Gastroenterology & Hepatology

October 2023 - Volume 19, Issue 10

Management Considerations for the Older Adult With Inflammatory Bowel Disease

Ellen Axenfeld, MD
Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York

Seymour Katz, MD
Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York
Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, New York University Langone Health, New York, New York

Adam S. Faye, MD, MS
Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York
Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, New York University Langone Health, New York, New York

Corresponding author: 
Dr Adam S. Faye
Division of Gastroenterology and Hepatology
New York University Langone Health
305 East 33rd Street
New York, NY 10016
Tel: (516) 643-3546
Fax: (212) 263-3096

Abstract: As the prevalence of older adults with inflammatory bowel disease (IBD) is rising, understanding the unique challenges in both diagnosis and management is becoming increasingly important. Knowledge of phenotypic differences as well as overlapping symptoms with other medical conditions is critical to obtaining a timely diagnosis of IBD in older adults. Although older adults with IBD are at higher risk for adverse events compared with younger adults with IBD, recent data have suggested that ongoing disease activity may be a significant driver of adverse clinical outcomes rather than use of current treatment modalities. Ultimately, earlier and effective treatments can improve outcomes and quality of life for older adults with IBD. However, to help improve medical decision-making, clinicians must move away from the use of chronological age alone and begin to integrate measures of biological age, such as frailty and sarcopenia, into risk stratification tools. This article reviews the management considerations for older adults with IBD and provides the rationale for incorporating measures of biological age into current practice.

Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is a chronic inflammatory disorder of the gastrointestinal tract that arises from an immune response to environmental triggers among genetically susceptible individuals.1 Classically, IBD has been thought of as a disease of the young. More recently, there has been an epidemiologic shift, with older adults representing the fastest-growing subpopulation of individuals with IBD. This shift is particularly owed to the rise in incidence among older adults, coupled with the aging of the population.2 As a result, it is estimated that approximately one-third of the IBD population will soon be comprised of adults 60 years and older, with approximately 15% newly developing IBD during this time frame.3-6

Although data exploring treatment and management are present for younger adults with IBD, there is a dearth of these data for the older-adult IBD patient population. As a result, treatment decisions are largely based upon age and comorbidities alone, without consideration of important geriatric principles such as frailty, sarcopenia, and polypharmacy. Thus, it is important to detail what is known in this area as well as highlight knowledge gaps in clinical practice. This article discusses the unique clinical presentations for older adults, the impact of treatment decisions on clinical outcomes, and the rationale for incorporating biological age into medical decision-making for older adults with IBD.

Disease Course and Clinical Presentation in Older Adults With Inflammatory Bowel Disease

Among older adults who developed IBD earlier in life, there is a commonly discussed notion that the disease burns out over time. However, a French study on the long-term natural history of CD showed that after 20 years, a similar percentage of individuals experienced a disease flare in the 12 months prior compared with just 3 years after diagnosis (24% vs 34%, respectively).7 Additionally, a study comparing the postoperative recurrence rate in older adults undergoing ileocolic resection found no significant difference in 5-year recurrence rates compared with their younger counterparts when evaluated radiologically (33% younger vs 20% older), endoscopically (46% younger vs 40% older), or surgically (16% younger vs 9% older).8 Thus, ongoing disease activity needs to be treated among older adults, and the expectation that disease is likely to burn out in time should be cast aside. Treatment of older adults with IBD is critically important, as disease-related adverse events can lead to more severe consequences in this subpopulation. 

Clinical Phenotype of Older Onset

In addition to individuals who develop IBD earlier in life and are now aging, there is a clinically distinct population of older adults who develop incident IBD later in life.1 Typically, this bimodal peak of incidence occurs around age 60 years, and it is associated with a higher proportion of individuals having UC and a lower proportion having CD.9,10

The location and extent of disease also differs based upon age of IBD onset. More specifically, population-based studies have found that UC more often pre-sents as left-sided disease among older adults, with fewer older adults presenting with proctitis or pancolitis.9,11,12 The type of presentation, however, may also be specific to region, as older individuals who live in Asia are more likely to present with ulcerative proctitis (37.4%), with a similar proportion also presenting with left-sided colitis (31.8%) and pancolitis (30.8%). Similarly, among older individuals who newly develop CD, those in the Western hemisphere more often present with colonic disease, whereas those in Asia may present with ileocolonic disease.9,13 The phenotype of CD also appears to differ between individuals with older- and younger-onset IBD. Adults who develop CD later in life are more likely to have inflammatory and penetrating disease but less likely to develop stricturing disease.9 These disease locations and phenotypes are also more likely to remain stable among older individuals with new-onset IBD, compared with individuals with younger-onset IBD in which these characteristics may change over time.9,12,13

