CLINICAL AND SYSTEMATIC REVIEWS

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Colorectal Cancer Screening and Surveillance in the Elderly Patient Lukejohn W. Day, MD1,2, Louise C. Walter, MD3 and Fernando Velayos, MD, MPH4

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Older age is associated with a rise in colorectal cancer and adenomas, necessitating the need for CRC screening in older patients. However, decisions about CRC screening and surveillance in older adults are often difficult and challenging. The decision requires an individualized assessment that incorporates factors unique to performing colonoscopy in older adults in order to weigh the risks and benefits for each patient according to their overall health and preferences. This review addresses the factors unique to colorectal cancer and performing colonoscopy in older adults that are relevant in weighing the risks and benefits of screening and surveillance in this population. Am J Gastroenterol 2011; 106:1197–1206; doi:10.1038/ajg.2011.128; published online 26 April 2011

INTRODUCTION Colorectal cancer (CRC) is common, with nearly 146,970 new cases and 49,920 deaths in 2009 (1). It is the third most common cancer diagnosed in both men and women and the third leading cause of cancer-related deaths in the United States. While studies support CRC screening programs in reducing CRC death, they have not focused on or included older patient populations. The incidence of CRC doubles each successive decade between the ages of 40 and 80 (2). Consequently, the elderly (defined by the World Health Organization as ≥65 years of age) are disproportionately affected by CRC. Individuals over the age of 65 have an age-adjusted CRC incidence rate of 254.2/100,000 persons compared with 18.1/100,000 in individuals under the age of 65 (3). The elderly population is heterogeneous with some older adults being quite healthy, while others have significant comorbid medical conditions making the decision for screening and surveillance complex. Adding further to this discussion is the role and potential risks of colonoscopy in the very elderly patient (i.e., patients ≥80 years). This has emerged as a widely debated subject in light of the recent guidelines from the United States Preventative Services Task Force recommending against CRC screening in patients over the age of 75 years (4). Age also affects the benefits and harms of CRC screening and surveillance with some aspects of aging favoring screening (e.g., cancer incidence increases), while other aspects disfavor screening (e.g., life expectancy decreases). This review addresses several important topics that may facilitate the complex and challenging

decision-making process related to CRC screening and surveillance in the elderly patient. First, we examine the incidence of CRC and adenomas in the elderly followed by a discussion on the recurrence of CRC and new adenomas in the elderly after an initial screening colonoscopy. Second, we answer whether age should be a factor in CRC surveillance intervals. Third, we address a widely debated topic on when to discontinue CRC screening in the elderly and how comorbid medical conditions of the patient may influence this decision. Last, we focus on the specifics of colonoscopy itself with an emphasis on the effect of age on adverse events, safety of bowel preparation, and completion rates. At the end of each section, we provide a brief answer to each question. What is the incidence and prevalence of CRC and adenomas in elderly patients and does age play a factor?

The incidence rate of CRC increases steadily with age. In 2007, the Surveillance Epidemiology End Results registry reported that CRC incidence was 74.5/100,000 in persons 50–64 years of age, 186.0/100,000 in persons 65–74 years of age, and 290.1/100,000 in persons ≥75 years of age (Figure 1). This trend of increasing CRC incidence in the elderly was confirmed in a large prospective cohort study of average risk patients undergoing colonscopy (5). Also, the elderly constitute the greatest proportion of new diagnoses of CRC with 24.4% occurring in persons aged 64–74 years, 26.8% aged 75–84 years, and 12.2% in persons older than 85 years (3). Autopsy and colonoscopy studies demonstrate that, similar to CRC, the prevalence of precancerous adenomatous polyps and

1 Division of Gastroenterology, San Francisco General Hospital, San Francisco, California, USA; 2Department of Medicine, GI Health Outcomes, Policy and Economics (HOPE) Research Program, University of California, San Francisco, California, USA; 3Division of Geriatrics, San Francisco VA Medical Center and University of California, San Francisco, USA; 4Gastroenterology Division, Department of Medicine, University of California, San Francisco, California, USA. Correspondence: Lukejohn W. Day, MD, Division of Gastroenterology, San Francisco General Hospital, 1001 Potrero Avenue, 3D-5, San Francisco, California 94110, USA. E-mail: [email protected] Received 6 October 2010; accepted 7 March 2011

© 2011 by the American College of Gastroenterology

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years of age to 8.7–13% in patients over 70 years of age (5,12,13). Interesting observations from both autopsy and colonoscopy studies are that older patients have a higher predominance of right-sided adenomas compared with their younger counterparts (8,11,12) and may have larger-sized adenomas (9,11). Together, all of these data indicate that both precancerous polyps and CRC itself increase with advancing age, which supports CRC screening for older adults. The incidence and prevalence for both CRC and adenomas is associated with and steadily rises with age.

Age-adjusted SEER incidence rates by age at diagnosis/death colon and rectum, all races, both sexes 2000–2007 (SEER 17)

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1198

450

400

Rate per 100,000

350

300

250

Does increasing age influence the recurrence of new polyps or cancer detected after a screening colonoscopy and should surveillance recommendations be tailored by age?

200

150

100

50

0 2000

2005

2007

Year of diagnosis Ages < 65 Ages 65+ Ages 75+

Ages 50–64 Ages 65–74

Cancer sites include invasive cases only unless otherwise noted. Incidence source: SEER 17 areas (Sen Francisco, Connecticut, Detroit, Hawali, lowa, New Mexico, Seattie, Utah, Atlanta, Sen Josc-Moneterey, Los Angeles, Ajaska Native Registry, Rural Georgia, Calfornia excluding SF/SJM/LA, Kentucky, Louisiana and New Jersey). Retes are per 100,000 and are age adjusted to the 2000 US Std Population (19 age groups– Census P25-1130) Regression line are calculated using the Jointpoint Regression Program Version 3.4.3, Aprol 2010, National Cancer Institute.

