ANEMIA IN GERIATRIC POPULATION

RESOURCES:

Petros WP, Craig M. Anemias. In Dipiro JT, Pharmacotherapy A Pathophysiologic

Approach 7th Edition. McGraw Hill, New York, 2008; 1639 1663.
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Fam Physician. 2013; 87 (2): 98 104.
Merchant AA, Roy CN. Not so benign haematology: anaemia of the elderly. Br J
Haematol. Nov 2011; 156: 173 185.
Rohrig G. Anemia in the frail, elderly patient. Clinical interventions in Aging. 2016; 11:
319 326.
Andres E, Federici L, Serraj K, Kaltenbach G. Update of nutrient-deficiency anemia in
elderly patients. Eur J Intern Med. 2008; 19: 488 493.
Andres E, Serraj K, Federici L, Vogel T, Kaltenbach G. Anemia in elderly patients: new
insight into an old disorder. Geriatr Gerontol Int. 2013; 519 527.
Rimon E, Kagansky N, Kagansky M, et al. Are we giving too much iron? Low-dose iron
therapy is effective in octogenarians. Am J Med. 2005; 118: 1142 1147.

OBJECTIVES:
1. Identify factors that may contribute to anemia in the geriatric population.
2. Create a treatment plan for a patient with a macrocytic or microcytic anemia.
3. Provide comprehensive education to a patient with a macrocytic or microcytic
anemia .

DEFINITIONS AND PATHOPHYSIOLOGY

A. World Health Organization definition of anemia:
a. Men:
Hgb: _________
b. Women: Hgb:__________
c. Values not appropriate for aging population, but lack of specific targets
B. Lab values:
a. MCV
i. Not a good indicator in elderly population
b. MCHC
c. RDW
C. Types of anemia:
a. ______________________________________________
i. Tea & toast diet
b. ______________________________________________
D. Inflammaging
a. Chronic microvascular inflammation occurs with aging and may play a
role in anemia of chronic inflammation/disease in elderly patients
E. Epidemiology
a. Prevalence increases above age of 65
b. NHANES III found prevalence of > 20% in community dwelling seniors
over 85 YO
c. More common in hospitalized patients > those residing in nursing
facilities/LTCF > community dwelling seniors
d. Associated with physical impairment, frailty, cognitive decline,
depression and mortality in elderly patients
i. As aging occurs, the body has difficulty compensating for
decreased oxygen availability

MICROCYTIC ANEMIA
A. Iron deficiency anemia (IDA) is 2nd most common cause of anemia in elderly
B. Signs/Symptoms/Labs
S/Sx
Spoon shaped
nails
Pica
Pagophagia
Glossitis
Reduced salivary
flow
Stomatitis

Labs
MCV:
Serum ferritin:
Serum iron:
% Transferrin saturation:
TIBC:

RDW:
C. Causes:
a. Inadequate dietary intake/inadequate absorption
i. Without blood loss, takes years to develop into IDA
ii. Use of medications:
1. _________________________
2. _________________________
3. _________________________
iii. Tea and coffee inhibit absorption of iron
b. Functional iron deficiency
i. Inflammation increases __________, which inhibits the ability to
release iron into circulation
ii. Oral iron not effective in these patients must receive IV
D. Treatment:
a. All elderly patients with IDA should be evaluated for source of GIB
i. GI blood loss
1. Secondary to NSAID use, chronic steroids, gastritis,
esophagitis, H. pylori, portal HTN, cancers
ii. Source may be unidentified in up to 40% of patients
b. Stop any agents that may be contributing to bleeding, if possible
c. Treat iron loss with oral iron
i. IV iron does not replete faster, reserved for patients who do not
respond or cannot take oral iron
1. Sucrose most well tolerated for IV
2. May use IV iron in chronic HD patients
ii. Therapeutic response expected in _____________________
iii. Low dose iron acceptable in elderly patients (Rimon et al. Am J
Med 2005)
1. 15 mg elemental iron increased Hgb 1.3 points within 60
days compared to 1.4 points with 50 mg and 150 mg
elemental iron
2. More tolerable, less ADR
d. Adverse events/counseling points:
i. Constipation, darkening stools, nausea, vomiting
ii. Patients may take with stool soften

iii. Best to take on empty stomach, but if not tolerated may take
with food
iv. Avoid taking with acid suppressant drugs
Salt
Ferrous sulfate
Ferrous gluconate
Ferrous fumarate
Polysaccharide iron
complex

Elemental
Iron
20%
12%
33%
100%

mg elemental
iron
65 mg
36 mg
27 mg
33 mg
150 mg

mg of dosage
form
325 mg
325 mg
240 mg
100 mg
150 mg

MACROCYTIC ANEMIA
B12 Deficiency
A. Signs/Symptoms/Labs
S/Sx
Labs
Neurologic Sx
MCV:
Psychiatric
Serum B12:
Muscle weakness
Reticulocytes:
Glossitis
Homocysteine:
Anorexia
MMA:
B. Causes:
a. Inadequate intake
i. Tea and toast diet
ii. Poor dentition
iii. Financial reason
iv. Inability to prepare proper meals
b. Malabsorption syndromes
i. Cobalamin malabsorption, inability to cleave B 12 into circulation
ii. Atrophic gastritis affects 40% of patients > 80 YO
iii. Use of medications:
1. ____________________
2. ____________________
3. ____________________
c. Inadequate utilization
C. Treatment
a. Must treat early, especially if presenting with neurological dysfunction
i. May often be overlooked initially because elderly patients are
often described as altered
ii. Neurological function may be irreversible
b. Parenteral therapy if neurological symptoms
c. IM/SubQ schedule:
i. 1000 mcg cyanocobalamin X 1 week, followed by weekly X 1
month, then monthly thereafter
d. Therapeutic response:
i. Physical symptoms improve within ____________

ii. Hemoglobin normalization within _____________

D. Side effects:
a. Rare, but possible hypokalemia (due to increased utilization in RBC
production)
Folate Deficiency
A. Signs/Symptoms/Labs
S/Sx
Neurologic Sx
Psychiatric
Muscle weakness
Glossitis
Anorexia

Labs
MCV:
Folate:
Reticulocytes:
Homocysteine:
MMA:

B. Common in some elderly patients due to malnutrition

a. Ability to develop quickly because the body does not have large stores
of folate
b. As of 1990s, may foods are fortified with folate, which has decreased
prevalence of folate deficiency
c. Major dietary sources: fresh greens, citrus fruits, dairy, animal organs
(liver)
C. Other causes:
a. Hyperutilization of folate
i. Chronic inflammatory states
ii. Hemodialysis patients
iii. Drug causes:
1. _____________________
2. Phenytoin, phenobarbital
D. Treatment:
a. Folate replacement 1 mg daily
b. If patients have a malabsorptive state (inflammatory bowel disease),
may need doses as high as 1 to 5 mg
WRAP-UP
A. Anemia in elderly often mild, with vague symptoms that should not just be
considered part of aging
B. Often multifactorial
C. Always consider nutritional status, especially if patient lives at home/alone
D. Iron deficiency in elderly should always be evaluated for GI blood loss and
examine any potential medications that could contribute to GI bleeds
E. Consider potential B12 deficiency if patient presents with altered neurologic
dysfunction