Abstract
Background/Aims
The role of screening colonoscopy in older adults remains controversial because of procedural risks and limited life expectancy. We evaluated the diagnostic yield, procedural success, and safety of screening colonoscopy in patients aged ≥75 years.
Methods
We retrospectively reviewed 602 patients aged ≥75 years who underwent screening colonoscopy between January 2013 and December 2024. Patients were stratified into two age groups: 75–79 years (n=486) and ≥80 years (n=116). Baseline characteristics, procedural outcomes, and safety were compared.
Results
Baseline characteristics were comparable between groups. The detection rates were 10.5%, 6.8%, and 0.9% for non-advanced adenoma, advanced adenoma, and colorectal cancer, respectively. Cecal intubation success was high in both groups (98.1% vs. 99.1%, p=0.454), and adequate bowel preparation rates were similar (71.2% vs. 72.4%, p=0.880). Sedation was used less frequently in patients aged ≥80 years (65.5% vs. 76.7%, p=0.013). Complications were rare (1.5%) and comparable between groups, with only mild events.
Conclusions
Screening colonoscopy in adults aged ≥75 years demonstrated high procedural success, substantial neoplasia detection rates, and low adverse event rates, with comparable outcomes in patients aged ≥80 years. However, overall clinical benefit should be interpreted cautiously, particularly in those aged ≥80 years, supporting an individualized approach.
Keywords: Aged, Colonoscopy, Colorectal neoplasms, Life expectancy
Graphical abstract
INTRODUCTION
Colorectal cancer is one of the leading causes of cancer-related morbidity and mortality worldwide, and its incidence increases steadily with advancing age.1 Given that the global population continues to age, particularly in rapidly aging countries such as South Korea, the number of older individuals potentially eligible for colorectal cancer screening continues to grow.2,3 Colonoscopy remains the gold standard screening modality because of its ability to detect and remove precancerous lesions.4 However, the appropriate use of screening colonoscopy in older adults remains controversial.
Several international guidelines, including those of the United States Preventive Services Task Force, recommend individualized decision-making for colorectal cancer screening in adults aged 76–85 years, as the balance between screening benefits and procedural risks becomes less clear with advancing age.5,6 Advanced age is often accompanied by increased comorbidities, decreased physiologic reserve, and heightened susceptibility to adverse events (AEs), including cardiopulmonary complications and procedure-related bleeding or perforation.7 Additionally, the potential benefits of screening may be limited by reduced life expectancy, particularly given the estimated lag time to benefit of approximately 10 years for colorectal cancer prevention.8 Previous studies suggest that life expectancy declines to around this threshold near the age of 80 years, making this a clinically relevant point at which the net benefit of screening becomes more uncertain.9
Despite these concerns, emerging evidence suggests that older adults continue to exhibit substantial adenoma and colorectal cancer detection rates, implying that screening may remain beneficial in selected individuals.10 Several studies have reported high procedural success rates and acceptable safety profiles in older adult patients, although most available data are derived from Western populations or heterogeneous cohorts that included screening and diagnostic colonoscopies.11,12 In Asian populations, where colorectal cancer epidemiology and healthcare utilization patterns differ, robust real-world data evaluating the effectiveness and safety of screening colonoscopy in adults aged ≥75 years remain limited.
Given these uncertainties, further investigations are needed to guide screening decisions for older adults. This study aimed to evaluate the efficacy and safety of screening colonoscopy in individuals aged ≥75 years at a single tertiary medical center in South Korea. We also compared the outcomes between individuals aged 75–79 years and those aged ≥80 years to determine whether advanced chronological age significantly affected colonoscopy performance, diagnostic yield, or the risk of AEs.
METHODS
Patients and study design
This single-center retrospective study was conducted at the Daegu Catholic University Medical Center (DCUMC), Daegu, South Korea. We identified individuals aged ≥75 years who underwent screening colonoscopies at the DCUMC between January 2013 and December 2024.
To define a true screening cohort, patients were excluded if colonoscopy was performed for any diagnostic indication, including abdominal symptoms, anemia, positive fecal occult blood test results, elevated carcinoembryonic antigen levels, or overt gastrointestinal bleeding. Additional exclusion criteria included a history of colorectal cancer or other colonic diseases, colonoscopy for preoperative evaluation, post-polypectomy or post-surgical surveillance, or procedures performed for therapeutic endoscopic interventions. The indications for screening were determined using multiple data sources, including electronic medical records, referral documentation, and diagnostic codes. To improve accuracy, a manual review of clinical documentation, including physician notes and nursing records, was performed.
