Anemia should not be accepted as an inevitable consequence of aging. A cause is found in approximately 80 percent of elderly patients. The most common causes of anemia in the elderly are chronic disease and iron deficiency. Vitamin B12 deficiency, folate deficiency, gastrointestinal bleeding and myelodysplastic syndrome are among other causes of anemia in the elderly. Serum ferritin is the most useful test to differentiate iron deficiency anemia from anemia of chronic disease. Not all cases of vitamin B12 deficiency can be identified by low serum levels. The serum methylmalonic acid level may be useful for diagnosis of vitamin B12 deficiency. Vitamin B12 deficiency is effectively treated with oral vitamin B12 supplementation. Folate deficiency is treated with 1 mg of folic acid daily. Clinical Presentation Even though the high prevalence of anemia in the elderly makes it a condition that clinicians might expect to find frequently, several features of anemia make it easy to overlook. The onset of symptoms and signs is usually insidious, and many elderly patients adjust their activities as their bodies make physiologic adaptations for the condition. Typical symptoms of anemia, such as fatigue, weakness and dyspnea, are not specific and in elderly patients tend to be attributed to advancing age. Pallor can be a helpful diagnostic clue, but pallor can be hard to detect in the elderly. Conjunctival pallor is a reliable sign, and its presence should prompt the clinician to order blood tests for anemia.6 Aside from conjunctival pallor, few other signs are attributable specifically to anemia. Frequently, patients have signs of a disorder that is made worse by the anemia, such as worsening congestive heart failure, cognitive impairment, dizziness and apathy. Unless clinicians consider anemia as a possibility in the elderly, it can be easily overlooked. Anemia in older persons poses a clinical challenge in daily practice as the population ages. In many cases, 1 or more etiologies are detected, and a thorough investigation immediately leads to the correct diagnosis. In these patients, management is largely dependent on the underlying etiology, and in many cases, anemia can be corrected by interventional therapy independent of age. Good examples are iron, vitamin B12, or folate deficiency. EPO deficiency with or without overt exocrine kidney insufficiency can be detected quite often in older persons. A large number of patients turn out to have an underlying (chronic) inflammatory disease. The concept of a subclinical proinflammatory state called inflammaging may be a good explanation for the development of anemia in senior persons. In other cases, a clonal myeloid or other neoplasm is detected. In a relevant proportion of patients, no underlying cause of anemia is found after a first examination, resulting in the provisional diagnosis of UA. However, in many cases no underlying etiology is found even after a thorough diagnostic workup that includes an ex…

1. Brincelet mavumnkal biju
Anemia in elderly
Geriatrics

2. Introduction
❑ Anemia in elderly is a condition characterised by a lower than normal hemoglobin in the blood.
World health organisation criteria set the threshold for anemia as a hemoglobin concentration
below 12gram per deciliter in women and below 13 gram per deciliter in men.
❑ Anemia should not be accepted as an inevitable consequence of aging.
❑ A cause is found in approximately 80 percent of elderly patients.
❑ Anemia is common in the elderly and its prevalence increases with age.
❑ The prevalence of anemia in the elderly has been found to range from 8 to 44 percent, with
the highest prevalence in men 85 years and older.
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3. Clinical presentation
❑The onset of symptoms and signs is usually insidious.
❑Typical symptoms of anemia, such as fatigue, weakness
and dyspnea, are not specific and in elderly patient
tend to be attributed to advancing age.
❑Conjunctival pallor is a reliable sign.
❑Worsening congestive heart failure (CHF), cognitive
impairment, dizziness, and apathy.

4. EVALUATION
• Anemia in the elderly is evaluated in a manner similarto
that in younger adults, includingan assessment for signs of
gastrointestinalblood loss, hemolysis, nutritional
deficiencies, malignancy, chronic infections,renal or hepatic
disease, and other chronic diseases.
• In patients without evidence of an underlying disease, the
initial laboratoryevaluation should include a complete blood
count, red blood cell indices, a reticulocyte count and
peripheral blood smear.
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5. Mean corpuscular volume algorithmic approach to anemia diagnosis
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Mean corpuscular volume

6. Common causes of anemia in elderly
Cause of anemia Percentage of cases
• 30 -45
• 14 – 30
• 5 – 10
• 5 – 10
• 5
• 5
• 15 - 25
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• Anemia of chronic disease
• Iron deficiency
• Post hemorrhagic
• Vitamin B12 and folate deficiency
• Chronic leukaemia or lymphoma
• Myelodysplastic syndrome
• No identifiable cause

7. Differentiation of anemia of chronic disease and iron
deficiency anemia
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8. 8
Laboratory Rangefor normal. Iron deficiency Anemia of chronic
test Values Anemia disease
Serum iron, 60 to 100. <60. <60.
Microgramper deciliter
Total iron binding capacity 250 to 400. > 400. <250
Microgramper deciliter
Serum ferritin 100 to 300. < 100. >100
Nanogramsper milliliter

9. Anemia of chronic disease
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❑The most common form of anemia in the elderly
❑Mild to moderate anemia that tends to correlate in severity with the underlying disease
❑Rarely progresses to a hemoglobin below 10 gram per deciliter
❑The erythrocytes are usually normochromic and normocytic, but about one third of patients with anemia of chronic
disease have microcytosis.

10. 10
Diseases associated with anemia of chronic disease
1. Acute infections
2. Chronic infections:- Tuberculosis, infective endocarditis ,chronic urinary tract infection ,chronic fungal infection.
3. Chronic inflammatory disorders.
4. Osteoarthritis
5. Rheumatoid disease 10. Malignancy
6. Collagen vascular disease 11. Protein energy malnutrition
7. Poly myalgia rheumatica
8. Acute and chronic hepatitis
9. Decubitus ulcer
Pathogenesis
❑Decreased release of iron from macrophages to plasma
because of raised serum hepcidin levels.
❑Reduced cell lifespan.
❑Inadequate erythropoietin response to anemia caused
by cytokines such as interleukin 1 and Tumour necrosis
factor.

