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## Complete Summary

#### GUIDELINE TITLE

ASGE guideline: modifications in endoscopic practice for the elderly.

#### BIBLIOGRAPHIC SOURCE(S)

Qureshi WA, Zuckerman MJ, Adler DG, Davila RE, Egan JV, Gan SI,
Lichtenstein DR, Rajan E, Shen B, Fanelli RD, Van Guilder T, Baron TH,
Standards of Practice Committee, American Society for Gastrointestinal
Endoscopy. ASGE guideline: modifications in endoscopic practice for the
elderly. Gastrointest Endosc 2006 Apr;63(4):566-9. \[52 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16564853)

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   On May 5, 2006 the U.S. Food and Drug Administrations (FDA) notified
    healthcare professionals and consumers of reports of acute phosphate
    nephropathy, a type of acute renal failure, that is a rare, but
    serious adverse event associated with the use of oral sodium
    phosphates (OSP) for bowel cleansing. Documented cases of acute
    phosphate nephropathy include 21 patients who used an OSP solution
    (such as Fleet Phospho-soda or Fleet ACCU-PREP) and one patient who
    used OSP tablets (Visicol). Individuals at increased risk of acute
    phosphate nephropathy include: those of advanced age, those with
    kidney disease or decreased intravascular volume, and those using
    medicines that affect renal perfusion or function \[diuretics,
    angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor
    blockers (ARBs), and possibly nonsteroidal anti-inflammatory drugs
    (NSAIDs)\]. Recommendations were offered for providers and patients
    when choosing and using a bowel cleanser. See the [FDA Web
    site](http://www.fda.gov/medwatch/safety/2006/safety06.htm#phosphate)
    for more information.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Conditions requiring gastrointestinal endoscopy in geriatric patients,
including:

-   Cancer

-   Gastrointestinal ischemia

-   Biliary tract disease

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Gastroenterology\
Geriatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide guidance regarding endoscopic practice issues in the elderly

#### TARGET POPULATION

Geriatric patients requiring gastrointestinal endoscopy, including:

-   Physiologic age [\>]{.underline}65 years (geriatric patients)

-   Physiologic age [\>]{.underline}80 years (advanced age patients)

**Note**: Because physiologic age is a continuum, this article is not
intended to apply to rigidly defined age ranges.

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Consideration of general health and comorbid conditions in screening
    procedures

2.  Preprocedure preparation (lavage, consideration of interference with
    implanted cardiac devices)

3.  Attention to doses used for sedation and analgesia (narcotic and
    nonnarcotic central nervous system depressants \[CNS\] and
    benzodiazepines)

4.  Gastrointestinal endoscopy procedures

    -   Capsule endoscopy

    -   Colonoscopy

    -   Endoscopic retrograde cholangiopancreatography (ERCP)

    -   Endoscopic sphincterotomy

    -   Esophagogastroduodenoscopy (EGD)

    -   Percutaneous endoscopic gastrostomy (PEG)

5.  Intensified monitoring, including ready availability of oxygen

#### MAJOR OUTCOMES CONSIDERED

-   Age-related complication rates

-   Effect of confounding clinical conditions (e.g., dementia, cardiac
    dysfunction, pulmonary dysfunction)

-   Usefulness of elective screening

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

A MEDLINE literature search was performed, and additional references
were obtained from the bibliographies of the identified articles and
from recommendations of expert consultants.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Guidelines for appropriate utilization of endoscopy are based on a
critical review of the available data and expert consensus.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The summary of recommendations is followed by evidence grades (A-C)
identifying the type of supporting evidence. Definitions of the evidence
grades are presented at the end of the \"Major Recommendations\" field.

**[Indications and Contraindications]{.underline}**

For patients in any age group, endoscopy should be performed only when
the results will influence clinical management or outcome. The
indications for gastrointestinal endoscopy among the elderly are largely
the same as those for adults, with some variation in the relative
frequency based upon the development of age-related diseases such as
cancer, gastrointestinal ischemia, and biliary tract disease. The same
relative and absolute contraindications also pertain, without respect to
age. Increased attention should be paid, however, to the risk engendered
by age-related diseases, such as cardiac and pulmonary dysfunction.
Significant risk may outweigh the acknowledged benefits of a procedure.

