Elderly Adults with Late‐Onset Ulcerative Colitis Tend to Have Atypical, Milder Initial Clinical Presentations but Higher Surgical Rates and Mortality: A Taiwan Society of Inflammatory Bowel Disease Study

To the Editor: There is considerable controversy over the clinical presentation and prognosis of ulcerative colitis (UC) in elderly adults. An earlier study found a prevalence of left colitis over extensive forms,1 whereas the latest studies show that proctitis and left-sided UC are more common in elderly adults.2, 3 Some studies suggest that there is no association between mortality and age,4 whereas others have found greater risk of death in elderly adults.5 Moreover, most of these studies are from Western countries. Because the aging population and the incidence and prevalence of inflammatory bowel disease have recently begun to increase rapidly in Taiwan,6 this multicenter study was conducted to examine the clinical features and outcomes of UC in older adults in Taiwan. This was a retrospective study conducted at seven medical centers in Taiwan and included clinical data from 1991 to 2014. Late-onset UC was defined as onset of UC after the age of 60. Demographic characteristics, UC-related medication use, extent of disease, severity at diagnosis, greatest severity during the disease course, disease outcomes (hospitalizations for colitis flares, surgery, death) were recorded and analyzed. UC location was classified using the Montreal Classification System,7 and clinical severity was categorized using the modified Truelove and Witts Severity Index.8 T-tests were two-tailed, and P < .05 indicated statistical significance. Five hundred thirty-six individual with UC were identified, 14.4% (n = 77) had late-onset UC. The most common age for UC onset was the fourth decade, and no bimodal distribution was shown in this cohort. There was a difference in clinical presentation between individuals with early- and late-onset UC. Individuals with early-onset UC tended to present with the typical symptoms of UC, such as diarrhea (P = .03) and abdominal pain (P = .04) (Table 1), but the group with late-onset UC had less-typical symptoms, such as constipation (P = .001) and fever (P = .006). Diagnosis took significantly longer for individuals with late-onset UC (2.2 ± 4.5 years) than for those with early-onset UC (0.4 ± 0.8 years) (P < .001). The group with early-onset UC was more likely to have severe activity at initial diagnosis (32.4%) than the group with late-onset UC (16.8%) (P = .001), although there was no significant difference in highest severity over the entire clinical course. Individuals with late-onset UC were more likely to be smokers (10.4%) than those with early-onset UC (4.1%, P = .001). Individuals with late-onset UC were more likely to use suppository type medications and less likely to use intravenous corticosteroids, immunomodulators, and biologics. The number of admissions was similar between the two groups, whereas the rate of surgery was significantly higher in the group with late-onset UC (0.24) than in that with early-onset UC (00.18) (P = .04). Mortality (P < .001) and rates of sepsis (P = .009) were higher in the group with late onset. These results demonstrate that individuals with late-onset UC tend to have atypical presentations and milder severity at initial diagnosis, which may result in a longer time to diagnosis than in those with early-onset UC. A similar phenomenon has been previously reported.2, 3, 9 Doctors should be more aggressive in making an earlier diagnosis in elderly adults. Individuals with late-onset UC had higher rates of sepsis and surgery and greater mortality even when they had initial mild disease severity than those with early-onset UC and similar severity over the whole disease course. Individuals with late-onset UC were less likely to use intravenous corticosteroids, immunomodulators, and biologics. The group with late onset had higher rates of surgery, probably because they received less-aggressive treatment and inadequate control of UC activity. Age is a known risk factor for sepsis,10 and treatment with immunomodulators and biologics confer a risk of infection that may be more pertinent in elderly adults.10 All of the above indicate that comorbidities and infection control are important concerns when caring for elderly adults with UC. It is hoped that the information provided herein will decrease mortality and rates of sepsis in this group. In conclusion, individuals with late-onset UC more often have atypical clinical presentations and milder illness severity at initial diagnosis, which could result in delay of diagnosis. Moreover, elderly adults have higher mortality and rates of surgery. Medications to control UC activity should be cautiously adjusted and sepsis risk avoider, thereby improving outcomes in individuals with late-onset UC. Conflict of Interest: The authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Lin WC, Tung CC, Lin HH, Lin CC, Chang CW, Yen HH, Chuang CH, Hsu WH, Tsai W: acquisition of data, drafting the manuscript, statistical analysis. Wang HY, Lin JK, Wong JM: analysis and interpretation of data, critical revision of manuscript for important intellectual content. Wei SC: protocol design, drafting the manuscript, critical revision of manuscript for important intellectual content. All authors read and approved the final manuscript. Sponsor's Role: None.

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