Balancing safety and effectiveness in colonoscopy for older adults: a narrative review - PMC

Some studies focusing on asymptomatic individuals aged 80 years or older found a relatively low rate of significant new neoplasia (cancer in 0%–0.7%) and advanced adenomas in only about 2%–4%, suggesting that routine screening colonoscopy in very old, asymptomatic patients with negative prior results has limited benefit in diagnostic yield [21-23]. In contrast, elderly individuals who have never undergone CRC screening may harbor advanced lesions, and screening colonoscopy is highly beneficial and strongly recommended for this colonoscopy-naive population when their health status permits [8,9,24].

Colonoscopy has clear diagnostic value when patients present with alarm symptoms such as rectal bleeding, iron-deficiency anemia, or recent changes in bowel habits, regardless of age. Research has demonstrated that colonoscopy can be a valuable diagnostic tool even in very elderly individuals, with studies showing its efficacy in identifying sources of bleeding or malignancies that can be treated, thereby enhancing clinical outcomes

https://pmc.ncbi.nlm.nih.gov/articles/PMC12590080/

However, the interpretation of positive fecal immunochemical test (FIT) results necessitates further consideration. Current guidelines advocate a personalized approach to decision-making for adults aged 75 years and over, taking into account the potential burdens associated with CRC screening [8]. Additionally, the false-positive rate of FIT rises with age, and the routine performance of colonoscopies following positive FIT results in very elderly patients may incur further risks [28]. Consequently, it may be prudent to refrain from routine FIT screening in older adults aged 75 years and over who are reluctant to undergo a colonoscopy. The decision regarding the performance of a diagnostic colonoscopy in older patients with positive FIT should be made on an individual basis, with consideration given to the risk of the procedure rather than the patient's chronological age.

In conclusion, while the benefit of screening colonoscopy declines with advancing age and shorter life expectancy, the endoscopic procedure remains valuable for evaluating gastrointestinal symptoms or completing therapeutic interventions in older patients. Consequently, the decision to perform a colonoscopy should be made on an individual basis, considering the purpose of the procedure.

Adequate bowel preparation is of crucial importance for the safety and efficacy of a colonoscopy [29]. In older adult patients, achieving adequate good colon cleansing can present a greater challenge. Several age-related factors have been identified as contributing to higher rates of inadequate bowel preparation in this population. These include chronic constipation, decreased gastrointestinal motility, cognitive impairment, and difficulties in tolerating large volume bowel cleansing solutions. A number of studies have previously observed that older age is associated with an increased likelihood of suboptimal bowel preparation and incomplete examinations with increasing age

The lower completion rates observed in older adults are frequently attributed to various factors, including inadequate bowel preparation, the presence of diverticulosis, tortuous colons or obstructive lesions, and intolerance to colonoscopy due to abdominal discomfort. A significant contributing factor to incomplete procedures in the elderly is inadequate bowel preparation. While polyethylene glycol (PEG)-based preparation can present certain challenges for frail patients in completing the bowel preparation protocol, resulting in inadequate colon cleansing [29,30,34], alternative low-volume bowel cleansing agents with improved tolerability may elevate the risk of electrolyte imbalance and dehydration in the elderly patients with renal insufficiency, congestive heart failure, or decompensated cirrhosis.

CONCLUSIONS

The performance of a colonoscopy on elderly patients has been shown to carry with it a higher potential for positive outcomes, but also an elevated risk to the patient. It is an established fact that older adults bear the greatest burden of colorectal pathology, and that colonoscopy can provide significant benefits in terms of cancer prevention, diagnosis of symptoms, and therapeutic interventions. Concurrently, advanced age is associated with a number of challenges, including the presence of comorbid illnesses, physiological changes, and a reduced margin for error. This has the potential to increase the risk of adverse events. Generally, colonoscopy can be performed safely in the elderly, provided that due attention is paid to the selection of patients and to the management of the procedure itself. Optimizing bowel preparation, adjusting sedation practices, and close monitoring for complications are critical components of care. The selection of older patients for colonoscopy should be made on an individual basis, with a comprehensive evaluation of the indication for the procedure, the probability of benefit, and the patient's life expectancy and risk factors. 

Also: https://pmc.ncbi.nlm.nih.gov/articles/PMC4055990/

Among people who had a screening colonoscopy, 2.3% died or were hospitalized overnight within 30 days, compared with 1.17% of those who did not have a colonoscopy.

Other analyses suggested that the colonoscopy itself didn't substantially increase people's risk of death or hospitalization. Instead, the colonoscopy may have led to subsequent procedures that increased the chance of harm for older patients.

"For people ages 76 to 85 who are considering having a screening colonoscopy, these findings provide a clearer picture of the potential risks," Chubak said. "This should help patients make better-informed decisions with their doctors about whether the benefits of this screening method outweigh the risks for them."

https://kpwashingtonresearch.org/index.php/news-and-events/recent-news/news-2025/study-measures-risks-screening-colonoscopies-older-adults