Risk Factors 

As clinical characteristics differ between older- and younger-onset IBD, so do the risk factors for IBD development. Approximately 5% to 16% of individuals with younger-onset disease have a family history of IBD, in contrast to approximately 7% and 3% of older adults with CD and UC, respectively.9,14 This finding has been confirmed by genetic studies demonstrating a much stronger association between particular mutations (eg, NOD2) and development of earlier-onset IBD than development of older-onset IBD.15 

Regional differences in the presentation of older-onset IBD suggest that environmental factors may play an increasingly important role in the development of IBD as people age. One environmental risk factor that appears to be more strongly associated with the development of older-onset IBD is antibiotic use.16,17 From a Danish cohort of over 6 million individuals, use of antibiotics, particularly an antibiotic impacting the gastrointestinal microbiome, was associated with an increased risk of incident CD and UC, with the greatest effect seen among individuals aged 40 to 60 years and 60 years or older.18 In contrast, preliminary data suggest that statin use may reduce the odds of IBD development, particularly among older adults; however, further data are needed.19 

Diagnostic Delays 

As clinical presentations can vary and as older adults are more likely to have additional comorbid conditions, making a timely diagnosis of older-onset IBD can be challenging. Consequently, initial misdiagnoses are more common among older adults. A study from 1998 showed that 51% of adults older than 40 years received an incorrect initial diagnosis compared with 39% of younger individuals.20 Further, diagnostic delays are longer for older adults, with one study showing 16 months of delay among older adults compared with 5 months among younger adults with IBD.21 Diagnostic delay, in part, is a result of an overlapping presentation of older-onset IBD with other conditions, such as segmental colitis associated with diverticulosis, ischemic colitis, medication-associated colitis (eg, from nonsteroidal anti-inflammatory drug use), infectious colitis, radiation proctitis, and immune checkpoint inhibitor colitis.22

Treatment Considerations for the Older Adult 

Although many of the same principles apply when treating older and younger adults with IBD, there are important considerations that must be integrated into the care for older adults. These are generally represented by the 5Ms (Mind, Mobility, Medications, Multicomplexity, Matters Most), which have been developed by the geriatric community and integrated into practice.23 

The 5Ms of Geriatric Care

With an increasing number of older adults being seen in medical clinics across the globe, health care professionals in gastroenterology need to push beyond the consideration of age and comorbidities alone. Although comorbidities can help dictate appropriate medical therapy (eg, heart failure is generally a contraindication to anti–tumor necrosis factor [TNF] therapy), they alone offer only one piece of the puzzle. Multicomplexity, which focuses more on the biopsychosocial model of an illness, requires consideration of how ongoing medical issues impact an individual’s daily life. To truly understand this, providers must consider living conditions (eg, does an adult with ongoing urgency and diarrhea live in a one-story or multistory home?), social support, as well as the ability to cope and adapt with changes in disease status (eg, periods of remission or flares). This can impact medication choices, as well as treatment goals, and is fundamental to the care of older adults with IBD.

When deciding upon medication choices, it is important to consider not only the modality in which the medication is delivered (eg, enema in someone with limited mobility, injection in someone with arthritis and limited social support) but also the concept of polypharmacy. Polypharmacy, most commonly defined as the use of 5 or more medications, has been shown to be associated with an increasing number of adverse events, particularly among older adults.24 More specifically, polypharmacy has been associated with increased drug interactions, medication side effects, medication nonadherence, hospitalization, and death.25-27 This is particularly important within the older-adult IBD patient population, as prior data have found that 43% of older adults with IBD had severe polypharmacy (≥10 medications). Moreover, 35% were given at least 1 potentially inappropriate medication (listed in the Beers criteria), with 10% on long-term narcotics.28 In a more recent study, 29% of older adults with IBD experienced severe polypharmacy, with this number increasing to 39% at subsequent visits.29 Severe polypharmacy was also associated with an increased risk of hospitalization within 1 year (adjusted hazard ratio, 1.85; 95% CI, 1.13-3.01). These data highlight the impact that medication choices have on individual outcomes and argue against the reliance on mesalamine therapies (up to 4 pills a day, with possible rectal therapy) as well as prednisone tapers, which are commonly prescribed for older adults with IBD.9,11,30 

When evaluating older adults with IBD, consideration should be given to any currently prescribed medications that may be contributing to symptoms. Discontinuing these medications and limiting the number of newly prescribed medications can help prevent polypharmacy and lead to improved outcomes.31 Deprescribing efforts have, therefore, been a recent focus within geriatric care and may have particular benefit in the older-adult IBD patient population who are at high risk for polypharmacy.