Several studies of indications and outcomes of patients aged
[\>]{.underline}80 years have found elective and emergency endoscopic
procedures (including esophagogastroduodenoscopy \[EGD\], endoscopic
retrograde cholangiopancreatography \[ERCP\], and colonoscopy) to be
safe and that advanced age is not a contraindication to endoscopy. For
example, in a large multicenter trial on ERCP complications, age was not
found to be a risk factor for complications after endoscopic
sphincterotomy. In a retrospective analysis, endoscopic sphincterotomy
for bile duct stones was found to be a safe and effective treatment in
patients aged [\>]{.underline}70 years. In comparison to patients aged
70 to 89 years, those aged [\>]{.underline}90 years underwent more
emergency procedures and more frequently required multiple procedures
and stent placement. Several recent studies have shown colonoscopy to be
safe in elderly patients. In these studies, indications for colonoscopy
were both for symptoms and surveillance/screening. Unadjusted cecal
intubation rates varied from 69% to 94% and were generally comparable to
younger patients, though ileal intubation rates were lower. Poor colonic
preparations appear to be more frequent in the elderly and occur in 16%
to 21% of patients.

Ethical issues are raised by the use of diagnostic or therapeutic
modalities in patients with a limited life expectancy, a situation more
common in the elderly. The acuity of the situation and the likelihood of
benefit influence the decision to proceed with an endoscopic procedure.
For example, studies have shown that the 30-day mortality in elderly
patients receiving percutaneous endoscopic gastrostomy (PEG) is
approximately 19% to 22%, largely due to underlying medical illnesses.
There is particular controversy concerning the usefulness of PEG in
elderly patients with dementia.

Similarly, the use of elective screening procedures for colorectal
neoplasia in the elderly should be restricted to situations where it
will likely extend life expectancy. Physiologic age and prognosis must
be considered in the elderly. Most national guidelines for colorectal
cancer screening do not provide upper-age constraints, although the
concept of when to stop screening or surveillance on the basis of age
has been addressed in the literature. Factors to be taken into account
include lead time between screening and potential benefit, comorbid
medical illnesses, and life expectancy. Screening colonoscopy studies
have generally excluded patients aged [\>]{.underline}80 years, so there
are no data to address a mortality benefit in this age group. Some
authorities recommend limiting screening for colorectal cancer to those
patients aged \<80 years and discontinuing surveillance at age 85 years.
In view of the safety of colonoscopy in the age group [\>]{.underline}80
years and the high yield for advanced neoplasia, it has been proposed
that it may be appropriate to continue screening in this age group as
long as there are no life-limiting comorbidities.

**[Preprocedure Preparation]{.underline}**

Preparation for endoscopy in the geriatric or aged populations differs
little from that for younger adults. For EGD, the recommendations for
cessation of ingestion of solids and liquids are the same as for younger
patients. Preparation for colonoscopy with either standard dose
polyethylene glycol (PEG) lavage or sodium phosphate osmotic laxative
preparations can be used. Similar tolerability and efficacy of the 2
regimens has been demonstrated in the elderly. However, sodium phosphate
preparations are associated with hyperphosphatemia, hypernatremia, and
hypokalemia, although there were no clinically significant adverse
effects in clinical trials in healthy elderly patients. Caution should
be exercised in those patients with renal or cardiac dysfunction, in
whom fluid and electrolyte shifts can occur with the osmotic
preparations.

Elderly patients are more likely to have underlying heart disease and
implanted cardiac devices. Electrocautery used during endoscopic
procedures has the potential for causing electromagnetic interference
with these devices, possibly leading to pacemaker inhibition or false
detection of ventricular arrhythmias. The concern arises when using
standard monopolar snares, not biopsy forceps, sphincterotomy, and argon
plasma coagulation. Recommendations for management of patients with
pacemakers and implantable cardioverter defibrillators (ICDs) are not
well defined. Preprocedure evaluation of device function in
collaboration with cardiology personnel should be considered, especially
in patients with ICDs. A forthcoming American Society for
Gastrointestinal Endoscopy (ASGE) document will provide more specific
guidelines for these patients. Intracardiac defibrillators should be
inactivated before the use of electrocautery. This must always be done
with the use of continuous rhythm monitoring until the defibrillator is
reactivated after the procedure. Alternative means of tissue removal,
destruction, or hemostasis, such as cold snare or biopsy, injection
therapy, heater probe thermocoagulation, band ligation, and clipping
should be considered whenever possible in patients with ICDs.

