Balancing Risks: Colonoscopy in Patients With Dementia

Although elderly patients with dementia have similar rates of colonoscopy-related complications as patients without dementia, they have higher rates of other non-procedural complications, according to a new study.

Patients with dementia had higher rates of renal injury, pulmonary events, cerebrovascular accidents, and sepsis. They were also less likely to have routine discharges, more likely to have longer hospital stays, and had higher hospital costs.

“With the increasing age of the patient population, physicians performing procedures are now more frequently finding themselves in a challenging situation of having to perform them on those with dementia,” lead author Faris Shweikeh, MD, an internal medicine resident at Cleveland Clinic Akron General, Akron, Ohio, told Medscape Medical News.

“While our results suggest that colonoscopy in this population should be done with careful discretion, it ultimately reminds us about the importance of collaborative decision-making efforts between patients, their physicians, as well as family members,” he said.

The study was published online in Digestive Diseases and Sciences.

Patient Characteristics and Outcomes

Shweikeh and colleagues conducted a population-based analysis of the Agency for Healthcare Research and Quality’s National Inpatient Sample data from 2019 to identify patients over the age of 60 who received a colonoscopy.

First, they compared demographic and clinical data between the 50,692 patients without dementia and the 4323 patients with dementia.

The mean age was 80 in the dementia cohort and 74 in the non-dementia cohort. Among patients undergoing colonoscopy, patients with dementia were more likely than those without dementia to be women, non-White, Medicare beneficiaries, have a lower income, and receive a colonoscopy on an emergency basis. Obese patients with dementia had a lower percentage of colonoscopy than those without dementia (9.23% vs 16.6%).

The researchers then performed a matched comparison of outcomes among patients with and without dementia (4176 patients in each group).

The groups didn’t have significantly different rates of colonoscopy-related complications, such as colon perforation, post-colonoscopy bleeding, or splenic injury.

However, patients with dementia had higher rates of certain other complications, including renal/acute kidney injury, pulmonary/pneumonia, cerebrovascular accidents, and sepsis. Differences in the rates of cardiac arrest, myocardial infarction, and deep vein thrombosis/pulmonary embolism were not statistically significant between the groups.

Patients with dementia were significantly less likely to have routine discharges, were more likely to have longer hospital stays, and had higher hospital costs. For instance, 28.1% of patients with dementia had a routine discharge compared with nearly 55% of those without dementia. Patients with dementia also tended to stay at the hospital for about a day longer and incurred more than $55,000 in costs compared with about $48,000 among those without dementia.

The findings indicate that colonoscopy in patients with dementia “should be done with caution,” the authors wrote. “The overall picture of the patient’s pre-procedure clinical status should be considered, including indication of the procedure, patient mental status, other comorbidities, laboratory and imaging findings, and social situation.”

The study raises questions about informed decision-making because patients with dementia are more likely to rely on caregivers to make decisions, the authors wrote. This makes the interplay between the physician, patient, and family a significant consideration in patient selection, they added.

Further research is needed on colonoscopy in patients with dementia, particularly regarding the long-term clinical outcomes, the need to enhance their medical care, and the effect of socioeconomic factors, including palliative and ethical implications, the researchers wrote.

Guidelines Needed

“Colonoscopy screening is vital for colorectal cancer prevention in older adults, significantly reducing mortality by detecting precancerous polyps and early-stage cancers. However, the adoption of such screening in dementia patients is understudied,” said Minghui Sam Li, PhD, assistant professor of clinical pharmacy and translational sciences at the University of Tennessee Health Science Center, Memphis, Tennessee.

Li, who wasn’t involved with this study, has researched how Alzheimer’s disease and dementia affect colorectal cancer screening utilization, knowledge, and health disparities. He and colleagues found that cognitive impairment significantly influences both clinical and financial outcomes among older adults.

“Dementia patients often face barriers to preventive care due to cognitive decline, reduced independence, and challenges in compliance with screening procedures,” Li told Medscape Medical News. “Specific guidelines for colorectal cancer screening in dementia patients are lacking, highlighting the need for research to provide evidence-based recommendations.”

With colonoscopy in particular, patients, caregivers, and clinicians should consider customized clinical care and the potential negative outcomes of invasive procedures, Li added.

“Informed clinical and financial decisions hinge on a careful consideration of the costs, risks, and benefits associated with procedures,” he said. “In dementia cases, caregivers play a pivotal role in the decision-making process and should be a focus of future research endeavors.”

The authors reported no grants or financial support for the study, as well as no conflicts of interest or disclosures related to the study. Li reported no relevant disclosures.

Carolyn Crist is a health and medical journalist who reports on the latest studies for Medscape Medical News, MDedge, and WebMD.