Cognition and mobility are critical in determining the appropriate medical management of older adults with IBD. In a study of 405 older adults with IBD, 10% were noted to have cognitive impairments, 6% were noted to have reduced gait speed, and 20% had reduced grip strength.32 Although there is currently a dearth of data exploring the impact of these factors on clinical and treatment-related outcomes, there is a need to incorporate these assessments into clinical decision-making (eg, individuals with cognitive impairment may benefit from infusion therapy more than oral agents or injectables, when considering advanced therapies). Understanding an older patient’s cognitive function and mobility is also important when considering the impact of frailty and sarcopenia (as discussed in a later section) on both disease course and clinical management. 

The consideration of what matters most is of particular importance to older adults. Based upon individual preferences, as well as the varying time horizon of follow-up treatment goals, management decisions for older adults may differ from those for younger adults. Accordingly, the preservation of functional status and minimization of clinical symptoms may take precedence over the achievement of deep remission in certain cases. Additionally, frequency of endoscopic evaluation, both for disease activity and dysplasia assessment, should be based upon individual characteristics and preferences (eg, risk of dysplasia, mobility [risk of fall when completing preparation]). However, further work is needed to understand outcomes based on the preferences of older adults, as in the case of colorectal cancer screening in patients over 75 years.33 

Medical Management for the Older Adult

Older adults with IBD are often undertreated, as a lack of data has led management decisions to largely be based upon chronological age and comorbidities alone. Health care professionals who are concerned about the safety of advanced therapies and surgical intervention may preferentially treat older-adult IBD patients with mesalamines and intermittent courses of corticosteroids. In a 2014 study by Charpentier and colleagues, individuals with older-onset IBD were significantly less likely to be treated with anti-TNF therapy or immunomodulators and significantly more likely to be treated with mesalamines and corticosteroids.9 Further, when evaluating the cohort with older-onset CD, almost 90% were given mesalamines by 20 years of follow-up, despite mesalamines being shown to have limited efficacy in the treatment of CD.9 Additionally, a multicenter study demonstrated that almost one-third of older adults with IBD were prescribed corticosteroids for at least 6 months, with this number doubling from 36% between 1991 and 2000 to 64% between 2001 and 2010.30,34 Although updated data are needed, particularly given the relatively recent approval of additional advanced therapies (eg, vedolizumab [Entyvio, Takeda], ustekinumab [Stelara, Janssen], risankizumab [Skyrizi, AbbVie]), it is likely that there is a similar reluctance to use treatments such as anti-TNF therapy, Janus kinase inhibitors, or combination therapy in older adults owing to concerns about safety.

Risks vs Benefits of Using Advanced Therapies 

Despite concerns regarding the safety of advanced therapies among older adults with IBD compared with younger adults with IBD, recent data have suggested that ongoing disease activity may represent a more significant driver of adverse clinical outcomes.35-37 In a study by Cheng and colleagues, pooled data from randomized clinical trials have demonstrated that anti-TNF therapy compared with placebo among older adults with moderate-to-severe UC did not result in an increased risk of serious adverse events. In fact, treatment with anti-TNF therapy resulted in lower rates of serious adverse events (20% anti-TNF agents vs 25.4% placebo), lower rates of hospitalization (14.4% anti-TNF agents vs 21.1% placebo), and lower rates of severe infection (2.5% anti-TNF agents vs 5.6% placebo).38,39 These results support the notion that the safer treatment option for older adults with IBD is likely the more efficacious one.

Analogous results were seen in a nationwide Denmark study assessing the efficacy and safety of vedolizumab vs anti-TNF therapy among older adults with IBD.40 In a propensity-matched analysis, there was no difference in 1-year infectious risks between the 2 treatments; however, individuals treated with anti-TNF therapy were less likely to require IBD-related surgery, IBD-related hospitalization, or need for corticosteroids compared with individuals treated with vedolizumab. It should be noted that although propensity-matched scoring may account for many potential baseline differences between patients, there are likely additional unmeasured items (eg, social support) that may account for treatment decisions and potential outcome differences. 

