If I Had Colonospy at Age 54 Then 64 How Often After That Should Have Done Again
World J Gastrointest Endosc. 2014 Jun 16; 6(6): 220–226.
Performing colonoscopy in elderly and very elderly patients: Risks, costs and benefits
Received 2013 Dec 22; Revised 2014 Feb eighteen; Accustomed 2014 May 16.
Abstract
Many diagnostic and screening colonoscopies are performed on very elderly patients. Although colonoscopic yield increases with historic period, the potential benefits in such patients subtract because of shorter life expectancy and more frequent comorbidities. Colonoscopy in very elderly patients carries a greater gamble of complications and morbidity than in younger patients, and is associated with lower completion rates and higher likelihood of poor bowel preparation. Thus, screening colonoscopy in very elderly patients should be performed only afterward conscientious consideration of potential benefits, risks and patient preferences. On the other paw, diagnostic and therapeutic colonoscopy are more likely to benefit even very elderly patients, and in about cases should exist performed if indicated.
Keywords: Colonoscopy, Elderly, Colon polyp, Colon cancer, Screening, Surveillance, Complications, Yield, Bowel preparation
Core tip: Although colonoscopic yield increases with historic period, the potential benefits in elderly patients decrease because of shorter life expectancy and more than frequent comorbidities. Colonoscopy in very elderly patients carries a greater chance of complications and morbidity than in younger patients. Thus, colonoscopy in elderly patients should exist performed only afterwards careful consideration of potential benefits, risks and patient preferences.
INTRODUCTION
Colonoscopy is currently the procedure of choice for whole colon evaluation in patients who present with lower gastrointestinal symptoms. In the United States, it is also the about effective and most unremarkably used modality for colorectal cancer (CRC) screening in asymptomatic individuals (with or without a family history), and for surveillance in patients with a personal history of adenomatous polyps, CRC or inflammatory bowel disease. Finally, in appropriate circumstances it is an important therapeutic procedure, allowing for biopsy of suspicious lesions, handling of haemorrhage sources, placement of stents, and, most of all, removal of colorectal adenomatous polyps, thereby preventing the potential occurrence of CRC[1].
COLONOSCOPY IN ELDERLY PATIENTS
Because the incidence of colorectal pathology and symptoms increment with historic period, a large proportion of diagnostic, screening and surveillance colonoscopies are performed on "elderly" (defined every bit those > 65 years of age) and "very elderly" patients (> 80 years). In North America, the number of screening procedures in elderly patients has increased dramatically ever since many insurance programs, including medicare, began to cover screening colonoscopy in average-take chances beneficiaries[2,3]. Even so, performing colonoscopy in elderly patients poses a unique set up of challenges. In the elderly, the risks and benefits of colonoscopy should be carefully assessed in low-cal of lower life expectancy and the frequent presence of co-morbidities, then as to ensure that the potential benefits outweigh the risks and morbidity. This review will hash out issues pertaining to the procedural yield, potential benefits, technical feasibility, complication risks, logistical difficulties and costs associated with performing colonoscopy in elderly and very elderly individuals.
YIELD
The procedural yield is the percent of patients who are found to have clinically significant findings (especially neoplasia) on colonoscopy. Generally, the yield of colonoscopy increases with age[4]. According to Surveillance Epidemiology End Results (SEER) registry data every bit of 2007, the incidence of CRC is 120 cases per 100000 in persons aged fifty-64 years of age, 186 per 100000 in those 65-74, and 290.1 per 100000 in those ≥ 75[5]. It is well established that elderly patients have a higher prevalence of colorectal neoplasia[6,7], as well as other findings such as diverticulosis and hemorrhoids. As with younger patients, symptomatic elderly patients demonstrate a college yield than those who are asymptomatic[8].
