Anemia in the Elderly

Course #99082 - $20 • 5 Hours/Credits


Study Points

  1. Define anemia and its impact on the geriatric population.
  2. Describe the pathophysiology of anemias common in the elderly.
  3. Outline the role of nutrient deficiencies in the development of anemia.
  4. Compare and contrast other possible causes of anemia in the elderly.
  5. Discuss standards for the assessment of elders with anemia.
  6. Develop a treatment plan for geriatric patients with anemia.

    1 . Which group of patients has the highest incidence of anemia?
    A) Men 65 years of age
    B) Men 80 to 85 years of age
    C) Women 40 to 60 years of age
    D) Women older than 60 years of age

    OVERVIEW OF ANEMIA IN THE ELDERLY

    As noted, the risk of developing anemia increases with age. An average of 6.5% of individuals have anemia at 60 to 69 years of age; this increases to 19.4% at 80 to 85 years of age [5]. The prevalence of anemia is higher in elderly men than women, with the highest incidence (26%) occurring in men 80 to 85 years of age [5]. Rates of anemia in nursing home patients are estimated to be 48% to 63%, and anemic residents of long-term care have a higher associated mortality rate [9,10].

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    2 . Which of the following is a defining characteristic of anemia?
    A) Thrombocytopenia
    B) Decreased leukocytes
    C) Elevated erythrocyte count
    D) Hemoglobin (Hgb) less than 12 g/dL for women and less than 13 g/dL for men

    OVERVIEW OF ANEMIA IN THE ELDERLY

    The World Health Organization (WHO) defines anemia as a hemoglobin (Hgb) level less than 12 g/dL for women and less than 13 g/dL for men. An Hgb level of 10–11.9 g/dL for women and 11–12.9 g/dL for men is classified as mild anemia [13]. However, it is important to note that the use of Hgb level to define anemia has been controversial. In countries in which nutritional deficiencies, infection, or congenital blood disorders are common, it may be difficult to apply a universal Hgb cutpoint [14]. In addition, there appear to be racial differences in Hgb levels and the point at which symptoms of anemia emerge. Black patients in particular seem to tolerate a lower Hgb level than white patients. In general, black patients have a lower median Hgb and higher anemia prevalence [5]. Further research is needed to determine if a different Hgb level would be appropriate to diagnose and begin treatment for anemia in the black population [15].

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    3 . Of the following, which is the most prevalent cause of anemia in the elderly?
    A) Folate deficiency
    B) Endocrinopathies
    C) Chronic kidney disease
    D) Chronic disease/inflammation

    ETIOLOGY OF ANEMIA

    MOST COMMON CAUSES OF ANEMIA IN THE ELDERLY

    CausePrevalence
    Iron deficiency15% to 23%
    Chronic disease/inflammation15% to 35%
    Chronic kidney disease8%
    Endocrinopathies<5%
    Vitamin B12 or folate deficiencies<1% to 14%
    Myelodysplastic syndromes<1% to 5%
    Unexplained14% to 45%
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    4 . Anemia of inflammation and chronic disease can be defined as a(n)
    A) hemolytic defect.
    B) elevated reticulocyte count.
    C) high serum iron levels with low stores of iron.
    D) low serum iron while stores of iron are adequate.

    ETIOLOGY OF ANEMIA

    Anemia of inflammation and chronic disease (AI/ACD) is commonly seen in older patients. It is defined as a low serum iron and RBC levels despite iron stores that are normal or high, the result of blocked delivery of iron to developing RBCs and reduced intestinal absorption [17].

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    5 . In iron-deficiency anemia, which of the following is often present due to the decreasing iron supply?
    A) Leukopenia
    B) Macrocytosis
    C) Depleted iron stores
    D) Hyperchromic RBCs

    ETIOLOGY OF ANEMIA

    An estimated 15% to 23% of anemic elders have iron deficiency [11]. Iron-deficiency anemia is characterized by depletion of iron stores. Microcytic, hypochromic (smaller and paler) RBCs are often present due to the decreasing iron supply. However, the presence of normal RBCs (normocytic anemia) does not exclude iron-deficiency anemia, as microcytosis is a late finding of severe iron deficiency. Elderly individuals may be at increased risk for decreased iron absorption due to medication side effects, chronic illness and inflammation, dietary iron deficiencies, and malabsorption.