A risk of using anti-TNF therapy in older patients with IBD is that older adults are more likely to develop anti-TNF antibodies compared with their younger counterparts. Among 22,197 individuals using infliximab, 18.1% of older adults developed antibodies to infliximab therapy compared with 15.0% among younger individuals (P<.01). However, among individuals who were dose escalated (change in dose or frequency to achieve ≥10 mg/kg every 8 weeks), this difference was less apparent (10.6% with antidrug antibodies among older adults vs 9.9% among younger adults). The finding that older adults are more likely to make antidrug antibodies than younger adults, argues against the notion of immunosenescence and emphasizes that when using anti-TNF therapy among older adults with IBD, caution needs to be given to not underdose.41

When considering combination therapy (anti-TNF agent + immunomodulator) among older adults, similar results have been noted. In a post-hoc analysis of the REACT trial, Singh and colleagues found that there was no increased risk of complications among older adults who received combination therapy compared with those who received conventional management. Further, when assessing mortality, although older adults had a higher overall mortality compared with younger adults (4.5% older adults vs 0.2% younger adults), more deaths were observed in older adults on conventional management than on combination therapy. These results in conjunction with the aforementioned studies suggest that ongoing disease activity as opposed to the medications themselves may be a more significant driver of adverse clinical outcomes among older adults with IBD (Table).42,43 

Surgical Management of the Older Adult

A higher rate of adverse outcomes has been observed in older adults with IBD who underwent surgery. This finding has led to a deferral of surgical interventions in older patients owing to age and comorbidities alone. However, when considering risk factors contributing to an adverse 30-day surgical outcome, similar results are seen independent of age. More specifically, the presence of malnutrition, dependent functional status, preoperative sepsis, and need for emergency surgery carry similar odds for an adverse postoperative event among both older (≥60 years) and younger (<60 years) adults with IBD, although these factors are more common among older adults.44 The higher adverse event rate among older IBD patients may be a consequence of initial surgical deferral. To avoid surgery, given the higher risk of adverse outcomes, older individuals with IBD may preferentially be continued on medications with limited efficacy. The continuation of ineffective medication can paradoxically increase the risk of an adverse postoperative event, as ongoing inflammation and malnutrition may precipitate functional and cognitive decline. Therefore, an older-adult–specific IBD surgical risk stratification tool is urgently needed to help mitigate delays among individuals at lower operative risk and highlight potentially modifiable factors for individuals at higher operative risk.

Earlier IBD-related surgery, particularly before older individuals develop physiologic decline from ongoing inflammation, may be associated with improved outcomes. A study by Bewtra and colleagues found that elective colectomy compared with medical therapy for UC was associated with improved all-cause mortality among individuals 50 years and older.45 A recent LIR!C-like study that assessed real-world data from patients who underwent ileocecal resection or received anti-TNF therapy further supports the potential benefit of earlier IBD-related surgery.46,47 Among a Danish cohort of individuals with ileal CD, early surgical resection was associated with a 33% lower risk of the composite outcome (hospitalization, need for corticosteroids, need for surgery, development of perianal disease) compared with anti-TNF therapy. On subgroup analysis, individuals 40 years and older derived the most benefit from early surgical resection, with an associated hazard ratio of 0.56 (95% CI, 0.39-0.80) compared with anti-TNF therapy.46 

These data support the notion that for older adults with IBD, earlier surgery in patients who require it and elective surgical resection in select cohorts may lead to improved outcomes.

Incorporating Measures of Biological Age Into Risk Stratification Tools 

To improve current medical decision-making for older adults with IBD, there is an urgent need for accurate risk stratification tools. Because chronological age alone is a poor predictor of clinical outcomes, measures of biological age must be incorporated into current practice. Two such measures, frailty and sarcopenia, have both shown promise in this domain. 


