Clinical characteristics and treatment patterns of older and younger patients with inflammatory bowel disease

Abstract

BACKGROUND

Inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD), presents varying clinical characteristics depending on the age at disease onset. With the aging global population, understanding the differences in the presentation and management of older-onset and younger-onset IBD has become increasingly important for optimizing patient care.

AIM

To evaluate the demographic characteristics of and treatment strategies for older and younger adult patients with IBD.

METHODS

A retrospective cohort analysis was conducted on adult patients diagnosed with IBD between June 1993 and February 2023. Demographic, clinical, and therapeutic data were compared between patients with an older onset (≥ 60 years) and younger onset (18-60 years) of UC and CD.

RESULTS

A total of 1245 patients were included, of whom 56 (4.5%) had older-onset disease and 1189 (95.5%) had younger-onset disease. The median follow-up duration was 11 years. UC was more prevalent in the older-onset group (69.6% vs 48.7%, P = 0.002). Biological therapy was used less frequently in older-onset patients (26.8% vs 49.3%, P = 0.001). No significant differences in the extent of UC, CD location or behavior, or perianal involvement were detected between the groups. Smoking and a family history of IBD were more common among patients with a younger age at onset. Extraintestinal manifestations (EIMs) were less frequent in patients with an older age at onset (32.1% vs 51%, P = 0.006). Baseline disease activity scores were similar between groups. Thiopurine use was higher in younger patients (32.9% vs 16.1%, P = 0.008).

CONCLUSION

IBD patients with an older age at onset exhibit distinct demographic and therapeutic characteristics, particularly a lower frequency of EIMs and decreased utilization of immunosuppressive and biological therapies. This conservative approach likely reflects clinical precautions against treatment-related adverse events in elderly individuals; however, it highlights an urgent clinical need for age-specific guidelines to ensure that these patients receive adequate and safe disease management without compromising long-term outcomes.

Key Words: Inflammatory bowel disease; Ulcerative colitis; Crohn disease; Age at onset; Biological therapy

Core Tip: This retrospective cohort study highlights significant differences in the clinical presentation and management of patients with older-onset vs younger-onset inflammatory bowel disease. Our findings reveal that elderly patients present with fewer extraintestinal manifestations. Notably, older patients receive far fewer immunosuppressive and biological therapies than younger patients do, reflecting a conservative clinical approach likely driven by age-related safety concerns. These results emphasize the urgent clinical need for age-specific management guidelines to ensure that elderly patients receive adequate and safe therapies without compromising long-term outcomes.

INTRODUCTION

Inflammatory bowel disease (IBD), comprising Crohn’s disease (CD) and ulcerative colitis (UC), is a chronic inflammatory condition of the gastrointestinal tract with an uncertain etiology and is often linked to genetic predispositions, environmental influences, and irregular immune responses to the gut microbiota[1]. As the global population ages, the incidence of older-onset IBD is expected to increase significantly, alongside increases in incidence across all age groups, including both children and elderly individuals[2]. The phenotype and progression of IBD appear to vary based on the age at disease onset. Early in the disease course, severe episodes are more common, indicating that patients with an older age at onset might necessitate tailored management approaches to account for age-associated physiological alterations and differences in treatment tolerance[3]. However, many existing studies fail to clearly delineate between these age groups, with conflicting findings regarding the severity of disease progression in patients with older-onset IBD[4,5]. While some studies suggest milder disease progression in older individuals, others highlight worse outcomes or more aggressive complications[6]. With increasing reliance on early therapeutic interventions such as biologics or combination therapies, understanding age-specific disease progression is critical. Older patients often exhibit reduced tolerance to immunosuppressive regimens because of their increased vulnerability to infections and malignancies, necessitating a balance between the potential risks of aggressive treatment and the benefits of disease control[7,8]. Further investigations into the demographic, clinical, and therapeutic characteristics of patients with older-onset IBD are essential to develop tailored treatment protocols that align with their unique needs. The primary objective of this retrospective cohort study was to investigate the differences in demographic characteristics, clinical manifestations, and treatment patterns between patients with older-onset and younger-onset IBD. We hypothesize that patients with an older age at onset present with a distinct disease phenotype but receive more conservative medical therapies because of age-related safety concerns.