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    6 . What is the most common cause of iron-deficiency anemia in the elderly?
    A) Malnutrition
    B) Chronic kidney disease
    C) Medication side effects
    D) Gastrointestinal blood loss

    ETIOLOGY OF ANEMIA

    The most common cause of iron-deficiency anemia in the elderly is occult blood loss from the gastrointestinal tract. Blood loss from the gastrointestinal tract may be chronic or acute depending on the underlying etiology. It may be the result of nonsteroidal anti-inflammatory drug (NSAID) use, a gastric ulcer, colon cancer, diverticulosis, or angiodysplasia (i.e., vascular malformation in the gastrointestinal tract). In one study, gastrointestinal malignancy was present in 6% of patients with iron-deficiency anemia [19]. Referral to gastroenterology for endoscopic evaluation is crucial for all patients with iron-deficiency anemia (but particularly those with family histories of gastrointestinal cancers), and colonoscopy is recommended, regardless of age, to evaluate for possible bowel malignancy if upper endoscopy does not reveal a source of bleeding [20]. Stool should be tested for occult blood in the initial anemia work-up. It is important to also consider other potential causes of microcytic anemia during the evaluation of elderly patients with iron-deficiency anemia. For example, heavy metal poisoning may be an etiologic factor for anemia, and hypochromic, microcytic anemia may be associated with lead poisoning.

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    7 . Pernicious anemia is an autoimmune disorder that causes
    A) hemolysis.
    B) folate excess.
    C) vitamin B12 deficiency.
    D) elevated serum ferritin level.

    ETIOLOGY OF ANEMIA

    Pernicious anemia is caused by an autoimmune disease that leads to chronic malabsorption of vitamin B12 in older adults [21]. It is characterized by a decrease in RBCs resulting from impaired intestinal absorption of vitamin B12, caused by autoimmunity against intrinsic factor or gastric parietal cells (which produce intrinsic factor). Intrinsic factor is necessary for the absorption of vitamin B12, and decreased production of intrinsic factor leads to reduced absorption of vitamin B12 [21].

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    8 . Which of the following are good food sources of folate?
    A) Beer and lamb
    B) Liver and beans
    C) Milk and cheese
    D) Chicken and mashed potatoes

    ETIOLOGY OF ANEMIA

    Body stores of folate range from 500–20,000 mcg. It is necessary for humans to absorb 50–100 mcg of folate daily to replenish losses through bile and urine [31]. Food sources of folate include green vegetables, yeast, liver, beans, whole grains, and wheat bran. Many foods are also fortified with folate, including some breakfast cereals, rice, breads, and pasta [31]. Signs and symptoms of folate deficiency (e.g., weakness, fatigue, difficulty concentrating, dyspnea) develop gradually and are usually apparent after about four months.

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    9 . Myelodysplastic syndromes are characterized by
    A) chronic leukocytosis.
    B) nutrient-deficiency anemia and sickle cells.
    C) decreased erythropoietin production in the kidneys.
    D) peripheral blood cytopenias resulting from bone marrow dysfunction.

    ETIOLOGY OF ANEMIA

    Bone marrow is a blood-forming (hematopoietic) organ responsible for the production of most of the cellular components of the blood, including erythrocytes, leukocytes, and platelets. As an individual ages, he or she will produce a decreased amount of functional bone marrow, and disorders of hematopoiesis are more common in the elderly. Myelodysplastic syndromes (MDS) are one such group of disorders and a cause of anemia in older patients, although it is relatively uncommon. These disorders are characterized by one or more peripheral blood cytopenias resulting from bone marrow dysfunction [32]. According to the French-American-British (FAB) classification system, MDS is further classified according to cellular morphology, etiology, and clinical presentation as [32]:

    • Refractory anemia

    • Refractory anemia with ringed sideroblasts

    • Refractory anemia with excess blasts

    • Refractory anemia with excess blasts in transformation

    • Chronic myelomonocytic leukemia

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    10 . Approximately 30% of cases of myelodysplastic syndrome will progress to
    A) leukemia.
    B) thalassemia.
    C) sickle cell anemia.
    D) blood loss anemia.

    ETIOLOGY OF ANEMIA

    As noted, myelodysplasia is more common in elderly patients, and more than 75% of patients with MDS are older than 60 years of age at diagnosis [32]. Patients may be asymptomatic, and the disease is often found as the result of routine blood tests. When present, signs and symptoms include fatigue, pallor, frequent infections, easy bruising, and petechiae. An estimated 30% of cases will progress to acute leukemia [32].

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    11 . Macrocytosis, neutropenia, and thrombocytopenia are key characteristics of
    A) cheilitis.
    B) actinic keratosis.
    C) hemochromatosis.
    D) myelodysplastic syndrome.

    ETIOLOGY OF ANEMIA

    Anemia dominates the early course of MDS. Other key characteristics include macrocytosis, neutropenia, and thrombocytopenia. A poor prognosis is associated with advanced age, severe thrombocytopenia, and neutropenia.

