, but it is still ongoing. Do you have any specific considerations given COVID in older individuals, either in regards to medication selection, or how does this influence your patterns of care?

Dr. Bharati Kochar:
I think that's a great question and it's certainly a question patients ask all the time. What I will say is I think the considerations are probably the same as in younger adults, but the counterfactual becomes a lot more serious. So the risks of COVID-19 infection in older adults could be much more serious. And so it becomes much more important, I think, to try to prevent or decrease susceptibility to COVID-19 infection. And so one of the first papers that came out from the secure IBD cohort, Millie, that you were involved with, was very helpful in my clinical practice. Because it essentially showed that corticosteroids and mesalamine were actually the 2 medications that were associated with the highest risk of COVID-19 infection and not the anti-TNF agents. And maybe combination therapy is associated with a slightly increased risk for COVID-19 infection.

But the flip side is, I think, poorly controlled inflammation is also associated with susceptibility for serious infections. And so if combination therapy is what they need to really keep their disease and systemic inflammation in check, it's probably worth doing as well. So the pandemic really highlighted to us the importance of being as steroid-sparing as possible, even though we sort of think of it as a quick 6-week, or 8-week, or 12-week whatever taper and then we're done. I think any amount of corticosteroid exposure could certainly be dangerous, and especially the doses that we use in IBD, those doses of prednisone over 20 milligrams pretty often. So those are the biggest considerations I would say. I think there's a big push to try to get disease under control effectively, and not allow for a ton of systemic circulating inflammation that you're not adequately addressing with mild or "safer" therapies.

Millie Long:
Great point. No, and I totally agree. And then obviously optimizing vaccination strategies as much as we can from a prevention perspective. But yeah, we got to treat the disease not try to be... Treating the inflammation will help improve outcomes. Now I'm going to turn it over-

Dr. Bharati Kochar:
Yeah, I definitely agree. And I do think... Sorry, just sorry to interrupt, I guess. But I will say I do think it's a gastroenterologists' role, as you know, Millie, to talk about vaccines. And so we've been doing that and this just gets added to the long list of things we talk about in terms of vaccinations.

Millie Long:
Very fair point. Let me turn it over to Ray for additional questions.

Ray Cross:
Thanks Millie. I just want to remind our listeners that IBD Drive Time is sponsored by Advances in IBD and the Gastroenterology Learning Network. And speaking of advances in IBD, the first in-person regional course in 2023 will be in my home city, Baltimore, March 31st and April 1st. And Millie and I will both be speakers, so we hope to have you register and see you there.

Bharati, I just wanted to follow up about drug treatment. And I say things slightly differently to patients when I'm doing the risk/benefit discussion. When I get to the end and their eyes are glossed over and they look super afraid of the therapies I may have talked about, I remind them that nothing that I can give them is worse than poorly controlled disease or steroids. And somehow patients, and even some outside providers, still feel that steroids are safe and we know that they're not. Now, having said that, what about JAK inhibitors in your older patients? Are you a little more cautious with JAK inhibitors based on the ORAL surveillance study in rheumatoid arthritis?

Dr. Bharati Kochar:
The answer should be yes. But in reality, if you look at the inclusion criteria for patients in the ORAL surveillance trial, it's patients who are 50 years and older. So really quite a young older population. With one additional risk factor for cardiovascular disease. So that's actually not the majority of older patients. So there's many people that we see in clinic routinely who might be 70, or I have a 77-year old on a JAK inhibitor because her only comorbidity is depression. She's not at all multimorbid. And so I think it's just very important to recognize the inclusion criteria. But I do talk about it and I do say that there's potentially maybe a signal for increased risk of pretty significant serious events. That being said, I mean you're not starting a JAK inhibitor or denovo, right? It's usually the patient that has failed a TNF, or not failed, but has been through a TNF without a good response and probably another biologic or 2, sometimes 5, without a good response.

And for that patient, the counterfactual then is surgery. And a colectomy in major abdominal surgery comes with risks as well, including cardiovascular risks from sedation and the procedure itself. So nothing is really risk-free. And I think people understand that when you have that conversation in depth, they really like the way you phrase it. I mean, nothing we can do to them is really as bad as just continuous prednisone. So we don't have a head-to-head of prednisone and a JAK inhibitor, but prednisone has increased risk for venous thromboembolism and infections including herpes zoster. So it's not that we haven't done these things to our older patients with other medications for IBD in the past.

