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The United States Preventive Services Task Force recommends an upper age limit of 75 for asymptomatic colorectal cancer (CRC) screening, primarily because of the likely benefit of early detec-tion in a patient population with limited life expectancy. Colonoscopy is the gold standard for CRC screening. Complications of colonoscopy more common in older adults include fluid and electrolyte shifts, dehydration and delirium. Frailty assessment has successfully predicted outcomes in many clini-cal settings. However, thus far, assessment of frailty has not been widely used to predict risk of com-plications from colonoscopy in older adults.

Age is an imperfect predictor of CRC screening outcomes. Fitness for colonoscopy has been assessed by the American Society of Anesthesiologists (ASA) score as a measure of physical status, and the Eastern Cooperative Oncology Group (ECOG) score as a measure of function. Chronologic age is a marker of frailty, which more accurately describes “personal biologic age.”[[1]] For example, the physio-logic age of a 70-year-old with severe frailty may be more consistent with that of an average 85-year-old. Physical frailty is defined as “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.”[[2]] Frailty is a robust predictor of hospital readmissions, institutionalisation and mortality[[3]]. Frailty assessments have been shown to predict post-operative outcomes.[[3–4]] However, only one study has investigated the rela-tionship between frailty and colonoscopy outcomes.[[5]]

In a prospective cohort study, Taleban et al assessed the efficacy of an upper extremity muscle per-formance (UEMP) test, a measure of sarcopenia shown to correlate with the Fried frailty pheno-type,[[6]] to predict periprocedural colonoscopy outcomes in asymptomatic patients undergoing CRC screening. This UEMP test differentiated Non-Frail (n=49) from Pre-Frail/Frail (n=50) patients, and the incidence of complications were compared. Complications were seen in 41% of Non-Frail compared to 70% of Pre-Frail/Frail (p=0.01). The ASA score was also correlated with adverse outcomes (p=0.02), whereas age and Charlson Comorbidity Index were not.

These results suggest that frailty may predict outcomes in older adults undergoing colonoscopy and agree with literature that advocates using frailty assessments to predict perioperative outcomes.[[3,7]] However, the Taleban study has numerous weaknesses. First, the UEMP test is strictly a measure of sarcopenia, yet sarcopenia is just one component of frailty. Second, the UEMP test was validated against a binary model of frailty phenotype, which is used clinically as a screening tool rather than a rigorous assessment of frailty. Third, the Pre-Frail and Frail groups were combined, potentially masking the extent to which a proxy measurement of frailty actually predicts colonoscopy outcomes. Fourth, age was used as a covariate when analysing correlation between the UEMP test and outcomes, obviat-ing the use of frailty as a better marker of outcomes than age. Finally, utilising a tool that requires technology is not financially or logistically feasible on a population scale.

Despite these weaknesses, Taleban et al addressed an unmet need to better predict colonoscopy out-comes, and to our knowledge there have been no similar studies since it was published in 2018. Fur-ther research is needed to explore the use of frailty as a predictor of colonoscopy outcomes in older adults. An ideal frailty assessment for this purpose should (1) be evidence-based and validated, (2) include multiple domains (eg, medical comorbidities, cognition, function, nutrition and social support) and (3) be easily implementable at scale. The Edmonton Frail Scale (EFS)[[8]] and modified frailty index (mFI)[[9]] are ideal candidates to consider.

The EFS is a patient-centred, 11-item questionnaire covering multiple domains that can be adminis-tered by a nurse assistant in less than five minutes. Clock draw and timed-up-and-go tests directly as-sess cognition and physical function. Among other applications, the EFS has predicted post-operative outcomes in elective major abdominal surgery[[7]] and identified chemotherapy candidates in older adults with CRC.[[10]]

The mFI consists of 11 comorbidities that were derived by mapping variables of the Rockwood frailty index[[1]] onto the National Surgical Quality Improvement Program (NSQIP) in patients who underwent laparoscopic or open colectomy. The mFI does not include cognition, nutrition or social support do-mains. The mFI can be completed by chart review or, in some electronic medical record systems, au-tomatically. Because it was derived and validated in surgical patients, there is an extensive body of lit-erature demonstrating that the mFI correlates with post-surgical outcomes.[[3]]