11. Treatment
• There is no specific therapy for anemia of chronic disease exceptto manage or treat the
underlying disorder
• Iron therapy is of no benefit.
• Erythropoietin may be helpful in some elderly patients with anemia of chronic disease. The
dosage is 50 to 100 unit per kilogram 3 times a week.The dosage can be increased to 150
units per kilogram per dose if the response to a lower dose is inadequate

12. Iron deficiency anemia
❑The second most common cause of anemia in the elderly
❑Usually results from chronic gastrointestinal blood loss caused by non steroidal anti inflammatory drug induced
gastritis, ulcer, colon cancer, diverticula, angiodysplasia.
❑Chronic blood loss from genitourinary tract cancer, chronic hemoptysis and bleeding disorders may result in iron
deficiency but are much less common causes.
❑Older patients may become iron deficient because of inadequate intake or inadequate absorption of iron. Without
blood loss, anemia takes several years to develop.
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13. Treatment
❑Treatment of the cause of bleeding, iron supplementation should be initiated for the treatment of iron deficiency
anemia.
❑The usual recommended doses of elemental iron is 50 to 100 milligram 3 times a day, However, a smaller amount of
elemental iron, such as a single 325 milligram tablet of iron sulphate, may minimise side effects and improve
compliance.
❑Reticulocytosis usually starts with a week of initiation of oral iron supplementation. If the reticulocyte count
increases but the anemia does not improve, continued blood loss or inadequate iron absorption must be considered.
❑Intravenous iron replacement can be helpful in patients with iron deficiency that fails to respond to oral replacement.
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14. Vitamin B12 deficiency
• Vitamin B12(cobalamin)
deficiency is the cause
of anemia in 5 to 10
percent of elderly
patients, the actual
prevalence of vitamin
B12 deficiency is likely
to be much higher in
the elderly.
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Causes of vitamin B12 deficiency
❑Vitamin B12 deficiency rarelyis the result of inadequateintake, except in persons who
are strict vegans.
❑A common cause is reducedintestinal absorption of vitamin B12. Perniciousanemia is
a classic example of a disorderthat causes reducedintestinal absorption of vitamin
B12.
❑With pernicious anemia,the lack of intrinsic factor resultsfrom destruction of the
gastric parietal cells by autoimmuneantibodies.
❑Inadequateabsorption of vitamin B12 occurs in 10 to 20 percent of patients who have
had a partial gastrectomy.
❑It also may occur in patients with small bowel disordersand bacterial overgrowth.The
prevalenceof many of these conditions increaseswith age.

15. Folate deficiency
❑Develops as a result of inadequate dietary intake.
❑The body stores very little folate, onlyenough to last four to six hours.
❑Classicallycauses macrocytic anemia.
❑The red cell folate concentration is more reliable than the serum level and should be considered.
❑Identification of vitamin B12 deficiency is important: anemia secondary to vitamin B12 deficiency improves with folate
therapy,but folatetherapy does not reverse the neurologicaldamage caused by vitamin B12 deficiency. For this reason, it is
importantto ensure thatvitamin B12 deficiency is not alsopresent.
❑Folate deficiency is treated with oral folic acid, 1 milligramdaily.
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16. Myelodysplastic syndrome
❑Uncommon cause of anemia
❑More common cause in the elderly people.
❑Characterised by a defect in the developmental of one of the marrow cell lines, limitingthe release of functioningcells.
❑Anemia results when the red cell lines are affected.
❑Myelodysplasticsyndrome should be a diagnostic consideration when white cell or platelet abnormalitiesaccompany the
anemia.
❑The diagnosis by bone marrow biopsy.
❑Myelodysplasia is treated supportivelywith transfusions.
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17. Summary
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• Anemia in elderly patients often presents with fatigue,weakness,shortnessof breath.
• pale skin, dizziness and cold hands or feet can be indicative of reduced red blood cell count
• Cognitiveissues such as difficulty concentratingor memory problems may also be present.
• Chronicdiseases like kidney disease, inflammatorydisorders, or cancer can contribute to anemia.
• Nutritionaldeficiencies particularlyof iron,vitamin B12 or folate are common in elderly patients.
• Medications such as certain blood thinnersor chemotherapy drugs,also leads to anemia.
• Blood tests including complete blood count and peripheral blood smear help determine the type and severity of anemia in
elderly patients
• Serum ferritin,,vit B12 and folate levels aid in underlying nutritionaldeficiencies.
• Treatingthe underlyingcause, such as managingchronic illness or adjusting medications,is crucial.

18. Conclusion
•Approaching elderly people with anemia ;-
• conduct a thorough medical history,,consideringchronic diseases and medication usage.
• Performa comprehensivephysical examination,focusing on signs of anemia and potential contributing
factors.
• Communication is the key,ensuringelderlypatients understandthe importance of adherenceto
prescribedtreatments and regularfollow ups,
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19. • Anemia in elderly poses a substantial biomedical and public health concern
• Diagnostic complexity: defined by world health organisation criteria,it’s diverse types require nuanced diagnostic and
treatment
• Health impact :correlates with increased comorbidities and heightened hospitalisation risks
• Impacting hospitalisation risks,impacting mortality and quality of life
• Bridging research gaps and refining diagnostics are cured for effective intervention and improved outcomes in geriatric
anemia
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20. Thank you
Brincelet m biju
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