Surgical Endoscopy

, Volume 21, Issue 10, pp 1806–1809 | Cite as

Colonoscopy in the very elderly: a review of 157 cases

  • Marc Zerey
  • B. Lauren Paton
  • Philip D. Khan
  • Amy E. Lincourt
  • Kent W. Kercher
  • Frederick L. Greene
  • B. Todd Heniford
Article

Abstract

Background

Colonoscopy is currently the best diagnostic modality for evaluating colonic diseases but studies of its use in the very elderly are limited.

Methods

A single-institution review of all patients aged 85 years or older who underwent colonoscopy from June 2003 to June 2005 was performed. Parameters evaluated included indications for colonoscopy, findings, ability to perform a complete colonoscopy, and immediate and delayed (≤21 days) complications.

Results

A total of 157 patients aged 85 years or older (median = 87, range = 85–99) underwent colonoscopy during the two-year period. The cecal intubation rate was 90%. Number of cancers detected/indications for colonoscopy include gross or occult bleeding per rectum, 3/51 (5.9%); abnormal physical exam, 1/2 (50%); abnormal abdominal computed tomography, 3/5 (60%); anemia, 1/25 (4.0%); screening, 0/14; previous history of colonic malignancy, 0/10; previous history of polyps, 0/21; change in bowel habits, 0/5; family history of colonic malignancy, 0/6; abdominal pain, 0/4; diarrhea, 0/6; fecal impaction, 0/2; unknown, 0/6. Immediate complications included hemorrhage at a polypectomy site in one patient that was controlled endoscopically, one episode of bradycardia, and one incident of atrial fibrillation. There were no delayed complications resulting from colonoscopy.

Conclusions

Our data suggest that colonoscopy can be safely and successfully performed in the very elderly. In patients with symptoms or suggestive radiographic findings, cancer was detected in 4.0%–60% of cases. No cases of cancer were discovered in those patients who were asymptomatic.

Keywords

Colorectal cancer Colonoscopy Elderly 

Colonoscopy is currently the preferred strategy for colorectal cancer (CRC) screening because of its greater sensitivity and specificity when compared with other modalities [6, 10]. Evidence for its effectiveness comes from cohort studies, which show a decrease in the incidence and mortality of CRC in subjects who have had adenomas removed [14, 15, 26]. In contrast to recommendations on the age to begin screening [25], no guidelines exist regarding the efficacy or safety of screening in the elderly or whether it should be stopped altogether beyond a certain age. With limited resources and an increasing elderly population, a critical view of health care expenditures is warranted, including the tests we perform.

Those aged 65 and 85 years constitute 12.7% and 1.7%, respectively, of the entire U.S. population of 293 million [21]. People aged above 85 years are projected to be the fastest growing part of the elderly population during this century, rising from 5 million to 18 million by 2050 [20]. Although average life expectancy at birth in the United States was 77.5 years in 2003 [3], once an individual reaches 80 years, the life expectancy is 8.3 years; at age 85 the average life expectancy is 6.0 years. The decision to proceed with invasive testing and treatments depends on the clinical judgment of the physician, desires of the patient, presence of other life-limiting comorbidities, projected lifespan, and possibility and length of protective benefit from the procedure. For colonoscopy, the decision should also be based on evidence of the prevalence of colorectal neoplasia with advancing age.

Colonoscopy may have a limited value in the very elderly. Removing a benign (although premalignant) polyp in persons whose average life expectancy is less than ten years may have no impact on their survival rate [13]. However, diagnosing and treating colon cancers in which a 5-year survival rate is 60% may significantly affect life expectancy and quality of life. Considering these factors, we evaluated the clinical results, diagnostic yield, morbidity, mortality, and cost-effectiveness of colonoscopy in patients 85 years of age or older.

Methods

We performed a retrospective review of all patients aged 85 years or older who underwent colonoscopy from June 2003 to June 2005 at our institution. Parameters evaluated included age, indications for colonoscopy, findings, ability to perform a complete colonoscopy, and immediate and delayed (≤21 days) complications. Following Institutional Review Board approval, data were obtained from a prospectively compiled database of over 29,000 patients who had undergone diagnostic and therapeutic upper and lower endoscopy during the study period. For each colonoscopy, a mechanical bowel prep was administered and a history and physical examination were performed before the procedure. The risks and benefits of the procedure and the sedation options and risks were discussed with the patient. All questions were answered and informed consent was obtained. The heart rate, respiratory rate, oxygen saturation, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure. The colonoscope was passed under direct vision. Findings at colonoscopy, impressions, and recommendations were noted and dictated as a formal procedure note.

