Christina Ha, MD, on Managing IBD Among Older Patients

Americans aged 65 years and older number more than 54 million today, many of whom live alone and on limited incomes, all of which complicates the care of those with inflammatory bowel disease (IBD), Christina Ha, MD, said at the Advances in Inflammatory Bowel Disease virtual regional meeting September 11.

Dr Ha is an associate professor and gastroenterologist in the IBD Center at Cedars-Sinai in Los Angeles, California.

With the population of Americans aged 85 and older expected to grow 1 ½ times to 80 million by 2040, the special considerations of caring for these patients with IBD will become increasingly important, she said. Today, 1 in every 5 of those aged 65 to 74 years and 4 in 10 of those aged 85 year and older live alone. The median income of Americans over 65 was $27,398 in 2019, and this group saw out-of-pocket health care costs grow to almost $7,000 per year, Dr. Ha stated. “This impacts the ability to self-manage chronic complex disease states such as Crohn’s disease and ulcerative colitis due to limited social and financial resources.”

The prevalence of disabilities among the older population must be considered when caring for older patients with IBD, she explained. “We have to think in terms of cognitive impairment, hearing and visual compromise, as we are selecting medication therapy. We have to think about complexity of regimens, ease of administration, dexterity, and the likelihood of medication error.”

Age-associated physiologic changes such as loss of physical reserve, decline in functional status, increased susceptibility to falls are also common, with sarcopenia prevalent among patients with active IBD. These patients may also evidence decreased anal sphincter function, and reduced ability to manage rectal symptoms and nocturnal bowel movements.

“What’s different about IBD in older patients?” There are differences in intestinal microbiota, with Bacteroides dominant over firmicutes and decreased diversity. Altered GI mobility increased gastric pH and increased intestinal permeability may contribute to diarrhea,” Dr Ha explained. Age-associated microvascular ischemia is more common, as well.

Older patients present “multiple additional confounders” that must be factored into decisions about medical therapies, including pharmacokinetics, functional status, polypharmacy, and comorbidities. There are limited data on therapeutic efficacy of IBD therapeutics because older persons are often not included in clinical trials, she said.

The patient’s age influences treatment selection, Dr Ha stated, noting that one study showed that 32% of older patients were maintained on chronic steroids, only 24% received supplemental calcium and vitamin D, and there was no documentation of a steroid-sparing strategy for most older patients. Use of anti-tumor necrosis factor agents (TNFs) and immunomodulators among older patients was very low. “Other, larger studies replicated these results,” she noted, with a Swedish study showing 60% steroid exposure in patients aged 60 years and older.

Why? “There is limited safety and efficacy data about the mechanism of action of biologic agents among older patients,” Dr Ha said. “There are concerns about malignancy risks such nonmelanoma skin cancer, melanoma, and lymphoma with biologics and immunomodulators. She noted that clinicians tend to be more risk-averse with older patients. “This tendency toward avoiding meds associated with risk, rather than thinking about the risks associated with uncontrolled prolonged disease activity—this is how we need to change the paradigm,” she stated. “We rely on chronic steroids too much.”

The cost of biologics and small molecules is another issue for older patients with Medicare as the primary insurer. “What’s covered under Part D drug benefits versus what’s covered under Parts A and B, medical benefits, greatly impacts” the therapies these can receive and afford.

The studies that have been conducted with older patients generally support the use of biologics among this patient population, Dr Ha continued. In one trial, patients aged 65 years or older had a lower rate of response in the short term, but among those who did respond to biologic therapy, their response over a period of 6 months was the same as that of younger patients with IBD, regardless of comorbidities.

A study conducted with a Veterans Administration database of the use of vedolizumab among older patients with IBD showed that only 6% if these patients needed surgery and there no differences in response or in rates of infection or malignancies between the older and younger patients. In fact, Dr Ha pointed out, “the highest rates of infection and malignancies were found among patients treated with steroids.”

“Early control of disease is essential to decrease the risk of morbidity related to an increased burden of the disease,” Dr Ha stated. This in turn requires the early recognition and correction of modifiable variables. Malnutrition, comorbidities, hospitalization, use of steroids, use of narcotics, and increasing age are all associated with adverse effects of IBD therapy, she said. “If you look at these 6 variables, all but one of them are modifiable. So what this tells us is that with our older patients, we have to recognize if any of them are present, and if they are, we have to modify them early on.”

Dr Ha emphasized the importance of vaccination. “Don’t forget shingles, pneumonia, flu shot, COVID-19.” She also stressed the importance of avoid narcotics. “Unbelievably, hydrocodone plus acetaminophen are in the top 10 prescribed drugs for older patients. Avoid prolonged steroids and combination immunosuppression, which puts older patients at risk for malignancies. And keep older patients out of the hospital,” where they are at higher risk for Clostridioides difficile, venous thromboembolic events, and overall mortality.

Optimizing modifiable variables includes monitoring hemoglobin, Dr Ha said. “Declines in hemoglobin over time have worse outcomes over absolute value,” she explained. “Anemia is associated with higher incidence of cardiovascular disease, cognitive impairment, increased risk of falls and fractures, longer hospitalization, increased frailty and dementia, and mortality.” She recommended the use of intravenous infusion of iron.

Monitoring and improving functional status is also important, as sarcopenia upregulates cytokines, she noted; this can be reversed by physical therapy, which is covered by Medicare.

Anxiety and depression are common among older patients with chronic disease and/or limited function, “but they are not part of aging process,” Dr Ha stated. “Medicare does cover counseling services through Part B,” and patients who show symptoms of generalized anxiety and depression should be referred for these services.

“Medication reconciliation is important. Don’t forget supplements and OTC meds,” Dr Ha said. “Remove unnecessary medications and duplicates, such as 5-ASAs if a patient is doing well on biologics. Identify medication interactions and gastrointestinal adverse effects. Minimize the pill burden and choose the simplest regimen to optimize adherence. And don’t forget out of pocket expenses for patients covered by Medicare and on limited incomes.”

Older patients need closer monitoring to determine therapeutic response and safety, Dr Ha stated. “Start the appropriate regimen early, including surgery. Optimize nutrition and physical conditioning, check blood counts.”

Finally, she stated, “Make your decision on fit versus frail, on the patient’s functional age rather than the numeric age.”

--Rebecca Mashaw

Ha C. Managing IBD in the elderly. Presented at: Advances in Inflammatory Bowel Diseases regional meeting. September 11, 2021. Virtual