Figure 1. Age-adjusted Surveillance Epidemiology End Results (SEER) incidence rates by various age stratifications at diagnosis/death for colorectal cancer (2000–2007) (3).

advanced adenomas (defined as size ≥10 mm, villous/tubulovillous histological features, or high grade dysplasia) also increases with age (5–7). In autopsy studies, the prevalence of adenomatous polyps in persons ≥65 years of age ranges widely from 4 to 60% (7–11). There is considerable variation in the point estimate, likely due to geographical variations. These studies, nonetheless, show the trend that prevalence of adenomas rises after the age of 65 and continues to escalate sharply in the very elderly. Screening colonoscopy studies have found a much lower point prevalence of adenomatous polyps and advanced adenomas compared with autopsy studies, although a trend toward increasing prevalence with age was still present. In a large cohort of Israeli patients undergoing screening colonoscopy, Strul et al. noted that the prevalence of adenomas increased from 12.5% in persons 50–59 years of age to 25% in those patients 70–75 years of age (12). In several large prospective cohort studies, a similar trend was observed with advanced adenomas. Prevalence increased from 2.4–6.1% in persons 50–59 The American Journal of GASTROENTEROLOGY

The recurrence of new adenomas and CRC after an initial screening colonoscopy is not influenced by age. With respect to polyps, the National Polyp Study was the first to informally address the recurrence rate of new advanced adenomas after colonoscopy. In this randomized trial comparing 1 and 3 years surveillance intervals after polypectomy, no association with age and polyp recurrence was demonstrated (14). This was confirmed with data from the Cleveland Clinic Registry, which reported that age did not predict new adenoma recurrence (15). More recently, two separate studies utilizing the Mayo Rochester endoscopic database in patients who underwent surveillance colonoscopy examined the question of age and new polyp recurrence. In their first cohort study of 55,037 patients, there were equivalent recurrence rates for polyps ≥5 and ≥10 mm for all patients regardless of age such that only the index polyp size was a predictor of recurrence (16). In a parallel study that focused on patients ≥70 years, there was a slight increase in the detection of polyps ≥10 mm after initial colonoscopy for three age groups (70–74, 75–79, ≥80 years), but this was not statistically significant after adjusting for gender and screening/surveillance status (17). Both studies are important in that they confirm that age is not associated with the detection of new polyps after an index colonoscopy. Not unlike data on the recurrence of new polyps, several studies have illustrated that age does not significantly affect the detection of new CRC lesions after an initial colonoscopy. The National Polyp Study verified that age was not a predictor in the detection of adenomas with advanced pathological features (which included invasive cancers) at follow-up colonoscopy 1 year after a polypectomy (14). Similar detection rates for recurrent polyps > 10 mm, including invasive cancer, have been reported across several older age strata in patients undergoing surveillance colonoscopy (16). Furthermore, in multiple, large studies examining CRC recurrence in patients who had previously been diagnosed and treated for CRC, none have shown or reported age to be associated with cancer recurrence (18–27). Instead, other factors such as family history of CRC, presence of extracolonic malignancy, detection of synchronous lesions, coexisting adenomas (26), perforation (28), and symptoms (20) are all more predictive of CRC recurrence. The elderly are not at a significantly increased risk for the recurrence of either new adenomas or CRC after screening colonoscopy. As a result, surveillance guidelines do not need to be tailored by age. VOLUME 106 | JULY 2011 www.amjgastro.com

At what age does CRC screening cease to provide an important potential extension in life expectancy and, therefore, not be offered?

Numerous modeling studies have attempted to define the age at which screening, specifically utilizing colonoscopy, may not lead to a significant extension in life expectancy in older populations (29,30). Inadomi and Sonnenberg (29) illustrated that screening colonoscopy resulted in a significantly shorter extension of life in elderly patients (70–74 years) when compared with younger patients (50–54 years). In fact, employing a one-time screening colonoscopy after the age of 60 has significant diminishing returns with respect to the percentage of life years saved (30). Along the same lines, Lin et al. (31) demonstrated a 6.5-fold difference between the mean extension of life expectancy in patients ≥80 years compared with younger patients (50–54 years). In this study, the absolute extension of life expectancy was 0.13 vs. 0.85 years, respectively, for each group. These studies confirm what one might expect; although CRC increases with age, the net benefit of colonic screening, as measured by extension of life expectancy, diminishes with age given several factors: mortality due to competing comorbidities, risks associated with screening, and finally natural life expectancy. Another approach for attempting to define the age at which screening ceases to provide a meaningful extension in life expectancy has been to model the consequences of early discontinuation of screening. Decreasing the age at which a patient stops screening colonoscopy has been shown on several occasions to result in minimal reductions in life years gained. Zauber et al. (32) reported that lowering the screening age from 85 to 75 years resulted in minimal reductions in life years gained, but at the same time utilized far fewer colonoscopy resources. Equally, Maheshwari modeled the impact of ending CRC screening at various ages compared with lifelong screening and reported diminishing returns for days of life lost after the age of 70 in people who underwent any form of screening. In a separate analysis, they also illustrated that 80% of the total expected benefit of lifelong screening would be achieved by screening up to the age of 82 (33). The challenge of using modeling studies to define when cancer screening should no longer be offered is that these models cannot address the heterogeneity of life expectancies in the older population, where some individuals have the chance to gain over several years of life expectancy, while others very little. Another challenge with using these studies is that assumptions are based on the average life expectancy in the United States (77.8 years). One could argue that differences in life years saved by screening could vary depending on a patient’s geographic location given varying life expectancies in North America, Europe, Asia, and other nations. Despite the recognized limitations, these modeling data do support the hypothesis that although CRC incidence increases with age, the gain in life years achieved by CRC screening is reduced as one ages. Several published guidelines have addressed acceptable CRC screening methods and intervals, but few have addressed when to discontinue CRC screening, and in particular colonoscopy (34,35). The 2008 United States Preventative Services Task Force recommends against routine CRC screening in patients aged 76–85, © 2011 by the American College of Gastroenterology

but they caution that individual considerations such as health status of the patient should factor into this decision. Furthermore, the United States Preventative Services Task Force recommended against any CRC screening in patients older than 85 years (4), regardless of health status. This recommendation is based on the risks of CRC screening likely outweighing the potential benefits in the majority of people aged 85 or older. The gain in life expectancy from screening colonoscopy diminishes with increasing age and this gain becomes significantly less at ages over 80. While the United States Preventative Services Task Force is the only society to endorse an age at which CRC screening should no longer be offered most agree that the health status as well as age should have an important role in when to discontinue screening. Does a patient’s comorbid medical condition(s) influence the benefit from CRC screening in the elderly and thus be used in the decision to screen?

Comorbid medical conditions increase with advancing age and appear to have a powerful role in whether older adults are likely to derive net benefit from CRC screening. A comorbid medical condition reflects the presence of one or more disease(s) in addition to a patient’s primary disease. Examples include myocardial infarction, congestive heart failure, cerebrovascular disease, dementia, or ulcer disease. The benefit from screening appears to be influenced by age, health status, and screening modality. Ko et al. showed that the greatest number needed to screen to derive a benefit (defined as prevention of CRC-related death) was in the older, ill patient using fecal occult blood testing. Colonoscopy had the greatest benefit, but it also carried the greatest risk of complications, thus negating its overall benefit. Notably, in their study, men ≥85 years and women ≥90 years did not benefit from CRC screening under any proposed scenario of screening (fecal occult blood testing, sigmoidoscopy, or colonoscopy) (36). However, this study relied purely on modeling data for their conclusions and while helpful, it has limitations since it incorporated multiple assumptions. Extending beyond modeling data, more recent outcome data have become available. Two retrospective studies yielded similar conclusions that comorbid medical conditions reduce the benefit of CRC screening. In the first study, Kahi et al. retrospectively examined a group of Veterans Administration patients > 75 who had undergone colonoscopy and followed them for nearly 5 years. In their cohort of 404 patients, a small number of eight patients (2%) were diagnosed with CRC. In their study, the majority of patients overwhelmingly passed away from other illnesses such as cardiovascular (CV) and pulmonary disease as well as extracolonic malignancies. Only a small fraction of their cohort died as a direct result of CRC. Only age and severity of comorbidity (as reflected by Charlson comorbidity score) were predictive of mortality in patients who had undergone colonoscopy. Interestingly, in patients ≥80, the median survival after a diagnosis of CRC was < 5 years regardless of Charlson comorbidity score, indicating that comorbidity may have less of a role than simple age in survival among the very oldest patient (37). In a second study, Gross et al. examined 35,755 early stage CRC patients and found a The American Journal of GASTROENTEROLOGY