Numerous studies have confirmed high yields for both screening and diagnostic colonoscopy in elderly patients (Table 1). The reported yield of CRC in symptomatic elderly patients has ranged from three.vii% to fourteen.2%[ix-12]. In a study on 200 symptomatic octogenarians, 80% had colonoscopic findings that explained their symptoms[thirteen]. Controlled studies that compared the yield in patients of different ages have echoed these findings. In 1 report on 1353 elderly patients, the gamble of CRC development was higher in patients > 80 compared to those 70-74 years old[half dozen]. In another study that included 915 symptomatic and screening patients, more advanced adenomas and invasive cancers were identified in 53 patients over the historic period of 80 than in younger controls[14]. Studies on European patients also as minority groups in the United States accept too reported similar results. A large study on 2000 English patients showed that compared with younger patients, those > 65 years sometime had college overall diagnostic yields (65% vs 45%) as well equally CRC prevalence (7.1% vs i.3%)[15], while another study on 1530 African American and Hispanic patients showed that the CRC yield was significantly higher in those over 65 years of age than in younger counterparts (7.8% vs ane.8%)[xvi].
Table 1
Yield of colonoscopy in studies with subgroups of symptomatic and/or screening/surveillance "elderly" patients
| Ref. | n | Historic period (yr) | Completion | Cancers | Adenomas/polyps |
| Bat et al[ten], 1992 | 436 | fourscore+ | 63% | 14% | 29.80% |
| Ure et al[48], 1995 | 354 | 70+ | 78% | 6% | 24% |
| Sardinha et al[49], 1999 | 403 | eighty+ | 94% | 4.50% | - |
| Clarke et al[12], 2001 | 95 | 85+ | - | 12.70% | - |
| Lagares-Garcia et al[50], 2001 | 103 | 80+ | 92.lxx% | eleven.60% | xix.40% |
| Arora et al[51], 2004 | 110 | 80+ | 97%1 | 20% | - |
| Syn et al[9], 2005 | 225 | fourscore+ | 56% | 11% | 25% |
| Yoong et al[52], 2005 | 316 | 85+ | 69% | 8.90% | 14.twenty% |
| Karajeh et al[15], 2006 | 1000 | 65+ | 81.80% | 7.10% | half-dozen%2 |
COMPLICATIONS AND Adverse EVENTS
One of the primary concerns with performing colonoscopy on elderly patients is the potential for increased run a risk of complications. Adverse events are typically categorized as those occurring during or immediately after the process and those with a delayed presentation. Cardiopulmonary complications are the most common peri-procedural adverse events. The level of sedation, presence of comorbidities and procedure length and complexity all contribute to the run a risk and should be addressed to the extent known during pre-procedural planning, specially for elective colonoscopies.
Although early, modest studies suggested that colonoscopy in elderly patients did not result in more complications[17], more recent, larger and amend designed studies have shown convincingly that colonoscopy in the elderly is associated with more risk than in younger patients. Every bit demonstrated by a recent meta-analysis, very elderly patients had a significantly higher rate of overall agin events, including gastrointestinal haemorrhage and perforation[eighteen] (Tabular array two). Studies from Asia have also reported college risks of cardiovascular complications despite the fact that elderly patients on average received lower doses of sedatives[19].
Table two
Complication risks based on data from meta-analysis by Day et al[18]
| Age grouping (year) | > 65 | > lxxx |
| Cumulative adverse events | 26.01 (25.0-27.0) | 34.91 (31.nine-38.0) |
| Perforation | one.0% (0.9-1.5) | 1.5% (i.ane-1.nine) |
| Gastrointestinal bleeding | 6.3% (xviii.0-20.3) | 2.4% (ane.ane-4.6) |
| Cardiopulmonary complication | 19.1% (18.0-twenty.3) | 28.nine% (26.two-31.eight) |
| Mortality | ane.0% (0.7-2.two) | 0.five% (0.006-one.nine) |
Nevertheless, when taken in context, the complication rate is nonetheless quite low fifty-fifty for patients over 85 years of historic period, and in almost cases colonoscopy tin be done safely with appropriate monitoring and precautions[20]. Furthermore, several studies have shown that propofol sedation, despite its propensity to lower blood pressure, can exist used safely in elderly patients[21-23]. The overall major complication charge per unit in patients over fourscore is low, between 0.2% and 0.6%[eleven,15], although it increased with specific comorbid weather condition[24]. A large retrospective study reported an overall perforation rate of 0.082% for adults undergoing colonoscopy, with avant-garde age every bit a significant predictor[25]. Studies in minority patients in the United States (African Americans and Hispanics)[16], besides every bit from Asia[26], have also reported that complication rates are low in elderly patients. When determining procedural risk, physiological age, i.e., presence of comorbidities, is more of import than chronological age. Thus, the overall health condition of the patient should exist considered, instead of relying on rigid age cutoffs.
