Special situations
Most people picture Crohn's disease as something that strikes in your twenties or thirties. And while that is the most common window, a significant number of people receive their diagnosis much later in life. Roughly 10 to 15% of Crohn's cases are diagnosed after age 60, and some estimates place the figure even higher, with up to one in four IBD diagnoses occurring in people over 60. If you or a parent just received this diagnosis at an older age, you should know that late-onset Crohn's looks and behaves differently than the disease in younger patients. That distinction matters for everything from how quickly it gets recognized to which medications are safest.
Why It Takes Longer to Get Diagnosed
One of the defining challenges of Crohn's disease in older adults is the delay in reaching a correct diagnosis. Studies show that the average time to diagnosis in elderly patients is roughly six years, compared to two years in younger patients. Even more striking, up to 60% of elderly patients with Crohn's are initially misdiagnosed, compared to about 15% of younger patients.
The reasons for this are straightforward. The symptoms of Crohn's, including abdominal pain, diarrhea, weight loss, and rectal bleeding, overlap heavily with conditions that are far more common in older adults. Diverticulitis is the most frequent mimic, particularly because diverticular disease is widespread in people over 60 and can cause similar abdominal pain, localized inflammation, and even fistulas or strictures. Ischemic colitis, which results from reduced blood flow to the colon, can produce similar symptoms. Medication side effects from commonly prescribed drugs like nonsteroidal anti-inflammatory drugs (NSAIDs) and certain antibiotics can cause diarrhea and intestinal inflammation that looks like IBD on imaging.
There is also a condition called segmental colitis associated with diverticulosis, or SCAD, that can be nearly impossible to distinguish from Crohn's on biopsy alone. Colorectal cancer and microscopic colitis round out the list of conditions that delay accurate diagnosis. For older patients experiencing persistent GI symptoms, the takeaway is simple: if your symptoms are not improving with treatment for the condition you were told you have, ask your gastroenterologist whether IBD should be reconsidered.
How Late-Onset Crohn's Differs from Younger-Onset Disease
Crohn's disease that appears after age 60 tends to follow a different clinical pattern than the disease in younger patients. Understanding these differences can help set realistic expectations.
The most consistent finding across research is that late-onset Crohn's favors the colon. About 55% of patients diagnosed after age 60 have isolated colonic disease, compared to the younger population where the disease more commonly involves the terminal ileum or a combination of the small and large bowel. This colonic predominance is one reason the disease gets confused with diverticulitis and other colon-specific conditions.
The disease also tends to be less aggressive in its behavior. Using the Montreal classification system that gastroenterologists rely on to categorize Crohn's, older patients are 64% less likely to develop complicated disease, meaning strictures (narrowing) or penetrating complications like fistulas and abscesses, compared to those diagnosed younger. Symptoms at presentation tend to be milder as well. This is partly why the diagnosis gets missed. Doctors may not suspect Crohn's when the presentation is relatively subdued.
That said, milder disease behavior does not mean the condition is inconsequential. Chronic inflammation in the colon still carries real risks, including nutritional deficiencies, anemia, and an increased likelihood of colorectal cancer with long-standing disease. Treatment is still necessary, and monitoring still matters.
Medication Safety in Older Adults
Treating Crohn's in someone over 60 involves the same classes of medications used in younger patients, but the risk-benefit calculations shift in important ways. The AGA clinical practice update on managing IBD in elderly patients outlines several considerations that matter for this population.
Immunosuppression carries higher stakes in older bodies. The immune system naturally weakens with age, a process called immunosenescence, and adding immunosuppressive medications on top of that can meaningfully increase infection risk. Anti-TNF biologic drugs like infliximab and adalimumab, the most commonly used biologics for Crohn's, carry a nearly fivefold increase in serious adverse events in patients 65 and older compared to younger adults. The risk of serious and opportunistic infections, in particular, is the primary concern.
Janus kinase (JAK) inhibitors, a newer class of oral medications used in IBD, require cardiovascular risk assessment before starting therapy. While large meta-analyses have not found a significantly increased rate of major cardiovascular events in IBD patients on JAK inhibitors overall, current guidance recommends caution in patients over 50 who have existing cardiovascular risk factors. Your gastroenterologist should review your full cardiovascular history before prescribing these medications.
Polypharmacy is another practical concern. Many people over 60 are already taking multiple medications for conditions like high blood pressure, diabetes, or heart disease. Drug interactions with Crohn's medications need to be carefully reviewed, and simpler treatment regimens are generally preferred when they can achieve adequate disease control.
Infection Screening Before Starting Biologics
Before any patient begins biologic therapy, doctors are required to complete a screening process for latent infections. This step is especially important for older adults, who are more likely to have been exposed to certain infections over the course of their lives.
