The elderly and stopping rules

From Clinical Guidelines Wiki


Background

Australia has an ageing population and life-expectancy continues to rise making the question of when to stop surveillance colonoscopy increasingly important. Although the incidence of CRC or pathology at screening or diagnostic colonoscopy increases with age,[1] there is no evidence that metachronous neoplasia is greater in the elderly. It must also be remembered that colonoscopy and adenoma removal is highly protective for lengthy periods, that most polyps do not develop into CRC and that the lead time for progression of an adenoma to CRC is perhaps 10–20 years. Therefore, there may be minimal benefit in offering surveillance for most elderly individuals. Importantly, there is also increased risk associated with performing colonoscopy in the elderly. The elderly have more co-morbidities, reduced organ reserve and increased morbidity and mortality following procedures.[1][2] The 2011 Australian Clinical Practice Guidelines for Surveillance Colonoscopy[3] concluded that most individuals aged 75 years or older would not benefit from surveillance.

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Overview of evidence (non-systematic literature review)

Systematic review was not undertaken for this question. Non-systematic review of the general literature was undertaken with limited results. The literature on colonoscopy in the elderly is mostly from the US and focuses on the role of screening colonoscopy in the elderly rather than surveillance. Some parallels can be made in terms of procedure-related complications, however.

The area of decision-making in the elderly is not well-researched in terms of surveillance colonoscopy, although one study[4] looked at understanding decision-making around recommending surveillance colonoscopy in the elderly. Importantly, specialist recommendation markedly influenced primary-care providers recommending surveillance. Other influences were life expectancy, patient preferences, safety of the procedure and previous findings.

One older review of 1199 colonoscopies on patients ≥80years (of which 227 (19.3%) were done for surveillance), demonstrated the risk of advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia. was 14% and CRC 1%.[5] A more recent paper[6] looked at the incidence of CRC in patients undergoing surveillance colonoscopy and compared findings in those aged 50–74 years with those ≥75 years of age. In the older group, the rate of CRC was 0.24 per 1000 person-years vs 3.61 per 1000 person-years in the younger group, p<0.001. In Cox regression analysis, the HR for CRC in the elderly patients compared with the younger group was 0.06 (95% CI, 0.02–0.13, p<0.001), after adjusting for comorbid illness, sex, and ethnicity. This result seems counter-intuitive but may be indicative of the protection afforded by colonoscopy over time.

Life expectancy decreases with age and co-morbidity, a validated measure of which is the Charlson score,[7] which can be quickly calculated via online calculators or downloadable Apps. A single centre study followed 404 patients ≥75 years of age after colonoscopy for varying indications including surveillance and screening until death.[8] Mortality was predicted by age (HR 1.16 for each year after 75 years, 95% CI 1.07-1.3, p=0.0003) and Charlson score (HR 8.3 for each point increase, 95% CI 1.4-48.5, p=.02). The median survival of patients age 75–79 years was >5 years if the Charlson score was ≤4. Among patients age ≥80 years, the median survival was <5 years regardless of Charlson score.

A comprehensive review of the literature in terms of the elderly was recently published[2] and highlighted that the elderly are more likely to experience a poor bowel preparation, (regardless of compliance and preparation type) and that increasing age may be related to reduced completion rates. Most importantly, age was a critical factor in the occurrence of adverse events, with a 34.8 per 1000 colonoscopies composite rate (perforation, bleeding, cardiovascular and pulmonary events) in those ≥80 years. Octogenarians experienced a 70% increased risk of adverse events compared with those who were younger. The consequences of non-fatal events were noted as “more severe and protracted.”

In a large retrospective cohort study in the US, patients ≥50 years of age undergoing surveillance colonoscopy between 2001 and 2010,[6] 4834 patients ≥75 years of age were compared with 22,929 age 50–74 years. After adjustment for multiple factors, the elderly were more likely to be hospitalised post-procedure, RR 1.28 (1.07–1.53), p=0.006, with a Charlson score of ≥2 being an independent predictor when compared with a score of 0 or 1, (adjusted OR 2.54 [2.06–3.14]).