Frailty is a state of vulnerability that leads to a rapid decline when faced with a clinical stressor (Figure). Frailty is present in approximately 11% of older community dwellers but is more common within the older-adult IBD patient population. In a recent population-based study in Sweden, 49% of older adults with IBD were at low risk and 12% at high risk for frailty, compared with 21% and 6%, respectively, among older-adult non-IBD population controls.48 Additionally, in the geriatric literature, frailty has been associated with a number of adverse clinical outcomes among older adults, including hospitalization, falls, and mortality. Similar results have been observed in the IBD patient population, as frailty has been associated with adverse events from medical therapy, rehospitalization, and mortality.49-52 Recent data have also suggested that treatment of ongoing inflammation may improve frailty, as 27% of all adults with IBD who had ongoing inflammation developed frailty within 1 year compared with only 7% who had response to therapy.53,54 These data, however, are retrospective and evaluate frailty as an accumulation of deficits. Further work prospectively using the frailty phenotype (to measure weight loss, exhaustion, weakness, gait speed, and physical activity) is underway, and should provide additional data that can be incorporated into older-adult IBD–specific risk stratification tools.55 

Recent data from other subspecialties have also added to what is known about frailty.56,57 In contrast to what had been previously thought, frail individuals derived greater benefit as a result of advanced heart failure therapies compared with individuals who were not frail.58 This finding challenges the current paradigm of conservative care among frail individuals, and highlights that treating an underlying condition may mitigate, or even reverse, the development of frailty among older adults. Further data exploring this concept within the older-adult IBD patient population are therefore needed. 


Another closely related but clinically distinct marker associated with biological age is sarcopenia. Sarcopenia, defined as the loss of muscle mass, strength, and function, is an important predictor of clinical outcomes among older adults and has been widely studied within the preoperative state. Yet, data assessing sarcopenia in the older-adult IBD patient population are limited, despite its high overall prevalence, which has been reported as 42% among adults (median age, 33 years) with IBD.59 From the data available on all adults with IBD, several studies have shown that preoperative sarcopenia is associated with an increased risk of adverse surgical outcomes, including infection, deep vein thrombosis, readmission, and longer length of hospital stay.60,61 However, it should be noted that as with frailty, not all IBD studies have shown a positive association between the presence of sarcopenia and the development of adverse clinical outcomes.62 This heterogeneity is likely explained by the differing measures of muscle mass, the varying cutoffs and methodologies used to define low muscle mass in the IBD patient population, and the overall lack of functional assessments. 

Recent data assessing older adults with IBD prior to surgery have found that skeletal muscle mass, as opposed to psoas mass alone, may be a stronger predictor of adverse postoperative events.63 Furthermore, on multivariable analysis of 121 older adults with IBD, increasing skeletal muscle mass was associated with a lower risk of adverse postoperative outcomes. Future prospective work must: (1) validate these findings, (2) incorporate additional measures of muscle strength and function, (3) develop an older-adult–specific IBD preoperative risk calculator, and (4) explore the role of prehabilitation to improve sarcopenia in the preoperative state. 


As the population of older adults with IBD continues to rise, it is important for clinicians to make a timely diagnosis in patients with older-onset IBD and not delay the appropriate treatment modality. Clinicians must also limit polypharmacy and understand what matters most to the patient. For clinicians to effectively manage older adults with IBD, they need: (1) further data to develop treatment-related risk stratification tools that incorporate measures of biological age, (2) qualitative data regarding patient preferences, and (3) data describing which population of older adults can undergo surgical resection without need for further advanced therapies. Obtaining these data has the potential to change the current paradigm of practice and, in doing so, improve care for the growing population of older adults with IBD. 


Dr Axenfeld and Dr Katz have no relevant conflicts of interest to disclose. Dr Faye has received grant support from the National Institutes of Health (R03AG078927-01), American College of Gastroenterology Career Development Award, and Crohn’s and Colitis Foundation Clinical Research Alliance; he has also received consulting fees from Bristol Myers Squibb, AbbVie, M3 Consulting, and Douglas Pharmaceuticals.


1. Hong SJ, Katz S. The elderly IBD patient in the modern era: changing paradigms in risk stratification and therapeutic management. Therap Adv Gastroenterol. 2021;14:17562848211023399.

2. Molodecky NA, Soon IS, Rabi DM, et al. Increasing incidence and prevalence of the inflammatory bowel diseases with time, based on systematic review. Gastroenterology. 2012;142(1):46-54.e42. 

3. Gisbert JP, Chaparro M. Systematic review with meta-analysis: inflammatory bowel disease in the elderly. Aliment Pharmacol Ther. 2014;39(5):459-477. 

4. Jeuring SF, van den Heuvel TR, Zeegers MP, et al. Epidemiology and long-term outcome of inflammatory bowel disease diagnosed at elderly age—an increasing distinct entity? Inflamm Bowel Dis. 2016;22(6):1425-1434. 

