Colonoscopy in Nonagenarians Is Safe and May Be Associated With Clinical Benefit

Asher Shafrir, MD; Benjamin Koslowsky, MD; Dov Wengrower, MD; Eran Goldin, MD; Dan M. Livovsky, MD

Disclosures

J Am Geriatr Soc. 2019;67(6):1158-1163. 

In This Article

Abstract and Introduction

Abstract

Objectives: Data regarding colonoscopy in patients older than 90 years old is scarce. Yet the number of colonoscopies done on nonagenarians is rising. We aimed to determine the yield, safety, and therapeutic benefits of colonoscopy in these patients.

Design: Case-control study of older patients who underwent colonoscopy.

Setting: Gastroenterology institute at an academic medical center.

Participants: Patients older than 90 years (n = 128) compared with patients aged 80 to 89 years (n = 218) who underwent colonoscopy.

Intervention: Colonoscopy.

Measurements: Indication for the procedure, completion rates, adequacy of preparation, complications, colonoscopic findings, 30-day mortality, advanced adenoma and carcinoma detection rate, treatment, and long-term survival of patients diagnosed with colorectal cancer.

Results: Mean ages were 83.3 and 92.2 years old. Nonagenarians were more likely to undergo a colonoscopy while hospitalized (56.2 vs 23.4%; P < .001) and to undergo the examination due to rectal bleeding or sigmoid volvulus (35.2 vs 25.2 and 10.9 vs 0.5%, respectively; P < .001) and less likely for surveillance or constipation (11.7 vs 25.7 and 0 vs 6.9%, respectively; P < .001). Completion rates and severe adverse events were comparable. The 30-day mortality was 3.9% in nonagenarians and 0.4% in octogenarians (P = .02). Advanced adenomas and carcinoma were more common in nonagenarians (25.8 vs 16.5%, P = .03, and 14.8 vs 6.4%, P = .01, respectively). Increasing age, inpatient status, past polypectomy surveillance, and anemia were associated with higher rates of carcinoma. Half of the nonagenarians diagnosed with adenocarcinoma underwent surgery compared with 100% of octogenarians (P = .01). Among nonagenarians with colorectal cancer who died, mean survival was 605 (interquartile range = 11-878) days in those who underwent surgery and 112 (48-341) in those treated conservatively (P = .055 log-rank test).

Conclusion: Colonoscopy in nonagenarians has a high yield and is generally safe. Colonoscopy findings lead to surgery in more than half of these patients and was associated with a median survival of 20 months.

Introduction

With increasing life expectancy, clinicians are often faced with dilemmas concerning the treatment of older patients. Data regarding yield and safety of colonoscopy in patients older than 90 years are scarce. Yet the number of colonoscopies done on nonagenarians is rising.[1]

Increasing age is associated with a higher incidence of colorectal carcinoma (CRC),[2] and the use of colonoscopy for early detection of colorectal neoplasia is associated with a survival benefit.[3,4] However, the potential benefits of the procedure should be weighed against the possible risks and adverse effects. Few studies have shown that colonoscopy is safe, feasible, and improves life expectancy[2] in older patients; however the vast majority of these studied were mostly done on octogenarians or even younger populations (ie, 80-89 y).[5–8] Nonagenarians, that is, patients 90 years or older, represent a unique population in whom data are even more scarce.

On the one hand, the benefit of colonoscopy is questionable, due to a relatively short life expectancy. Moreover, due to comorbidities, sedation risks, and increased risk of dehydration and electrolyte disturbances during preparation, safety is a major concern. On the other hand, the yield is expected to be high because nonagenarians have high risk for significant findings on colonoscopy. It is in this setting that additional data are crucial to help the clinician make the appropriate decisions regarding performing a colonoscopy on a nonagenarian patient.

Furthermore, long-term follow-up after colonoscopy in nonagenarians including procedures performed and long-term prognosis has not been published previously. To the best of our knowledge, there is only one published study[9] exploring the feasibility, safety, and yield of colonoscopy in nonagenarians.

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