During colonoscopy, the vital signs, oxygen saturation and cardiac rhythm of all patients should be monitored continuously. Supplemental oxygen is often administered if patients are sedated. Increasingly, capnography is being used to identify early signs of respiratory depression. Conscious sedation is achieved by the utilise of a short-acting allaying with amnestic properties, such every bit intravenous midazolam or diazepam, and an opioid analgesic, such as fentanyl or meperidine. The utilize of deep sedation with propofol, typically administered by an anesthesia provider, is condign more popular in the United States. Nevertheless, gastroenterologist-administered propofol has too been shown to be safe in the elderly[22].
Up to one third of patients may have minor side-furnishings after outpatient colonoscopy, most frequently bloating or abdominal cramps. Depending on their level of independence, elderly patients living lonely may require additional post-procedure care. Postal service-procedure calls within 48 h by medical staff may exist helpful.
Many elderly patients have implanted cardiac pacemakers or defibrillators. The use of monopolar electrocautery during snare polypectomy can cause pacemaker inhibition or false detection of cardiac arrhythmias[27]. Thus, these devices are generally inactivated during the colonoscopy.
COLONOSCOPY COMPLETION RATES
Complete colonoscopy requires cecal intubation or, for those who have had an ileocecectomy, reaching the ileocolonic anastomosis. In the United States, studies on patients of all ages undergoing elective screening or surveillance colonoscopy written report loftier completion rates above 95%[28]. Studies on symptomatic patients (including those with non-traversable obstructing lesions) study completion rates of around 83%[29].
Colonoscopy in the elderly is technically more challenging than in younger patients because of various factors, including more than extensive diverticulosis, higher incidence of tortuosity or mail-surgical adhesions, and higher risk of complications[four]. Elderly patients are likewise less likely to tolerate large amounts of sedation, and have a higher probability of suffering inadequate bowel preparation[xiii,xxx,31], both of which can prevent complete colonoscopy.
A wide range of completion rates in elderly patients take been reported, including 56% (this included 8 obstructing lesions that could non be traversed)[ix], 63% (on the first attempt) or 89% (second attempt)[10], 83.5%[thirteen], and as high equally 88.one% (for patients > 73 years old)[xxx]. For patients in their belatedly 60'southward, the completion rate was quite respectable at 90.3% in one study[16], while a prospective study reported an "endoscopic success rate" of 90% for octogenarians[31]. Overall, a meta-analysis showed that for elderly patients > 65 years of age, the mean completion rate was 84%, while for those > 80, the completion rate was 84.7%[18]. Many of the studies that directly compared completion rates between elderly patients and younger controls showed a meaning difference in favor of the younger grouping[sixteen,31,32].
BOWEL PREPARATION ISSUES
In a previous meta-analysis of 20 studies, suboptimal bowel grooming was documented in 18.8% of patients > 65 years of age, and in 12.i% of those > 80[18]. Equally summarized in Figure 1, elderly patients have a higher likelihood of poor bowel preparation due to slower colonic transit and higher incidence of obstipation[4,33]. Inadequate bowel preparation was a large factor in many studies that demonstrated lower colonoscopy completion rates in older patients[13,30,31]. The nearly normally used bowel preparation regimen, 4 L of pegylated ethylene glycol, represents a substantial ingestion book for elderly patients, who are also more than likely to have renal, cardiac or hepatic conditions that make them ineligible for small volume alternative osmotic laxatives, such as sodium sulfate or sodium picosulfate. Moreover, frequent trips to the commode constitute a fall risk for the delicate elderly patient with mobility issues.
Published studies reporting rates of poor or inadequate bowel preparation for colonoscopy in elderly patients and non-elderly controls: Chatrenet[13], Duncan[11], George[53], Karajeh[15], Lukens[31], Ma[nineteen] and Syn[9].
