From the Guidelines
Elderly patients undergoing Esophagogastroduodenoscopy (EGD) are at a higher risk of complications, including hemorrhage, aspiration pneumonia, myocardial infarction, and bowel perforation, with cardiopulmonary events accounting for more than 50% of complications 1. When considering EGD in elderly patients, it is crucial to conduct thorough pre-procedure assessments, including evaluation of comorbidities, particularly cardiovascular and pulmonary conditions, as these increase procedural risks.
- Medication review is essential, with special attention to anticoagulants and antiplatelets;
- Sedation protocols should be modified with reduced initial doses and careful titration to minimize respiratory depression and hemodynamic instability.
- Cognitive assessment before obtaining consent is crucial, as dementia or delirium may affect understanding and cooperation. The procedure itself should be performed efficiently, with continuous monitoring of vital signs and oxygen saturation. Post-procedure, elderly patients require extended recovery monitoring and clear discharge instructions provided to both the patient and caregiver. A comprehensive geriatric assessment (CGA) and management, including screening for frailty using a validated tool, can improve outcomes in elderly patients undergoing EGD 1. These considerations are important because elderly patients have reduced physiological reserves, altered drug metabolism, and higher prevalence of comorbidities that increase procedure-related complications. Involvement of a physician specialized in the care of older adults to co-manage these patients, and/or the use of targeted interventions, should occur as soon as possible after the procedure, if not before 1. Proactive management of frail patients may also decrease overall costs of care 1. Overall, careful consideration and management of elderly patients undergoing EGD can help minimize risks and improve outcomes.
From the Research
Considerations for Performing EGD in Elderly Patients
- The incidence of both benign and malignant gastrointestinal (GI) disease rises with increasing age, making endoscopic procedures like EGD common in elderly patients 2.
- When considering EGD in elderly patients, it is essential to weigh the anticipated benefits against the increased risks associated with procedural sedation and some endoscopic procedures 2.
- Sedation-related adverse events, such as hypoxia and hypotension, may be a concern in elderly patients undergoing EGD, particularly when using propofol-based sedation 3.
- The addition of midazolam to propofol-based sedation did not reduce safety and efficacy in one study, suggesting that sedation using propofol alone could be suitable for diagnostic EGD 3.
- Early EGD (within 24 hours) in elderly patients with non-variceal upper gastrointestinal bleeding (NVGIB) may be associated with decreased hospital stay and charges, but also with increased mortality and inter-hospital transfer 4.
Sedation and Anesthesia Considerations
- Dexmedetomidine in combination with low doses of midazolam may be more effective than midazolam alone for sedation in awake fiberoptic intubation, with fewer adverse reactions and higher patient satisfaction 5.
- The choice of sedation and anesthesia should be carefully considered in elderly patients undergoing EGD, taking into account their individual health status and comorbidities.
Screening and Age-Related Considerations
- National and international guidelines suggest that 75 years is an appropriate age to begin weighing the risks and benefits of screening procedures, such as colonoscopic colorectal screening and Barrett's surveillance, in elderly patients 6.
- Most guidelines advocate for complete cessation of screening after the age of 85 years, although this may vary depending on the patient's individual health status and comorbidities 6.