In summary, we recommend that older patients undergoing colonoscopy should be screened for frail-ty. A clear decision-making pathway that uses frailty assessment must first be established to guide clin-ical care. Frailty assessment must be coupled with clinical reasoning and used to facilitate goals-of-care discussions while weighing the individualised benefits versus risks of colonoscopy. Future studies are needed to investigate the value of the EFS and mFI to predict periprocedural outcomes of colonoscopy in older adults.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Tyson Oberndorfer: Taranaki District Health Board, Base Hospital, Older Peoples Health & Rehabilitation Service; Department of Internal Medicine. Dr R Jurawan: Taranaki District Health Board, Base Hospital, Gastroenterologist; Department of Internal Medicine.

Acknowledgements

Correspondence

Tyson A Oberndorfer, MD, MS, FACP, Specialist Geriatrician, Older Peoples Health & Rehabilitation, Taranaki DHB

Correspondence Email

tyson.oberndorfer@tdhb.org.nz

Competing Interests

Nil.

1) Rockwood K and Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med. 2011;27(1): 17-26. [PMID: 21093719]

2) Morley JE, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6): 392-7. [PMID: 23764209]

3) Panayi AC, et al. Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg. 2019;218(2): 393-400. [PMID: 30509455]

4) Han B, Li Q, Chen X. Effects of the frailty phenotype on post-operative complications in older surgical patients: a sys-tematic review and meta-analysis. BMC Geriatr. 2019;19(1): 141. [PMID: 31126245]

5) Taleban S, et al. Frailty Assessment Predicts Acute Outcomes in Patients Undergoing Screening Colonoscopy. Dig Dis Sci. 2018;63(12): 3272-3280. [PMID: 29934724]

6) Toosizadeh N, Mohler J, Najafi B. Assessing Upper Extremity Motion: An Innovative Method to Identify Frailty. J Am Geriatr Soc. 2015;63(6): 1181-6. [PMID: 26096391]

7) He Y, et al. Assessment of predictive validity and feasibility of Edmonton Frail Scale in identifying postoperative complications among elderly patients: a prospective observational study. Sci Rep. 2020;10(1): 14682. [PMID: 32895396]

8) Rolfson DB, et al. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5): 526-9. [PMID: 16757522]

9) Obeid NM, Azuh O, Reddy S. Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: exploring frailty and aggressive laparoscopic approaches. J Trauma Acute Care Surg. 2012;72: 878–883. [PubMed: 22491599]

10) Meyers BM, et al. Utility of the Edmonton Frail Scale in identifying frail elderly patients during treatment of colorec-tal cancer. J Gastrointest Oncol. 2017;8(1): 32-38. [PMID: 28280606]

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The United States Preventive Services Task Force recommends an upper age limit of 75 for asymptomatic colorectal cancer (CRC) screening, primarily because of the likely benefit of early detec-tion in a patient population with limited life expectancy. Colonoscopy is the gold standard for CRC screening. Complications of colonoscopy more common in older adults include fluid and electrolyte shifts, dehydration and delirium. Frailty assessment has successfully predicted outcomes in many clini-cal settings. However, thus far, assessment of frailty has not been widely used to predict risk of com-plications from colonoscopy in older adults.

Age is an imperfect predictor of CRC screening outcomes. Fitness for colonoscopy has been assessed by the American Society of Anesthesiologists (ASA) score as a measure of physical status, and the Eastern Cooperative Oncology Group (ECOG) score as a measure of function. Chronologic age is a marker of frailty, which more accurately describes “personal biologic age.”[[1]] For example, the physio-logic age of a 70-year-old with severe frailty may be more consistent with that of an average 85-year-old. Physical frailty is defined as “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.”[[2]] Frailty is a robust predictor of hospital readmissions, institutionalisation and mortality[[3]]. Frailty assessments have been shown to predict post-operative outcomes.[[3–4]] However, only one study has investigated the rela-tionship between frailty and colonoscopy outcomes.[[5]]

In a prospective cohort study, Taleban et al assessed the efficacy of an upper extremity muscle per-formance (UEMP) test, a measure of sarcopenia shown to correlate with the Fried frailty pheno-type,[[6]] to predict periprocedural colonoscopy outcomes in asymptomatic patients undergoing CRC screening. This UEMP test differentiated Non-Frail (n=49) from Pre-Frail/Frail (n=50) patients, and the incidence of complications were compared. Complications were seen in 41% of Non-Frail compared to 70% of Pre-Frail/Frail (p=0.01). The ASA score was also correlated with adverse outcomes (p=0.02), whereas age and Charlson Comorbidity Index were not.

