Clin-STAR Journey Story

An IBD Specialist Turns to Geriatric Principles to Guide Treatment for Older Adults

Inflammatory bowel diseases (IBD) affect more than 3 million Americans. Most are diagnosed between the ages of 18 and 40 with Crohn’s disease or ulcerative colitis. “We don’t think of IBD as a geriatric topic,” says Bharati Kochar, MD, MSCR. But in clinic, during her advanced fellowship training, she realized that 20 to 30 percent of IBD patients were 60 years and older.

Physicians have long known that a small group of patients receives a first diagnosis of IBD in their 60s. Today, with the general population of older adults increasing, so too has the number of later-in-life IBD diagnoses. In addition, many of the patients Dr. Kochar was seeing had been diagnosed young. With advances in treatment, people with IBD are living longer.

Now physicians are grappling with how to treat these older IBD patients. Mainstay therapies suppress the immune system, which leads to infections, and can be dangerous for people already weakened by fatigue and weight loss. In addition, clinical trials for these treatments were carried out with participants in their 30s. Their safety and efficacy for older adults, who may also have other chronic diseases, have not been well studied. Older adults often don’t receive these therapies for fear of harm.

“It’s great news that people are aging with IBD. But we have no guidance on treating them,” says Dr. Kochar.

Dr. Kochar earned her medical degree at Brown University in 2011, and from 2011 to 2014 she trained in internal medicine at The Johns Hopkins Hospital. She completed a fellowship in gastroenterology and hepatology, as well as advanced training in IBD, at the University of North Carolina Hospitals from 2014 to 2018. She remained on staff there until joining MGH in 2019. She also earned a master’s degree in clinical research at UNC.

“I sort of fell into geriatrics out of what I see as a huge need,” says Dr. Kochar, “but I had no training.” Soon after arriving at MGH, she found a mentor in Christine Ritchie, chair and director of research for the Division of Palliative Care and Geriatric Medicine. With Dr. Ritchie’s guidance, Dr. Kochar began investigating how the geriatrics framework of frailty could help characterize IBD patients.

In a retrospective study, Dr. Kochar and colleagues found that frailty-related diagnosis codes were prevalent among people with IBD. Further work showed they were associated with nearly twice the odds of infection after immunosuppressant treatment and nearly triple the odds of mortality. In general, older adults had worse outcomes than younger people.

But databases only tell part of the story, mostly considering chronological age but not accounting well for patients’ physical functioning or reserve. In IBD, people often experience geriatric syndromes at earlier ages. And among older adults, “Physiologically, everyone who’s 60 and above is not the same,” says Dr. Kochar.

Surgeons and other specialists are beginning to develop frailty assessments to stratify risk, and predict which patients are likely to withstand the challenges of treatment. With an NIA-supported GEMSSTAR Award, Dr. Kochar has launched the first prospective study of frailty in older adults with IBD. “My aim right now is to understand how relevant frailty is as a concept, and how can we best measure and apply it in older people with IBD.” Dr. Kochar also recently received a grant from the Crohn’s and Colitis Foundation to expand the research to include 400 patients across four other IBD centers.

Ultimately, being able characterize IBD patients who are physiologically more fit to withstand treatment with immunosuppressants—to create a means of risk-stratification—would expand their access to such treatments. More tailored decisions about surgeries and therapies could also improve quality of life for all.

“Doctors like myself, who are used to treating younger people—when we see older, frailer people, we have a bias against treatment. But my hypothesis is that if we treat their underlying inflammatory condition, their frailty will actually improve.”

“When people in the GI world ask me, ‘why are you doing geriatrics?’ I say the only thing that’s basically guaranteed—hopefully—is for our patients to do so well that they’re going to age. And we need to understand what to do for them when they’re older.”