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reduction in life expectancy of 60% in men and 70% in women (at 67 years) in patients with three chronic medical conditions compared with patients with no chronic conditions. These data imply that survival, in even an early diagnosis of CRC, is more strongly associated with the number of coexisting illnesses rather than age. Going even further, they demonstrated that patients with a greater burden of chronic disease had poorer survival after CRC cancer therapy (38). Even though this study relied on administrative claims data, it sheds light on the importance of the number of coexisting disease(s) and its detrimental effect on life expectancy and survival with treatment after a diagnosis of CRC. Thus, both studies demonstrate that the burden and severity of comorbidity decreases the net benefit from screening from two vantage points. First, comorbidity is associated with decreased survival after treatment for CRC, even when CRC is detected early by screening. Second, patients with more severe comorbid medical conditions succumb to other diseases other than CRC even in the setting of screening. The only exception is in the very elderly, where age itself, and not comorbidity, appears to be the key determinant of mortality. Increasing number and severity of comorbid medical conditions adversely affect one’s survival after a diagnosis of CRC discovered through screening colonoscopy. Comorbidity should strongly be considered when making recommendations about CRC screening to older patients, including how an individual’s comorbidities may affect their life expectancy and the risk for adverse effects of screening and treatment. Does age have an important role in adverse event rates in patients who undergo colonoscopy and are some adverse events more likely than others in the elderly?

Adverse outcomes have a pivotal role in deciding whether or not to pursue colonoscopy in elderly patients. Controversy exists on this topic with some studies suggesting that increasing age is an independent risk factor for developing an adverse event related to colonoscopy (39,40), whereas others argue that there is no association between adverse events and older age (41–43). A major limitation is that studies examining adverse events of colonoscopy encompass a wide range of patient ages, include small numbers of elderly patients, and few include adverse events as a primary outcome. A recent systematic review examined all available data on the elderly and colonoscopic complications shedding light on this topic. Their composite adverse event rate (defined by an end point of perforation, bleeding, and CV/pulmonary events) for patients over 65 years of age was 25.9 per 1,000 colonoscopies, and 34.8/1,000 colonoscopies for patients ≥80, rates dramatically higher than what is reported for all patients undergoing colonoscopy. Furthermore, the authors found octogenarians had a 70% greater risk of experiencing an adverse event as compared with younger patients (44). This summary of the literature indicates that older patients may be at an elevated risk for an adverse event associated with colonoscopy. While data examining the association between overall adverse events related to colonoscopy and age is debated, data about specific complications yield firmer conclusions. First, minor complications from colonoscopy are not influenced by age. Common symptoms The American Journal of GASTROENTEROLOGY

such as bloating and abdominal pain are present in nearly a third of patients after colonoscopy and were associated with sex and poor bowel preparation, but not age (45). Second, major adverse outcomes such as perforation, bleeding, and CV/pulmonary complications are all influenced in part by age (Table 1). The risk of perforation has consistently been shown to be influenced by age (46–50). Individuals over 65 have a 30% higher risk of developing a colonic perforation compared with younger patients and a nearly 13-fold higher risk compared with patients of the same age who have not had a colonoscopy performed (44). Speculated explanations for this increased risk include a greater prevalence of diverticulosis in older patients, more tortuous colons, higher rates of CRC resulting in obstruction, and a greater detection of polyps requiring therapeutic intervention. Age is also a factor in post-polypectomy bleeding (40,41,47,49–51) with older patients having more severe post-polypectomy bleeds and greater blood transfusion requirements (52). However, comorbid medical conditions (50), size/number of polyps removed (53–55), sex (53), and therapeutic maneuver such as a polypectomy (47), all increase the risk of bleeding more than age in most studies. Age appears to affect CV/pulmonary adverse events, but some controversy does exist. Initially, early small studies demonstrated that patients older than 65 were no more likely to have a CV/ pulmonary complication than younger patients (42,51). Studies also demonstrated that while the very elderly had a greater risk of hypoxia and hypotension during colonoscopy, none of the these complications resulted in a serious outcome or mortality (51,56,57). One of the largest studies examining 53,220 Medicare claims demonstrated higher CV complications in very old patients ( > 80 years) compared with younger patients 66–69 undergoing colonoscopy; however, these complication rates did not appreciably differ when compared with a similar age-matched cohort who did not undergo colonoscopy (40). Sharma et al. (58) helped to clarify this issue showing in a large group of patients, using the National Endoscopic Database (Clinical Outcomes Research Initiative (CORI)), that advancing age was a positive predictor of CV/pulmonary adverse outcomes in patients undergoing colonoscopy and that this risk was greater in older patients. Yet, it should be noted that other factors such as American Society of Anesthesiologists (ASA) classification, inpatient procedures, and trainee involvement were more predictive of cardiopulmonary events than age. In the end, an important consideration for all these complications is that the consequences of each one are more severe and protracted in the elderly resulting in longer hospitalizations and significant economic costs (59–63). Age is a critical factor in the occurrence of adverse events related to colonoscopy. While age is not a factor in minor adverse outcomes, it does increase the risk for other major adverse events such as perforation, bleeding, and CV/pulmonary complications. However, the degree of risk for each of these outcomes associated with age varies and may be more influenced by other factors in some cases. Is adequate bowel preparation harder to achieve in the elderly?