Results

From June 2003 to June 2005 a total of 16,133 colonoscopies were performed by members of the Departments of Surgery and Gastroenterology at the Carolinas Medical Center. One hundred fifty-seven (1%) were performed on patients aged 85 years or older (median = 87, range = 85–99). Patient demographics and location of colonoscopy (inpatient vs. outpatient) are detailed in Table 1. The cecal intubation rate was 90%. Indications for colonoscopy and findings are displayed in Table 2. There was a total of eight (5.1%) colonic carcinomas detected. Furthermore, 108 adenomatous and 28 hyperplastic polyps were removed. Three patients had biopsy-proven colitis.
Table 1.

Patient demographics

Gender

Male, Female

57 (36.3%), 100 (63.7%)

Age (years)

Mean (range)

87.9 (85–99)

Setting

Inpatient, Outpatient

51 (32.5%), 106 (67.5%)

Table 2.

Findings at colonoscopy as a function of indication

Indication

N

Normal

Cancer

Adenomas

> 2 adenomas

Angiodysplasia

Colitis

Screening

14

8 (57%)

0

10

1

0

0

Bleeding

51

23 (45%)

3

32

4

1

0

Anemia

25

15 (60%)

1

15

2

1

0

Previous colonic malignancy

10

4 (40%)

0

8

1

0

0

Previous polyp

21

6 (29%)

0

18

2

0

0

Abnormal CT

5

0 (0%)

3

1

0

0

1

Abnormal P/E

2

1 (50%)

1

1

0

0

0

Family history colonic malignancy

6

3 (50%)

0

6

1

0

0

Abdominal pain

4

3 (75%)

0

2

0

0

0

Diarrhea

6

2 (33%)

0

5

1

1

1

Change in bowel habits

5

3 (60%)

0

2

0

0

0

Fecal impaction

2

2 (100%)

0

0

0

0

0

Unknown

6

1 (17%)

0

8

1

0

1

Total

157

71 (45%)

8 (5.1%)

108

13 (8.3%)

3 (1.9%)

3 (1.9%)

CT = computed tomography; P/E = physical examination

The number of cancers detected for a given indication for colonoscopy was as follows: gross or occult bleeding per rectum, 3/51 (5.9%); abnormal physical exam, 1/2 (50%); abnormal abdominal computed tomography, 3/5 (60%); anemia, 1/25 (4.0%); screening, 0/14; previous history of colonic malignancy, 0/10; previous history of polyps, 0/21; change in bowel habits, 0/5; family history of colonic malignancy, 0/6; abdominal pain, 0/4; diarrhea, 0/6; fecal impaction, 0/2; unknown, 0/6 (Table 2). Six of eight patients in whom a malignancy was found underwent colectomy (5 curative, 1 palliative) (Table 3). The staging for patients who had surgery was T3N0MX (Stage II) for five patients and T3N2M1 for one patient [4]. One patient from this group died postoperatively of acute respiratory failure and cardiovascular collapse secondary to pulmonary emboli. The postoperative course of the remaining five patients was uneventful, with overall length of stay varying between 4 and 12 days. As a result of multiple medical problems, including severe dementia, surgery was not considered a viable option in one patient (following discussion with patient’s power of attorney) and thus was offered comfort measures alone. Finally, one patient presented with a left axillary mass of unknown primary. This was followed by a CT scan that revealed a lesion on the left adrenal gland and another at the cecum. A colonoscopy confirmed the presence of a cecal mass and on biopsy was found to be a poorly differentiated neuroendocrine tumor. It is unknown if the patient underwent resection.
Table 3.

Outcomes of patients with cancer detected at colonoscopy

Patient

Setting

Indication

Location of tumor

Operative procedure

Stage

Complications

LOS (days)

87M

Inpatient

Abnormal CT

Cecum

RHC

T3N0MX

Pulmonary embolism, death

N/A

87F

Inpatient

Bleeding

Ascending colon

RHC

T3N0MX

None

10

85F

Outpatient

Anemia

Hepatic flexure

RHC

T3N0MX

None

8

97F

Inpatient

Abnormal CT

Splenic flexure

LHC

T3N0MX

None

10

86F

Outpatient

Abnormal P/E

Rectum

LAR

T3N2M1

None

12

95F

Inpatient

Bleeding

Rectum

Not performed

N/A

N/A

N/A

85M

Outpatient

Abnormal CT

Cecum

Not performed

N/A

N/A

N/A

85M

Inpatient

Bleeding

Cecum

RHC

T3N0MX

None

4

CT = computed tomography; P/E = physical examination; RHC= right hemicolectomy; LHC= left hemicolectomy; LAR= low anterior resection

Staging of tumor based on American Joint Committee on Cancer [1]

Complications that occurred during colonoscopy included hemorrhage at a polypectomy site in one patient that was controlled endoscopically, one episode of bradycardia, and one incident of atrial fibrillation. There were no delayed complications resulting from colonoscopy.

