The incidence of inflammatory bowel diseases (IBD) in older adults is increasing. We performed a systematic review and meta-analysis to evaluate progression of elderly-onset (EO)-IBD in population-based cohorts and compared it with adult-onset (AO)-IBD.In a systematic review through June 1, 2019, we identified population-based cohort studies of EO-IBD reporting cumulative risk of hospitalization, surgery, mortality, treatment patterns, and escalation and/or malignancy. Data were synthesized using random-effects meta-analysis as cumulative risk of events at 1 y, 5 y, and 10 y, and compared with data from patients with AO-IBD in the same cohorts.We identified 9 studies, comprising 14,765 patients with EO-IBD. In patients with EO-Crohn's disease (CD), the cumulative 5-year risk of surgery was 22.6% (95% CI, 18.7-27.2) and was similar to that of patients with AO-CD (relative risk [RR], 1.04; 95% CI, 0.80-1.34). Overall exposure to corticosteroids was comparable between patients with EO-CD vs AO-CD (5 y risk: 55.4%; 95% CI, 53.4-57.4; RR, 0.88; 95% CI, 0.78-1.00), but exposure to immunomodulators (31.5%; 95% CI, 29.7-33.4; RR, 0.62; 95% CI, 0.51-0.77) or biologic agents (6.5%; 95% CI, 5.6-7.6; RR, 0.36; 95% CI, 0.25-0.52) was significantly lower for patients with EO-CD than for patients with AO-CD. Similarly, in patients with EO-ulcerative colitis (UC), the cumulative 5 y risk of surgery was 7.8% (95% CI, 5.0-12.0), similar to the risk for patients with AO-UC (RR, 1.29; 95% CI, 0.79-2.11). Overall exposure to corticosteroids was comparable between patients with EO-UC vs AO-UC (5 y risk: 57.2%; 95% CI, 55.6-58.7; RR, 0.98; 95% CI, 0.91-1.06), but exposure to immunomodulators (16.1%; 95% CI, 15.0-17.2; RR, 0.58; 95% CI, 0.54-0.62) or biologic agents (2.0%; 95% CI, 1.6-2.5; RR, 0.36; 95% CI, 0.24-0.52) was significantly lower for patients with EO-UC than for patients with AO-UC. Patients with EO-IBD appeared to have increased mortality, but not malignancy, compared with the general population. There were few data on comorbidities or adverse effects of medications.In a systematic review and meta-analysis, we found that patients with EO-IBD have a similar risk of surgery as patients with AO-IBD. However, patients with EO-IBD are less likely to receive treatment with immunomodulators or biologic agents.