Proper bowel preparation is critical to the success of a colonoscopy. Reported rates of poor bowel preparation in elderly patients VOLUME 106 | JULY 2011 www.amjgastro.com

CRC Screening and Surveillance in the Elderly Patient

1201

Perforation

Bleedinga

Cardiovascular/pulmonary

Mortality

0

11.3

59.3

0

DiPrima et al. (41)

6.6

16.6

13.2

0

Nelson et al. (110)

0

N/Ac

N/A

N/A

2.0

N/A

N/A

N/A

Study Patients ≥65 years Ure et al. (108)b

Gatto et al. (48) d

Cappell (115)

0

0

106.4

0

Karajeh et al. (42)

0

0

2.0

0

Kahi et al. (37)d

0

14.9

0

0

Ma et al. (51)

0

0

114.3

0

Arora et al. (46)

0.9

N/A

N/A

N/A

Warren et al. (40)

0.6

6.4

19.4

1.0

Bat et al. (64)

2.3

4.6

2.3

0

Chatrenet et al. (66)

5.0

0

0

0

Patients ≥80 years

Sardinha et al. (57)

0

2.3

198.6

0

Perry et al. (71)

1.9

1.9

0

0

Clarke et al. (116) e

10.5

N/A

N/A

N/A

Lagares-Garcia et al. (111)

N/A

N/A

9.7

9.7

Kirchgatterer et al. (112)

1.1

4.2

1.1

0

Lukens et al. (56)

N/A

N/A

360

N/A

George et al. (67) Gatto et al. (48) Arora and Singh (109)

0

0

3.4

0

3.0

N/A

N/A

N/A

0

9.1

9.1

0

Syn et al. (70)

4.1

0

0

4.1

Duncan et al. (69)

0.8

2.5

1.7

0

Ko et al. (45)

0

N/A

N/A

0

Tsutsumi et al. (107)

0

9.1

0

0

Zerey et al. (113)e

0

6.4

12.7

0

Arora et al. (46)

1.2

N/A

N/A

N/A

Warren et al. (40)

N/A

N/A

27.5

N/A

GI, gastrointestinal. a GI bleeding reflects both polypectomy and non-polypectomy sources of bleeding. b Patients ≥70 years. c Not recorded in study. d Patients ≥75 years. e Patients ≥85 years.

widely range between 4 and 57% (42,51,56,64–71) (Table 2). Age appears to exert influence on the adequacy of bowel preparation; however, the consistency of the data is evident only in the very elderly. As an example, two small studies found no difference in either poor or adequate bowel preparations between older ( > 65 years) and younger patients (42,51), while another found that © 2011 by the American College of Gastroenterology

older patients even when compliant with their bowel preparation had more than a threefold increased risk of having an inadequate preparation (72). There is greater consistency of the data for the very elderly. Lukens (56) demonstrated that octogenarians more often had a poorer preparation compared with younger patients, independent of the preparation utilized. Likewise, SchmilovitzThe American Journal of GASTROENTEROLOGY

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Table 1. Reported rates (per 1,000 colonoscopies) for perforation, GI bleeding, cardiovascular/pulmonary complications, and mortality in elderly patients

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Table 2. Successful completion of colonoscopy and poor bowel preparations in the elderly Study

Design

Number of colonoscopies performed

Successful completion of colonoscopy (%)

Poor bowel preparation on colonoscopy (%)

354

78

N/Ab

Patients ≥65 years Ure et al. (108)a

Retrospective

Nelson et al. (110)

Prospective

1,128

84.6

N/Ab

Karajeh et al. (42)

Prospective

1,000

81.8

23.4

Ma et al. (51)

Prospective

70

85.7

14.3

Bat et al. (64)

Prospective

436

87–89

19

Chatrenet et al. (66)

Retrospective

200

83.5

11.5

Burtin et al. (65)

Prospective

65

52

57

Sardinha et al. (57)

Retrospective

428

94

N/Ab

Perry et al. (71)

Prospective

476

91.4

7.3

Lagares-Garcia et al. (111)

Retrospective

93

90.3

N/Ab

Lukens et al. (56)

Prospective

100

90

16

George et al. (67)

Retrospective

291

68

14.8

Kirchgatterer et al. (112)

Retrospective

781

71

N/Ab

Arora and Singh (109)

Prospective

110

89.1

N/Ab

Syn et al. (70)

Prospective

Duncan et al. (69)

Retrospective

Tsutsumi et al. (107)

Patients ≥80 years

Zerey et al. (113)c d

Schmilovitz-Weiss et al. (68)

247

56

25.9

1,134

94.6

3.6

Prospective

110

92.7

N/Ab

Prospective

157

90

N/Ab

Prospective

41

71.4

19.5

Patients ≥70 years. b Information not reported with the selected study. c Patients ≥85 years. d Patients ≥90 years. a

Weiss (68) found that advancing age was a factor in colonic cleansing, with a higher prevalence of poor bowel preparations in patients over 90 years compared with patients aged 70–79 years. Postulated explanations for poorer bowel preparations in the very elderly include altered gastrointestinal motility, increased rates of constipation, less compliance, poorer understanding of preparation instructions, history of previous surgery, and higher burden of comorbid disease. There is significant variation reported in the prevalence of poor bowel preparations noted on colonoscopy in elderly patients. However, adequate bowel preparation is more difficult to achieve in the very elderly regardless if they are compliant or of the type of bowel preparation utilized. Are all bowel preparations for colonoscopy safe and effective in the elderly?

Two types of bowel preparations have been traditionally used for colonoscopy—polyethylene glycol electrolyte lavage solution (PEG) and now to a lesser degree oral sodium phosphate (OSP). PEG is by far the most frequently used bowel preparation and has been used for some time with an excellent safety profile in the The American Journal of GASTROENTEROLOGY

elderly. PEG is quite safe and is the preferred agent for both the pediatric (73–75) and pregnant (76) patient who requires colonic cleansing. It does not result in dramatic physiologic parameter shifts such as patient weight, blood pressure, or electrolytes (76–79), all of which may have more dramatic consequences should they occur in an elderly patient. No significant increase in adverse events related to PEG and the elderly have been demonstrated, (80–82) although there are case reports of adverse events. Pulmonary aspiration, pancreatitis, and ischemic colitis have been observed in the elderly, but these are exceedingly rare (80,81). Also, in elderly patients with impaired thirst sensation, case reports of fatal dysnatremia have been reported with PEG usage (83). As a result, adequate hydration is strongly encouraged during bowel preparation (80). More common complaints observed in the elderly taking PEG include dizziness, abdominal pain, fecal incontinence, and nausea (Table 3). PEG requires ingestion of a large volume of liquid. Failure to complete such a large preparation is a concern and problem with non-compliance rates of 3–32%, (84) with this being a particular problem in the elderly (85,86). Concerns about the elderly being able to tolerate and comply with such a large volume load are VOLUME 106 | JULY 2011 www.amjgastro.com

Table 3. Adverse events associated with PEG and OSP usage in elderly patients PEG

OSP

Dizziness (48%)

Hyperphosphatemia (58.1–100%)

Fecal incontinence (27–39%)

Fecal incontinence (23–55%)

Abdominal pain (7–23%)

Elevated creatinine/renal injury (55.2%)

Nausea (2–17.5%)

Hypocalcemia (5.1–58%)

Insomnia (13%)

Hypokalemia (5.4–56%)

Fatigue (12.7)