Tuberculosis screening is mandatory before starting anti-TNF biologics because these drugs suppress a key immune pathway that keeps latent TB in check. Reactivation of dormant TB on biologic therapy can be life-threatening. Screening typically involves a blood test called an interferon-gamma release assay (IGRA) or a tuberculin skin test, along with a chest X-ray.
Hepatitis B screening is also required, because biologic therapy can trigger reactivation of hepatitis B in patients who are chronic carriers. Hepatitis C and HIV testing are part of the standard panel as well.
Vaccination is another critical step. Ideally, all recommended vaccines should be brought up to date before immunosuppressive therapy begins. This includes influenza, pneumococcal, and herpes zoster vaccines. Once a patient is on immunosuppressive medications, live vaccines are contraindicated due to the risk of the vaccine itself causing infection. For older adults who may not have kept up with vaccine schedules, this pre-treatment window is an important opportunity to catch up.
Cancer Surveillance Considerations
Crohn's disease increases the risk of colorectal cancer, and surveillance colonoscopy is a standard part of long-term management. For patients diagnosed later in life, the surveillance conversation has some unique dimensions.
The general guideline is that surveillance colonoscopy should begin eight years after the onset of IBD symptoms, with intervals of one to three years depending on risk factors like disease extent, family history of colorectal cancer, and the presence of primary sclerosing cholangitis. For someone diagnosed with Crohn's at age 65, this means surveillance would typically start around age 73.
At the same time, general population guidelines suggest that discussions about stopping colorectal cancer screening should begin around age 75, based on the diminishing benefit in patients with limited life expectancy or significant comorbidities. This creates a situation where the IBD surveillance clock and the general screening clock may conflict. Your gastroenterologist should weigh your overall health, life expectancy, inflammatory burden, and colonoscopy findings when making individualized recommendations rather than applying a blanket rule.
Modern surveillance techniques, including high-definition colonoscopy and chromoendoscopy with targeted biopsies, have improved the detection of precancerous changes and make the procedure more efficient than the older method of taking dozens of random biopsies.
Surgery in Older Crohn's Patients
While late-onset Crohn's tends to be less complicated in its behavior, some patients will still require surgery. Research on surgical outcomes in older Crohn's patients paints a nuanced picture.
Older patients face higher rates of postoperative complications, particularly anastomotic leaks, which occur where two sections of bowel are reconnected after a resection. Major complications are more frequent in patients over 50 compared to younger surgical patients. Recovery time tends to be longer, and the presence of other medical conditions complicates anesthesia and postoperative care.
On the other hand, older patients who make it through surgery tend to experience fewer clinical flares afterward compared to younger patients. Within the first year after ileocecal resection, younger patients were more than twice as likely to experience a clinical flare (36% vs. 16%). This may reflect the generally less aggressive disease behavior in older-onset Crohn's. However, older patients were also less likely to receive biologic therapy after surgery, which raises questions about whether the lower flare rates are partly offset by undertreatment.
Coordinating Care Across Multiple Conditions
One of the most practical challenges of managing Crohn's disease after 60 is that it rarely exists in isolation. Most older adults are already managing other health conditions and seeing multiple specialists. Adding a gastroenterologist and a new set of medications to an existing care team requires coordination.
Your gastroenterologist needs to know every medication you take, because immunosuppressive Crohn's drugs can interact with common medications for blood pressure, diabetes, and heart conditions. Your primary care doctor and any other specialists should be aware of your Crohn's diagnosis and treatment, particularly if you are on immunosuppressive therapy, because it affects decisions about vaccines, elective procedures, and infection management.
Keeping organized records of your medications, symptoms, lab results, and appointment notes becomes genuinely important when multiple doctors are involved. Bringing clear, consolidated data to each appointment helps your care team make safer decisions and reduces the risk of gaps in communication between providers.
Living Well with a Late Diagnosis
A Crohn's diagnosis after 60 can feel disorienting, particularly if you spent decades without digestive problems. But the research consistently shows that late-onset Crohn's tends to follow a milder course than younger-onset disease, with less complicated behavior and good response to treatment when the right therapy is selected with appropriate caution.
The key priorities are getting an accurate diagnosis without unnecessary delay, working with a gastroenterologist experienced in managing IBD in older adults, completing thorough infection screening and vaccination before starting immunosuppressive therapy, and maintaining regular surveillance. With clear communication between you and your medical team, Crohn's disease at any age is a condition that can be managed effectively.
Track your medications and symptoms with Aidy to bring clear data to your GI appointments. With multiple medications and conditions, organized data helps your doctors coordinate care safely.