MATERIALS AND METHODS

Study population

This retrospective analysis included data from patients diagnosed with UC or CD at a tertiary referral center between June 1993 and February 2023. Patients were eligible for inclusion if they had a confirmed diagnosis of UC or CD and were 18 years or older at the time of the diagnosis. Patients with indeterminate colitis were excluded from this study because of the limited number of patients in this group.

Variables

In this study, demographic and IBD characteristics, including age, sex, weight, height, prodromal time, type of disease, disease duration, extraintestinal manifestations (EIMs), current and previous IBD medications, IBD-related hospitalization, and previous IBD-related surgery, were collected from the electronic medical records. Disease behavior and location were classified according to the Montreal classification to ensure consistency across data points. Clinical disease activity was measured using the partial Mayo score for UC and the Crohn’s Disease Activity Index (CDAI) for CD. Laboratory values [hemoglobin, albumin, and C-reactive protein (CRP) levels] were extracted from the electronic medical records if tests had been performed within three months of the baseline assessment. Patients with substantially incomplete medical records or missing key demographic data were excluded from the final analysis to ensure the integrity of the data. Furthermore, because the study period spanned 30 years (1993-2023), we must acknowledge that evolving treatment paradigms—particularly the introduction and increasing use of biological agents in the past two decades—may have historically influenced the overall therapeutic strategies used in this cohort.

Outcomes

The aim of this study was to investigate the differences between UC and CD in terms of disease behavior, site of involvement, prodromal period, change in disease type according to sex, need for hospitalization, history of surgery, EIMs, choice of medical treatment, and use of biological agents in older and younger patients. This study did not include patients under the age of 18 years. Patients were categorized into two groups based on age: Younger-onset (18-60 years) and older-onset (≥ 60 years) groups.

Ethical considerations

This retrospective study was approved by the Ethics Committee of Ankara Bilkent City Hospital (No. E2-24-6116), and no conflicts of interest or sponsors of this analysis existed. The requirement for written informed consent was waived because of the retrospective design of this study and the use of anonymized data, as approved by the Ethics Committee.

Statistical analysis

Descriptive statistics are shown as n (%) for qualitative data. For quantitative data, the means and standard deviations are reported for normally distributed data, and medians and minimum-maximum values (interquartile ranges) are reported for nonnormally distributed data. Intergroup comparisons of categorical variables were performed using Pearson’s χ² test or Fisher’s exact test. The normality of continuous variables was assessed using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Since the assumption of a normal distribution was not fulfilled for the analyzed variables, the Mann-Whitney U test was used to compare continuous variables between two independent groups. The type 1 margin of error (α) was accepted as 0.05 for all the statistics. SPSS version 29.0 was used to analyze the data. Missing data were assessed for all variables included in the analysis. Cases with substantial missing key variables were excluded from the study. No imputation methods were applied.

RESULTS

Patient characteristics

A total of 1245 adult patients with IBD were included, of whom 56 (4.5%) had older-onset disease and 1189 (95.5%) had younger-onset disease. The median follow-up duration was 11 years. UC was more prevalent in the older-onset group (69.6% vs 48.7%, OR = 2.42, 95%CI: 1.35-4.32, P = 0.002).

Patients with older-onset disease had a shorter disease duration but similar prodromal time. Smoking and family history of IBD were less common in the older-onset group. No significant differences were observed in sex distribution, prior surgery, or hospitalization rates between groups.

Disease extent, localization, and behavior

No significant differences were observed in UC extent or CD behavior between the groups. However, a higher frequency of ileal involvement (L1) was noted in older-onset CD (OR = 1.49, 95%CI: 1.10-2.10, P = 0.005).

