Older IBD patients missing out on quality care

Older patients with IBD receive a different standard of care than younger patients and are significantly less likely to experience steroid free clinical remission.

A retrospective Melbourne study compared patient care and outcomes in 89 patients >60 years attending the IBD clinic between 2018 and 2019 with 50 adult patients aged 30-45 years.

The older cohort had a longer duration of IBD (16.5 v 13 years; p <0.01) and a higher incidence of comorbidities such as hypertension (38.2% v 0%; p <0.01) and diabetes (21.3% v 6.0%; p <0.03).

The study, published in the Internal Medicine Journal [link here], found older patients had a significantly lower rate of steroid free clinical remission than the younger cohort (65.2% v 80.0%; p=0.049).

There was also a trend for older patients to have more IBD-related hospital admissions during the follow-up period compared to the younger cohort (27.0% v 16.0%; p=0.18).

However, the two cohorts had similar rates of disease complications including need for surgery (26.9% v 24.3%; p=0.63), penetrating complications (11.5% v 5.4%; p=0.42) and anaemia (11.5% v 13.5%; p=0.13).

Corticosteroids, aminosalicylates and azathioprine use were similar in both cohorts.

The older cohort was less likely to be treated with anti-TNF agents such as infliximab (15.7% v 36.0%; p=0.006) and adalimumab (13.5% v 30.0%; p=0.018), though treatment with vedolizumab (5.8% v 6.0%; p=1) and ustekinumab (2.9% v 2.0%; p=1) were similar.

Outpatient preventive care measures were also less likely to be provided to the older patients compared with the younger cohort.

These measures included nutritional assessment and treatment with a dietician (7.9% v 30.0%; p=0.001), questioning about smoking habits (41.6% v 64.0%; p=0.01), skin cancer assessment (21.3% v 34.0%; p=0.10) and influenza vaccinations (19.3% v 42.0%; p=0.006).

“This result stands in contrast with guidelines emphasising the importance of these measures for elderly patients with IBD. Older age is associated with greater need for preventive care, consideration of the safety and efficacy of therapies, and better management of comorbidities.”

Routine investigations such as testing of calcium and vitamin D (42.7% v 68.0%; p = 0.004) as well as a bone mineral density scan (25.8% v 44.0%; p = 0.10) were less frequently tested in the older cohort.

Contact with the specialist IBD nursing staff was also significantly less in the older cohort (43.2% v 76.0%; p < 0.001).

“Across the whole cohort, as well as specifically within the elderly cohort, those with IBD nursing contact were more likely to receive preventative care measures (such as skin cancer assessment and vaccination) than those who did not,” the study said.

It said specialist IBD nurses may be the ideal clinicians to coordinate delivery of preventive care to these patients and provide support to primary care practitioners.

“Better integration of these services may allow gastroenterologists to focus on medical management of IBD.”

“The management of elderly patients with IBD is a challenge that requires a multidisciplinary model of care that includes greater involvement of specialist IBD nurses, considered use of immunomodulators and biologic drugs, and a greater focus on preventive care,” it said.

One of the investigators, Melbourne gastroenterologist Dr Chamara Basnayake, told the limbic that the newer therapies of vedolizumab and ustekinumab were now much more accessible than during the study period.

“I think with those two medications we will be far more comfortable in treating older patients with comorbidities because we wouldn’t be so anxious about them getting cancer among other issues. So we would expect actually the outcomes to be much better now, because we have these two biologics available to us.”

On the issue of preventive care, he said patients sometimes fell through the gaps as gastroenterologists and GPs often expected the other to take the lead.

“So GPs actually think it’s a gastroenterologist’s job to concentrate on preventative care, because I think they’re anxious about these patients having a complex medical condition with immunosuppressants,” he said.

“Maybe we don’t concentrate on this population as well as we should. This is a group with lots of different medications for other reasons, lots of medical comorbidities, and in the soup of medical issues that we have to deal with, we concentrate on that and we don’t have time to concentrate on preventative care when we should.”

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