Discussion

Given the medicoeconomic climate in this country, it is relevant to address organ-specific health concerns related to various segments of our population. In a healthy elderly patient, the decision to proceed with invasive testing and treatments should be weighed against a possibly limited physiologic reserve to deal with potential complications. Other factors include the clinical judgment of the physician, desires of the patient, presence of other life-limiting comorbidities, projected life span, and length of protective benefit from the procedure.

A total of 1,372,910 new cancer cases and 570,280 deaths were expected in the United States in 2005. When deaths are aggregated by age, cancer has surpassed heart disease as the leading cause of death for persons younger than 85 since 1999 [7]. Adenocarcinoma of the colon and rectum is the third most common site of new cancer cases and deaths in both men and women in the United States [7]. The estimated number of new cases in 2005 was 145,290 with 56,290 deaths from the disease [7]. The lifetime risk of developing colorectal cancer in the United States is approximately 6%, with over 90% of cases occurring after age 50 [4]. Colonoscopy is an important tool for the diagnosis and surveillance of colonic neoplasms and for the treatment of appropriately selected lesions [14]. Numerous publications have documented the benefits of colonoscopy [2, 11, 12, 16, 22, 23], however, only a few have discussed its value in the elderly [5, 17, 18, 24].

We have retrospectively reviewed outcomes for all patients 85 and older who underwent colonoscopy over a two-year period. Colonoscopy was well tolerated by the large majority of patients. Three patients (1.9%) experienced short-term complications related to the procedure: Two patients experienced arrhythmia (both self-limited) and one patient had bleeding at the polypectomy site which was controlled endoscopically at the time of the original procedure. There were no perforations or other delayed complications resulting from the colonoscopy itself. Complete visualization of the colon was also possible in the majority of patients (90%). These findings demonstrate that colonoscopy is safe and successful in the majority of patients in this age group. Indeed, its safety profile is similar to that of barium enema [8], but with the added advantage of being able to biopsy at the time of the procedure if the need arises.

In our study cohort colonoscopy detected an invasive cancer in eight patients (5.1%), all of whom presented with an abnormality based on history, physical exam, laboratory values, or radiology. Among these patients, six underwent resection (5 curative, 1 palliative for obstruction), one declined, and whether the final patient had surgery remains unknown. Five of six patients (83.3%) who underwent resection had an uneventful postoperative course despite their age.

There were no carcinomas detected in patients who presented for screening or who were asymptomatic. This compares with expected rates of 0.5%–1.0% for large cohorts of patients of all ages undergoing screening colonoscopy [11, 18]. Stevens and Burke [18] tried to establish whether the prevalence of neoplasia detected by colonoscopy diminished with advancing age, to warrant ceasing colonoscopic screening. In the asymptomatic patients they surveyed, they found that the prevalence of neoplasia (including adenomas) was less in patients between 81 and 100 years old (14%) compared with patients between 50 and 80 years old (21%). However, they also determined that the incidence of advanced adenomas and multiple adenomas increased with age.

Recently, Duncan et al. [5] reviewed 1199 colonoscopies in patients 80 years and older and distinguished between findings in symptomatic and asymptomatic patients. Colonoscopy detected only four malignancies in asymptomatic patients who had presented for colorectal cancer screening (0%; 0/86), polyp surveillance (1.3%; 3/227), and colorectal cancer surveillance (0.9%; 1/108). These findings were in contrast to the relatively higher rates of cancer and advanced adenomas in patients who had anemia, occult or frank gastrointestinal bleeding, changes in bowel habits, or other symptoms (6.3%; 27/431). Given the lack of cancers found in both screening and surveillance groups, the authors concluded that we should refine the role of colonoscopy in the elderly.

Despite there being no malignancies detected in patients who underwent colonoscopy for screening or followup purposes, we would not discourage screening or followup colonoscopy in asymptomatic patients based on these results. This particular group of patients was relatively small (less than one-third of patients sampled). In addition, the very elderly patients tolerated the procedure well. Several published reports conclude that colonoscopy remains a safe, well-tolerated procedure with a low rate of complications in the elderly [9, 17, 19]. Therefore, making a steadfast recommendation to stop colonoscopic screening in an asymptomatic patient based on age alone would be premature.

Conclusions

Our results show that the safety profile of colonoscopy in the very elderly is excellent. Those patients with symptoms or radiographic findings have a relatively high incidence of colonoscopic abnormalities. If cancer is detected, this is usually amenable to resection. Age alone is not a contraindication. The decision to proceed with colonoscopy for colorectal cancer screening should be individualized in the asymptomatic elderly patient.

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Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Marc Zerey
    • 1
  • B. Lauren Paton
    • 1
  • Philip D. Khan
    • 1
  • Amy E. Lincourt
    • 1
  • Kent W. Kercher
    • 1
  • Frederick L. Greene
    • 1
  • B. Todd Heniford
    • 1
  1. 1.Division of Gastrointestinal and Minimally Invasive SurgeryCarolinas Medical CenterCharlotteUSA

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