Demographic and clinical variables, including age, sex, body mass index (BMI), comorbidities, and use of antithrombotic agents (aspirin, other antiplatelet agents, and anticoagulants), were extracted from electronic medical records. The comorbidity burden was assessed using the Charlson comorbidity index (CCI), which was calculated by summing the weighted scores of predefined comorbid conditions.13 For subgroup analyses, patients were stratified into two age groups: 75–79 years and ≥80 years.
Colonoscopy
Colonoscopy was performed with or without sedation based on patient preference and the endoscopist’s clinical judgment. Sedation was induced using midazolam, propofol, pethidine, or a combination of these agents at the discretion of the endoscopist. In older adult patients, reduced initial doses were generally administered (e.g., midazolam 1–2 mg and propofol 20–30 mg), followed by careful titration according to their clinical response. Continuous monitoring, including electrocardiography and pulse oximetry, was routinely performed, and supplemental oxygen was provided during sedation procedures. All the examinations were initiated with the patient in the left lateral decubitus position. During insertion, position changes or abdominal compression were applied when required to facilitate scope advancement and minimize looping. Cecal intubation was confirmed when the tip of the colonoscope reached the ileocecal valve, allowing adequate visualization of the cecum and appendiceal orifice. The choice of the bowel preparation regimen was determined at the discretion of the attending physician. Bowel cleanliness was assessed using the Boston bowel preparation scale, and adequate preparation was defined as a total score ≥6 with ≥2 points in each segment. Polypectomy or biopsy was performed when clinically indicated.
Study outcomes
The primary outcomes were cecal intubation rates, bowel preparation quality, neoplasia detection rates, and occurrence of colonoscopy-related AEs. Secondary outcomes included sedation use and the type of treatment performed during colonoscopy. “Neoplasia” was defined as any lesion confirmed as an adenoma or colorectal cancer on histopathological examination. Advanced adenoma was defined as an adenoma ≥1 cm in size containing high-grade dysplasia or demonstrating a villous or tubulovillous histological component. AEs were defined as complications requiring medical evaluation, treatment, or hospitalization within 30 days of the procedure. AEs included immediate or delayed bleeding, perforation, cardiopulmonary events related to sedation, and reactions associated with bowel preparation, such as vomiting or electrolyte disturbances. Additionally, AEs were classified according to their severity based on the American Society for Gastrointestinal Endoscopy (ASGE) lexicon.14 Mild AEs were defined as those requiring minimal or no intervention that resolved without sequelae.
Statistical analyses
Descriptive statistics were used to summarize the patient characteristics and procedural outcomes. Categorical variables are presented as frequencies and percentages, whereas continuous variables are expressed as means±standard deviations or medians with interquartile ranges, as appropriate. Group comparisons were performed using the Student t-test or Mann-Whitney U-test for continuous variables and the chi-squared test or Fisher’s exact test for categorical variables. Statistical significance was defined as a two-sided p-value <0.05. All analyses were performed using IBM SPSS Statistics for Windows ver. 21.0 (IBM Corp.).
Ethical considerations
The study protocol was approved by the Institutional Review Board of the DCUMC (protocol no. 2025-07-034).
RESULTS
Baseline patient characteristics
In total, 23,114 colonoscopies were performed during the study period. After excluding individuals aged ≤74 years (n=18,294) and those undergoing colonoscopies for non-screening indications (n=4,218), 602 screening colonoscopies in patients aged ≥75 years were included in the final analysis, accounting for 2.6% of all procedures (Fig. 1).
Fig. 1.
Flow diagram of study participants. CEA, carcinoembryonic antigen; GI, gastrointestinal; CRC, colorectal cancer.
The mean age of the study population was 77.6±2.50 years, with 486 patients (80.7%) aged 75–79 years and 116 patients (19.3%) aged ≥80 years. Overall, 59.3% of the participants were male, with no significant difference in sex distribution across age subgroups (p=0.192). The mean BMI was 24.2±3.03 kg/m² and did not differ significantly between the 75–79-year and ≥80-year groups (24.3±3.10 vs. 23.9±2.74 kg/m², p=0.122). The mean CCI of the overall cohort was 4.28±1.26. Patients aged ≥80 years had significantly higher CCI scores than those aged 75–79 years (5.25±1.19 vs. 4.05±1.16, p<0.001). Regarding antithrombotic therapy, 68.3% of patients did not receive antithrombotic agents, 30.6% were taking one agent, and 1.2% were taking two or more agents. Although antithrombotic use was more common in the ≥80-year group, the difference did not reach statistical significance (p=0.074) (Table 1). Regarding bowel preparation, 2 L polyethylene glycol (PEG) solution was used in the majority of cases (n=560, 93.0%), followed by 4 L PEG (n=29, 4.8%) and oral sulfate solution (n=10, 1.5%), and other regimens (n=3, 0.5%).