EIMs

EIMs were significantly less frequent in older-onset patients (32.1% vs 51%, OR = 0.46, 95%CI: 0.26-0.81, P = 0.006). Peripheral arthralgia was the most common manifestation in both groups. Detailed distributions of EIMs are provided in Table 1.

Table 1 Demographic characteristics of adult nongeriatric and geriatric patients with inflammatory bowel disease.

	Total, n = 1245			UC, n = 618			CD, n = 627
	Older-onset, n = 56	Younger-onset, n = 1189	P value/OR (95%CI)	Older-onset UC, n = 39	Younger-onset UC, n = 579	P value/OR (95%CI)	Older-onset CD, n = 17	Younger-onset CD, n = 610	P value/OR (95%CI)
Age at the onset of IBD (median year)	71.5	46	< 0.001	72	49	< 0.001	71	43	< 0.001
Total disease duration (median year)	6	11	< 0.001	6	12	< 0.001	6	11	< 0.001
Prodromal period (median month)	3	4	0.687	2	1	0.247	7	11	0.976
Female/male	15 (27)/41 (73)	464 (42)/725 (58)	0.066	8 (21)/31 (79)	215 (37)/364 (63)	0.036	7 (41)/10 (59)	249 (41)/361 (59)	0.036
Smokers (current/ex/non)	6 (10)/29 (52)/21 (38)	277 (23)/368 (31)/544 (46)	0.003	4 (10)/20 (51)/15 (39)	75 (13)/206 (36)/298 (51)	0.143	2 (12)/9 (53)/6 (35)	202 (33)/162 (27)/246 (40)	0.04
Family history of IBD	2 (4)	155 (13)	0.03/0.25 (0.06-1.01)	1 (2.6)	80 (13.8)	0.044	1 (5.9)	75 (12.3)	0.708
Surgery during follow-up	20 (35.7)	464 (39)	0.619	8 (20.5)	89 (15.4)	0.393	12 (70.6)	375 (61.5)	0.446
Hospitalized at the time of diagnosis	13 (23.2)	422 (35.5)	0.060	5 (12.8)	142 (24.5)	0.097	8 (47.1)	280 (45.9)	0.925
Hospitalized for conditions related to IBD	23 (41.1)	571 (48)	0.309	14 (35.9)	184 (31.8)	0.594	9 (52.9)	387 (63.4)	0.376
BMI (kg/m2)	25	24	0.109	24.5	25	0.663	29	23	0.016
UC/CD	39 (69.6)/17 (30.4)	579 (48.7)/610 (51.3)	0.002/2.42 (1.35-4.32)	-	-	-	-	-	-
UC (disease extent)
Proctitis	6 (15.4)	53 (9.2)	0.414	6 (15.4)	53 (9.2)	0.414	-	-	-
Left side	17 (43.6)	288 (49.7)		17 (43.6)	288 (49.7)		-	-	-
Extensive	16 (41)	238 (41.1)		16 (41)	238 (41.1)		-	-	-
CD (disease location)
Ileal (L1)	9 (52.9)	260 (42.9)	0.005	-	-	-	9 (52.9)	260 (42.9)	0.005/1.49 (1.10-2.10)
Colonic (L2)	1 (5.9)	81 (13.1)		-	-	-	1 (5.9)	81 (13.1)
Ileo-colonic (L3)	5 (29.4)	267 (43.4)		-	-	-	5 (29.4)	267 (43.4)
Upper GI disease (L4)	2 (11.8)	2 (0.6)		-	-	-	2 (11.8)	2 (0.6)
CD (disease behavior)						-
Inflammatory disease (B1)	12 (70.6)	457 (74.8)	0.065	-	-	-	12 (70.6)	457 (74.8)	0.065
Stenosing (B2)	4 (23.5)	49 (8.5)		-	-	-	4 (23.5)	49 (8.5)
Penetrating (B3)	1 (5.9)	104 (16.7)		-	-	-	1 (5.9)	104 (16.7)
CD P (perianal disease)	3 (17.6)	202 (32.7)	0.180	-	-	-	3 (17.6)	202 (32.7)	0.180
EIMs	18 (32.1)	606 (51)	0.006/0.46 (0.26-0.81)	12 (30.8)	272 (47)	0.04/0.50 (0.25-1.02)	6 (35.3)	334 (54.8)	0.112
Erythema nodosum	0	27	0.630	0	11	1.0	0	16	1.0
Pyoderma gangrenous	0	9	1.0	0	3	1.0	0	6	1.0
