Practical considerations for colorectal cancer screening in older adults

Table 1 Comments on colorectal cancer screening across professional organizations

Professional organization	Recommended ages for screening	Other considerations
American College of Gastroenterology (2021)	50-75	Screening after age 75 should be considered on an individualized basis; providers must engage in shared decision making
United States Preventive Services Task Force (2021)	45-75	Screening adults aged 76-85 should be conducted on an individualized basis; do not screen adults age 86 years and above
United States Multi-Society Task Force on Colorectal Cancer (2021)	45-75	Consider discontinuation when persons up to date with screening, who have prior negative screening reach age 75 or have < 10 yr of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities.
Canadian Task Force on Preventive Health Care (2016)	50-74	Recommend not screening adults aged 75 yr and older. (Weak recommendation; low-quality evidence)
American College of Physicians (2019)	50-75	Discontinue screening in average-risk adults older than 75 yr or in adults with a life expectancy of 10 yr or less
American Cancer Society (2018)	45-75	Screening adults aged 76-85 should be conducted on an individualized basis; screening discouraged above age 85

Adapted from Ref. [14].

Table 2 Charlson comorbidity index conditions and scoring

Condition	Value	Score
Age	< 50, 50-59, 60-69, 70-79, 80+	0, +1, +2, +3, +4
Myocardial infarction	Yes/no	+1
CHF	Yes/no	+1
PVD	Yes/no	+1
CVA or TIA	Yes/no	+1
Dementia	Yes/no	+1
COPD	Yes/no	+1
Connective tissue disease	Yes/no	+1
Peptic ulcer disease	Yes/no	+1
Liver disease	None/mild/severe	+1 (mild), +3 (moderate-severe)
Diabetes mellitus	None or diet controlled /uncomplicated/end-organ damage	+1 (uncomplicated), +2 (end-organ damage)
Hemiplegia	Yes/no	+2
CKD	Yes/no	+2
Solid tumor	None/localized/metastatic	+2 (local), +6 (metastatic)
Leukemia	Yes/no	+2
Lymphoma	Yes/no	+2
AIDS	Yes/no	+6

CHF: Congestive heart failure; PVD: Peripheral vascular disease; CVA: Cerebrovascular accident; TIA: Transient ischemic attack; COPD: Chronic obstructive pulmonary disorder; CKD: Chronic kidney disease; AIDS: Acquired immunodeficiency syndrome.

Table 3 Colonoscopy-associated risks in older adults

Risk	Associated problems	Mitigation
Perforation	Bleed, infection, necrotic bowel	Endoscopic technique (carbon dioxide insufflation, use of pediatric endoscopic equipment, careful navigation of diverticular disease), adequate bowel preparation
Bleeding	Post-polypectomy bleed	Hemoclip placement for bleeding prevention when appropriate, diluted epinephrine injection, use of detachable snare, thermal coagulation
Cardiovascular event	Arrythmia	Medication review, screen for high-risk medications, confirm dosing appropriate for renal function; adjustment of anesthesia
Anticoagulation therapy interruption	Risk of thrombosis, MI, CVA	Liaise with prescribing physician; avoid colonoscopy during high-risk period; avoid interruption if possible
Delirium	Cognitive impairment	Risk assessment; optimize medication list, avoid holding medications with withdrawal potential on morning of procedure
Medication interaction	Polypharmacy increases sensitivity to anesthesia	Medication review; adjustment of anesthesia
Dehydration	Electrolyte disturbances	Appropriate counseling prior to colonoscopy prep; caretaker supervision to ensure patient safety during prep

MI: Myocardial infarction; CVA: Cerebrovascular accident.