Crohn's disease initially diagnosed after age 60 years

SIR—Recent studies have explored clinical features of Crohn's disease [ 1–4 ]. Using a database of over 1,000 patients, Crohn's disease was previously observed to be female-predominant, primarily affecting young adults with a high rate of stricturing and/or penetrating complications. Indeed, over 80% had a diagnosis established prior to age 40 years and less than 5% were diagnosed after age 60 years. Prior retrospective studies described the clinical features of Crohn's disease in the elderly, although in some, elderly was defined as over age 50 years, or even age 40 years, and patient numbers were limited [ 5–8 ]. Even in Crohn's own experience of 530 patients, only 7 were seen after age 60 years [ 8 ]. Moreover, an elderly cohort might not be entirely reflective if initially diagnosed before age 60 years. The present study explored the location and behaviour of Crohn's disease using the Vienna method [ 9 ] applied to elderly patients diagnosed after age 60 years. All patients were derived from an established database [ 1–4 ] defined as elderly onset if a diagnosis was established after age 60 years with at least 2 years of follow-up data, and referred by British Columbia family physicians from 1979 to 2003, inclusive. Diagnosis of Crohn's disease was based on the criteria of Lennard–Jones [ 10 ]. Patients were classified using the Vienna method [ 9 ]. Specific features used to define each patient included: disease location defined as the maximal extent of disease, or disease at first resection (i.e. L1, ileum, possibly involving cecum; L2, colon; L3, ileocolon; L4, upper gastrointestinal tract regardless of other disease sites); and, disease behaviour (eg. B1, non-stricturing and non-penetrating; B2, structuring; B3 penetrating). In the Vienna method, the disease is defined as B3 if, at any time, intra-abdominal or perianal fistula, perianal ulceration, inflammatory mass and/or abscess have developed, even if a co-existing stricture is present. Definition of disease behaviour in the Vienna method has no specific time limit [ 9 ] and was defined in a cumulative fashion at the most recent patient encounter. Statistical analyses were done using Fisher's exact test. There were 43 patients (i.e. 19 males, or 44.2%). The duration of follow-up was at least 6 years or more for almost 50%, with a mean of 6.2 years (males, 5.2 years; females, 7.0 years). These either exceed or are similar to the recorded follow-up for more limited numbers of elderly-onset cohorts reported in other studies [ 5–8 ]. Most were diagnosed between 60 and 69 years (i.e. 12 of 19 males, and 15 of 24 females), and for each decade, the population was female-predominant, possibly reflecting the female-predominance of this age group in the general Canadian population. Age at diagnosis for males ranged from 60 to 86 years (median, 68 years; mean, 69.2 years), while females ranged in age from 60 to 82 years (median, 68 years; mean, 68.8 years). Oldest age at initial diagnosis for males was 86 years, and females 83 years, both less than the highest recorded age of 92 years in Crohn's disease. These results are consistent with the female-predominant pattern of Crohn's disease reported from other North American or European centres [ 5–8 ]. Most had colonic involvement alone (18 of 43, or 41.9%) rather than involvement of the ileum alone (13 of 43, or 30.2%) or combined ileocolonic disease (10 of 43, or 23.2%) ( P < 0.05). Most females had ileocolonic disease (8 of 24, or 33%) or disease localised to the ileum or colon alone (7 of 24 each, or 29.2%). In contrast, most males had disease localised in the colon (11 of 19, or 57.9%), although ileal involvement (6 of 19, or 31.6%) or combined ileocolonic disease was also present (2 of 19, or 10.5%). This disease pattern in males was significant ( P < 0.05). In addition, colonic involvement occurred more often in males than females ( P < 0.05). Upper tract disease was detected in only 2 females, both with concomitant ileal involvement. One female also had jejunal involvement with strictures while the other had stenosing disease in both oesophagus and duodenum. No male had upper tract disease. Most patients had complex disease (28 of 43, or 65.1%) that could be defined as either stricturing (19 of 43, or 44.2%) or penetrating type (9 of 43, or 20.9%) while ‘inflammatory’ or B3 disease was present in 15 of 43, or 34.9% ( P < 0.05). Females had more complex disease (i.e. 18 of 24, or 75%; P < 0.05) as reflected in the development of either the stricturing (i.e. stenosing) (i.e. 12 of 24, or 50%) or penetrating (i.e. perforating) complications (i.e. 6 of 24, or 25%) compared to B3 disease type (i.e. 6 of 24, or 25%). Although more males (i.e. 10 of 19, or 52.6%) also had complex disease, a higher percentage of males (i.e. 9 of 19, or 47.4%) compared to females (i.e. 6 of 24, or 25%) had ‘inflammatory’ or B3 disease. Comparisons between the overall database and elderly-onset Crohn's disease for disease location and behaviour were based on the Vienna method [ 9 ]. More colonic disease (41.9 versus 27.2%) and less upper tract disease (4.7 versus 13.1%) were detected in the elderly-onset population ( P < 0.05). In addition, this group had more structuring (44.2 versus 33.6%) and less penetrating (20.9 versus 37.2%) disease complications. Prior studies on Crohn's disease noted that the initial diagnosis was made after age 40 years in about 15% [ 1 ]. The present report now focuses on an elderly cohort first diagnosed with Crohn's disease after age 60 years. Although less than 5% of the entire Crohn's disease database, a female-predominant pattern emerged, similar to the entire database with adults diagnosed before age 40 years [ 1 ]. These findings in a prospectively accumulated Canadian population are consistent with older retrospective American studies showing a female-predominant pattern [ 7 ]. Disease was localised mainly in the colon, particularly in males, with less upper gastrointestinal tract involvement. These findings suggest that Crohn's disease in the elderly is a far less extensive inflammatory disease process, especially compared to pediatric patients where the disease appears to be more clinically aggressive and extensive [ 3 , 4 ]. Moreover, the findings here confirm important observations in an earlier report by Fabricius et al. [ 6 ] showing less extensive disease. Additional studies are needed to determine if ageing per se has a direct effect on the extent of involvement with this complex inflammatory process in Crohn's disease as well as the role of ageing in the localisation of the disease to different sites along the length of the gastrointestinal tract. In this elderly cohort, disease behaviour could often be classified as ‘inflammatory’ (non-stenosing, non-penetrating) disease, rather than more complex with stricturing or penetrating complications. Moreover, this phenotypic expression of disease behaviour may be, in part, sex-dependent as more elderly males were defined with inflammatory disease, compared to elderly females. Complex disease was seen in both sexes, and most often, stenosing, rather than penetrating, complications developed. This is not entirely surprising since our prior long-term studies on the natural history of Crohn's disease in those followed for over two decades from the same database indicated that the number of patients with penetrating disease complications accumulates with time as the period of follow-up is prolonged [ 2 ]. Further studies are needed to explore the effects of ageing on this heterogeneous inflammatory process in Crohn's disease along with possible age-dependent effects on its phenotypic expression. Crohn's disease initially diagnosed in the elderly occurs in a female-predominant population. The inflammatory process was limited, often only involving the colon rather than more extensive parts of the gastrointestinal tract. The disease behaviour could be classified as ‘inflammatory’ in type, rather than being more complex with strictures or penetrating complications. Phenotypic expression of the clinical features in Crohn's disease may be related to the ageing process. There are no conflicts of interest. There are no sources of funding for this work.

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