<p><iframe width="560" height="315" src="https://www.youtube.com/embed/AlObkXKEv1M?si=YIldr4UnR4eJn1jP" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe><br /> As life expectancy increases, so does the number of older adults who have ulcerative colitis. There are several unique considerations when treating older patients compared with younger patients, including differences in insurance access and coverage that may limit treatment options, an increased likelihood of polypharmacy, and frailty.</p>

We used to think that the onset of ulcerative colitis mainly occurred in young people aged 18 to 35 years, but we now know that there is a second bump in incidence between 55 and 65 years of age. And that is currently getting stretched even further because people are living longer. So, the epidemiology is changing. It can also be confusing to define what “older” means, as some literature indicates that older age starts at 55 years, whereas other sources say 60 or 65 years.

 

Caring for an older patient can come with more and different considerations than those that come with caring for somebody who is younger. The concept of the Geriatric 5Ms describes the following 5 key areas when caring for older adults: mind, mobility, medications, multicomplexity, and matters most. Right now, the most recent clinical practice update on inflammatory bowel disease in older adults is the 2021 update from the American Gastroenterological Association. The American College of Gastroenterology is undertaking a new guideline for older adults with gastrointestinal issues, and one of the chapters will be focused on inflammatory bowel disease, with publication probably happening around September 2025.

 

The older a patient with ulcerative colitis is, the less likely they are to be offered a biologic. That makes sense because of the fear of immunosuppression. However, this, ironically, means that older people are taking more steroids, which is the worst option for patients with ulcerative colitis in the big picture. Additionally, small molecules may not be the best option, even though they are oral medications, because they come with a cardiac risk. So, they are not my first go-to either.

 

When determining which biologic to use, I choose the one with the most acceptable risk profile, but cost and coverage must always be considered. Patients with Medicare may not have access to certain medications. Although some patients may have secondary insurance for medications, the co-pay could be 20%, for example. When a biologic costs $14,000, 20% is a lot, and there is no way to afford that on a fixed income.

 

After it is determined that a patient can afford a medication, you have to think about whether that medication is going to interact with anything else that they are already taking. In terms of polypharmacy, is the patient on so many drugs that they may not take them the way that they are supposed to? What happens if they miss a dose here and there?

 

An additional consideration in the care of older individuals is that you may have older patients who live in 2 different states at different times of the year, and they should have a provider in both states. Another big issue to consider in patient care is frailty. Finally, in terms of surgery, as people are living longer, chronologic age should not be a barrier to considering which treatment options a patient with ulcerative colitis has. Often, patients end up with a permanent ileostomy, but I think that some older patients are J-pouch candidates, and this decision should be individualized.