Ulcerative Colitis in the Elderly: Diagnostic and Therapeutic Considerations

Ulcerative colitis in the elderly is characterized by a bimodal incidence distribution, with a significant second peak and the highest prevalence observed in individuals aged ≥60 years. The pathogenesis of elderly UC involves immunosenescence, marked by Th17/Treg imbalance and the accumulation of cells with a pro-inflammatory senescence-associated secretory phenotype (SASP). This is accompanied by age-related dysbiosis, increased intestinal permeability, and mitochondrial dysfunction that impairs mucosal regeneration. Clinically, older patients more frequently present with left-sided colitis, characterized by anemia and weight loss, while abdominal pain is less common. Managing geriatric UC is challenging due to inadequate colonoscopy preparation and complex differential diagnosis. Furthermore, older adults face a fivefold increased risk of Clostridioides difficile infection and a sharply rising risk of colorectal cancer if diagnosed after 70 years of age. The treatment of elderly UC requires careful consideration, with 5-aminosalicylic acid remaining the first-line therapy. However, renal monitoring is essential, as steroids increase infection and osteoporosis risks, while thiopurines are restricted due to myelotoxicity and malignancy risks. Vedolizumab offers better safety than anti-TNF agents among biologics. A comprehensive, multidisciplinary approach is necessary to optimize pharmacotherapy and mitigate high-risk surgical interventions, taking into account multimorbidity, polypharmacy, nutritional status, and mental health.