Colonoscopy in the very elderly.

Introduction: Colonoscopy is the gold standard test for investigating lower gastrointestinal symptoms and is an important therapeutic tool for colonic polypectomy. This paper is aimed at the general physician and examines the role of colonoscopy in very elderly patients by exploring the particular risks in this population, the yield of colonoscopy and potential alternative investigations.

Sources of data: Original research and review articles were identified through selective PubMed searches. Guidelines were identified through interrogation of national and international society websites in addition to PubMed searches.

Areas of agreement: Advanced age alone is not a reason to avoid investigation. The decision to perform colonoscopy in this population must take into account indication and yield, risks of the procedure and bowel preparation, physical fitness of the patient, potential alternative and the ability to consent. As a general rule, the principle of 'first doing no harm' should be applied and requires balancing of the risks of the procedure and preparation with the benefits of doing the test.

Areas of controversy: There is no defined upper age limit at which colonoscopy is contraindicated, however; the National Health Service Bowel Cancer Screening Programme stops inviting patients for screening and surveillance colonoscopy at age 75.

Growing points and areas timely for developing research: The concepts of 'first do no harm' and shared decision-making are not new but are increasingly important, particularly in this patient group. It is crucial to provide patients with information about risks, benefits and alternative investigations to empower their decision-making.