5. Nguyen GC, Sheng L, Benchimol EI. Health care utilization in elderly onset inflammatory bowel disease: a population-based study. Inflamm Bowel Dis. 2015;21(4):777-782. 

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

7. Etienney I, Bouhnik Y, Gendre JP, et al. Crohn’s disease over 20 years after diagnosis in a referral population. Gastroenterol Clin Biol. 2004;28(12):1233-1239. 

8. El Halabi J, Bachour SP, Shah RS, et al. Chronologic age is not associated with risk of post-operative recurrence in Crohn’s disease. Presented at: Digestive Disease Week (DDW); May 21-24, 2022; San Diego, CA. No. 456.

9. Charpentier C, Salleron J, Savoye G, et al. Natural history of elderly-onset inflammatory bowel disease: a population-based cohort study. Gut. 2014;63(3):423-432.

10. King D, Reulen RC, Thomas T, et al. Changing patterns in the epidemiology and outcomes of inflammatory bowel disease in the United Kingdom: 2000-2018. Aliment Pharmacol Ther. 2020;51(10):922-934. 

11. Gower-Rousseau C, Vasseur F, Fumery M, et al. Epidemiology of inflammatory bowel diseases: new insights from a French population-based registry (EPIMAD). Dig Liver Dis. 2013;45(2):89-94. 

12. Lakatos PL, David G, Pandur T, et al. IBD in the elderly population: results from a population-based study in Western Hungary, 1977-2008. J Crohns Colitis. 2011;5(1):5-13. 

13. Mak JWY, Lok Tung Ho C, Wong K, et al. Epidemiology and natural history of elderly-onset inflammatory bowel disease: results from a territory-wide Hong Kong IBD registry. J Crohns Colitis. 2021;15(3):401-408. 

14. Halme L, Paavola-Sakki P, Turunen U, Lappalainen M, Farkkila M, Kontula K. Family and twin studies in inflammatory bowel disease. World J Gastroenterol. 2006;12(23):3668-3672. 

15. Connelly TM, Berg AS, Harris L III, Brinton D, Deiling S, Koltun WA. Genetic determinants associated with early age of diagnosis of IBD. Dis Colon Rectum. 2015;58(3):321-327. 

16. Agrawal M, Jess T. Implications of the changing epidemiology of inflammatory bowel disease in a changing world. United European Gastroenterol J. 2022;10(10):1113-1120. 

17. Torres J, Ungaro RC, Colombel JF. Is prevention the best way to modify inflammatory bowel disease? How close are we? Gastroenterology. 2022;162(5):1452-1455. 

18. Faye AS, Allin KH, Iversen AT, et al. Antibiotic use as a risk factor for inflammatory bowel disease across the ages: a population-based cohort study. Gut. 2023;72(4):663-670. 

19. Lochhead P, Khalili H, Sachs MC, Chan AT, Olén O, Ludvigsson JF. Association between statin use and inflammatory bowel diseases: results from a Swedish, nationwide, population-based case-control study. J Crohns Colitis. 2021;15(5):757-765. 

20. Wagtmans MJ, Verspaget HW, Lamers CB, van Hogezand RA. Crohn’s disease in the elderly: a comparison with young adults. J Clin Gastroenterol. 1998;27(2):129-133. 

21. Cross E, Saunders B, Farmer AD, Prior JA. Diagnostic delay in adult inflammatory bowel disease: a systematic review. Indian J Gastroenterol. 2023;42(1):40-52. 

22. Nimmons D, Limdi JK. Elderly patients and inflammatory bowel disease. World J Gastrointest Pharmacol Ther. 2016;7(1):51-65. 

23. Molnar F, Frank CC. Optimizing geriatric care with the GERIATRIC 5Ms. Can Fam Physician. 2019;65(1):39.

24. Varghese D IC, Haseer Koya H. Polypharmacy. In: StatPearls (Internet) Treasure Island (FL): StatPearls Publishing. Jan 2023.

25. Chang TI, Park H, Kim DW, et al. Polypharmacy, hospitalization, and mortality risk: a nationwide cohort study. Sci Rep. 2020;10(1):18964. 

26. Lavan AH, Gallagher P. Predicting risk of adverse drug reactions in older adults. Ther Adv Drug Saf. 2016;7(1):11-22. 

