Anemia in Elderly

By Dr. Sariga J
 Chief complaints

• Patient A, a 75 year old male, who is a farmer by occupation

presented with chief complaints of
• Breathlessness * 1 month
• Difficulty in swallowing * 1 month

History of presenting illness

• The patient was apparently asymptomatic, 1 month back after

which he developed breathlessness, which aggravates on
Case Scenario walking/climbing stairs[NYHA Code II] and relieves on taking rest
• No h/o orthophea or PND
• Patient also complains of difficulty in swallowing, noticed while
taking pills for the past 1month
• H/O sleeplessness present for the past 3 months
• H/O fatigue present for the past 6 months
• H/O back & leg pain for the past 6 months
• No h/o palpitation
• No h/o limb swelling
Past history

• K/C/O seizures for the past 2 years, on Tab sodium valproate

• K/C/O CKD for past 2 years, non-oliguric
• Not a K/C/O DM/H7W

Personal history

• Chronic alcoholic for the past 30 years, takes 250 ml of brandy 2-3 times a week
• Not a smoker
• Mixed diet, reduced appetite
• Normal bowel & bladder habits
• Sleep disturbance

Family history

• Not significant
O/E

• Conscious oriented
• Pallor *
• No Clubbing Cyanosis, Lymphadenopathy, pedal edema
• BP – 110/70 mmHg
• PR – 82 beats/minute, regular
• SpO2 – 97%
• RR – 20 breathes/min

S/E

• CUS – JVP not elevated, S1 S2 heard, no murmur

• RS – Bilateral air entry present, Normal vesicular breath sounds
• P/A – Soft, Non tendar, No organomegaly
• CNS No focal neurological deficit
Definition
• Anemia is defined as qualitative or quantitative decrease in the number
of RBCs or Hb, resulting in reduced oxygen carrying capacity of blood.
• In <65 years old, WHO defines it as hemoglobin (Hb) level of <13 g/dL in men
and <12 g/dL in women.
• Hb declines with age and are distinct in different ethnic groups
• Optimal Hb to avoid hospitalization and mortality rate is
• 65 – 80 years old  8-11 gms/dl
• >80 years old  7.5 gms/dl
• Even a mild anemia may substantially affect physical and cognitive
capacities and quality of life
Epidemiology of anemia in senior adults

• Prevalence of anemia in elderly  10% - 24%

• Elderly who are Hospitalization : 40%
• Elderly who are in Nursing Home: 47%
• Prevalence of anemia in >80 years: 50%
• In 80 years old: Men>Women
Classification

Morphologica
Functional Etiological
l
 (40%) (6.6%) (53.3%)

Morphologica
l
Classification
 Marrow production
defects(hypoproliferation)

Red cell maturation

Functional
defects(ineffective erythropoiesis)
Classification

Decreased red cell survival (Blood

loss/Hemolysis)
 Causes Number (%)
Iron deficiency anemia 24.8%
 Chronic gastritis 8
 Upper gastrointestinal ulcer 3
 Nutritional 5
 Gastrointestinal malignancy 2
 Others 8
Anemia of chronic disease 22.9%
 Solid tumor malignancy 8

Etiological
 Chronic liver disease 7
 Chronic infection 4
 Chronic inflammatory condition 2

Classificatio  Others
Chronic kidney disease
3
12.4%

n Haematological disorder
 Myelodysplastic syndrome
 Multiple myeloma
20%
4
2
 Chronic lymphoproliferative disease 3
 Chronic myeloproliferative disease 3
 Non-Hodgkin lymphoma 3
 Hodgkin Lymphoma 1
 Aplastic anemia 2
 Beta thalassemia 3
Folate/vitamin B12 deficiency 2.8%
Hypothyroidism 0.9%
Multi-factorial cause 7.6%
Unexplained cause 8.6%
 Category and subtypes Specific examples
Chronic inflammatory diseases   
Diseases  Rheumatologic diseases 
Rheumatoid arthritis, polymyalgia
rheumatica 

frequently  Chronic infectious diseases  Chronic hepatitis, osteomyelitis 

associated
 Inflammaging  Frailty, cachexia, geriatric syndromes 
 Miscellaneous  Chronic leg ulcers 

with Nonhematopoietic neoplasms 

 Gastrointestinal tumors 
 
Colorectal cancer, gastric cancer, etc 

anemia at  Multiorgan metastasis 

 BM metastasis 
End-stage carcinomas 
Various cancer types including breast and

older Endocrinologic and metabolic causes 

prostate 
 

age(1/2)  Low production of EPO 

 Thyroid dysfunction 
Renal anemia or pure EPO deficiency* 
Hypothyroidism or hyperthyroidism 
 Insulin deficiency  Diabetes mellitus 
 Category and subtypes Specific examples
Blood loss   
 Gastrointestinal tract bleeding  Peptic ulcer, ulcerative colitis, etc 

