Life with IBD
Most people think of inflammatory bowel disease (IBD) as something that strikes in your twenties or thirties. The reality is that roughly 10% to 15% of all IBD diagnoses occur in people over 60, and researchers have identified a distinct second peak of incidence between ages 50 and 70. If you or someone you care about is dealing with new gut symptoms later in life, IBD belongs on the list of possibilities, even if your doctor hasn't mentioned it yet.
The problem is that getting to that diagnosis takes significantly longer for older adults. Where a younger patient might wait two years from first symptoms to a confirmed IBD diagnosis, older patients wait an average of six years. That delay can mean years of unnecessary suffering and, in some cases, disease progression that could have been prevented.
Why IBD Gets Missed in Older Adults
Up to 60% of elderly patients with IBD are initially misdiagnosed, compared to about 15% of younger patients. The reason comes down to overlap. The symptoms of IBD, including diarrhea, abdominal pain, rectal bleeding, and weight loss, look a lot like several other conditions that are more common in people over 50.
Diverticular disease is the most frequent misdiagnosis, which makes sense given that diverticula become increasingly common with age. Ischemic colitis, medication-related diarrhea from NSAIDs or antibiotics, microscopic colitis, and colorectal cancer all enter the differential diagnosis. Each of these conditions is more prevalent in older adults, so doctors often pursue them first.
Compounding the challenge, elderly-onset IBD often presents differently than the textbook version. Older adults with Crohn's disease may not have the classic cramping abdominal pain and frequent diarrhea. Instead, they might present with constipation, low-grade fever, general malaise, or gastrointestinal bleeding as their primary symptoms. When the symptoms themselves are atypical, even experienced gastroenterologists can be steered toward other diagnoses.
How IBD Looks Different After 50
The disease itself behaves differently in older adults, and understanding those differences matters for both diagnosis and treatment planning.
In Crohn's disease, elderly-onset patients show a strong tendency toward purely colonic involvement, with about 65% of cases affecting only the colon. In younger patients, ileocolonic disease (involving both the small intestine and colon) is more common. This colonic predominance in older patients is one reason it gets confused with other conditions affecting the large intestine.
The behavior of the disease also tends to be less aggressive. Elderly-onset Crohn's patients have lower rates of penetrating disease (fistulas and abscesses) and perianal complications compared to younger patients. Between 64% and 78% of older patients present with inflammatory disease that is non-stricturing and non-penetrating.
For ulcerative colitis diagnosed after 50, left-sided colitis and proctitis are more frequent at diagnosis compared to younger-onset patients. The disease course tends to be somewhat more stable, though this should not be interpreted as a reason to delay treatment. Uncontrolled inflammation at any age carries risks, including increased colorectal cancer risk with longstanding disease.
Treatment Decisions Get More Complicated
The same medications used to treat IBD in younger adults are available for older patients, but the risk-benefit calculations shift in important ways.
Infection risk is the central concern. The immune system naturally becomes less effective with age, a process called immunosenescence. Adding immunosuppressive IBD medications on top of that age-related decline creates a compounded risk. Observational studies show that the risk of infection with anti-TNF therapy is considerably higher in the elderly IBD population, and advanced age is an independent risk factor for severe infections and mortality in patients receiving these drugs.
Combination therapy, using an anti-TNF biologic alongside a thiopurine immunomodulator, carries the greatest risk for serious infection in patients aged 65 and older compared to monotherapy with either drug class alone. Many gastroenterologists now favor monotherapy approaches in older patients when possible, accepting a potentially modest reduction in efficacy to avoid the compounded infection risk.
Newer biologics offer some advantages in this population. Vedolizumab, ustekinumab, and risankizumab have more favorable safety profiles regarding infections and malignancy risk compared to older anti-TNF agents. Vedolizumab is gut-selective, meaning it primarily affects the immune system in the intestinal tract rather than suppressing immunity system-wide. This mechanism may offer a better balance of efficacy and safety for older patients, though long-term data in the elderly population remains limited.
Polypharmacy and Drug Interactions
Beyond the IBD medications themselves, older patients face a practical challenge that younger patients rarely encounter: polypharmacy. Research shows that older IBD patients take an average of nine routine medications, and 43% are on ten or more. With that many prescriptions, drug interactions become a genuine concern.
About 74% of older IBD patients have at least one potential medication interaction, and 40% have interactions specifically involving their IBD drugs. Corticosteroids, often used for flare management, can worsen diabetes, accelerate bone loss, and interact with blood pressure medications. Methotrexate interacts with several common drugs, including certain antibiotics and NSAIDs. These interactions make close coordination between a gastroenterologist and a primary care physician essential.
Vaccinations and Preventive Care
Starting immunosuppressive therapy in an older adult requires a proactive approach to vaccinations. The American Gastroenterological Association recommends that patients receive all appropriate vaccines at the earliest opportunity, ideally before beginning immunosuppressive treatment.
For patients 65 and older, this includes a high-dose or adjuvanted influenza vaccine annually, pneumococcal vaccination, a respiratory syncytial virus (RSV) vaccine, and staying current on COVID-19 boosters. The critical rule is that patients on immune-modifying agents should avoid live vaccines, which includes the live shingles vaccine (Zostavax), though the newer recombinant shingles vaccine (Shingrix) is safe. Given that shingles risk is elevated both by age and by certain IBD medications, getting Shingrix before starting treatment is a practical priority.
Annual skin cancer screening is also recommended for patients on immunomodulators, anti-TNF biologics, or small molecule therapies, as these medications can increase skin cancer risk.
What to Bring to Your GI Appointment
If you are over 50 and experiencing new or worsening digestive symptoms, the most valuable thing you can do is arrive at your gastroenterology appointment with clear documentation. A detailed symptom log, including frequency, severity, timing relative to meals, and any associated symptoms like joint pain or skin changes, helps your doctor distinguish between the many conditions that share similar presentations. Medication lists matter too, as your doctor needs the complete picture of every prescription, supplement, and over-the-counter drug you take to evaluate both diagnostic possibilities and safe treatment options.
Track your symptoms and medications with Aidy to bring clear data to your GI appointments, giving your doctor the information they need to reach the right diagnosis faster and build a treatment plan that accounts for your full health picture.