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    12 . Anemia of chronic kidney disease is associated with
    A) exposure to radiation.
    B) increased erythropoietin production.
    C) decreased erythropoietin production.
    D) increased hemolytic response of the body.

    ETIOLOGY OF ANEMIA

    Kidney function and glomerular filtration rate (GFR) naturally decreases with age, and it may be further decreased in the presence of chronic illnesses such as hypertension and diabetes, the two main causes of chronic kidney disease. With declining kidney function there is a decreased production of erythropoietin from the kidneys, and this is the primary etiology of anemia associated with chronic kidney disease. It can be difficult to differentiate the effects of normal aging on the kidneys from chronic kidney disease. Although GFR decreasing with age is considered normal, the diagnostic criteria for chronic kidney disease are not modified according to a patient's age. Chronic kidney disease is defined as kidney damage or a GFR less than 60 mL/minute/1.73 m2 for more than three months [37]. It is further staged according to severity of GFR impairment and other symptoms (Table 2).

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    13 . Hemolysis causes the RBCs to
    A) become macrocytes.
    B) have an extended life span.
    C) fail to live the usual 120 days.
    D) multiply to excessive numbers.

    ETIOLOGY OF ANEMIA

    Hemolytic anemias occur as a result of deficiency of RBCs secondary to premature destruction. Hemolysis causes RBCs to live less than 120 days, their usual lifespan. The bone marrow is not able to increase production to compensate for the loss of RBCs, resulting in anemia [38]. Hemolytic anemias are usually categorized as inherited (e.g., sickle cell anemia) or acquired (e.g., the result of an immune disorder or infection). Some patients will have no known cause [38].

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    14 . A normal erythrocyte (red blood cell) count is in the range of
    A) 4,500–10,000 cells/mcL.
    B) 13–17 g/dL in men and 12–16 g/dL in women.
    C) 40% to 52% in men and 36% to 48% in women.
    D) 4.7–6.1 million cells/mcL in men and 4.2–5.4 million cells/mcL in women.

    LABORATORY ASSESSMENT OF ANEMIA

    The CBC is important for the diagnosis of anemia and for monitoring disease progression and treatment efficacy. When assessing the elderly anemia patient, the most important components of the CBC are [47]:

    • Erythrocyte (RBC) count: Reports the total number of RBCs per liter of whole blood.

      • Normal range for men: 4.7–6.1 million cells/mcL

      • Normal range for women: 4.2–5.4 million cells/mcL

    • Hgb: Measures the amount of hemoglobin present in the blood. Dehydration may produce a falsely high Hgb.

      • Normal range for men: 13–17 g/dL

      • Normal range for women: 12–16 g/dL

    • Hematocrit (HCT): Packed cell volume in proportion to blood volume.

      • Normal range for men: 40% to 52%

      • Normal range for women: 36% to 48%

    • Mean cell (corpuscular) volume (MCV): Measures the average size of RBCs, a diagnostic parameter for evaluating anemia, and differentiates microcytic and normocytic anemia in the elderly.

      • Normal range: 81–100 fL

      • Macrocytosis: Greater than 100 fL with large RBCs

      • Microcytosis: Less than 81 fL with small RBCs

    • Mean cell hemoglobin (MCH): Average amount of Hgb in an RBC.

      • Normal range: 27–34 Hgb/cell

    • Mean cell hemoglobin concentration (MCHC): Average concentration of Hgb in an RBC.

      • Normal range: 30% to 36%

    • RBC distribution width (RDW-CV): Measures variations in the size of RBCs.

      • Normal range: 12% to 14%

    • Leukocyte (white blood cell) count: Reports the number of leukocytes in the blood; the differential includes different types of leukocytes (i.e., neutrophil, eosinophil, basophil, lymphocyte, monocyte).

      • Normal range: 4,500–10,000 cells/mcL

    • Thrombocytes/platelet count: Number of platelets present.

      • Normal range: 150,000–450,000 cells/mcL

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    15 . An elevated reticulocyte count in the anemic patient indicates
    A) myelodysplasia.
    B) hemolytic anemia.
    C) decreased erythropoietic response.
    D) inappropriate response to anemia.