Peripheral arthralgia	10	380	0.026	6	168	0.067	4	212	0.337
Peripheral arthritis	0	107	0.012	0	36	0.157	0	71	0.241
Back pain	9	201	0.871	5	82	0.816	4	119	0.756
Ankylosing spondylitis	1	68	0.363	1	27	1.0	0	41	0.619
Sacroiliitis	0	31	0.396	0	10	1.0	0	21	1.0
Aphthous ulcer	4	238	0.017	2	122 g	0.016/0.20 (0.05-0.86)	2	116	0.752
Thromboembolism	0	31	0.396	0	15	0.615	0	16	1.0
Osteoporosis	2	19	0.243	2	7	0.105	0	12	1.0
PSC	2	19	0.243	2	7	0.105	0	12	1.0
Uveitis	0	16	1.0	0	6	1.0	0	10	1.0
Episcleritis	0	5		0	2	1.0	0	3	1.0
Medications (conventional)
Thiopurine	9 (16.1)	391 (32.9)	0.008/0.39 (0.19-0.81)	7 (17.9)	100 (17.3)	0.914	2 (11.8)	291 (47.7)	0.003/0.08 (0.01-0.41)
Methotrexate	0	51 (4.3)	0.165	0	5 (0.9)	1.0	0	46 (7.5)	0.628
Sulfasalazine	0	53 (4.5)	0.167	0	10 (1.7)	1.0	0	43 (7)	0.622
Mesalazine	10 (17.9)	407 (34.2)	0.011	8 (20.5)	122 (21.1)	0.934	2 (11.8)	285 (46.7)	0.004
Budesonide	11 (19.6)	324 (27.2)	0.210	9 (23.1)	114 (19.7)	1.0	2 (11.8)	210 (34.4)	0.243
Steroids	0	75 (6.3)	0.044	0	2 (0.3)	0.608	0	73 (12)	0.051
Cyclosporin	1 (1.8)	1 (0.1)	0.088	0	0	0.914	0	0	-
Biological therapy	15 (26.8)	586 (49.3)	0.001/0.38 (0.21-0.69)	11 (28.2)	157 (27.1)	0.882	4 (23.5)	429 (70.3)	< 0.001/0.13 (0.04-0.40)
Infliximab	9 (16.1)	365 (30.7)	0.02/0.43 (0.20-0.90)	6 (15.4)	99 (17.1)	0.783	3 (17.6)	266 (43.6)	0.033/0.28 (0.08-0.97)
Adalimumab	6 (10.7)	384 (32.8)	< 0.001/0.25 (0.11-0.59)	4 (10.3)	93 (16.1)	0.335	2 (11.8)	291 (47.7)	0.003/0.15 (0.03-0.64)
Vedolizumab	6 (10.7)	111 (9.3)	0.730	6 (15.4)	36 (6.2)	0.041/2.74 (1.08-6.97)	0	75 (12.3)	0.246
Ustekinumab	1 (1.8)	81 (6.8)	0.173	1 (2.6)	13 (2.2)	0.603	0	69 (11.1)	0.240
Sertolizumab	0	31 (2.6)	0.396	0	3 (0.5)	1.0	0	28 (4.6)	1.0
Steroid dependence	21 (37.5)	532 (44.7)	0.286	1 (2.6)	6 (1)	0.649	5 (29.4)	306 (50.2)	0.091
Steroid resistance	4 (7.1)	30 (2.5)	0.062	4 (10.3)	16 (2.8)	0.032	0	14 (2.3)	1.0
IM resistance	8 (14.3)	409 (34.4)	0.002/0.32 (0.15-0.68)	4 (10.3)	99 (17.1)	0.267	4 (23.5)	310 (50.8)	0.026/0.30 (0.10-0.90)
Thiopurine side effects	7 (12.5)	141 (11.9)	0.885	4 (10.3)	43 (7.4)	0.527	3 (17.6)	98 (16.1)	0.745
Methotrexate side effects	2 (3.6)	44 (3.7)	1.0	0	2 (0.3)	1.0	0	42 (6.9)	0.338
Biologic resistance/intolerance	0	15 (3)	1.0	0	6 (1)	1.0	0	9 (1.5)	0.377
Baseline Hb concentration (mg/L)	12.6 (2.3)	13 (2.8)	0.332	13 (2.1)	12.9 (2.9)	0.571	12.4 (2.3)	13 (2.8)	0.445
Baseline albumin concentration (g/L)	41 (8.75)	42 (9)	0.574	41 (11)	43 (8)	0.093	42 (10)	41 (-)	0.701
Baseline CRP level (mg/L)	11.4 (28.7)	10.2 (26.9)	0.722	4.8 (30.6)	9.1 (24.3)	0.491	17.3 (23)	11.7 (31)	0.724
Baseline CDAI (CD)	302 (277)	297 (179)	0.728			-	302 (277)	297 (178)	0.377
Baseline total Mayo score	9 (3)	9 (4)	0.847	9 (3)	9 (4)	0.800	-	9.3 2.4	-
Baseline partial Mayo score	7 (2)	7 (2)	0.710	7 (2)	7(2)	0.730	-	6.7 1.8	-