Diseases  Diffuse GI tract bleeding 

 Surgical procedures 
Anticoagulant-mediated bleeding 
Multiple abdominal surgeries 

frequently  Different locations 

Increased consumption or destruction of
Epistaxis, hematuria 

associated
 
erythrocytes 
 Chronic nonmechanical hemolysis  Autoimmune hemolytic anemia 

with  Mechanical destruction of red cells 

 Hypersplenism 
Heart valve–mediated red cell lysis 
Hepato-/splenomegaly 

anemia at Lack of nutrients 

 Vitamin deficiency 
 
Vitamin B12 and/or folate deficiency 

older  Trace element deficiency  Copper deficiency† 

age(2/2)
 Iron deficiency  Blood loss 
Drug-induced anemia   
 Chemotherapy  Chemotherapy-induced pancytopenia 
 Antimetabolites, anticonvulsants  Folate deficiency 
 Toxic drug reactions  Drug-induced hemolysis 
 • In a given disease, often >1 factor may
contribute to the development of anemia.
Pathogenesis Based on pathophysiological concepts,
underlying diseases may be divided into the
and basic following 3 groups.
mechanisms • Anemias based on iron, folate, and/or vitamin
of anemia at B12 deficiency
• Anemias developing in the context of chronic
older age inflammation and in CKD
• Unexplained Anemia & Clonal Anemia
Anemias based on iron, folate, and/or
vitamin B12 deficiency(1/2)
• Lack of iron is by far the most frequent nutritional deficiency anemia.

• Age-dependent alterations in function of GI tract, polypharmacy, and social

Isolation may lead to malnutrition and subsequent anemia

• However, it is important to consider bleeding because of a variety of

medications (e.g., acetylsalicylic acid, standard or direct oral anticoagulants)
or GI diseases, including cancer, is the most frequent cause of iron-deficient
anemia in older patients

• Thus, apart from iron replacement therapy, a careful GI diagnostic workup is

mandatory to define a possible site of blood loss in these patients
Anemias based on iron, folate, and/or
vitamin B12 deficiency(2/2)
• Malnutrition, particularly in association with alcohol abuse, may result in
folate deficiency
• In addition, drugs like anticonvulsants and methotrexate are further causes
• Pernicious anemia, the classic vitamin B12-deficient anemia, is relatively rare
• Importantly, for these subtypes of anemia effective medication is available. For
e.g., In vitamin B12 deficiency anemia, neurologic symptoms are often detected and usually
resolve immediately on initiation of vitamin B12 supplementation
• Thus, early and correct diagnosis is essential. Therefore, we always include
folate and vitamin B12 measurement in our basic laboratory screening in
elderly anemic patients.
• Anemias developing in the context
of chronic inflammation and in CKD
• At least one-third of anemic
patients older than 65 years
show a hyperinflammatory state
typical for CKD or for AI (cancer,
autoimmune disease, and
chronic infection)
• UAs and Clonal anemias
• Clonal leukocytes are detectable
in a considerable proportion of
older individuals. Such clonal
hematopoiesis is associated with
increased mortality and an
augmented prevalence of
hematologic malignancies, such
as MDS. Remarkably, numbers of
somatic mutations in blood
leukocytes increase with age
 • Symptoms

• Weakness & Lethargy (80%)

General Signs •
•
Shortness of breath (45.7%)
Oedema (22.9%)
& Sysmptoms •
•
Headaches (19%)
Vertigo (18.1%)
• Palpitations (14.3%)
• Bleeding (12.4%)
• Tinnitus (6.7%)
 • Signs
General • Pallor (Skin & Conjunctiva)
• Platynychia or Koilonychia
Signs & • Pedal oedema

Sysmptoms • Tachycardia
• Bounding pulse
• Hemic murmur
• Cardiac failure
 Iron deficiency anemia

• Blood loss (Melena, Hematochezia, Hematuria)

• Pica (desire to consume unusual substances e.g., Ice, Dirt)
• Koilonychia, vertical nail ridges
• Glossitis

Specific Signs •
•
Cheilosis
Dysphagia

& Symptoms Vitamin B12 deficiency

• Neuropathy
• Ataxia
• Dementia

Hemolysis

• Jaundice
• Dark Urine (If intravascular hemolysis)
References
1. Patterns of geriatric anemia: A hospital-based prospective
observational study conducted in a tertiary care center (July 2014 –
Dec 2015) in North India done by PGI Chandigarh
2. ASH – American society of Hemtalogy
3. Case Study – NetCE
Thank You