27. von Buedingen F, Hammer MS, Meid AD, Müller WE, Gerlach FM, Muth C. Changes in prescribed medicines in older patients with multimorbidity and polypharmacy in general practice. BMC Fam Pract. 2018;19(1):131. 

28. Parian A, Ha CY. Older age and steroid use are associated with increasing polypharmacy and potential medication interactions among patients with inflammatory bowel disease. Inflamm Bowel Dis. 2015;21(6):1392-1400. 

29. Drittel D, Delau OR, Chodosh J, et al. Su1811 Polypharmacy and medication utilization over time among older adults with inflammatory bowel disease. Gastroenterology. 2023;164(6):S-693-S-694. 

30. Juneja M, Baidoo L, Schwartz MB, et al. Geriatric inflammatory bowel disease: phenotypic presentation, treatment patterns, nutritional status, outcomes, and comorbidity. Dig Dis Sci. 2012;57(9):2408-2415. 

31. Ibrahim K, Cox NJ, Stevenson JM, Lim S, Fraser SDS, Roberts HC. A systematic review of the evidence for deprescribing interventions among older people living with frailty. BMC Geriatr. 2021;21(1):258. 

32. Asscher VER, Waars SN, van der Meulen-de Jong AE, et al. Deficits in geriatric assessment associate with disease activity and burden in older patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2022;20(5):e1006-e1021. 

33. Cheong J, Faye A, Shaukat A. Colorectal cancer screening and surveillance in the geriatric population. Curr Gastroenterol Rep. 2023;25(7):141-145. 

34. Ananthakrishnan AN, Donaldson T, Lasch K, Yajnik V. Management of inflammatory bowel disease in the elderly patient: challenges and opportunities. Inflamm Bowel Dis. 2017;23(6):882-893. 

35. de Jong ME, Smits LJT, van Ruijven B, et al. Increased discontinuation rates of anti-TNF therapy in elderly inflammatory bowel disease patients. J Crohns Colitis. 2020;14(7):888-895. 

36. Khan N, Vallarino C, Lissoos T, Darr U, Luo M. Risk of infection and types of infection among elderly patients with inflammatory bowel disease: a retrospective database analysis. Inflamm Bowel Dis. 2020;26(3):462-468. 

37. Lobatón T, Ferrante M, Rutgeerts P, Ballet V, Van Assche G, Vermeire S. Efficacy and safety of anti-TNF therapy in elderly patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2015;42(4):441-451. 

38. Cheng D, Cushing KC, Cai T, Ananthakrishnan AN. Safety and efficacy of tumor necrosis factor antagonists in older patients with ulcerative colitis: patient-level pooled analysis of data from randomized trials. Clin Gastroenterol Hepatol. 2021;19(5):939-946.e4. 

39. Faye AS, Dodson JA, Shaukat A. Safety and efficacy of anti-TNF therapy in older adults with ulcerative colitis: a new path forward. Gastroenterology. 2022;162(6):1762-1764.

40. Singh S, Iversen AT, Allin KH, Jess T. Comparative outcomes and safety of vedolizumab vs tumor necrosis factor antagonists for older adults with inflammatory bowel diseases. JAMA Netw Open. 2022;5(9):e2234200. 

41. Faye A, Hong S, Axelrad J, Katz S, Hudesman D, Dervieux T. S970. Older adults are at higher risk for developing anti-TNF antibodies. Am J Gastroenterol. 2022;117(10S):e703.

42. Khanna R, Bressler B, Levesque BG, et al; REACT Study Investigators. Early combined immunosuppression for the management of Crohn’s disease (REACT): a cluster randomised controlled trial. Lancet. 2015;386(10006):1825-1834. 

43. Singh S, Stitt LW, Zou G, et al. Early combined immunosuppression may be effective and safe in older patients with Crohn’s disease: post hoc analysis of REACT. Aliment Pharmacol Ther. 2019;49(9):1188-1194. 

44. Fernandez C, Gajic Z, Esen E, et al. Preoperative risk factors for adverse events in adults undergoing bowel resection for inflammatory bowel disease: 15-year assessment of ACS-NSQIP [published online August 25, 2023]. Am J Gastroenterol. doi:10.14309/ajg.0000000000002395.

45. Bewtra M, Newcomb CW, Wu Q, et al. Mortality associated with medical therapy versus elective colectomy in ulcerative colitis: a cohort study. Ann Intern Med. 2015;163(4):262-270. 