Data are presented as mean ± SD, median (interquartile range), or n (%), unless otherwise stated. IBD: Inflammatory bowel disease; UC: Ulcerative colitis; CD: Crohn’s disease; BMI: Body mass index; GI: Gastrointestinal; EIMs: Extraintestinal manifestations; PSC: Primary sclerosing cholangitis; IM: Immunomodulator; Hb: Hemoglobin; CRP: C-reactive protein; CDAI: Crohn’s Disease Activity Index.

Medical treatments

Conventional therapies were widely used in both groups; however, thiopurine use was significantly lower in older-onset patients (16.1% vs 32.9%, OR = 0.39, 95%CI: 0.19-0.81, P = 0.008). Biological therapy was also less frequently administered in the older-onset group (26.8% vs 49.3%, OR = 0.38, 95%CI: 0.21-0.69, P = 0.001). Among biologics, infliximab and adalimumab were the most commonly used agents in both groups.

No significant differences were observed between the older and younger groups in terms of the overall need for surgery during follow-up (18.2% vs 9.9%, OR = 2.02, 95%CI: 0.42-9.66, P = 0.306) or the development of steroid dependence (38.2% vs 44.1%, OR = 0.78, 95%CI: 0.45-1.36, P = 0.407). Notably, the incidence of steroid resistance tended to increase in the elderly cohort (7.1% vs 2.4%, OR = 3.11, P = 0.056).

Immunomodulator resistance was significantly lower in older-onset CD compared with younger-onset patients (23.5% vs 50.8%, P = 0.026). No significant difference was observed between the groups in terms of immunomodulator-related adverse effects.

Disease severity and baseline laboratory tests

Baseline disease activity scores (CDAI and Mayo scores) and laboratory parameters (hemoglobin, albumin, and CRP levels) were comparable between the older- and younger-onset groups. All results are summarized in Table 1.

DISCUSSION

This study provides a comprehensive comparison of clinical characteristics and treatment patterns between older-onset and younger-onset patients with IBD. The key findings indicate that patients with older-onset disease exhibit distinct demographic features, fewer EIMs, and significantly lower use of immunomodulators and biological therapies, despite having similar baseline disease activity and comparable clinical outcomes.