Conclusion ANALYSES
Several determination analysis studies have addressed the costs, risks and benefits of colonoscopy in elderly patients. The potential for screening-related complications was greater than the estimated benefit in some population subgroups aged 70 years and older. At all ages and life expectancies, the potential reduction in mortality from screening outweighed the risk of colonoscopy-related expiry[34]. In another study, a patient with no familial risk factors with negative colonoscopy at historic period 50, 60 or 70 is less probable to benefit from additional screening colonoscopy compared to a 75 years quondam private with no antecedent screening. Furthermore, an private in superb health at age 80 may benefit from colonoscopy whereas a patient with prior depression take a chance adenomas just moderate to severe wellness impairment is unlikely to benefit from colonoscopy even at age < 75. Upfront investment in screening and polypectomy in younger persons may decrease ultimate CRC-related costs, including subsequent screening and surveillance, for older Americans. While these savings could potentially be kickoff past future health costs for other diseases in the elderly, screening 50 years onetime persons would notwithstanding be cost-effective[35].
EQUIPMENT AND LOGISTICAL Problems
Colonoscopes and accessories are the aforementioned for elderly patients as their younger counterparts, although some endoscopists favor pediatric colonoscopes because the more flexible shaft can facilitate passage in the presence of tortuosity or diverticulosis. All patients undergoing sedation demand an adult escort after the procedure, potentially posing a burden on some elderly individuals living in social isolation.
OVERVIEW: SCREENING COLONOSCOPY IN ELDERLY PATIENTS
In the absence of additional gamble factors such as family history, the prevailing consensus is to begin screening at historic period 50 and to continue at intervals adamant by the screening modality used, as well as whatsoever history of adenomatous polyps or cancer. Currently, all three major United states of america gastroenterology societies (American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and American College of Gastroenterology), the American Cancer Social club and the United States Preventive Services Task Forcefulness (USPSTF) take endorsed screening colonoscopy starting time at age 50 for average chance patients, with subsequent intervals of every 10 years in the absence of any personal history of adenomas or family unit history of CRC[36-39]. However, the USPSTF is the only body to recommend discontinuation of screening in boilerplate-risk individuals at age 75[39]. In a publication on colonoscopy developed by the American Gastroenterological Association for the American College of Physicians "Choosing Wisely" Campaign to control health care costs, it is stated that "routine (colonoscopies) ordinarily aren't needed after age 75."
At that place is business that continued screening in very elderly individuals is associated with diminishing utility and increasing costs, morbidity and risks to both individual and society. Life expectancy in light of advanced age and co-morbidities should be considered when because screening in very elderly persons. Screening may not be warranted in asymptomatic patients for whom detecting and removing precancerous polyps would be unlikely to change their long term survival. Moreover, elderly patients who have been screened often incur frequent early repeat colonoscopies, leading to additional risk, morbidity and toll[40].
In a previous study using Declining Exponential Approximation of Life Expectancy analysis, we found that the prevalence of neoplasia was thirteen.viii% in 50-54 years sometime patients, 26.v% in the 75 to 79 years former group, and 28.vi% in the group aged 80 years or older. Despite higher prevalence of neoplasia in elderly patients, estimated mean extension in life expectancy was much lower in the group aged eighty years or older than in the 50 to 54 years old grouping (0.13 years vs 0.85 years). Even though prevalence of neoplasia increases with age, screening colonoscopy in very elderly persons (aged ≥ 80 years) results in only fifteen% of the expected proceeds in life expectancy in younger patients (Table 3)[41]. In a similar study, the survival of elderly patients undergoing colonoscopy was significantly lower than that for younger patients, with important screening implications[42]. Another decision analysis besides showed that the benefits of screening were outweighed past screening-related complication risks in subgroups of patients over 75, especially if they were in poor health[34]. Surveys accept shown that providers exercise contain historic period and comorbidity in screening recommendations; yet, their recommendations were often inconsistent with guidelines[43]. Other factors come up into play when screening decisions are fabricated; for example, elderly patients of low socioeconomic class were less likely to be screened for CRC regardless of insurance status[44].