Ray Cross:
I completely agree. I completely agree. So something I know you're super interested in, you talked about multiple comorbidities, but the concept of frailty and really not looking at chronological age, but looking sort of at this concept of frailty in patients. Do you want to talk to listeners a little bit about that?

Dr. Bharati Kochar:
Sure, thanks. So frailty is a pretty poorly defined term on the whole, but the thought is that it's maybe a surrogate for biologic reserve, or your ability to bounce back from a stressor as you get older. And in inherently it's an aging-related concept. And there's a couple of different ways of defining frailty. There's probably many different ways of defining frailty, but sort of under 2 leading conceptual models.

One is sort of an accumulation of deficits or things that can happen to you, and another is a phenotype of things like fatigue and unintentional weight loss. But the concept is that frailty is inherently an inflammatory condition at older ages. And so there seems to be a lot of overlap between frailty and IBD, even in younger adults. And so I'm interested in thinking about if that's a construct that could be applicable to older adults with IBD as sort of a surrogate of the eyeball test. A more objective way of looking at a person and instead of just deciding that they can't tolerate this, or that they're very robust if there's kind of a more objective measure of doing this.

So there's been kind of a proliferation of papers looking at frailty retrospectively in IBD, and they all kind of show that frailty is a marker for kind of adverse events or is maybe one other predictor of adverse events in older adults, sort of like chronologic age can be, and comorbidities can be. But what's important to tease out is what of these frailty factors is really pertinent to patients with IBD. And so that's what we're trying to do prospectively with the Crohn's and Colitis Foundation funded cohort, the longitudinal cohort of older individuals with Crohn's and colitis. So stay tuned for those results hopefully sometime soon.

Ray Cross:
I was just going to say my frailty index is very subjective. It's just the eyeball test and you look frail or you don't look frail, regardless of age. And I don't think we have an IBD specific frailty measure yet, although you're going to probably develop one. There's some objective things that providers can put on a checklist to identify a more frail individual.

Millie Long:
So before she answers, let me comment. Because we're a site for this logic study that she's doing, and one of the questions is, is what I think the frailty is as the doctor? Like your eyeball test, Ray. And then there's objective things like a walk test. And I am wrong most of the time. So I think that this is something that we may not have the right training to assess. Is that fair Bharati? I mean...

Dr. Bharati Kochar:
You, me, and everyone else Millie. But I think, and I don't know that wrong is necessarily, I'm not saying this just to defend myself, but is necessarily the term. I think it just kind of shows that maybe the accumulation of deficits, which is what that eyeball test is really kind of measured against, is maybe not the best way of looking at frailty in our older patients with IBD. And so maybe it's something else. And maybe it's not the whole frailty phenotype, but a component of that frailty phenotype that's maybe most tied to their biologic reserve. And so in other conditions, they have what Ray was talking about, this sort of tailored frailty assessment. And that's maybe what we do need to get to. Alternatively, it could be completely irrelevant. So anytime you go into research, you have to be willing to accept an all hypothesis.

So I'm still willing to keep an open mind. I'm not saying that frailty is the be all and end all, but I think the idea is really just to look for a measure beyond chronologic age. Because again, and you don't even need to be a physician to know this, but not every 60 year old is the same and not every 70 year old is the same. So we have the 89-year-old marathon runners, and then we have the 50-year-old patients that really look like they probably don't have 10 years of life left. And so just trying to find a way of objectifying that because having the eyeball test is a very subjective measure and not as uniform as what we're trying to get to with these frailty studies.

Ray Cross:
And another topic that comes up, Bharati, I'm not going to say Millie's getting older, but as I've gotten older, my patients are aging with me. But I just saw one of my favorite patients today who's 73, had a surveillance exam last year, had a tubular adenoma, small one, removed from the right colon, and he's due for surveillance. He'll be about 74 or 75 for his next exam. So when do you stop? I mean, do we put just a number on it? What I've been doing is just trying to get a sense, "Are they likely going to be alive for 10 years and if so, I think ongoing surveillance is reasonable." I have the uncomfortable conversation. "Do you want to know if you have precancer or cancer? Are you going to do anything about it?" It's sort of an awkward conversation, but it has to happen. So how do you approach them?