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Expert opinion and guidelines from other countries

The Norwegian Guidelines[9] for surveillance are the only international recommendations to have an age cut-off of ≥75 years of age for surveillance.

Practice Points

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Careful assessment and shared decision-making should be utilised when considering surveillance colonoscopy in the elderly, most of whom will have no significant findings and will not benefit.

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Surveillance colonoscopy in those ≥75 years should be considered based on age, co-morbidity and the preferences of the patient. The reproducible and validated Charlson score is useful to assess life expectancy and could be implemented to assist decision-making (see Tables 17 and 18 below).

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In obtaining consent for colonoscopy for an elderly patient, complication rates should reflect the individual risk based on age and comorbidity rather than ‘standard’ figures.

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Surveillance recommendations for individuals age ≥75years


Table 17. Surveillance recommendations for individuals age ≥75 years

Age (years) Charlson scorea
≤4 >4
75–80 Surveillance colonoscopy to be considered b,c Surveillance colonoscopy not recommended
>80 Surveillance colonoscopy not recommended
aCharlson for colonoscopy benefit can be simplified as per Table 18; bcolonoscopy should be considered an option dependent on a clear conversation about the low risk of significant colorectal pathology, taking the patient’s wishes into consideration; cconsent for colonoscopy should include age appropriate statistics on risk.
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Charlson score for colonoscopy benefit


Table 18. Charlson score for colonoscopy benefit

Age Medical conditions
75–79 years

(3 points for age)

May have one of these conditions only (1 point each):

Mild liver disease

Diabetes without end-organ damage

Cerebrovascular disease

Ulcer disease

Connective tissue disease

Chronic pulmonary disease

Dementia

Peripheral vascular disease

Congestive heart failure

Myocardial infarction

May not have any of these medical conditions

(≥1 point each):

Moderate/severe liver disease

Diabetes with end-organ damage

Hemiplegia

Moderate or severe renal disease

AIDS

MetastaticCancer that has spread from the primary site of origin (where it started) into different area(s) of the body. or non-metastaticCancer that has spread from the primary site of origin (where it started) into different area(s) of the body. solid organ or haematopoietic malignancy

80 years

(4 points for age)

May not have any of the above medical conditions
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References

  1. 1.01.1 Lin OS. Performing colonoscopy in elderly and very elderly patients: Risks, costs and benefits. World J Gastrointest Endosc 2014 Jun 16;6(6):220-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24932373.
  2. 2.02.1 Day LW, Walter LC, Velayos F. Colorectal cancer screening and surveillance in the elderly patient. Am J Gastroenterol 2011 Jul;106(7):1197-206;quiz 1207 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21519362.
  3. Cancer Council Australia Colonoscopy Surveillance Working Party. Clinical Practice Guidelines for Surveillance Colonoscopy – in adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Sydney: Cancer Council Australia; 2011 Dec.
  4. Le ST, Lash BR, Schroy PC 3rd, Calderwood AH. Physician Perceptions of Surveillance Follow-up Colonoscopy in Older Adults. J Am Board Fam Med 2017 May;30(3):371-373 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/28484069.
  5. Duncan JE, Sweeney WB, Trudel JL, Madoff RD, Mellgren AF. Colonoscopy in the elderly: low risk, low yield in asymptomatic patients. Dis Colon Rectum 2006 May;49(5):646-51 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16482421.
  6. 6.06.1 Tran AH, Man Ngor EW, Wu BU. Surveillance colonoscopy in elderly patients: a retrospective cohort study. JAMA Intern Med 2014 Oct;174(10):1675-82 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25111954.
  7. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 2011 Mar 15;173(6):676-82 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21330339.
  8. Kahi CJ, Azzouz F, Juliar BE, Imperiale TF. Survival of elderly persons undergoing colonoscopy: implications for colorectal cancer screening and surveillance. Gastrointest Endosc 2007 Sep;66(3):544-50 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17725944.
  9. Hoff G, Sauar J, Hofstad B, Vatn MH. The Norwegian guidelines for surveillance after polypectomy: 10-year intervals. Scand J Gastroenterol 1996 Sep;31(9):834-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8888428.

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