Tabular array 3
Outcomes for 1244 individuals who underwent screening colonoscopy; classification is according to the most advanced lesion for each patient[41]
| Age group (yr) | n | Patients with advanced neoplasia | Mean life-expectancy (year) | Mean polyp lag time2 (yr) | Mean LE extension (yr) | Adjusted mean LE extension |
| 50-54 | 1034 | 331 (3.2%) | 28.87 | 5.23 | 0.85 | 2.94% |
| 75-79 | 147 | 7 (4.7%) | 10.37 | v.44 | 0.17 | i.64% |
| 80+ | 63 | 9three (14%) | seven.59 | 3.58 | 0.13 | i.71% |
OVERVIEW: DIAGNOSTIC COLONOSCOPY IN ELDERLY PATIENTS
Many gastrointestinal conditions, such equally constipation, incontinence, diverticulosis and hemorrhoids, are more mutual with advancing age. CRC is much more mutual in symptomatic patients over 65 than in younger controls, with a risk ratio as high as 17[45]. In all patients with colorectal symptoms, colonoscopy is usually the preferred diagnostic examination for whole colon evaluation and has supplanted barium enemas and sigmoidoscopy. Direct visualization of the colonic mucosa can be extremely useful for the diagnosis of colitis and confirmation of polyps or masses. Of course, colonoscopy as well allows for histologic assessment through biopsies. Certainly any elderly patient without prior colonoscopy who presents with significant new colorectal symptoms should be offered diagnostic colonoscopy.
1 of the about common colorectal symptoms leading to hospitalization is lower gastrointestinal bleeding. With advancing age at that place is an increased incidence of bleeding from diverticulosis, arteriovenous malformations, malignancy, ischemic colitis, radiations colitis and ano-rectal lesions. When viable, colonoscopy is the best diagnostic test and may offer therapeutic options. In elderly hospitalized patients, completing a four L polyethylene glycol training tin can be difficult; sometimes placement of a nasogastric tube is required. Equally an culling diagnostic modality, the technetium red blood cell browse can localize agile haemorrhage, while angiography is another diagnostic option, and like colonoscopy offers therapeutic possibilities.
OVERVIEW: THERAPEUTIC COLONOSCOPY IN ELDERLY PATIENTS
Colonoscopy offers a variety of therapeutic options to control bleeding, remove polyps and minor tumors, and salvage colonic obstruction due to benign or malignant strictures; these maneuvers are especially useful in elderly patients considering they may obviate the need for surgery. However, small polyps may not demand to be removed because the relative complication risk is high and the benefit is probably low[41].
For haemorrhage patients, endoscopic hemostasis tin be accomplished using epinephrine injection, thermal or electrocoagulation, or deployment of clips. Polypectomy is performed in the same style contained of age, i.e., pocket-sized polyps are removed with cold snare polypectomy or biopsy forceps, larger polyps are removed with snare polypectomy with monopolar coagulation, and apartment or sessile polyps are removed after saline submucosal injection, possibly supplemented by argon plasma coagulation. With increasing age, big and apartment polyps are more mutual. Benign colonic strictures may be seen in patients with a surgical anastomosis, or in the presence of chronic ischemic colitis, inflammatory bowel disease or diverticulitis. In such patients, endoscopic dilation tin can be attempted under fluoroscopic observation. Malignant strictures are at greater risk of perforation with dilation. In selected patients with colonic malignancy who are not surgical candidates or who need preoperative decompression, self-expanding stents tin can be placed across the obstruction. Studies on endoscopic mucosal resection and endoscopic submucosal autopsy have included pocket-size numbers of elderly and very elderly patients, showing that these procedures are possible even in advanced age, although there are meaning complication risks similar to those seen in younger patients[46,47].
CONCLUSION
Colonoscopy in very elderly patients (over 80 years of historic period) carries a greater risk of complications, adverse events and morbidity than in younger patients, and is associated with lower completion rates and higher chance of poor bowel preparation. Although colonoscopic yield increases with age, several studies have suggested that the potential benefits are significantly decreased because of shorter life expectancy and greater prevalence of comorbidities. Thus, screening colonoscopy in very elderly patients should be performed only later on conscientious consideration of potential benefits, risks and patient preferences. Diagnostic and therapeutic colonoscopy are more than likely to benefit even very elderly patients, and in most cases should be performed if indicated.
Footnotes
P- Reviewers: Albuquerque A, Agaba EA, Uraoka T South- Editor: Wen LL L- Editor: A E- Editor: Zhang DN
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4055990/