Anemia is common in the elderly and its prevalence increases with age. While anemia is often accepted as an inevitable consequence of aging, a cause can be identified in approximately 80% of elderly patients with anemia. The most common causes of anemia in the elderly are anemia of chronic disease, iron deficiency, vitamin B12/folate deficiency, and blood loss. Evaluation and treatment of anemia in the elderly is similar to younger patients and involves identifying the underlying cause.

1. ANEMIA IN ELDERLYANEMIA IN ELDERLY
By / Marwa Mahmoud KhalifaBy / Marwa Mahmoud Khalifa
Hematology ResidentHematology Resident
Alex. Main University hospitalAlex. Main University hospital

2.  Anemia should not be accepted as an inevitableAnemia should not be accepted as an inevitable
consequence of aging.consequence of aging.
 A cause is found in approximately 80 percent ofA cause is found in approximately 80 percent of
elderly patients.elderly patients.
 Anemia is common in the elderly and itsAnemia is common in the elderly and its
prevalence increases with age.prevalence increases with age.
 The prevalence of anemia in the elderly hasThe prevalence of anemia in the elderly has
been found to range from 8 to 44 percent, withbeen found to range from 8 to 44 percent, with
the highest prevalence in men 85 years andthe highest prevalence in men 85 years and
older.older.

3. Clinical PresentationClinical Presentation
 The onset of symptoms and signs isThe onset of symptoms and signs is
usually insidious.usually insidious.
 Typical symptoms of anemia, such asTypical symptoms of anemia, such as
fatigue, weakness and dyspnea, are notfatigue, weakness and dyspnea, are not
specific and in elderly patients tend to bespecific and in elderly patients tend to be
attributed to advancing age.attributed to advancing age.

4.  Conjunctival pallor is a reliable sign.Conjunctival pallor is a reliable sign.
 Worsening congestive heart failure,Worsening congestive heart failure,
cognitive impairment, dizziness andcognitive impairment, dizziness and
apathy.apathy.

5. EVALUATIONEVALUATION
 Anemia in the elderly is evaluated in a mannerAnemia in the elderly is evaluated in a manner
similar to that in younger adults, including ansimilar to that in younger adults, including an
assessment for signs of gastrointestinal bloodassessment for signs of gastrointestinal blood
loss, hemolysis, nutritional deficiencies,loss, hemolysis, nutritional deficiencies,
malignancy, chronic infection (such asmalignancy, chronic infection (such as
subacute endocarditis), renal or hepaticsubacute endocarditis), renal or hepatic
disease, and other chronic disease.disease, and other chronic disease.
 In patients without evidence of an underlyingIn patients without evidence of an underlying
disease, the initial laboratory evaluation shoulddisease, the initial laboratory evaluation should
include a complete blood count, red blood cellinclude a complete blood count, red blood cell
indices, a reticulocyte count and peripheralindices, a reticulocyte count and peripheral
blood smear.blood smear.

7. Common Causes of Anemia inCommon Causes of Anemia in
the Elderlythe Elderly
Cause of anemiaCause of anemia Percentage ofPercentage of
casescases
Anemia of chronic diseaseAnemia of chronic disease 30 to 4530 to 45
Iron deficiencyIron deficiency 15 to 3015 to 30
PosthemorrhagicPosthemorrhagic 5 to 105 to 10
Vitamin B12 and folate deficiencyVitamin B12 and folate deficiency 5 to 105 to 10
Chronic leukemia or lymphomaChronic leukemia or lymphoma 55
Myelodysplastic syndromeMyelodysplastic syndrome 55
No identifiable causeNo identifiable cause 15 to 2515 to 25

8. Differentiation of Anemia ofDifferentiation of Anemia of
Chronic Disease and IronChronic Disease and Iron
Deficiency AnemiaDeficiency Anemia

9. LaboratoryLaboratory
testtest
Range forRange for
normalnormal
valuesvalues
IronIron
deficiencydeficiency
anemiaanemia
Anemia ofAnemia of
chronicchronic
diseasedisease
Serum iron,Serum iron,
μg per dLμg per dL
60 to 10060 to 100 < 60< 60 < 60< 60
Total iron-Total iron-
bindingbinding
capacity,capacity,
μg per dLμg per dL
250 to 400250 to 400 > 400> 400 < 250< 250
SerumSerum
ferritin,ferritin,
ng per mLng per mL
100 to 300100 to 300 < 100< 100 > 100> 100

10. Anemia of Chronic DiseaseAnemia of Chronic Disease
 The most common form of anemia in theThe most common form of anemia in the
elderlyelderly
 Mild to moderate anemia that tends toMild to moderate anemia that tends to
correlate in severity with the underlyingcorrelate in severity with the underlying
diseasedisease
 Rarely progresses to a hemoglobin below 10 gRarely progresses to a hemoglobin below 10 g
per dLper dL
 The erythrocytes are usually normochromicThe erythrocytes are usually normochromic
and normocytic, but about one third of patientsand normocytic, but about one third of patients
with anemia of chronic disease havewith anemia of chronic disease have
microcytosismicrocytosis