During capsule endoscopy there is a theoretical potential for
interference from the digital radiofrequency communication between the
capsule and the data recorder, so the presence of a cardiac pacemaker or
ICD is considered a relative contraindication to capsule endoscopy.
Recently, reports on small series of patients have been published
showing capsule endoscopy to be safe in patients who were monitored and
studied in a hospital setting. No significant interference with
pacemaker or ICD function was seen, and there was no interference with
the capsule endoscopy images. Because large studies are not available,
it may be advisable that patients with implanted cardiac devices be
evaluated by a cardiologist before capsule endoscopy and patients with
ICDs be observed in a hospital setting with continuous cardiac
monitoring.

**[Sedation and Analgesia]{.underline}**

Most gastrointestinal endoscopy is performed using moderate sedation.
Guidelines regarding conscious sedation and monitoring of adult patients
have been previously published. Sedation in the elderly requires
awareness of their increased response to sedatives. A variety of
physiologic processes contribute to the increase in sensitivity and
sedation risk in geriatric patients. Arterial oxygenation progressively
deteriorates with age, with and without oxygen supplementation.
Cardiorespiratory stimulation in response to hypoxia or hypercarbia is
blunted and delayed. Narcotic and non-narcotic central nervous system
(CNS) depressants produce greater respiratory depression and a greater
incidence of transient apnea and episodic respirations. The risk for
aspiration also rises as a result of a significant increase in the
sensory stimulus threshold required for reflexive glottic closure.

The age-related increase in lipid fraction of body mass yields an
expansion of the distribution volume for pharmacologic agents, which are
highly lipid soluble, including the benzodiazepines. In conjunction with
reduced hepatic and renal clearance mechanisms, this can prolong
recovery for elderly patients after sedation. Finally, a complex
interplay among heightened CNS sensitivity and alterations in drug
receptors, volumes of distribution, and intercompartmental transfer
contributes to the reduced dosage requirements of all of the standard
sedative agents. Nevertheless, age alone is not a major determinant of
morbidity. Rather, age-related diseases and rapid or excessive dosing
contribute more to the cardiopulmonary complications of sedation than
does age itself.

Drugs used for sedation in geriatric patients should have a short
half-life, with minimally active metabolites and limited side effects.
Doses based solely on mg/kg body weight may produce profound respiratory
depression and hypotension. The primary modification in sedation
practices required in the geriatric population is administration of
fewer agents at a slower rate and with a lower cumulative dose. As in
younger adults, midazolam and/or narcotics are generally used. Fentanyl
may have an advantage over meperidine in the elderly due its quicker
onset of action and shorter half-life. Propofol has a narrower margin of
safety in elderly patients but has been shown to be safe when used in
elderly patients. Lower initial doses of sedative-hypnotics, usually
half the normal recommended adult dose, along with slow and gradual
titration to effect is a useful guide when sedating the geriatric
patient.

One means of minimizing risk in the elderly patient is to perform
endoscopy with minimal or no sedation. Although moderate sedation
significantly improves tolerance for EGD, several studies have
demonstrated the role of newer ultrathin endoscopes in allowing
nonsedated upper endoscopy, including in elderly patients. Two studies
have shown successful nonsedated PEG placement with the use of ultrathin
endoscopes. Other advantages of smaller caliber upper endoscopes are the
reduced likelihood of oxygen desaturation and arrhythmias during the
procedure.

**[Monitoring/Procedural Care]{.underline}**

As with all moderate sedation, standard monitoring procedures should be
followed. Great care should be exercised in older patients with
rheumatoid arthritis because neck extension during upper endoscopy or to
improve ventilation may cause atlanto-axial subluxation with the
potential to produce spinal cord injury.

There should be a low threshold for oxygen administration before and
during moderate sedation because it reduces the incidence of oxygen
desaturation. Oxygen supplementation should be used liberally in
patients with known cardiovascular or pulmonary compromise, realizing
that oxygen dosing has the potential risk of causing respiratory
depression when patients with chronic hypercarbia lose the respiratory
drive of hypoxemia.