Dr. Bharati Kochar:
That's a great question. I would say potentially similarly in the absence of data. So we don't really know exactly when to stop. And I would say that sort of when to stop for routine colon cancer surveillance is probably a little bit up for discussion as well. But what I do also tell my patients is sometimes it's not just the procedure, but it's the prep for the procedure that can actually be pretty difficult to tolerate. So for a full colonoscopy, especially a surveillance exam, you want a very good prep. I've had a number of patients in their 80s who've prepped for the colonoscopy but fell running to the bathroom, then had a hip fracture, then ended up in the hospital, then got a DVT. Had another patient last week that showed up who was 82 for a screening exam. Very robust, robust gentleman, showed up for a colonoscopy and started having pretty significant SVT in the preop bay. Got hypotensive, probably from dehydration. So even though we were trying to aggressively rehydrate him, weren't about to give him sedation for a colonoscopy. So it's not just... And electrolyte imbalances can happen more easily at older ages. So it's not just the procedure, which is actually a relatively safe procedure if you think about it, but it's more the sedation and the prep for the procedure that I think become factors in that conversation.

But I agree with you. I think having that conversation on, "Is this really worth it? If we find low-grade dysplasia, are you going to get another colonoscopy in 6 months or 12 months? If we find high grade dysplasia, do you want a colectomy? Or another surveillance procedure or another colonoscopy, if it's a localized lesion that we can do an ESD on, are you really going to do all of this?" And if you're 85 and you sort of just want to say, "I don't want to do all of this." Is that unreasonable? Maybe we do leave you alone. So I think we're just at the stage right now where it's all so individualized, but this is what takes very long conversations in clinic. And I don't think it's like a reflexive comeback in 2 years thing, after 70, 75, or 80.

Ray Cross:
To put a plug in for the Red Journal, Jordan Axelrad and I just wrote a short piece for the Red Journal on when to stop surveillance in IBD. And Jordan Axelrad's the lead author on that. So if you want to learn more about when to stop, go to the Red Journal. It's now been published online. So Bharati, my favorite question, the fun question; tell the listener something about yourself that they may not know, or something maybe even that Millie and I may not know.

Dr. Bharati Kochar:
Okay, that might be the hardest question so far. Okay. We'll talk about something more recent because I think it kind of goes along the topic of aging. The human body starts declining after 35. Did you know this? And so what I have started doing recently this month is decided to embrace winter sports to some degree, no downhill skiing still. But my kids really love ice skating, and so I started taking some ice skating lessons and now can do a spin on the ice.

Ray Cross:
Wow.

Dr. Bharati Kochar:
But my daughter can do walls twirls or whatever that is. And so she's still way better than me, but they really, really like it. And so I thought that it's a good experience for them to see me struggling at something. Struggling to stand up on the ice while they're just jetting around. And it's a good thing to start embracing the winter, and start learning new things as I get older.

Ray Cross:
How long did it take you to learn Bharati?

Dr. Bharati Kochar:
Oh, I would-

Ray Cross:
I would look like Rocky Balboa.

Dr. Bharati Kochar:
I'm terrible.

Ray Cross:
The movie Rocky, trying to ice skate. And I think Millie had a bad ice skating experience.

Dr. Bharati Kochar:
I should clarify, I am not an ice skater. I don't know that I'm all done. I had four lessons in January so far. I can stand up on the ice, I can go around the rink, I can spin a little bit, not too fast.

Millie Long:
That's pretty impressive though.

Dr. Bharati Kochar:
I can do a bunny hop and that's that. So by no means... I can survive on the ice without getting a hip fracture while my two kids are on the ice. That was the goal. And so far that's, that's there.

Ray Cross:
Bharati, this has been wonderful. We're lucky to have you. You're one of the world's experts on frailty and IBD, and hopefully you'll join us again in the future.

Dr. Bharati Kochar:
Thank you so much, Ray. That was so flattering. Thanks for having me, both of you. I really appreciate it.