11. Diseases Associated with Anemia of ChronicDiseases Associated with Anemia of Chronic
DiseaseDisease
1.1. Acute infectionsAcute infections
2.2. Chronic infections:Tuberculosis ,InfectiveChronic infections:Tuberculosis ,Infective
endocarditis ,Chronic urinary tract infection,endocarditis ,Chronic urinary tract infection,
Chronic fungal infectionChronic fungal infection
3.3. Chronic inflammatory disordersChronic inflammatory disorders
4.4. OsteoarthritisOsteoarthritis
5.5. Rheumatoid diseaseRheumatoid disease
6.6. Collagen vascular diseaseCollagen vascular disease
7.7. Polymyalgia rheumaticaPolymyalgia rheumatica
8.8. Acute and chronic hepatitisAcute and chronic hepatitis
9.9. Decubitus ulcerDecubitus ulcer
10.10.MalignancyMalignancy
11.11.Protein–energy malnutritionProtein–energy malnutrition

12. PATHOGENESISPATHOGENESIS
 Decreased release of iron fromDecreased release of iron from
macrophages to plasma because of raisedmacrophages to plasma because of raised
serum hepcidin levels .serum hepcidin levels .
 Reduced cell lifespan.Reduced cell lifespan.
 Inadequate erythropoeitin response toInadequate erythropoeitin response to
anemia caused by cytokines such as IL1 andanemia caused by cytokines such as IL1 and
TNF.TNF.

13. TREATMENTTREATMENT
 There is no specific therapy for anemia ofThere is no specific therapy for anemia of
chronic disease except to manage or treat thechronic disease except to manage or treat the
underlying disorder.underlying disorder.
 Iron therapy is of no benefit.Iron therapy is of no benefit.
 Erythropoietin may be helpful in some patientsErythropoietin may be helpful in some patients
with anemia of chronic disease. The dosage iswith anemia of chronic disease. The dosage is
50 to 100 U per kg three times a week. The50 to 100 U per kg three times a week. The
dosage can be increased to 150 U per kg perdosage can be increased to 150 U per kg per
dose if the response to a lower dose isdose if the response to a lower dose is
inadequate.inadequate.

14. Iron Deficiency AnemiaIron Deficiency Anemia
 The second most common cause of anemia in theThe second most common cause of anemia in the
elderlyelderly
 Usually results from chronic gastrointestinal bloodUsually results from chronic gastrointestinal blood
loss caused by nonsteroidal anti-inflammatoryloss caused by nonsteroidal anti-inflammatory
drug–induced gastritis, ulcer, colon cancer,drug–induced gastritis, ulcer, colon cancer,
diverticula or angiodysplasia.diverticula or angiodysplasia.
 Chronic blood loss from genitourinary tract cancer,Chronic blood loss from genitourinary tract cancer,
chronic hemoptysis and bleeding disorders maychronic hemoptysis and bleeding disorders may
result in iron deficiency but are much less commonresult in iron deficiency but are much less common
causes.causes.
 Older persons may become iron deficient becauseOlder persons may become iron deficient because
of inadequate intake or inadequate absorption ofof inadequate intake or inadequate absorption of
iron. Without blood loss, anemia takes severaliron. Without blood loss, anemia takes several
years to develop.years to develop.

15. TREATMENTTREATMENT
 Treatment of the cause of bleeding, ironTreatment of the cause of bleeding, iron
supplementation should be initiated for the treatmentsupplementation should be initiated for the treatment
of iron deficiency anemia.of iron deficiency anemia.
 The usual recommended dose of elemental iron is 50The usual recommended dose of elemental iron is 50
to 100 mg three times a day; however, a smallerto 100 mg three times a day; however, a smaller
amount of elemental iron, such as a single 325-mgamount of elemental iron, such as a single 325-mg
tablet of iron sulfate, may minimize side effects andtablet of iron sulfate, may minimize side effects and
improve compliance.improve compliance.
 Reticulocytosis usually starts within a week ofReticulocytosis usually starts within a week of
initiation of oral iron supplementation. If theinitiation of oral iron supplementation. If the
reticulocyte count increases but the anemia does notreticulocyte count increases but the anemia does not
improve, continued blood loss or inadequate ironimprove, continued blood loss or inadequate iron
absorption must be considered.absorption must be considered.
 Intravenous iron replacement can be helpful inIntravenous iron replacement can be helpful in
patients with iron deficiency that fails to respond topatients with iron deficiency that fails to respond to
oral replacement.oral replacement.

