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ANEMIA IN THE ELDERLY

Special Considerations Regarding


Management
Canadian Multicentre Anemia Symposium

2002 Anemia Awareness Week

Anemia in the Elderly


Anemia in the elderly is not part of normal aging.
Anemia is common & increases with each
successive decade.
Prevalence 10-45% with an incidence between 10-15
per 1000.
Higher in men than women of any given age
and in Afro-Americans.

Anemia in the Elderly


Special Considerations
Multifactorial often with multiple medical problems
& polypharmacy.
Onset of symptoms is usually insidious & frequently
nonspecific.
Anemia in the elderly has increased consequences.
RBC indices often unreliable.
Myelosuppression more common & severe.
Quality of life issues may be more pronounced.

Anemia in the Elderly


Time of Diagnosis
Annual medical examination

7%

Onset of acute medical problem

8%

Follow up of a chronic medical problem

9%

Following admission to hospital

75%

Anemia in the Elderly


Multiple diagnoses
No diagnosis
Single diagnosis
Anemia of chronic disease
Malnutrition
Infection
Postoperative bleeding

53%
17%
30%
10%
9%
4%
3%

Alcohol
Iron deficiency

1%
1%

Modified from Principles of Geriatric Medicine and Gerontology 4 th ed. 1999

Anemia in the Elderly


Anemia of Chronic Disease
Most common cause of anemia in hospitalized patients.

Anemia correlates with severity of underlying disease.


Serum erythropoietin levels may be inappropriately low.
Response to erythropoietin administration variable.
In selected diseases (e.g. Myeloma, RA, CRF) responses to
erythropoietin possible with serum levels < 200 U/L (N, 12 52).

Anemia in the Elderly


Diseases Associated with Anemia of Chronic Disease
Acute infections
Chronic infections

Malignancy
Metastatic carcinoma

Tuberculosis

Hematologic malignancies

Infective endocarditis

Leukemia

Chronic urinary tract infection

Lymphoma

Chronic fungal infection

Myeloma

Chronic inflammatory disorders

Chronic renal insufficiency

Osteoarthritis

Hypothyroidism

Rheumatoid disease

Protein-energy malnutrition

Collagen vascular disease


Polymyalgia rheumatica
Acute and chronic hepatitis
Decubitus ulcer

Anemia in the Elderly


Anemia of Chronic Disease
Pathogenesis
Impairment of iron utilization
Inhibition of erythropoeisis
Blunted response to erythropoietin
Reduced RBC survival
Possible functional adaptation of innate immune system
Iron sequestration as a microbicidal strategy
Altered macrophage responses
Cytokine mediated
Th1 - IFN, TNFL
Th2 IL-4, IL-10, IL-6

Anemia in the Elderly


Iron Def.

ACD

Serum iron

Reduced

Reduced

TIBC

Increased

Reduced

Transferrin saturation

Reduced

Normal

Serum ferritin

Reduced

Normal or
Increased

Plasma transferrin receptor

Increased

Normal

Transferrin receptor / ferritin


index

High

Low

Anemia in the Elderly


Sensitivity & Specificity of Serum Ferritin in Iron Deficiency Anemia
Serum ferritin
(ug per L)

Sensitivity (%)

Specificity (%)

Likelihood
ratio*

< 200

94

71

3.2

< 45

85

92

11.1

< 15

59

99

54.5

Anemia in the Elderly


B12 deficiency often unrecognized in the elderly
Typical signs & symptoms of B12 deficiency often not present.
Only about 60% of pts. with B12 def are anemic.
B12 deficiency accounts for anemia in 5-10% of elderly patients.
Inadequate absorption occurs in 10-30% of pts. with partial gastrectomy.
Pernicious anemia undiagnosed in 2% of healthy individuals over 60 yrs.
Neurologic symptoms may precede anemia.

Anemia in the Elderly


Neurological presentation of B12 deficiency
Paresthesias of fingers & toes
Reduced vibration sense (256-Hz) & proprioception
Ataxia (Combined system disease)
Perversion of taste & smell
Optic atrophy
Dementia, Memory Loss & Depression
Megaloblastic Madness Paranoid Schizophrenia
Specific MRI abnormalities

Anemia in the Elderly


Vitamin B12 deficiency
Serum B12 levels do not reliably predict tissue deficiency.
Serum or urine methylmalonic acid & serum homocystiene
more reliable indicators of tissue B12 levels.
Screening in elderly if serum B12 < 260 pmol/L.
Anemia may not be characterized by macrocytic &
megaloblastic changes.
Oral therapy 1-2 mg daily comparable to IM injections.

Anemia in the Elderly


Myelodysplastic (MDS) Syndromes
Most cases occur between 60-90 years.
MDS may represent up to 5% of anemia in elderly.
1. Ineffective hematopoiesis.
- Anemia present in 80-90% of cases.
- Neutropenia in 50% of cases often with monocytosis.
- Thrombocytopenia in 25% of cases.

2. Clonal Evolution
- 10-40% develop AML.
- Chromosome abnormalities in 40% of cases
Trisomy 8
5 & 7 deletions (CSFs)
11q23 (MLL gene)

Anemia in the Elderly


Myelodysplastic Syndromes
Supportive care remains major treatment approach
Transfusions, Amicar, Antibiotics

Unproven therapies
Transfusions + desferral administration.
Epo + G-CSF + Danazol.

Experimental therapies
Immune therapies ATG, CSA, Thalidomide
Chemotherapy anti-CD33 Ab, 5-azacytidine

Anemia in the Elderly


Indications for Bone Marrow
2 or more cell lines affected
Monoclonal gammopathy
Indeterminate iron status
Leukoerythroblastic peripheral smear

Anemia in the Elderly


Potential Areas of Future Research
Etiology & treatment of myelodysplastic syndrome.
Nutritional benefits of L-carnitine.
Regulation of erythropoiesis.
Combination growth factor therapy.
Tools for Fatigue & QOL assessments.
Effects of anemia on survival & therapy responses in cancer.
Immunomodulatory & neurocognitive effects of
erythropoietin.

Canadian Multicentre Anemia


Symposium
www.anemiainstitute.org

2002 Anemia Awareness Week


Supported by an unrestricted educational grant from Janssen-Ortho Inc.