The literature reveals variations in the epidemiology of IBD, with some studies reporting no significant differences in incidence, while others report that either UC or CD is more prevalent among the elderly population[9,10]. Our study revealed a higher prevalence of UC among patients with an older age at onset than among patients with a younger age at onset. This finding is consistent with the literature indicating that UC is more common in older adults[11], possibly because of the cumulative effects of environmental factors and improved diagnostic techniques over time.

The sex distribution showed a higher proportion of male patients in both the older-onset and younger-onset groups, consistent with global patterns of IBD epidemiology. The higher incidence of UC in older-onset patients may reflect cumulative environmental exposures, diagnostic delays, or age-related immune changes. The relationship between smoking and IBD has been studied for a long time, and it has been shown to exert different effects on both CD and UC[12-14]. A significantly lower prevalence of active smokers was observed among patients with older-onset CD than among their younger counterparts. This difference may reflect age-related cessation trends or a protective effect on CD development in older individuals who quit smoking. Additionally, this study revealed a significantly lower family history of IBD among patients with an older age at onset. The reduced family history of IBD in patients with an older age at onset suggests that environmental factors might play a more dominant role in disease onset than genetic factors[15]. Patients with older-onset IBD exhibit distinct clinical presentations and complications[16,17]. Our study did not show significant differences in the extent of the disease between patients with older-onset and younger-onset UC. Conversely, patients with older-onset CD were more likely to exhibit ileal disease and nonpenetrating, nonstenosing disease behavior. These findings emphasize the need for tailored diagnostic and therapeutic approaches based on the age at onset. EIMs are common in patients with IBD, affecting a significant portion of patients with both CD and UC. These manifestations often involve systems such as the musculoskeletal, dermatological, hepatobiliary, and ocular systems, leading to complications that can impact patients’ quality of life even beyond their intestinal symptoms. The prevalence and presentation of EIMs can vary based on the age at onset, disease type, and geographical factors. EIMs are more frequently observed in younger patients with IBD, with peripheral arthritis, ankylosing spondylitis, and primary sclerosing cholangitis being relatively common. However, studies suggest that patients with older-onset IBD generally exhibit a lower frequency of EIMs. This reduction could be attributed to age-related changes in the immune system, such as immunosenescence, which potentially leads to a less active systemic immune response in older patients. Additionally, different disease courses and treatment approaches for older individuals may influence the occurrence of these manifestations[18]. This study revealed that while EIMs remain a notable aspect of IBD, their frequency is somewhat lower in patients with older-onset disease than in their younger counterparts. These observations are consistent with those of other studies suggesting that the immune response in older adults may lead to fewer systemic complications, thus reducing the risk of developing EIMs. These data emphasize the importance of a tailored clinical approach for older patients with IBD that considers not only intestinal symptoms but also the lower risk and different profile of EIMs. Recognizing these age-related differences can aid clinicians in better managing older patients by prioritizing intestinal health while carefully monitoring for potential but less frequent EIMs. Our results indicated that elderly patients had significantly fewer peripheral joint manifestations (32.1% vs 51%). However, these findings must be interpreted with caution because of potential diagnostic bias: While joint pain in younger patients is readily attributed to EIMs of IBD, similar symptoms in elderly patients are frequently misdiagnosed as osteoarthritis or age-related degenerative changes, leading to underreporting. Furthermore, the significantly lower use of immunomodulators and biologics in the older-onset group raises the critical question of whether this difference stems from reasonable medical precaution against infections and malignancies or if it represents insufficient treatment. Without key data on the long-term prognosis and efficacy of these conservative strategies, fully verifying the rationality of current age-specific management remains challenging.

The treatment landscape for older-onset IBD differs substantially from that of younger patients, largely due to concerns regarding treatment-related risks[7]. One of the most clinically relevant findings of this study is the markedly lower use of immunomodulators and biological therapies in patients with older-onset IBD. This difference likely reflects a multifactorial decision-making process rather than a single underlying cause. In routine clinical practice, elderly patients often present with multiple comorbidities, polypharmacy, and increased susceptibility to infections and malignancies, all of which may influence treatment selection. In addition, factors such as frailty, reduced physiological reserve, and shorter life expectancy may lead clinicians to adopt a more conservative therapeutic approach. Importantly, this pattern may represent appropriate risk-based clinical decision-making rather than undertreatment. However, due to the lack of detailed data on comorbidities, frailty status, and physician or patient preferences, the exact drivers of this therapeutic difference cannot be fully determined in the present study.