Table 1.
Baseline characteristics of study participants
| Characteristic | Total (n=602) | Age, 75–79 yr (n=486) | Age, ≥80 yr (n=116) | p-value |
|---|---|---|---|---|
| Age (yr) | 77.6±2.50 | 76.6±1.32 | 81.7±2.05 | <0.001 |
| Sex | 0.192 | |||
| Male | 357 (59.3) | 282 (58.0) | 75 (64.7) | |
| Female | 245 (40.7) | 204 (42.0) | 41 (35.3) | |
| Body mass index (kg/m2) | 24.2±3.03 | 24.3±3.10 | 23.9±2.74 | 0.122 |
| Charlson comorbidity index | 4.28±1.26 | 4.05±1.16 | 5.25±1.19 | <0.001 |
| Use of antithrombotic agents | 0.074 | |||
| None | 411 (68.3) | 342 (70.4) | 69 (59.5) | |
| 1 | 184 (30.6) | 139 (28.6) | 45 (38.8) | |
| ≥2 | 7 (1.2) | 5 (1.0) | 2 (1.7) |
Values are presented as mean±standard deviation or number (%).
Efficacy outcomes of colonoscopy
Among the 602 screening colonoscopies performed in patients aged ≥75 years, neoplastic lesions were detected in 110 cases (18.3%). Non-advanced adenomas accounted for 63 cases (10.5%), whereas advanced adenomas were identified in 41 cases (6.8%). Colorectal cancer was diagnosed in six patients (0.9%). Among the colorectal cancer cases, two patients had stage I disease, one had stage IIa disease, and one had stage IV disease. Staging information was unavailable in two patients due to loss to follow-up despite additional chart review. Although the neoplasia detection rate tended to be higher in patients aged ≥80 years than in those aged 75–79 years (24.1% vs. 16.9%), this difference did not reach statistical significance (p=0.092). Bowel preparation was adequate in 430 patients (71.4%), with similar rates observed between the 75–79-year and ≥80-year groups (71.2% vs. 72.4%, p=0.880). Cecal intubation was successfully performed in 592 procedures with an overall success rate of 98.3%. The success rate did not differ significantly between age groups (75–79 years: 98.1%; ≥80 years: 99.1%, p=0.454) (Table 2).
Table 2.
Effectiveness outcomes of screening colonoscopy
| Variable | Total (n=602) | Age, 75–79 yr (n=486) | Age, ≥80 yr (n=116) | p-value |
|---|---|---|---|---|
| Neoplasia detection | 110 (18.3) | 82 (16.9) | 28 (24.1) | 0.092 |
| Non-advanced adenoma | 63 (10.5) | 45 (9.3) | 18 (15.5) | 0.070 |
| Advanced adenomaa) | 41 (6.8) | 33 (6.8) | 8 (6.9) | 1.000 |
| Colorectal cancer | 6 (0.9) | 4 (0.8) | 2 (1.7) | 0.721 |
| Bowel preparation quality | 0.880 | |||
| Adequate | 430 (71.4) | 346 (71.2) | 84 (72.4) | |
| Poor | 172 (28.6) | 140 (28.8) | 32 (27.6) | |
| Cecal intubation | 0.454 | |||
| Success | 592 (98.3) | 477 (98.1) | 115 (99.1) | |
| Failure | 10 (1.7) | 9 (1.9) | 1 (0.9) |
Values are presented as number (%).
Advanced adenoma was defined as an adenoma measuring ≥1 cm, containing high-grade dysplasia, or exhibiting a villous component.
Safety outcomes
Sedation was administered in 449 of 602 procedures (74.6%). The use of sedation was significantly lower among patients aged ≥80 years compared with those aged 75–79 years (65.5% vs. 76.7%, p=0.013). A total of nine colonoscopy-related AEs were documented, corresponding to an overall incidence of 1.5%. These included five cases of bleeding, three cases of sedation-related complications, and one case related to bowel preparation. Bleeding events occurred either due to mucosal injury during scope insertion or following biopsy or endoscopic mucosal resection (EMR). All bleeding episodes were successfully treated using hemoclips or argon plasma coagulation. Sedation-related AEs included transient hypotension and decreased consciousness, all of which were promptly reversed by flumazenil administration. The single bowel preparation-related AE involved a patient with stage 4 chronic kidney disease who developed syncope secondary to electrolyte imbalance and required a short (3-day) hospitalization. All AEs were categorized based on the ASGE lexicon, classified as mild in severity, and successfully managed without further complications (Supplementary Table 1). The incidence of AEs tended to be higher in the ≥80-year group than in the 75–79-year group (2.6% vs. 1.2%); however, this difference did not reach statistical significance (p=0.242) (Table 3).