These results suggest that frailty may predict outcomes in older adults undergoing colonoscopy and agree with literature that advocates using frailty assessments to predict perioperative outcomes.[[3,7]] However, the Taleban study has numerous weaknesses. First, the UEMP test is strictly a measure of sarcopenia, yet sarcopenia is just one component of frailty. Second, the UEMP test was validated against a binary model of frailty phenotype, which is used clinically as a screening tool rather than a rigorous assessment of frailty. Third, the Pre-Frail and Frail groups were combined, potentially masking the extent to which a proxy measurement of frailty actually predicts colonoscopy outcomes. Fourth, age was used as a covariate when analysing correlation between the UEMP test and outcomes, obviat-ing the use of frailty as a better marker of outcomes than age. Finally, utilising a tool that requires technology is not financially or logistically feasible on a population scale.

Despite these weaknesses, Taleban et al addressed an unmet need to better predict colonoscopy out-comes, and to our knowledge there have been no similar studies since it was published in 2018. Fur-ther research is needed to explore the use of frailty as a predictor of colonoscopy outcomes in older adults. An ideal frailty assessment for this purpose should (1) be evidence-based and validated, (2) include multiple domains (eg, medical comorbidities, cognition, function, nutrition and social support) and (3) be easily implementable at scale. The Edmonton Frail Scale (EFS)[[8]] and modified frailty index (mFI)[[9]] are ideal candidates to consider.

The EFS is a patient-centred, 11-item questionnaire covering multiple domains that can be adminis-tered by a nurse assistant in less than five minutes. Clock draw and timed-up-and-go tests directly as-sess cognition and physical function. Among other applications, the EFS has predicted post-operative outcomes in elective major abdominal surgery[[7]] and identified chemotherapy candidates in older adults with CRC.[[10]]

The mFI consists of 11 comorbidities that were derived by mapping variables of the Rockwood frailty index[[1]] onto the National Surgical Quality Improvement Program (NSQIP) in patients who underwent laparoscopic or open colectomy. The mFI does not include cognition, nutrition or social support do-mains. The mFI can be completed by chart review or, in some electronic medical record systems, au-tomatically. Because it was derived and validated in surgical patients, there is an extensive body of lit-erature demonstrating that the mFI correlates with post-surgical outcomes.[[3]]

In summary, we recommend that older patients undergoing colonoscopy should be screened for frail-ty. A clear decision-making pathway that uses frailty assessment must first be established to guide clin-ical care. Frailty assessment must be coupled with clinical reasoning and used to facilitate goals-of-care discussions while weighing the individualised benefits versus risks of colonoscopy. Future studies are needed to investigate the value of the EFS and mFI to predict periprocedural outcomes of colonoscopy in older adults.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Tyson Oberndorfer: Taranaki District Health Board, Base Hospital, Older Peoples Health & Rehabilitation Service; Department of Internal Medicine. Dr R Jurawan: Taranaki District Health Board, Base Hospital, Gastroenterologist; Department of Internal Medicine.

Acknowledgements

Correspondence

Tyson A Oberndorfer, MD, MS, FACP, Specialist Geriatrician, Older Peoples Health & Rehabilitation, Taranaki DHB

Correspondence Email

tyson.oberndorfer@tdhb.org.nz

Competing Interests

Nil.

