Crohn's Disease in Seniors
Inflammatory bowel disease (IBD), which comprises Crohn's disease (CD) and ulcerative colitis (UC), is thought to be primarily a condition of young individuals. However, a significant proportion of new cases of IBD are diagnosed in elderly persons, and, given the negligible impact of IBD on mortality, younger patients with IBD will contribute to an increasing pool of 'elderly' IBD patients as they age. The prevalence of IBD is increasing worldwide, with the result that ageing of the population makes IBD in the elderly a growing problem. Recent estimations indicate that approximately 20% of the United States population will be aged over 65 years by the year 2030. At present, 10–15% of patients diagnosed with IBD are aged >60 years. Of these, 65% present in their 60s, 25% in their 70s and 10% in their 80s. Consequently, the number of elderly patients with IBD is expected to grow.
Caring for older IBD patients who have either presented later in life or have had IBD for several decades presents the physician with unique challenges. The characteristics of IBD in the elderly remain uncertain because data are scarce at the population level and come mainly from referral centers. Moreover, data from clinical trials cannot be extrapolated to this population, as older patients are excluded in the vast majority. Other recent trials did not set an upper age limit for eligibility, but the median age in most was the fourth decade.
Since it was first reported in 1935, late-onset IBD has attracted much interest among clinical investigators. Despite advances in our knowledge of IBD, controversy remains concerning the epidemiology, clinical presentation, diagnosis, clinical course and management of IBD in the elderly. Management of late-onset IBD is complex because of problems with misdiagnosis, treatment of comorbid diseases, multiple drug interactions, impaired mobility and cognition, and difficult social and financial issues.
The aging population has a huge impact on the costs of health care delivery. For example, in Canada in 2005, individuals aged over 65 years accounted for 14% of the population, but 60% of all acute care service spending. It is therefore important to study and optimize health care delivery to the elderly.
Elderly patients with IBD can be divided into two groups: elderly patients with onset of IBD at a late age (late-onset IBD); and elderly patients with long-standing IBD, that is, those who had first been diagnosed as having IBD at a younger age (long-standing IBD). Most authors make no distinction between the age within each of the groups, although this, as will be reviewed, may be clinically relevant.
Managing Your Care
Studies suggest that the course and recommended treatment of IBD on its own does not vary greatly from that of a younger patient. However, a patient’s overall health at the time of diagnosis plays a large role in determining both how the disease affects him or her and how aggressively the physician may treat the disease.
The length of time between initial symptoms and diagnosis may be longer for older adults than for younger patients for various reasons. These include the fact that IBD presents with different symptoms in older patients than in younger ones, and a patient’s physician must rule out other possible diseases. Should this lead to more serious symptoms or complications, a patient may require more aggressive treatment.
In addition, while the nature of a patient’s response and tolerance for specific IBD medications is not that much different than in a younger patient, response time to the medications may not be as quick. This is important for a patient’s physician to consider when determining course of treatment.
Finally, special considerations must be taken into account, such as a patient’s ability to live independently, other diseases or illnesses that require attention, and the medications the patient is taking for these other conditions. For example, biologic therapy, which is one of many treatments for IBD, may have adverse affects if a patient has congestive heart failure, or if used with certain medications, such as some for rheumatoid arthritis because they may increase the risk for infection. It is increasingly important that patients discuss their medical needs with their healthcare professionals, closely monitor the progression of their disease, and make preparations for unforeseen issues.
Here is a broad, but certainly not complete list of options for patients to consider when developing a plan to take charge of their IBD treatment:
Affording Care: Between co-pays for doctors’ appointments, medications and various testing, and travel expenses for these visits, paying for health care can be costly. It is important to note that:
The new health care legislation prohibits insurance companies from denying coverage based on pre- existing conditions, such as IBD.
The new legislation will also prohibit lifetime caps on all private insurance plans and provide financial assistance for Medicare recipients who are faced with the prescription drug coverage gap, “the doughnut hole.”