Abdominal pain (11–32%)

Headache (7.9%)

Nausea (9–36%)

Hypokalemia (2.9–20.5%)

Insomnia (15%)

Dysnatremia (hyponatremia/ hypernatremia) (4.1%)

Dizziness (3–55%)

Emesis (3.2%)

Vomiting (4–7%)

Aspiration pneumonia ( < 1%)

Hypotension (4%)

Pancreatitis ( < 1%) Ischemic colitis ( < 1%) OSP, oral sodium phosphate; PEG, polyethylene glycol electrolyte lavage solution.

tempered by split dosing regimens of PEG that have consistently been shown to be equally effective, with improved compliance, as same day dosing (87–90). An alternative to PEG is smaller volume OSP. Randomizedcontrolled trials indicate that OSPs are better tolerated than PEG and provide similar rates of colonic visualization during colonoscopy (91). In the elderly population, three small randomized trials showed no difference between PEG and OSP with respect to subjective tolerability of the bowel preparation and rates of effective bowel cleansing (85,86,92). Elderly patients were more compliant with OSP bowel preparation, but also had significantly more electrolyte disturbances than patients taking PEG (85,92). While PEG and OSP appear to be comparable with regards to several factors (85,86,92), concerns in OSPs regarding kidney injury dysfunction and electrolyte disturbances in the elderly have tempered their use. There have been reports of acute kidney injury secondary to acute phosphate nephropathy in the elderly that have been temporally associated with the use of OSPs (92–95). Three retrospective studies comparing oral phosphate solutions with PEG reported that older age was a risk factor for the development of acute kidney injury (96–98). A retrospective study by Khurana (99) found that elderly patients taking OSPs had a higher rate of glomerular filtration rate decline compared with age and comorbid medical condition matched patients who did not undergo colonoscopy. Additional concerns about the safety of OSP use in the elderly persist with regards to electrolyte derangements. Patients over 65 years of age are more prone to the development of many electrolyte abnormalities including hypocalcemia (100), hypokalemia (100), and hypernatermia (101), all of which may be further exacerbated by OSP use. These electrolyte disturbances can lead to © 2011 by the American College of Gastroenterology

cardiac arrhythmia and cases of ventricular tachycardia have been associated with OSP use (102). Given all of these concerns using OSPs, the Food and Drug Administration issued a black box warning and its use has been severely limited (103). With the concerns regarding nephrotoxicity, dehydration, and electrolyte disturbances in the elderly, OSPs are currently no longer recommended for this patient population (104,105). PEG is the preferred agent for bowel preparation in the elderly. It appears to have a better safety profile compared with other available products. Issues remain with PEG in regard to its tolerability and compliance in older patients. Of utmost importance for the elderly patient is adequate hydration during bowel preparation. What is the completion rate of colonoscopy in the elderly and is age a factor?

Successful completion rates for colonoscopy, in most patients, is > 90% (106). There are a wide range of reported completion rates for colonoscopy in the elderly, but rates appear to be somewhat lower (42,51,56,57,64–71,107–113) (Table 2). It may be that endoscopists subjectively judge a colonoscopy in the elderly to be more difficult and require a longer time to intubate the cecum compared with middle aged and younger patients (114). While limited data indicate that age may affect completion rates, it is clear that other factors correlated with age need to be considered as well. For example, Karajeh et al. prospectively demonstrated that patients older than 65 had lower colonoscopic completion rates compared with younger patients (81.6% vs. 86.5%); yet this difference disappeared when one adjusted for colonoscopies not completed secondary to obstructive disease. In this study, stricturing due to diverticular disease and/or malignancy was five times more likely the reason for a failed colonoscopy in older patients; there was no difference noted in bowel preparation, technical aspects of the procedure or patient discomfort (42). For octogenarians, reported completion rates also show considerable variation ranging from 52% to a high of 95% (56,57,64–71,107,109,111–113). A minimal number of these studies compared completion rates with younger patients. Of those that did, three of these studies found that older age was associated with increased failure to complete a colonoscopy, (56,68,108), while two found no such association (107,109). Indeed, one large study determined that other factors such as poor bowel preparation are more strongly associated with a procedural failure than age itself (110). A wide range of colonoscopic completion rates are reported for the elderly. Other factors, such as a patient’s underlying disease process and adequate bowel preparation, may have a role in completion rates besides age; however, some limited data suggest that age may be an independent factor.

CONCLUSION In summary, decisions about CRC screening and surveillance in older adults are complex and challenging. Clearly, advancing age is associated with a rise in both CRC and adenomas necessitating the need for CRC screening in older patients. However, after a screening colonoscopy, the detection of recurrent CRC The American Journal of GASTROENTEROLOGY

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and adenomas is unaffected by age highlighting that current guidelines for surveillance do not need alteration based on age. Controversy ensues about when to stop CRC screening and surveillance in older patients. At certain ages, it appears that the risks and increased resources used outweigh the potential benefits to the older patient. Furthermore, comorbid medical conditions, of which older patients have a higher burden of, have an important role in CRC screening as patients with more severe and a greater number of comorbidities have less benefit from screening. The decision about whether or not to recommend screening in an elderly patient requires an individualized assessment that goes beyond making decisions solely based on age and instead weighs the risks and benefits for each patient according to their overall health and preferences. Factoring into the decision-making process about whether to pursue colonoscopy in older patients is the associated complication with the procedure. Older patients are at greater risk especially with respect to perforation, bleeding, and CV/pulmonary complications. Also, technical factors associated with colonoscopy need to be considered when presented with an elderly patient. PEG is the safest and currently recommended bowel preparation for older patients. However, higher rates of poor bowel preparation are seen in the elderly, specifically the octogenarian. Last, completion rates vary widely in older patients and age may have a role in the ability of the endoscopist to complete the procedure. All of these contributing factors are critical for the gastroenterologist in terms of deciding whether or not to pursue colonoscopy in the elderly patient, but more importantly in discussions and the informed consent process with the patient and their families. CONFLICT OF INTEREST

Guarantors of the article: Lukejohn W. Day, MD and Fernando Velayos, MD, MPH. Specific author contributions: Conducted literature review, drafted and revised the manuscript, and approved the final draft submitted: Lukejohn W. Day; reviewed the manuscript: Louise C. Walter; drafted and revised the manuscript and approved the final draft submitted: Fernando Velayos. Financial support: F.V. was supported in part by NIH UCSF-CTSI Grant number KL2 RR024130. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. L.C.W. was supported by a VA Health Services Research and Development Grant IIR-04-427 and by Grant 1R01CA134425 from the National Cancer Institute. Potential competing interests: None. REFERENCES 1. Jemal A, Siegel R, Ward E et al. Cancer statistics 2009. CA Cancer J Clin 2009;59:225–49. 2. Rabeneck L, El-Serag HB, Davila JA et al. Outcomes of colorectal cancer in the United States: no change in survival (1986–1997). Am J Gastroenterol 2003;98:471–7. 3. Survelliance Epidemiology and End Results. US National Institutes of Health. Cancer Facts 2006 (online). 2009 Available at: http://seer.cancer. gov/statisticsAccessed 11 July 2010. 4. US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:627–37.