46. Agrawal M, Ebert AC, Poulsen G, et al. Early ileocecal resection for Crohn’s disease is associated with improved long-term outcomes compared with anti-
tumor necrosis factor therapy: a population-based cohort study. Gastroenterology. 2023;165(4):976-985.e3.

47. Stevens TW, Haasnoot ML, D’Haens GR, et al; LIR!C study group. Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol. 2020;5(10):900-907. 

48. Kochar B, Jylhävä J, Söderling J, et al; SWIBREG Study Group. Prevalence and implications of frailty in older adults with incident inflammatory bowel diseases: a nationwide cohort study. Clin Gastroenterol Hepatol. 2022;20(10):2358-2365.e11. 

49. Faye AS, Wen T, Soroush A, et al. Increasing prevalence of frailty and its asso-
ciation with readmission and mortality among hospitalized patients with IBD. Dig 

Dis Sci. 2021;66(12):4178-4190. 

50. Kochar B, Cai W, Cagan A, Ananthakrishnan AN. Pretreatment frailty is independently associated with increased risk of infections after immunosuppression in patients with inflammatory bowel diseases. Gastroenterology. 2020;158(8):2104-2111.e2. 

51. Kochar B, Cai W, Cagan A, Ananthakrishnan AN. Frailty is independently associated with mortality in 11 001 patients with inflammatory bowel diseases. Aliment Pharmacol Ther. 2020;52(2):311-318. 

52. Qian AS, Nguyen NH, Elia J, Ohno-Machado L, Sandborn WJ, Singh S. Frailty is independently associated with mortality and readmission in hospitalized patients with inflammatory bowel diseases. Clin Gastroenterol Hepatol. 2021;19(10):2054-2063.e14. 

53. Faye AS. Connecting the dots: IBD and frailty. Dig Dis Sci. 2022;67(2):406-407. 

54. Kochar BD, Cai W, Ananthakrishnan AN. Inflammatory bowel disease patients who respond to treatment with anti-tumor necrosis factor agents demonstrate improvement in pre-treatment frailty. Dig Dis Sci. 2022;67(2):622-628. 

55. Fried LP, Tangen CM, Walston J, et al; Cardiovascular health study collaborative research group. frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-M156. 

56. Butt JH, Jhund PS, Belohlávek J, et al. Efficacy and safety of dapagliflozin according to frailty in patients with heart failure: a prespecified analysis of the DELIVER trial. Circulation. 2022;146(16):1210-1224. 

57. Jhund PS, Claggett BL, Talebi A, et al. Effect of dapagliflozin on total heart failure events in patients with heart failure with mildly reduced or preserved ejection fraction: a prespecified analysis of the DELIVER trial. JAMA Cardiol. 2023;8(6):554-563. 

58. Butt JH, Dewan P, Merkely B, et al. Efficacy and safety of dapagliflozin according to frailty in heart failure with reduced ejection fraction: a post hoc analysis of the DAPA-HF trial. Ann Intern Med. 2022;175(6):820-830. 

59. Ryan E, McNicholas D, Creavin B, Kelly ME, Walsh T, Beddy D. Sarcopenia and inflammatory bowel disease: a systematic review. Inflamm Bowel Dis. 2019;25(1):67-73. 

60. Carvalho D, Viana C, Marques I, Costa C, Martins SF. Sarcopenia is associated with postoperative outcome in patients with Crohn’s disease undergoing bowel resection. Gastrointest Disord (Basel). 2019;1(1):201-209.

61. Pedersen M, Cromwell J, Nau P. Sarcopenia is a predictor of surgical morbidity in inflammatory bowel disease. Inflamm Bowel Dis. 2017;23(10):1867-1872. 

62. Alipour O, Lee V, Tejura TK, et al. The assessment of sarcopenia using psoas muscle thickness per height is not predictive of post-operative complications in IBD. Scand J Gastroenterol. 2021;56(10):1175-1181. 

63. Faye A, Delau O, Chodosh J, et al. Skeletal muscle is a better predictor of postoperative outcomes among older adults with IBD as compared to psoas muscle. Presented at: DDW; May 6-9, 2023; Chicago, IL.

64. Fried LP, Cohen AA, Xue QL, Walston J, Bandeen-Roche K, Varadhan R. The physical frailty syndrome as a transition from homeostatic symphony to cacophony. Nat Aging. 2021;1:36-46.

Millennium Medical Publishing, Inc