Beginning in September 2010, new insurance plans were required to provide a number of preventive services free of charge, including colorectal cancer screenings
At any age, a patient may be eligible for Social Security disability benefits or Supplemental Security Income depending on their disease’s impact on their ability to work and overall financial situation, respectively.
Even if a patient is under the age of 65, he or she may be eligible for Medicare benefits if he or she received Social Security disability benefits for 24 months.
IBD patients may also be eligible for Medicaid coverage.
Many sponsored patient assistance programs exist to assist patients in affording care. If a patient does not have employer-sponsored health insurance and is ineligible for Medicare and/or Medicaid coverage, individual plans are available.
Doctors and Treatment Facilities: The ideal gastroenterologist and his or her affiliated treatment facilities and hospitals are partners with their patients in managing the treatment of the disease. All should provide features such as close proximity, the latest in diagnostic and treatment technologies, and give patients the time and attention they require.
Preventive Care: In addition to regular screenings advised for all seniors, gastroenterologists may recommend more frequent colonoscopies, as individuals with IBD involving the colon have an increased risk of developing colon cancer.
Extra Support: Depending on your health and mobility, IBD patients may require additional help with medical care and everyday tasks. This may alleviate some of the physical and emotional toll the disease takes on a patient’s life.
Alcohol and Smoking: Alcohol and tobacco affect each IBD patient differently. However, its use should be limited because of its potential for making IBD symptoms worse, damaging the patient’s overall health and interfering with medications.
Diet: While there is no specific diet that will make the inflammation associated with IBD better or worse, for any individual, certain foods may worsen symptoms. The patient’s doctor, nurse, or dietitian may outline a diet that meets his or her specific needs. It is important to stick to this plan to ensure your nutritional and caloric needs are met and flares are kept to a minimum.
Hydration: Seniors are less able to withstand dehydration, which may occur with diarrhea. It is advisable for seniors to drink plenty of fluids, even with infrequent diarrhea.
Medication: One of the easiest ways to manage IBD is by regularly taking prescribed medication.
Unfortunately, it’s just as easy to forget. Sticking to a routine, setting reminders, and utilizing pill counters are just a few ways of ensuring the patient gets every dose.
Preventive Treatments: In addition to IBD medications, IBD patients may be taking one or more medications to prevent certain illnesses, such as low-dose aspirin or warfarin following a heart attack. These medications may interact with those for IBD, or worsen IBD symptoms. It is important for patients to tell their doctor about all of the medications they are taking, and alert his or her physician if they suspect a problem.
Journaling: Patients may need to keep a daily journal to write down information on items such as meals and activities, along with specific details regarding each flare he or she experiences. In time, patterns may help the patient and their doctor understand why they happen, and how to avoid them.
Medical Knowledge and Records: It is important for patients to maintain a complete and current file of their medical records and understand of all their diseases for successful disease management. Along with copies of doctor’s notes and laboratory, endoscopy, pathology, and radiology reports, patients should know:
Mind and Body
The public may see IBD as nothing more than a set of physical symptoms, but anyone living with one of these diseases knows that the emotional toll can be even more challenging. IBD patients are at risk for a number of psychological problems, including depression, anxiety, social isolation, and negative self image.
As part of “self-care,” it is important for patients to monitor their emotional state, and reach out for help when times get too tough to handle alone. Remember, the mind and body interact with each other, so managing one without the other is really not managing either at all. Here are some suggestions:
Support Groups: Whether it is online by computer or face-to-face, joining with other IBD patients to share feelings and experiences may help patients validate their emotions and realize they are not alone. CCFA has more then 40 chapters and affiliates nationwide. Find a local support group and other events in your area by visiting http://www.ccfa.org/chapters/
Therapists: When family and friends aren’t enough to help the patient deal with an emotional problem, seeking the help of a therapist isn’t a sign of weakness, but rather one of wisdom and commitment to his or her health.