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5. Lieberman DA, Weiss DG, Bond JH et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med 2000;343:162–8. 6. Khullar SK, DiSario JA. Colon cancer screening. Sigmoidoscopy or colonoscopy. Gastrointest Endosc Clin N Am 1997;7:365–86. 7. Neugut AI, Jacobson JS, De Vivo I. Epidemiology of colorectal adenomatous polyps. Cancer Epidemiol Biomarkers Prev 1993;2:159–76. 8. Clark JC, Collan Y, Eide TJ et al. Prevalence of polyps in an autopsy series from areas with varying incidence of large-bowel cancer. Int J Cancer 1985;36:179–86. 9. Correa P, Strong JP, Reif A et al. The epidemiology of colorectal polyps: prevalence in New Orleans and international comparisons. Cancer 1977;39:2258–64. 10. Marigo C, Correa P, Haenszel W. Cancer and “cancer related” colorectal lesions in Sao Paulo, Brazil. Int J Cancer 1978;22:645–54. 11. Eide TJ, Stalsberg H. Polyps of the large intestine in Northern Norway. Cancer 1978;42:2839–48. 12. Strul H, Kariv R, Leshno M et al. The prevalence rate and anatomic location of colorectal adenoma and cancer detected by colonoscopy in average-risk individuals aged 40–80 years. Am J Gastroenterol 2006;101 :255–62. 13. Imperiale TF, Wagner DR, Lin CY et al. Results of screening colonoscopy among persons 40 to 49 years of age. N Engl J Med 2002;346:1781–5. 14. Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993;329:1977–81. 15. Noshirwani KC, van Stolk RU, Rybicki LA et al. Adenoma size and number are predictive of adenoma recurrence: implications for surveillance colonoscopy. Gastrointest Endosc 2000;51 (4 Part 1): 433–7. 16. Harewood GC, Lawlor GO. Incident rates of colonic neoplasia according to age and gender: implications for surveillance colonoscopy intervals. J Clin Gastroenterol 2005;39:894–9. 17. Harewood GC, Lawlor GO, Larson MV. Incident rates of colonic neoplasia in older patients: when should we stop screening? J Gastroenterol Hepatol 2006;21:1021–5. 18. Castells A, Bessa X, Daniels M et al. Value of postoperative surveillance after radical surgery for colorectal cancer: results of a cohort study. Dis Colon Rectum 1998;41:714–23; discussion 23–24. 19. Khoury DA, Opelka FG, Beck DE et al. Colon surveillance after colorectal cancer surgery. Dis Colon Rectum 1996;39:252–6. 20. Makela JT, Laitinen SO, Kairaluoma MI. Five-year follow-up after radical surgery for colorectal cancer. Results of a prospective randomized trial. Arch Surg 1995;130:1062–7. 21. Obrand DI, Gordon PH. Incidence and patterns of recurrence following curative resection for colorectal carcinoma. Dis Colon Rectum 1997;40: 15–24. 22. Patchett SE, Mulcahy HE, O’Donoghue DP. Colonoscopic surveillance after curative resection for colorectal cancer. Br J Surg 1993;80:1330–2. 23. Schoemaker D, Black R, Giles L et al. Yearly colonoscopy, liver CT, and chest radiography do not influence 5-year survival of colorectal cancer patients. Gastroenterology 1998;114:7–14. 24. Stigliano V, Fracasso P, Grassi A et al. Endoscopic follow-up in resected colorectal cancer patients. J Exp Clin Cancer Res 2000;19:145–8. 25. Weber CA, Deveney KE, Pellegrini CA et al. Routine colonoscopy in the management of colorectal carcinoma. Am J Surg 1986;152:87–92. 26. Togashi K, Konishi F, Ozawa A et al. Predictive factors for detecting colorectal carcinomas in surveillance colonoscopy after colorectal cancer surgery. Dis Colon Rectum 2000;43 (10 Suppl): S47–53. 27. Renehan AG, Egger M, Saunders MP et al. Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials. BMJ 2002;324:813. 28. Harris GJ, Church JM, Senagore AJ et al. Factors affecting local recurrence of colonic adenocarcinoma. Dis Colon Rectum 2002;45:1029–34. 29. Inadomi JM, Sonnenberg A. The impact of colorectal cancer screening on life expectancy. Gastrointest Endosc 2000;51:517–23. 30. Sonnenberg A, Delco F. Cost-effectiveness of a single colonoscopy in screening for colorectal cancer. Arch Intern Med 2002;162:163–8. 31. Lin OS, Kozarek RA, Schembre DB et al. Screening colonoscopy in very elderly patients: prevalence of neoplasia and estimated impact on life expectancy. JAMA 2006;295:2357–65. 32. Zauber AG, Lansdorp-Vogelaar I, Knudsen AB et al. Evaluating test strategies for colorectal cancer screening: a decision analysis for the US Preventive Services Task Force. Ann Intern Med 2008;149:659–69.