**Equipment**

The monitoring devices, resuscitative equipment, and drugs used for
geriatric patients are the same as those used for all patients. Oxygen
should be readily available. Endoscopes and accessories are the same as
those used in younger adults. Pediatric instruments, particularly
colonoscopes with more flexible insertion tubes, may be useful in older
patients who frequently have significant fixation or narrowing of the
sigmoid colon as a result of prior surgery or diverticular disease.

**Therapeutic Interventions**

There are no age-specific differences in the technical aspects of
endoscopic therapies for geriatric patients. As previously discussed,
prudent judgment should be used regarding the relative risk and benefit
for endoscopic therapies, which may have little bearing on prognosis or
quality of life due to significant underlying comorbidities.

**[Summary]{.underline}**

-   Most diagnostic and therapeutic endoscopic interventions can be
    safely performed in elderly patients. (**B**)

-   Preparation for endoscopy in the elderly differs little from that in
    younger adults, but caution regarding fluid and electrolyte shifts
    should be exercised when using colonoscopy preparations. (**B**)

-   Colonoscopic screening and surveillance for colorectal cancer in
    patients of advanced age should be individualized on the basis of
    general health and comorbid medical illnesses. (**C**)

-   Moderate sedation in the elderly requires heightened attention to
    dosing and the effects of standard sedatives. (**C**)

-   Initial doses of sedatives should be lower than standard adult
    dosing and titration should be more gradual to allow assessment of
    the full dose effect at each dose level. (**C**)

-   Intensified monitoring is appropriate for many elderly patients.
    (**C**)

**[Definitions]{.underline}**:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and classified for the
recommendations using the following scheme:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

When little or no data exist from well-designed prospective trials,
emphasis is given to results from large series and reports from
recognized experts. Guidelines for appropriate utilization of endoscopy
are based on a critical review of the available data and expert
consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate use of endoscopy in the elderly

#### POTENTIAL HARMS

-   Increased attention should be paid to the risk engendered by
    age-related diseases, such as cardiac and pulmonary dysfunction.
    Significant risk may outweigh the acknowledged benefits of a
    procedure.

-   Sodium phosphate preparations are associated with hyperphosphatemia,
    hypernatremia, and hypokalemia, although there were no clinically
    significant adverse effects in clinical trials in healthy elderly
    patients. Caution should be exercised in those patients with renal
    or cardiac dysfunction, in whom fluid and electrolyte shifts can
    occur with the osmotic preparations.

-   Cardiopulmonary complications of sedation.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   The relative and absolute contraindications for gastrointestinal
    endoscopy among the elderly are largely the same as those for
    adults.

-   During capsule endoscopy there is a theoretical potential for
    interference from the digital radiofrequency communication between
    the capsule and the data recorder, so the presence of a cardiac
    pacemaker or implantable cardioverter defibrillator (ICD) is
    considered a relative contraindication to capsule endoscopy.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Further controlled clinical studies are needed to clarify aspects of
this statement, and revision may be necessary as new data appear.
Clinical consideration may justify a course of action at variance to
these recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Qureshi WA, Zuckerman MJ, Adler DG, Davila RE, Egan JV, Gan SI,
Lichtenstein DR, Rajan E, Shen B, Fanelli RD, Van Guilder T, Baron TH,
Standards of Practice Committee, American Society for Gastrointestinal
Endoscopy. ASGE guideline: modifications in endoscopic practice for the
elderly. Gastrointest Endosc 2006 Apr;63(4):566-9. \[52 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16564853)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Apr

#### GUIDELINE DEVELOPER(S)

American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Waqar A. Qureshi, MD; Marc J. Zuckerman, MD;
Douglas G. Adler, MD; Raquel E. Davila, MD; James V. Egan, MD; S. Ian
Gan, MD; David R. Lichtenstein, MD; Elizabeth Rajan, MD; Bo Shen, MD;
Robert D. Fanelli, MD (*SAGES Representative*); Trina Van Guilder, RN
(*SGNA Representative*); Todd H. Baron, MD (*Chair*)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society for Gastrointestinal Endoscopy (ASGE) Web
site](http://www.asge.org/PublicationsProductsIndex.aspx?id=352).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 7, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008