1) Rockwood K and Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med. 2011;27(1): 17-26. [PMID: 21093719]

2) Morley JE, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6): 392-7. [PMID: 23764209]

3) Panayi AC, et al. Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg. 2019;218(2): 393-400. [PMID: 30509455]

4) Han B, Li Q, Chen X. Effects of the frailty phenotype on post-operative complications in older surgical patients: a sys-tematic review and meta-analysis. BMC Geriatr. 2019;19(1): 141. [PMID: 31126245]

5) Taleban S, et al. Frailty Assessment Predicts Acute Outcomes in Patients Undergoing Screening Colonoscopy. Dig Dis Sci. 2018;63(12): 3272-3280. [PMID: 29934724]

6) Toosizadeh N, Mohler J, Najafi B. Assessing Upper Extremity Motion: An Innovative Method to Identify Frailty. J Am Geriatr Soc. 2015;63(6): 1181-6. [PMID: 26096391]

7) He Y, et al. Assessment of predictive validity and feasibility of Edmonton Frail Scale in identifying postoperative complications among elderly patients: a prospective observational study. Sci Rep. 2020;10(1): 14682. [PMID: 32895396]

8) Rolfson DB, et al. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5): 526-9. [PMID: 16757522]

9) Obeid NM, Azuh O, Reddy S. Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: exploring frailty and aggressive laparoscopic approaches. J Trauma Acute Care Surg. 2012;72: 878–883. [PubMed: 22491599]

10) Meyers BM, et al. Utility of the Edmonton Frail Scale in identifying frail elderly patients during treatment of colorec-tal cancer. J Gastrointest Oncol. 2017;8(1): 32-38. [PMID: 28280606]

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The United States Preventive Services Task Force recommends an upper age limit of 75 for asymptomatic colorectal cancer (CRC) screening, primarily because of the likely benefit of early detec-tion in a patient population with limited life expectancy. Colonoscopy is the gold standard for CRC screening. Complications of colonoscopy more common in older adults include fluid and electrolyte shifts, dehydration and delirium. Frailty assessment has successfully predicted outcomes in many clini-cal settings. However, thus far, assessment of frailty has not been widely used to predict risk of com-plications from colonoscopy in older adults.

Age is an imperfect predictor of CRC screening outcomes. Fitness for colonoscopy has been assessed by the American Society of Anesthesiologists (ASA) score as a measure of physical status, and the Eastern Cooperative Oncology Group (ECOG) score as a measure of function. Chronologic age is a marker of frailty, which more accurately describes “personal biologic age.”[[1]] For example, the physio-logic age of a 70-year-old with severe frailty may be more consistent with that of an average 85-year-old. Physical frailty is defined as “a medical syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.”[[2]] Frailty is a robust predictor of hospital readmissions, institutionalisation and mortality[[3]]. Frailty assessments have been shown to predict post-operative outcomes.[[3–4]] However, only one study has investigated the rela-tionship between frailty and colonoscopy outcomes.[[5]]

In a prospective cohort study, Taleban et al assessed the efficacy of an upper extremity muscle per-formance (UEMP) test, a measure of sarcopenia shown to correlate with the Fried frailty pheno-type,[[6]] to predict periprocedural colonoscopy outcomes in asymptomatic patients undergoing CRC screening. This UEMP test differentiated Non-Frail (n=49) from Pre-Frail/Frail (n=50) patients, and the incidence of complications were compared. Complications were seen in 41% of Non-Frail compared to 70% of Pre-Frail/Frail (p=0.01). The ASA score was also correlated with adverse outcomes (p=0.02), whereas age and Charlson Comorbidity Index were not.

These results suggest that frailty may predict outcomes in older adults undergoing colonoscopy and agree with literature that advocates using frailty assessments to predict perioperative outcomes.[[3,7]] However, the Taleban study has numerous weaknesses. First, the UEMP test is strictly a measure of sarcopenia, yet sarcopenia is just one component of frailty. Second, the UEMP test was validated against a binary model of frailty phenotype, which is used clinically as a screening tool rather than a rigorous assessment of frailty. Third, the Pre-Frail and Frail groups were combined, potentially masking the extent to which a proxy measurement of frailty actually predicts colonoscopy outcomes. Fourth, age was used as a covariate when analysing correlation between the UEMP test and outcomes, obviat-ing the use of frailty as a better marker of outcomes than age. Finally, utilising a tool that requires technology is not financially or logistically feasible on a population scale.