    LABORATORY ASSESSMENT OF ANEMIA

    Examination of a peripheral blood smear for morphologic abnormalities of RBCs (and for leukocytes and platelets as well) should be part of any evaluation of anemia. Anisocytosis indicates excessive numbers of RBCs with varying sizes; poikilocytosis denotes variation in shape and contour of RBCs [48]. Reticulocytes, which are young RBCs that mature in the marrow before release into the circulation, will appear in the blood in large numbers when there is accelerated RBC production, as occurs with hemolysis. A normal reticulocyte value is 0.5% to 1.5%; however, the reticulocyte count may be elevated in an anemic patient (reticulocytosis), indicating an erythropoietic response to the anemia [48]. Reticulocytosis may also raise suspicion for hemolytic anemia or increased RBC destruction. A low reticulocyte count (reticulocytopenia) usually indicates decreased RBC production and may point toward aplastic anemia, bone marrow depression, nutritional anemia, or ACI.

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    16 . A low serum ferritin level is indicative of
    A) cytopenia.
    B) poikilocytosis.
    C) iron-deficiency anemia.
    D) anemia of chronic inflammation.

    LABORATORY ASSESSMENT OF ANEMIA

    The iron profile, including the ferritin level, will give information about the iron availability, absorption, and iron stores of the body. Serum ferritin levels of 12–100 ng/mL can be present in both iron-deficiency anemia and AI/ACD [6]. Low serum ferritin levels are indicative of iron-deficiency anemia, and these patients should be evaluated for occult gastrointestinal bleeding from a malignancy or other cause.

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    17 . Pagophagia, a craving for ice, is present in roughly 50% of patients with
    A) aplastic anemia.
    B) iron-deficiency anemia.
    C) anemia of chronic inflammation.
    D) anemia of chronic kidney disease.

    ASSESSMENT OF ELDERS WITH ANEMIA

    Pica may develop in some patients with anemia. Pica is a condition whereby the patient has an unusual and specific craving to eat non-food items, such as dirt, ice, starch, ashes, or clay. Pica is associated with both mineral deficiency (including iron-deficiency anemia) and mental health conditions. Pagophagia, a craving (pica) for ice, is present in about 50% of patients with iron deficiency, even in the absence of frank anemia [51]. Probing for pica is not part of the routine medical history, but it should be included for any patient presenting with anemia, as it is a powerful clue to iron deficiency.

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    18 . The recommended dosage of epoetin alfa is
    A) 30–50 U/kg orally twice a week.
    B) 100–200 U/kg orally daily.
    C) 100–150 U/kg subcutaneous three times per week.
    D) 30,000 U subcutaneously daily.

    DEVELOPMENT OF THE TREATMENT PLAN

    The recommended dosage of epoetin alfa is 100–150 U/kg subcutaneously three times per week along with supplemental oral iron [18]. If no improvement is seen in six to eight weeks, this dose may be increased to daily administration or to 300 U/Kg three times weekly. A once-weekly dose of 30,000–40,000 U subcutaneously is also available. If the patient has no response to treatment after 12 weeks, it is unlikely to be clinically useful [18].

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    19 . Iron overload may become a problem after as few as
    A) 1 blood transfusion.
    B) 10 blood transfusions.
    C) 20 blood transfusions.
    D) 35 blood transfusions.

    DEVELOPMENT OF THE TREATMENT PLAN

    Treatment of MDS generally consists of supportive care, including transfusion of RBCs, which temporarily corrects the low blood counts. Platelet infusions become less effective over time and are associated with a risk of alloimmunization [32]. Frequent transfusions can cause an iron overload, which can damage the liver and other organs; iron overload may become a problem after as few as 10 transfusions. When the serum ferritin level is between 1,000 and 2,000 ng/mL, the patient may require iron chelation therapy with subcutaneous or oral deferasirox or subcutaneous deferoxamine and vitamin C [32,55].

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    20 . The FDA released a black box warning regarding the use of erythropoietin-stimulating agents in patients with chronic kidney disease with Hgb levels of
    A) 8 g/dL or less.
    B) 10 g/dL or less.
    C) 11 g/dL or greater.
    D) 15 g/dL or greater.

    DEVELOPMENT OF THE TREATMENT PLAN

    However, the severe adverse effects of epoetin alpha and other ESAs have made their use complicated [63]. Studies of have shown increased thromboembolic events, tumor progression, and cardiovascular events when Hgb levels are greater than 12 g/dL [51,53]. The FDA has issued a black box warning for epoetin alfa regarding the increased risk of death, serious cardiovascular events, and stroke in patients with chronic kidney disease with Hgb levels of 11 g/dL or greater [55]. Although no optimal dose or Hgb target has been established for patients with kidney disease to prevent these adverse events, an Hgb level that raises more than 1 g/dL in one week may indicate an increased risk and should initiate a reduction in ESA dose [55]. The lowest possible dose of ESA to prevent blood transfusion should be used.

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