Anemia in the Elderly

• Anemia is defined as hemoglobin (Hgb) less than 13 in men and less than 12 in women.
• Unexplained anemia of the elderly (UAE) is the most common type of anemia.
• It takes 6-9 months to correct anemia.

Impact of Anemia

• Over 20% of individuals over 85 years old are affected by anemia.
• Institutionalized individuals are more prone to anemia and infection due to chronic problems.
• Anemia increases mortality and morbidity, leading to more falls, memory loss, life restriction, and frequent hospitalizations.
• Anemia impairs wound healing.
• Bone marrow function decreases with age.
• The elderly have less lymphoid tissue as they age.
• Functional decline occurs in stem cells as people age.
• Bone marrow in older patients cannot respond as quickly as it would in younger patients.
• More chronic illnesses in older age increase the likelihood of anemia and make it harder to address.
• Poor heart function/pumping restricts blood from getting to tissues.
• Anemia increases the risks of syncope, falls, mortality, and morbidity.
• Myeloproliferative disease can mimic myelodysplastic syndrome (MDS).

Clinical Signs & Symptoms

• Taking a patient's history is most important in diagnosing anemia.
• Diagnosis begins by observing clinical signs and symptoms.
• Anemia of old age should only be diagnosed after ruling out other potential causes.
• Shortness of breath (SOB) and fatigue are the hallmarks of anemia.
• A workup should be done if a patient experiences both SOB and fatigue.
• Order a complete blood count (CBC), iron, and B12 tests if a patient reports fatigue.
• Patients are always at risk for anemia when bleeding.
• Conduct a new workup for any new symptoms.
• The workup should be focused on risk factors, as these can increase the development of anemia.
• Risk factors include chronic alcohol use, malnutrition, chronic pancreatitis or gastritis, chronic kidney disease (CKD), liver disease, gastrointestinal (GI) bleeding, cancer, and androgen deficiency.
• The kidney produces erythropoietin (EPO).
• The liver produces proteins needed for blood cell production.
• Testosterone aids in red blood cell (RBC) development.
• Order a CBC, Vitamin B12, and iron studies for patients with chronic fatigue, malabsorption, and malnutrition.

Workup

• The complete blood count with differential (CBC w/ diff) includes hemoglobin and hematocrit (H&H), mean corpuscular volume/red cell distribution width (MCV/RDW) for size, mean corpuscular hemoglobin (MCH) for weight, mean corpuscular hemoglobin concentration (MCHC) for Hgb concentration, neutrophils for infection, and basophil and eosinophil counts for allergic reactions and parasites.
• The reticulocyte count assesses bone marrow and erythropoietic function.
• An elevated reticulocyte count indicates a problem exists, such as GI bleeding or chemo-radiation history.
• Iron studies include ferritin, transferrin, iron, and total iron binding capacity (TIBC).
• Iron studies are crucial for diagnosing the type of anemia.
• Ferritin stores iron; it can decrease with GI bleeds or inflammation.
• Patients cannot undergo surgery until their ferritin is fixed.
• Transferrin is iron bound to globulin that increases with low iron levels.
• Saturation measures the percentage of transferrin that is bound with iron.
• TIBC measures all proteins available for binding iron.
• Creatinine levels assess kidney function.
• Vitamin B12, folate, and thyroid levels are also measured.
• Liver function tests (LFT) are performed to determine the levels of proteins needed to produce RBCs, as well as B12 and folate.
• Additional lab tests include:EPO to assess chronic kidney disease.
• C-reactive protein (CRP) detects serious inflammation that can sequester iron and affect iron lab results.
• Lactate dehydrogenase (LDH) is helpful for diagnosing hemolytic anemia.
• Low haptoglobin means RBCs are being destroyed, indicating hemolytic anemia.
• Bone marrow tests are performed on individuals with bone marrow issues such as cancers or leukemia.
• Peripheral blood smears are taken to check for abnormalities.
• Blast cells indicate cancer or new proliferation.
• Bite cells indicate G6PD deficiency.
• Auer rods indicate acute myeloid leukemia (AML).
• Target cells indicate thalassemia.

CBC components

• Interpreting CBC results is the first step in anemia workups.
• Hematocrit (Hct) is 3x hemoglobin (Hgb).
• Microcytic and normocytic conditions are most common in the elderly.
• If iron deficiency is ruled out, chronic disease should be considered next.
• Chronic kidney disease (CKD) is the most common chronic disease so order creatinine and GFR tests.
• In cases of macrocytic disease, order a blood smear and reticulocyte count.
• Suspect myelodysplastic syndrome or malignancy if there are abnormalities on the blood smear.

Types of Anemia

• Iron deficiency is the most common type of anemia.
• Blood loss is the most common cause of iron deficiency.
• Other types of anemia include anemia of chronic disease, B12/folate deficiency, and thalassemia.
• Target cells are associated with thalassemia.
• Aplastic anemia is characterized by pancytopenia and may require a bone marrow transplant.
• Pancytopenia is low RBC, WBC, and platelet counts. Sickle cell anemia includes joint pain with kids.
• Sickle cell anemia- Sickle cell, HJ, target shaped on smear.
• Hemolytic anemia is characterized by a positive Coombs test, elevated LDH, and indirect bilirubin.
• Prednisone can be prescribed for hemolytic anemia.
• Lead poisoning is microcytic.
• G6PD deficiency is characterized by bite cells, and oxidative drugs should be avoided.

Treatment of Anemia

• Treatment is directed at the underlying cause of the anemia.
• All treatments require patient education.
• Correcting blood loss is a key treatment strategy.
• Vitamin B12 deficiency is treated with B12 supplementation via sublingual or intramuscular injection.
• Sublingual administration is recommended for the elderly.
• Oral administration is not recommended.
• Iron deficiency is treated with iron supplements and Vitamin C (orange juice).
• Additional diagnostics may be needed.
• Follow-up should occur within 4 weeks of the treatment.
• Patients may not return to normal, but symptoms will improve with treatment.