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33. Maheshwari S, Patel T, Patel P. Screening for colorectal cancer in elderly persons: who should we screen and when can we stop? J Aging Health 2008;20:126–39. 34. Rex DK, Johnson DA, Anderson JC et al. American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]. Am J Gastroenterol 2009;104:739–50. 35. Winawer S, Fletcher R, Rex D et al. Colorectal cancer screening and surveillance: clinical guidelines and rationale-update based on new evidence. Gastroenterology 2003;124:544–60. 36. Ko CW, Sonnenberg A. Comparing risks and benefits of colorectal cancer screening in elderly patients. Gastroenterology 2005;129:1163–70. 37. Kahi CJ, Azzouz F, Juliar BE et al. Survival of elderly persons undergoing colonoscopy: implications for colorectal cancer screening and surveillance. Gastrointest Endosc 2007;66:544–50. 38. Gross CP, McAvay GJ, Krumholz HM et al. The effect of age and chronic illness on life expectancy after a diagnosis of colorectal cancer: implications for screening. Ann Intern Med 2006;145:646–53. 39. Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut 1983;24:376–83. 40. Warren JL, Klabunde CN, Mariotto AB et al. Adverse events after outpatient colonoscopy in the Medicare population. Ann Intern Med 2009;150:849–57. 41. DiPrima RE, Barkin JS, Blinder M, et al. Age as a risk factor in colonoscopy: fact versus fiction. Am J Gastroenterol 1988;83:123–5. 42. Karajeh MA, Sanders DS, Hurlstone DP. Colonoscopy in elderly people is a safe procedure with a high diagnostic yield: a prospective comparative study of 2000 patients. Endoscopy 2006;38:226–30. 43. Ko CW, Riffle S, Michaels L et al. Serious complications within 30 days of screening and surveillance colonoscopy are uncommon. Clin Gastroenterol Hepatol 2010;8:166–73. 44. Day LW, Somsouk M, Inadomi JM. Adverse events in older patients undergoing colonoscopy: a meta-analysis (abstract). Gastroenterology 2010;138 (5 Suppl): S–126. 45. Ko CW, Riffle S, Shapiro JA et al. Incidence of minor complications and time lost from normal activities after screening or surveillance colonoscopy. Gastrointest Endosc 2007;65:648–56. 46. Arora G, Mannalithara A, Singh G et al. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009;69 (3 Part 2): 654–64. 47. Crispin A, Birkner B, Munte A et al. Process quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies. Endoscopy 2009;41:1018–25. 48. Gatto NM, Frucht H, Sundararajan V et al. Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. J Natl Cancer Inst 2003;95:230–6. 49. Levin TR, Zhao W, Conell C et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 2006;145:880–6. 50. Rabeneck L, Paszat LF, Hilsden RJ et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008;135:1899–906, 906 e1. 51. Ma WT, Mahadeva S, Kunanayagam S et al. Colonoscopy in elderly Asians: a prospective evaluation in routine clinical practice. J Dig Dis 2007;8:77–81. 52. Yousfi M, Gostout CJ, Baron TH et al. Postpolypectomy lower gastrointestinal bleeding: potential role of aspirin. Am J Gastroenterol 2004;99:1785–9. 53. Paspatis GA, Vardas E, Theodoropoulou A et al. Complications of colonoscopy in a large public county hospital in Greece. A 10-year study. Dig Liver Dis 2008;40:951–7. 54. Watabe H, Yamaji Y, Okamoto M et al. Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors. Gastrointest Endosc 2006;64:73–8. 55. Heldwein W, Dollhopf M, Rosch T et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 2005;37:1116–22. 56. Lukens FJ, Loeb DS, Machicao VI et al. Colonoscopy in octogenarians: a prospective outpatient study. Am J Gastroenterol 2002;97:1722–5. 57. Sardinha TC, Nogueras JJ, Ehrenpreis ED et al. Colonoscopy in octogenarians: a review of 428 cases. Int J Colorectal Dis 1999;14:172–6. 58. Sharma VK, Nguyen CC, Crowell MD et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 2007;66:27–34. 59. Araghizadeh FY, Timmcke AE, Opelka FG et al. Colonoscopic perforations. Dis Colon Rectum 2001;44:713–6.

© 2011 by the American College of Gastroenterology

60. Farley DR, Bannon MP, Zietlow SP et al. Management of colonoscopic perforations. Mayo Clin Proc 1997;72:729–33. 61. Iqbal CW, Chun YS, Farley DR. Colonoscopic perforations: a retrospective review. J Gastrointest Surg 2005;9:1229–35; discussion 36. 62. Jentschura D, Raute M, Winter J et al. Complications in endoscopy of the lower gastrointestinal tract. Therapy and prognosis. Surg Endosc 1994;8:672–6. 63. Lo AY, Beaton HL. Selective management of colonoscopic perforations. J Am Coll Surg 1994;179:333–7. 64. Bat L, Pines A, Shemesh E et al. Colonoscopy in patients aged 80 years or older and its contribution to the evaluation of rectal bleeding. Postgrad Med J 1992;68:355–8. 65. Burtin P, Bour B, Charlois T et al. Colonic investigations in the elderly: colonoscopy or barium enema? Aging (Milano) 1995;7:190–4. 66. Chatrenet P, Friocourt P, Ramain JP et al. Colonoscopy in the elderly: a study of 200 cases. Eur J Med 1993;2:411–3. 67. George ML, Tutton MG, Jadhav VV et al. Colonoscopy in older patients: a safe and sound practice. Age Ageing 2002;31:80–1. 68. Schmilovitz-Weiss H, Weiss A, Boaz M et al. Predictors of failed colonoscopy in nonagenarians: a single-center experience. J Clin Gastroenterol 2007;41:388–93. 69. Duncan JE, Sweeney WB, Trudel JL et al. Colonoscopy in the elderly: low risk, low yield in asymptomatic patients. Dis Colon Rectum 2006;49:646–51. 70. Syn WK, Tandon U, Ahmed MM. Colonoscopy in the very elderly is safe and worthwhile. Age Ageing 2005;34:510–3. 71. Perry WB, Opelka FG, Hicks TC et al. Geriatric Colonoscopy. Perspectives in Colon and Rectal Surgery 2000;13:93–1000. 72. Chung YW, Han DS, Park KH et al. Patient factors predictive of inadequate bowel preparation using polyethylene glycol: a prospective study in Korea. J Clin Gastroenterol 2009;43:448–52. 73. Sondheimer JM, Sokol RJ, Taylor SF et al. Safety, efficacy, and tolerance of intestinal lavage in pediatric patients undergoing diagnostic colonoscopy. J Pediatr 1991;119 (1 Part 1): 148–52. 74. Gremse DA, Sacks AI, Raines S. Comparison of oral sodium phosphate to polyethylene glycol-based solution for bowel preparation for colonoscopy in children. J Pediatr Gastroenterol Nutr 1996;23:586–90. 75. Tolia V, Fleming S, Dubois RS. Use of Golytely in children and adolescents. J Pediatr Gastroenterol Nutr 1984;3:468–70. 76. Wexner SD, Beck DE, Baron TH et al. A consensus document on bowel preparation before colonoscopy: prepared by a task force from the American Society of Colon and Rectal Surgeons (ASCRS), the American Society for Gastrointestinal Endoscopy (ASGE), and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Gastrointest Endosc 2006;63:894–909. 77. Ernstoff JJ, Howard DA, Marshall JB et al. A randomized blinded clinical trial of a rapid colonic lavage solution (Golytely) compared with standard preparation for colonoscopy and barium enema. Gastroenterology 1983;84:1512–6. 78. Brady III CE, DiPalma JA, Pierson WP. Golytely lavage--is metoclopramide necessary? Am J Gastroenterol 1985;80:180–4. 79. Fordtran JS, Santa Ana CA, Cleveland Mv B. A low-sodium solution for gastrointestinal lavage. Gastroenterology 1990;98:11–6. 80. Lichtenstein GR, Cohen LB, Uribarri J. Review article: bowel preparation for colonoscopy--the importance of adequate hydration. Aliment Pharmacol Ther 2007;26:633–41. 81. Nelson DB, Barkun AN, Block KP et al. Technology Status Evaluation report. Colonoscopy preparations. May 2001. Gastrointest Endosc 2001;54:829–32. 82. Clark LE, Dipalma JA. Safety issues regarding colonic cleansing for diagnostic and surgical procedures. Drug Saf 2004;27:1235–42. 83. Ayus JC, Levine R, Arieff AI. Fatal dysnatraemia caused by elective colonoscopy. BMJ 2003;326:382–4. 84. Hsu CW, Imperiale TF. Meta-analysis and cost comparison of polyethylene glycol lavage versus sodium phosphate for colonoscopy preparation. Gastrointest Endosc 1998;48:276–82. 85. Thomson A, Naidoo P, Crotty B. Bowel preparation for colonoscopy: a randomized prospective trail comparing sodium phosphate and polyethylene glycol in a predominantly elderly population. J Gastroenterol Hepatol 1996;11:103–7. 86. Rodriguez-Alcalde D, Marin-Gabriel JC, Rodriguez-Munoz S et al. Tolerability, safety, and efficacy of sodium phosphate preparation for colonoscopy: the role of age. Rev Esp Enferm Dig 2008;100:17–23. 87. Aoun E, Abdul-Baki H, Azar C et al. A randomized single-blind trial of split-dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation. Gastrointest Endosc 2005;62:213–8.

