Ulcerative colitis (UC) in the elderly: diagnostic and therapeutic considerations

Ulcerative colitis (UC) demonstrates 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-manifested by Th17/Treg imbalance and the accumulation of cells with a pro-inflammatory senescence-associated secretory phenotype (SASP)-alongside 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 (e.g., colorectal cancer, ischemic colitis). 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. While 5-aminosalicylic acid remains the first-line therapy, it requires renal monitoring. Conversely, steroids increase infection and osteoporosis risks, thiopurines are restricted due to myelotoxicity and malignancy risks, and among biologics, vedolizumab offers better safety than anti-TNF agents. Ultimately, managing UC in older adults requires a comprehensive, multidisciplinary approach that accounts for multimorbidity, polypharmacy, nutritional status, and mental health to optimize pharmacotherapy and mitigate high-risk surgical interventions.