16. Vitamin B12 DeficiencyVitamin B12 Deficiency
 Vitamin B12 (cobalamin) deficiency is theVitamin B12 (cobalamin) deficiency is the
cause of anemia in 5 to 10 percent ofcause of anemia in 5 to 10 percent of
elderly patients, the actual prevalence ofelderly patients, the actual prevalence of
vitamin B12 deficiency is likely to be muchvitamin B12 deficiency is likely to be much
higher in the elderly.higher in the elderly.

17. CAUSES OF VITAMIN B12CAUSES OF VITAMIN B12
DEFICIENCYDEFICIENCY
 Vitamin B12 deficiency rarely is the result of inadequateVitamin B12 deficiency rarely is the result of inadequate
intake, except in persons who are strict vegans.intake, except in persons who are strict vegans.
 A common cause is reduced intestinal absorption of vitaminA common cause is reduced intestinal absorption of vitamin
B12. Pernicious anemia is a classic example of a disorderB12. Pernicious anemia is a classic example of a disorder
that causes reduced intestinal absorption of vitamin B12.that causes reduced intestinal absorption of vitamin B12.
 With pernicious anemia, the lack of intrinsic factor resultsWith pernicious anemia, the lack of intrinsic factor results
from destruction of the gastric parietal cells by autoimmunefrom destruction of the gastric parietal cells by autoimmune
antibodiesantibodies
 Inadequate absorption of vitamin B12 occurs in 10 to 30Inadequate absorption of vitamin B12 occurs in 10 to 30
percent of patients who have had a partial gastrectomy.percent of patients who have had a partial gastrectomy.
 It also may occur in patients with small bowel disorders andIt also may occur in patients with small bowel disorders and
bacterial overgrowth. The prevalence of many of thesebacterial overgrowth. The prevalence of many of these
conditions increases with age.conditions increases with age.

18. TREATMENTTREATMENT
 Vitamin B12 deficiency is treated by vitamin B12Vitamin B12 deficiency is treated by vitamin B12
supplementation, parenterally or orally.supplementation, parenterally or orally.
 The intramuscular dose is 1,000 μg, often givenThe intramuscular dose is 1,000 μg, often given
daily for one week to build up stores, thendaily for one week to build up stores, then
weekly for one month and then monthlyweekly for one month and then monthly
thereafter.thereafter.
 Oral therapy with 1,000 to 2,000 μg of vitaminOral therapy with 1,000 to 2,000 μg of vitamin
B12 daily has been shown to be as effective asB12 daily has been shown to be as effective as
intramuscular injectionsintramuscular injections
 A response to therapy, characterized by anA response to therapy, characterized by an
increase in reticulocytosis, often occurs within aincrease in reticulocytosis, often occurs within a
week of the initiation of vitamin B12 therapy.week of the initiation of vitamin B12 therapy.

19. Folate DeficiencyFolate Deficiency
 Develops as a result of inadequate dietary intake.Develops as a result of inadequate dietary intake.
 The body stores very little folate, only enough to last fourThe body stores very little folate, only enough to last four
to six months.to six months.
 Classically causes macrocytic anemiaClassically causes macrocytic anemia
 The red cell folate concentration is more reliable than theThe red cell folate concentration is more reliable than the
serum level and should be considered.serum level and should be considered.
 Identification of vitamin B12 deficiency is important:Identification of vitamin B12 deficiency is important:
anemia secondary to vitamin B12 deficiency improvesanemia secondary to vitamin B12 deficiency improves
with folate therapy, but folate therapy does not reversewith folate therapy, but folate therapy does not reverse
the neurologic damage caused by vitamin B12the neurologic damage caused by vitamin B12
deficiency. For this reason, it is important to ensure thatdeficiency. For this reason, it is important to ensure that
vitamin B12 deficiency is not also present.vitamin B12 deficiency is not also present.
 Folate deficiency is treated with oral folic acid, 1 mg daily.Folate deficiency is treated with oral folic acid, 1 mg daily.

20. Myelodysplastic SyndromeMyelodysplastic Syndrome
 Uncommon cause of anemiaUncommon cause of anemia
 More common cause in the elderly than in youngerMore common cause in the elderly than in younger
patients.patients.
 Characterized by a defect in the development of one ofCharacterized by a defect in the development of one of
the marrow cell lines, limiting the release of functioningthe marrow cell lines, limiting the release of functioning
cells.cells.
 Anemia results when the red cell lines are affected.Anemia results when the red cell lines are affected.
 Myelodysplastic syndrome should be a diagnosticMyelodysplastic syndrome should be a diagnostic
consideration when white cell or platelet abnormalitiesconsideration when white cell or platelet abnormalities
accompany the anemia.accompany the anemia.
 The diagnosis by bone marrow biopsy.The diagnosis by bone marrow biopsy.
 Myelodysplasia is treated supportively with transfusions.Myelodysplasia is treated supportively with transfusions.