The American Journal of GASTROENTEROLOGY

1205

REVIEW

CRC Screening and Surveillance in the Elderly Patient

REVIEW

1206

Day et al.

88. El Sayed AM, Kanafani ZA, Mourad FH et al. A randomized single-blind trial of whole versus split-dose polyethylene glycol-electrolyte solution for colonoscopy preparation. Gastrointest Endosc 2003;58:36–40. 89. Landreneau SW, Di Palma JA. Update on preparation for colonoscopy. Curr Gastroenterol Rep 2010;12:366–73. 90. Cohen LB. Split dosing of bowel preparations for colonoscopy: an analysis of its efficacy, safety, and tolerability. Gastrointest Endosc 2010;72:406–12. 91. Belsey J, Epstein O, Heresbach D. Systematic review: adverse event reports for oral sodium phosphate and polyethylene glycol. Aliment Pharmacol Ther 2008;29:15–28. 92. Seinela L, Pehkonen E, Laasanen T et al. Bowel preparation for colonoscopy in very old patients: a randomized prospective trial comparing oral sodium phosphate and polyethylene glycol electrolyte lavage solution. Scand J Gastroenterol 2003;38:216–20. 93. Gonlusen G, Akgun H, Ertan A et al. Renal failure and nephrocalcinosis associated with oral sodium phosphate bowel cleansing: clinical patterns and renal biopsy findings. Arch Pathol Lab Med 2006;130:101–6. 94. Aasebo W, Scott H, Ganss R. Kidney biopsies taken before and after oral sodium phosphate bowel cleansing. Nephrol Dial Transplant 2007;22: 920–2. 95. Markowitz GS, Whelan J, D’Agati VD. Renal failure following bowel cleansing with a sodium phosphate purgative. Nephrol Dial Transplant 2005;20:850–1. 96. Hurst FP, Bohen EM, Osgard EM et al. Association of oral sodium phosphate purgative use with acute kidney injury. J Am Soc Nephrol 2007;18:3192–8. 97. Russmann S, Lamerato L, Marfatia A et al. Risk of impaired renal function after colonoscopy: a cohort study in patients receiving either oral sodium phosphate or polyethylene glycol. Am J Gastroenterol 2007;102:2655–63. 98. Singal AK, Rosman AS, Post JB et al. The renal safety of bowel preparations for colonoscopy: a comparative study of oral sodium phosphate solution and polyethylene glycol. Aliment Pharmacol Ther 2008;27: 41–7. 99. Khurana A, McLean L, Atkinson S et al. The effect of oral sodium phosphate drug products on renal function in adults undergoing bowel endoscopy. Arch Intern Med 2008;168:593–7. 100. Beloosesky Y, Grinblat J, Weiss A et al. Electrolyte disorders following oral sodium phosphate administration for bowel cleansing in elderly patients. Arch Intern Med 2003;163:803–8.

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101. Caswell M, Thompson WO, Kanapka JA et al. The time course and effect on serum electrolytes of oral sodium phosphates solution in healthy male and female volunteers. Can J Clin Pharmacol 2007;14:e260–74. 102. Clarkston WK, Tsen TN, Dies DF et al. Oral sodium phosphate versus sulfate-free polyethylene glycol electrolyte lavage solution in outpatient preparation for colonoscopy: a prospective comparison. Gastrointest Endosc 1996;43:42–8. 103. Oral sodium phosphate (OSP) products for bowel cleansing (marketed as Viscol and OsmoPrep, and oral sodium phosphate products available without a prescription). Available at: http://www.fda.gov/medwatch/ safety/2008/safety08.htm#OSP, Accessed 15 December 2010. 104. Lien YH. Is bowel preparation before colonoscopy a risky business for the kidney? Nat Clin Pract Nephrol 2008;4:606–14. 105. Rex DK. Dosing considerations in the use of sodium phosphate bowel preparations for colonoscopy. Ann Pharmacother 2007;41:1466–75. 106. Rex DK, Petrini JL, Baron TH et al. Quality indicators for colonoscopy. Gastrointest Endosc 2006;63 (4 Suppl): S16–28. 107. Tsutsumi S, Fukushima H, Osaki K et al. Feasibility of colonoscopy in patients 80 years of age and older. Hepatogastroenterology 2007;54:1959–61. 108. Ure T, Dehghan K, Vernava III AM et al. Colonoscopy in the elderly. Low risk, high yield. Surg Endosc 1995;9:505–8. 109. Arora A, Singh P. Colonoscopy in patients 80 years of age and older is safe, with high success rate and diagnostic yield. Gastrointest Endosc 2004;60:408–13. 110. Nelson DB, McQuaid KR, Bond JH et al. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc 2002;55:307–14. 111. Lagares-Garcia JA, Kurek S, Collier B et al. Colonoscopy in octogenarians and older patients. Surg Endosc 2001;15:262–5. 112. Kirchgatterer A, Hubner D, Aschl G et al. Colonoscopy and sigmoidoscopy in patients aged eighty years or older. Z Gastroenterol 2002;40:951–6. 113. Zerey M, Paton BL, Khan PD et al. Colonoscopy in the very elderly: a review of 157 cases. Surg Endosc 2007;21:1806–9. 114. Ristikankare M, Hartikainen J, Heikkinen M et al. The effects of gender and age on the colonoscopic examination. J Clin Gastroenterol 2001;32:69–75. 115. Cappell MS. Safety and efficacy of colonoscopy after myocardial infarction: an analysis of 100 study patients and 100 control patients at two tertiary cardiac referral hospitals. Gastrointest Endosc 2004;60:901–9. 116. Clarke GA, Jacobson BC, Hammett RJ, Carr-Locke DL. The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort. Endoscopy 2001;33:580–4.

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