Anemia in the Elderly

Anemia in the Elderly Kathryn S. Kolibaba, M.D. Compass Oncology October 2013 Anemia in the Elderly: Outline Anemia in the elderly • How is it diffe...
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Anemia in the Elderly Kathryn S. Kolibaba, M.D. Compass Oncology October 2013

Anemia in the Elderly: Outline Anemia in the elderly • How is it different than anemia in other age groups Scope of the problem Approach to the diagnosis Treatment Indications for referral to a specialist • Myelodysplasia

What is Anemia? ANEMIA IS NEVER NORMAL Anemia Reduction below normal of the mass of red blood cells in the circulation Estimated by: Hemoglobin concentration, hematocrit, RBC count Men: HGB < 13.5 or HCT < 41% Women: HGB < 12.0 or HCT < 36%

Anemia in the Elderly Multiple studies support that the elderly do not have a ―lower normal range‖ Anemia, while common in the elderly, is still abnormal HGB < 13 in males and < 12 in females is associated with an increased relative risk of mortality (1.6 and 2.3 respectively)

Defining Anemia in the Elderly

(Hgb, g/dL) Men

Wome n

PowerChart

< 14.5

< 12.0

Williams (US populations, does not include elderly)

< 14.0

< 12.3

WHO (world populations, does not include elderly)

< 13.0

< 12.0

NHANES III/Kaiser-Scripps (Caucasian race, age > 60 yr )

< 13.2

< 12.2

Impact of Anemia in the Elderly Observational studies show anemia in the elderly to be associated with • Poorer functional ability • Impaired cognitive function • Symptoms of depression • Poorer quality of life • Increased mortality Goals of evaluating anemia in the elderly • Identify reversible etiologies

Prevalence of Anemia in the Elderly National Health and Nutrition Examination Survey III 1988-1994. Non-institutionalized US population Prevalence • NHANES III (>64 yrs) – 11% • ~1 % Hgb below 10 • NHANES III (>84 yrs) – 20% women 26% men

Study of Anemia in the Elderly National Health and Nutrition Examination Survey III • Defined iron deficiency as 2 of the following: ferritin < 12, transferrin saturation < 15%, or erythrocyte protoporphyrin > 1.24 uM • Defined folate deficiency as RBC folate 74 yrs with Fe def anemia • 68% had bleeding source found on EGD/colonoscopy • 28% had colon cancer • 5% had UGI malignancy Diagnosis • Ferritin may be falsely elevated due to malignancy, etc so some advocate using higher cut-off (50) (age?) • Some have advocated using sTfR/log ferritin ratio Gastroenetrol Clin Biol 2007:31:169

Evaluation of Microcytic Anemia Iron Deficiency

MCV Serum iron TIBC Iron Saturation Ferritin

Low Low >350 Low Low (100)

Evaluation of Microcytic Anemia Iron Deficiency Serum Erythropoietin

Anemia of Chronic Disease

Very High

Low, for degree of anemia

Bone Marrow sideroblasts

Absent

Absent

Bone Marrow iron

Absent

Present

Treatment of Iron Deficiency Identify the source of the blood loss Oral iron therapy – 325 mg ferrous sulfate t.i.d. – Provides 150-200 mg elemental iron daily – Absorption increased if taken between meals with an acidic beverage or food – Hemoglobin should rise 1-2 g/dL per month – After anemia is fully resolved, continue iron for 4-6 months to replete iron stores

If oral iron is poorly absorbed or tolerated, parenteral iron may be given Risk of anaphylaxis

Erythropoietin Resistance Erythropoietin rises with age Anemia of chronic disease/inflammation Block in iron utilization by red cells Shortened red cells survival Inhibition of erythropoiesis by cytokines, IL-1, TNF Relative deficiency of erythropoietin

Erythropoietin therapy • Restricted to renal insufficiency • Cost effective as compared with transfusion • Hematocrit must be less than 30% for initiation of treatment

Anemia in the Hospital

BMC Pulm Medicine 2010; 10:15

Special Cases Exceptions People who live at high altitude have greater RBC volume Smokers have increased HCT African-American HGBs are 0.5 to 1.0g/dL lower than Caucasians Athletes increased plasma volume Fe deficiency Hemolysis Polycythemia Use of performance enhancing agents)

Indications for Referral to a Hematologist Pancytopenia Circulating primitive cells (blasts) Very low reticulocyte count, i.e. 2.5

0.4 years

Questions?

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