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As the prevalence of inflammatory bowel disease (IBD) increases in the elderly population, we sought to characterize IBD-related outcomes in this population.We identified incident IBD cases in Ontario, Canada between 1999 and 2008 and categorized subjects by age at diagnosis as young adults (18–40 yr); middle-age adults (41–64 yr); and elderly (≥65 yr) from within population-based health administrative data. We determined the risk of IBD-related surgery and mortality in those with elderly-onset IBD compared with other age groups.Of 21,218 persons with IBD, there were 1749 cases of elderly-onset ulcerative colitis (UC) and 725 cases elderly-onset Crohn's disease (CD). Elderly UC had higher rates of IBD-related surgery than those with young-adult UC (adjusted hazard ratio, 1.34; 95% CI, 1.16–1.55), although there was no difference in surgical rates between age groups in CD. IBD-specific mortality was higher in elderly-onset CD (33.1/10,000 person-year) compared with that in middle-age CD (5.6/10,000 person-year, P < 0.0001) and young adult CD (1.0/10,000 person-year) but was not different by age in UC. The leading cause of death in elderly UC and CD was solid malignancies accounting for 22.9% and 26.4% of deaths, respectively, whereas IBD was third most frequent cause of death accounting for 6.3% and 9.1% of deaths, respectively.Elderly-onset patients with UC were more likely to undergo surgery while elderly-onset patients with CD exhibited higher IBD-specific mortality than those with younger-onset disease. These findings should prompt more optimized disease management in elderly IBD.