Table 3.
Safety outcomes
| Variable | Total (n=602) | Age, 75–79 yr (n=486) | Age, ≥80 yr (n=116) | p-value |
|---|---|---|---|---|
| Sedation use | 449 (74.6) | 373 (76.7) | 76 (65.5) | 0.013 |
| Complications | 9 (1.5) | 6 (1.2) | 3 (2.6) | 0.242 |
| Bleeding | 5 | 3 | 2 | |
| Sedation-related | 3 | 2 | 1 | |
| Bowel prep-related | 1 | 1 | 0 | |
| Serious adverse events | 0 | 0 | 0 |
Values are presented as number (%) or number only.
prep, preparation.
Treatment of detected neoplastic lesions
Among the 110 patients in whom neoplastic lesions were identified, 43 lesions were removed using cold forceps or polypectomy, whereas 44 lesions were treated with EMR. Endoscopic submucosal dissection was performed in three cases. Of the six patients diagnosed with colorectal cancer, two with stage I disease underwent surgical management: one underwent laparoscopic right hemicolectomy, and the other underwent transanal excision. A total of 18 patients (16.4%) did not return for follow-up or declined further treatment for neoplastic lesions. There was no significant difference in the distribution of treatment modalities between the 75–79-year and ≥80-year age groups (Table 4).
Table 4.
Treatment of detected neoplasia
| Variable | Total | Age, 75–79 yr | Age, ≥80 yr | p-value |
|---|---|---|---|---|
| No. of detected neoplasia | 110 (100.0) | 82 (100.0) | 28 (100.0) | |
| Treatment modality | 0.827 | |||
| Cold forceps removal or polypectomy | 43 (39.1) | 31 (37.8) | 12 (42.9) | |
| Endoscopic mucosal resection | 44 (40.0) | 35 (42.7) | 9 (32.1) | |
| Endoscopic submucosal dissection | 3 (2.7) | 2 (2.4) | 1 (3.6) | |
| Surgical resectiona) | 2 (1.8) | 1 (1.2) | 1 (3.6) | |
| Refusal of treatment | 18 (16.4) | 13 (15.9) | 5 (17.9) |
Values are presented as number (%).
Surgical resection included laparoscopic right hemicolectomy and transanal excision.
DISCUSSION
In this study of 602 adults aged ≥75 years who underwent screening colonoscopies, we found that the procedures were associated with high technical success rates, a meaningful diagnostic yield, and a low incidence of AEs. These outcomes were comparable between patients aged 75–79 years and those aged ≥80 years, indicating that advanced chronological age alone did not significantly compromise the effectiveness or safety of screening colonoscopies.
Our findings align with those of previous studies, demonstrating meaningful adenoma and colorectal cancer detection rates among older adults. Several Western cohort studies have reported comparable or even higher adenoma detection rates in individuals aged ≥75 years compared with younger populations.11,12,15 In addition, a population-based study from Korea demonstrated that individuals aged ≥80 years who underwent colonoscopies had a significantly lower incidence of colorectal cancer and colorectal cancer-related mortality than those who did not undergo colonoscopies.16 These results support the concept that the neoplastic risk continues to rise with age and that older adults may remain appropriate candidates for screening when life expectancy and functional status are favorable.10 However, most previous studies included heterogeneous populations with screening and diagnostic colonoscopies, limiting the ability to draw conclusions specifically applicable to asymptomatic older individuals. The present study addresses this gap by evaluating a well-defined screening-only cohort, thereby providing a clearer assessment of the true screening performance in older adults.
The procedural quality outcomes in our cohort were generally well-maintained, as reflected by the high cecal intubation rates. However, the bowel preparation adequacy rate (71.4%) was lower than the recommended quality benchmark for screening colonoscopies. Suboptimal bowel preparation is a well-recognized factor that can negatively affect lesion detection, including adenoma detection rates, and may therefore influence the diagnostic yield. Achieving adequate bowel preparation may be particularly challenging in older populations because of age-related factors such as decreased gastrointestinal motility, comorbidities, and reduced adherence to preparation regimens.17 Previous studies have similarly reported an increased risk of inadequate preparation with advancing age.18,19 Nevertheless, prior studies suggested that screening colonoscopies can still be performed with acceptable procedural outcomes in older individuals when appropriate preparation and techniques are ensured.20,21 Given the suboptimal bowel preparation rate observed in our cohort, these findings should be interpreted with caution, and further efforts to optimize bowel preparation in this population are warranted.