Despite these weaknesses, Taleban et al addressed an unmet need to better predict colonoscopy out-comes, and to our knowledge there have been no similar studies since it was published in 2018. Fur-ther research is needed to explore the use of frailty as a predictor of colonoscopy outcomes in older adults. An ideal frailty assessment for this purpose should (1) be evidence-based and validated, (2) include multiple domains (eg, medical comorbidities, cognition, function, nutrition and social support) and (3) be easily implementable at scale. The Edmonton Frail Scale (EFS)[[8]] and modified frailty index (mFI)[[9]] are ideal candidates to consider.

The EFS is a patient-centred, 11-item questionnaire covering multiple domains that can be adminis-tered by a nurse assistant in less than five minutes. Clock draw and timed-up-and-go tests directly as-sess cognition and physical function. Among other applications, the EFS has predicted post-operative outcomes in elective major abdominal surgery[[7]] and identified chemotherapy candidates in older adults with CRC.[[10]]

The mFI consists of 11 comorbidities that were derived by mapping variables of the Rockwood frailty index[[1]] onto the National Surgical Quality Improvement Program (NSQIP) in patients who underwent laparoscopic or open colectomy. The mFI does not include cognition, nutrition or social support do-mains. The mFI can be completed by chart review or, in some electronic medical record systems, au-tomatically. Because it was derived and validated in surgical patients, there is an extensive body of lit-erature demonstrating that the mFI correlates with post-surgical outcomes.[[3]]

In summary, we recommend that older patients undergoing colonoscopy should be screened for frail-ty. A clear decision-making pathway that uses frailty assessment must first be established to guide clin-ical care. Frailty assessment must be coupled with clinical reasoning and used to facilitate goals-of-care discussions while weighing the individualised benefits versus risks of colonoscopy. Future studies are needed to investigate the value of the EFS and mFI to predict periprocedural outcomes of colonoscopy in older adults.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Tyson Oberndorfer: Taranaki District Health Board, Base Hospital, Older Peoples Health & Rehabilitation Service; Department of Internal Medicine. Dr R Jurawan: Taranaki District Health Board, Base Hospital, Gastroenterologist; Department of Internal Medicine.

Acknowledgements

Correspondence

Tyson A Oberndorfer, MD, MS, FACP, Specialist Geriatrician, Older Peoples Health & Rehabilitation, Taranaki DHB

Correspondence Email

tyson.oberndorfer@tdhb.org.nz

Competing Interests

Nil.

1) Rockwood K and Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med. 2011;27(1): 17-26. [PMID: 21093719]

2) Morley JE, et al. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013;14(6): 392-7. [PMID: 23764209]

3) Panayi AC, et al. Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. Am J Surg. 2019;218(2): 393-400. [PMID: 30509455]

4) Han B, Li Q, Chen X. Effects of the frailty phenotype on post-operative complications in older surgical patients: a sys-tematic review and meta-analysis. BMC Geriatr. 2019;19(1): 141. [PMID: 31126245]

5) Taleban S, et al. Frailty Assessment Predicts Acute Outcomes in Patients Undergoing Screening Colonoscopy. Dig Dis Sci. 2018;63(12): 3272-3280. [PMID: 29934724]

6) Toosizadeh N, Mohler J, Najafi B. Assessing Upper Extremity Motion: An Innovative Method to Identify Frailty. J Am Geriatr Soc. 2015;63(6): 1181-6. [PMID: 26096391]

7) He Y, et al. Assessment of predictive validity and feasibility of Edmonton Frail Scale in identifying postoperative complications among elderly patients: a prospective observational study. Sci Rep. 2020;10(1): 14682. [PMID: 32895396]

8) Rolfson DB, et al. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5): 526-9. [PMID: 16757522]

9) Obeid NM, Azuh O, Reddy S. Predictors of critical care-related complications in colectomy patients using the National Surgical Quality Improvement Program: exploring frailty and aggressive laparoscopic approaches. J Trauma Acute Care Surg. 2012;72: 878–883. [PubMed: 22491599]

10) Meyers BM, et al. Utility of the Edmonton Frail Scale in identifying frail elderly patients during treatment of colorec-tal cancer. J Gastrointest Oncol. 2017;8(1): 32-38. [PMID: 28280606]

Contact diana@nzma.org.nz
for the PDF of this article

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