Despite these differences, our results showed that mesalamine remained the most frequently used conventional therapy for UC across all age groups, with no significant difference between the cohorts (20.5% vs 21.1%, P = 1.0). This underscores its established role as a mainstay of treatment in managing UC, regardless of the age at onset[19]. Furthermore, in terms of long-term outcomes, our study showed that hospitalization rates related to IBD were comparable between older and younger patients, despite the more conservative treatment approach in the elderly cohort. Notably, despite the lower use of immunosuppressive and biological therapies in the older-onset group, no significant differences were observed in hospitalization rates, surgical interventions, or steroid dependence. This finding suggests that a more conservative treatment strategy in elderly patients may not necessarily lead to worse short- to mid-term clinical outcomes. The widespread use of mesalamine across all age groups underscores its safety profile and established role in maintaining remission, particularly in UC. These findings indicate that older-onset IBD patients require different clinical approaches to balance the benefits of aggressive treatment against the risks of adverse effects. The necessity for age-specific guidelines and more extensive clinical trials, including older patients, is paramount to better understand the safety and efficacy of various treatment modalities in this group. Future research should focus on longitudinal studies to assess the long-term impact of different treatment approaches in older adults with IBD.

This study has several limitations that should be explicitly acknowledged. First, the single-center, retrospective design introduces inherent selection bias and limits our ability to make definitive causal inferences. Second, relying on medical records spanning up to 30 years means that the accuracy of the data depends strongly on the completeness of historical documentation; subjective symptoms or social habits (e.g., smoking quantity) might have been underreported or inconsistently recorded. Third, a detailed analysis of crucial confounding factors, such as age-related comorbidities (e.g., Charlson Comorbidity Index), medication safety profiles, adverse drug reactions, and long-term clinical outcomes, such as surgical resection rates or steroid dependence, is lacking. Without these findings, determining whether the lower use of biologicals in elderly individuals is due to reasonable clinical precautions against comorbidities or simply insufficient treatment remains challenging. Fourth, we were unable to evaluate the quality of life and functional status (e.g., frailty), which are of paramount significance when managing IBD in the aging population. Another important limitation is the lack of comprehensive data on treatment-related adverse events, particularly for biological therapies. Although immunomodulator-related side effects were recorded, the absence of detailed safety and drug retention data for biologics restricts the ability to fully evaluate the risk-benefit balance of these treatments in elderly patients. Finally, the relatively small sample size of the older-onset group (n = 56) reduces the statistical power and may limit the interpretation of true clinical differences in specific subgroups. Therefore, the observed differences in treatment patterns should be interpreted with caution, as they may reflect appropriate clinical adaptation to patient-specific risks rather than suboptimal care.

CONCLUSION

This study highlights significant differences in the demographics, disease characteristics, and treatment patterns between patients with older-onset and younger-onset IBD. Patients with an older age at onset present unique challenges, including a higher prevalence of UC, lower rates of a family history and smoking, distinct disease behaviors, and reduced usage of aggressive treatments such as thiopurines and biologics. These findings emphasize the need for tailored clinical approaches and age-specific guidelines to optimize the care and outcomes for patients with older-onset IBD. Further research and the inclusion of older patients in clinical trials are essential to develop effective treatment strategies and improve the quality of life of this population. By understanding and addressing the unique needs of patients with older-onset IBD, health care providers can ensure comprehensive and effective management of this increasingly prevalent group.

ACKNOWLEDGEMENTS

We would like to express our sincere gratitude to Dr. Hanife Uzar for her valuable assistance with the statistical analyses conducted in this study.