The overall AE rate of 1.5% was low, and all events were mild according to standardized criteria and were successfully managed without long-term consequences. The risk of colonoscopy-related complications generally increases with advancing age.19,22,23 However, previous studies indicated that chronological age itself may not be the primary determinant of AEs, with specific comorbidities such as congestive heart failure and chronic kidney disease contributing more directly to complication risk.23 In our study, a substantial proportion of patients had a moderate to high comorbidity burden based on the CCI. However, because this index reflects comorbidities rather than frailty, individuals undergoing screening colonoscopies are likely to represent a relatively healthy subset of the older adult population. Therefore, selection bias cannot be fully excluded, and the low AE rate observed in our study should be interpreted with caution, particularly when generalizing our results to frail older individuals. With respect to specific AEs, bleeding complications are typically associated with therapeutic interventions such as polypectomy; older adults often have higher rates of antithrombotic use.24 In our cohort, 30.6% of participants were receiving antithrombotic agents, which may have influenced the bleeding risk. Bowel preparation-related AEs should also be considered in this population. We observed a case of electrolyte imbalance in a patient with chronic kidney disease, highlighting the importance of adequate hydration and careful monitoring during bowel preparation.25
Sedation is another important consideration in older adult patients. Although the risk of sedation-related AEs, including hypoxia, hypotension, and arrhythmias, increases with age, it can be safely administered with appropriate dose reduction and close monitoring.26,27 In our cohort, sedation was used in 74.6% of procedures, with lower utilization among patients aged ≥80 years (65.5%), reflecting a more cautious approach. Although a direct causal relationship could not be established in this retrospective analysis, the conservative sedation strategy may have contributed to the low rates of cardiopulmonary AEs. Current Korean guidelines recommend initiating sedation at half the standard dose and titrating conservatively in older patients.28,29 However, detailed information on sedation protocols is not available, which limits our ability to fully evaluate their impact on safety outcomes. Taken together, these findings underscore the importance of careful patient selection, individualized sedation strategies, and vigilant monitoring to ensure safe colonoscopies in older adult patients.
An additional strength of this study is the evaluation of the subsequent management of detected neoplasia. Most lesions were amenable to endoscopic resection, supporting the potential therapeutic benefits of screening colonoscopies in older individuals. Early-stage colorectal cancer was identified in a subset of patients; however, staging information was incomplete in some cases. Although early detection is a key goal of screening, the overall stage distribution should be interpreted with caution.1,30 Importantly, 16.4% of the patients with detected neoplasia declined further treatment or were lost to follow-up, indicating that the diagnostic yield does not necessarily translate into preventive benefits in real-world settings. In addition, in patients aged ≥80 years, the removal of non-advanced adenomas may not result in meaningful clinical benefits owing to the limited life expectancy and competing risks of mortality. Therefore, although the diagnostic yield was substantial, the overall preventive effectiveness of screening colonoscopies may have been attenuated in this population.
This study had some limitations. First, its retrospective, single-center design may limit its generalizability. Second, frailty, functional status, and life expectancy were not assessed directly. Furthermore, individuals undergoing screening colonoscopies may represent a relatively healthier and more health-conscious subset of the older adult population, a phenomenon often referred to as the “healthy user effect,” which potentially leads to an overestimation of procedural safety and feasibility. Third, the analysis did not include long-term outcomes, such as cancer incidence or mortality, which would further clarify the net clinical benefit of screening colonoscopy in this age group.
Overall, screening colonoscopies in adults aged ≥75 years demonstrated acceptable procedural performance and a meaningful diagnostic yield, with a low rate of AEs. However, its overall clinical benefit should be interpreted with caution, particularly in patients aged ≥80 years. Therefore, a selective and individualized approach that incorporates life expectancy, comorbidity burden, and patient preferences is warranted, with an emphasis on shared decision-making.
Footnotes
Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
Author Contributions
Conceptualization: JL, JHB, HHJ; Data curation: JL, MK, GHY, JHB, HHJ; Formal analysis: JL, MK, GHY, JHB, HHJ; Investigation: JL, MK, GHY, JHB, HHJ; Methodology: JGK, EYK; Supervision: JGK, EYK; Writing–original draft: JL, JHB; Writing–review & editing: all authors.
Supplementary Material
Supplementary Table 1. Details of colonoscopy-related adverse events.
Supplementary materials related to this article can be found online at https://doi.org/10.5946/ce.2026.020.
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Associated Data
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Supplementary Materials
Supplementary Table 1. Details of colonoscopy-related adverse events.