Blood Matters in the Elderly 

By Dr. Ng Soo Chin, The Malaysia Star

Malaysia

September 2, 2007

Understanding anaemia in the ageing population.

There are two compelling reasons why we should not accept anaemia as part of ageing process. 

Firstly, most elderly persons are able to maintain their haemoglobin above anaemic levels. The WHO (World Health Organization) defines anaemia as <13 g/dl for males and <12g/dl for females. 

Secondly, up to 80% of anaemic elderly patients have an identifiable cause of anaemia when they are being investigated in studies. Hence anaemia is not a consequence of normal ageing. 

How common is anaemia? 

In 2004, the American Society of Haematology conducted a special forum to address the problem of anaemia in the elderly as it is considered a public health crisis in haematology. 

It is estimated that more than three million people in the US aged 65 and older have anaemia. The prevalence is reported as 10-45% of elderly populations in various studies and there are more anaemic men than women! 

Generally, the prevalence of anaemia increases with each decade. It is hence a common growing health problem as the population ages. 

Why is anaemia an important finding in elderly patients? 

Anaemia is a manifestation of an underlying disorder, and in the elderly, some of the underlying causes are potentially treatable, for instance, gastrointestinal cancer, pernicious anaemia, malnutrition etc. 

In the elderly, anaemia results in a decrease in physical performance and strength as shown by poorer balancing; walking abilities and hand grip strength. Impairment in cognitive function is also seen in elderly anaemic patients. The functional and cognitive impairment will impact negatively on their quality of life. 
In elderly patients with congestive heart failure or chronic renal failure, higher mortality is seen in patients with concurrent anaemia. This is an important observation that warrants more studies. 

What are the special considerations in anaemia in the elderly? 

The onset of anaemia is rather insidious and symptoms are non-specific. 
Most patients fail to report to their doctors regarding symptoms of lethargy, breathlessness on exertion and so on as they consider these symptoms as part of ageing and they tend to adjust their lifestyle to cope with the functional impairment. 

Since the old concept that anaemia is part of ageing is held by some doctors, anaemia in the elderly is not diagnosed or treated as vigorously as younger patients. 

Doctors tend to have a tough time trying to unravel the underlying problem(s) as elderly patients tend to have multiple medical problems and the use of multiple drugs (polypharmacy) further complicate the overall picture. 
What are the common causes of anaemia and the diagnostic tests needed in the elderly? 

This could range from mundane causes such as nutritional deficiencies to life threatening causes such as Myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). 

In ambulatory patients, chronic diseases (such as kidney diseases, infection, malignancy and chronic inflammatory diseases) and iron deficiency are important causes. 

Blood loss from surgery, gastrointestinal or genital urinary bleed are more commonly seen in a hospital setting. Frequently (up to 53% in a study), multiple pathologies are detected. 

Some diagnoses are more common in the elderly patients, and the diagnostic workout should be structured accordingly, with emphasis on detecting treatable causes. 

A good history, a focused physical examination and limited non-invasive laboratory assessments will suffice in most patients. Prof C Lockard Conley once commented that if all the blood tests for anaemia were performed, patients not only ended up more profoundly anaemic, but would be financially depleted as well! 

The laboratory tests would include a full blood picture, hepatic and renal functions, serum ferritin and serum B12 level and stool for occult blood. 
The most revealing tests are the examination of peripheral blood film and the measurement of reticulocyte count. 

GI endoscopy is useful in patients with documented iron deficiency anaemia i.e. low serum ferritin, and not as a routine screen for elderly anaemic patients. 
Bone marrow examination is indicated in patients with suspected marrow pathologies such as MDS/AML, multiple myeloma or secondary deposits from cancer elsewhere. 

What is Myelodysplastic syndrome? 

Myelodysplastic syndrome (MDS) occurs in up to 5% of elderly anaemics. It is a clonal marrow disorder characterised by ineffective synthesis of blood cells. Anaemia is a prominent feature in the disorder. It generally runs a downhill course, though the benign subtypes of MDS patients can have stable disease and can enjoy a long period of good quality life. 

Treatment for the elderly is mainly supportive i.e. blood- product support, iron chelating agents for patients who are chronic red cell transfusion dependent and antibiotics for intercurrent infections. 

Bone marrow transplants, which could cure young MDS, cannot be an option in the elderly due to transplant deaths related mainly to overwhelming graft-versus-host disease. 

Newer treatment agents including thalidomide,lenalidomide and hypomethylating agents such as azacitidine are making some headway in treating MDS. 

What is the role of blood transfusion in elderly anaemic patients? 

Blood transfusions in the form of packed cells are useful to alleviate the symptoms of anaemia quickly. It is not a definitive therapy for any anaemia. 
It could be considered a form of short-lived tissue transplantation employed to provide temporary support in an ill patient before the underlying problem is tackled. 

It is important to make sure those baseline blood tests such as serum ferritin or B12 levels are done before blood is transfused. The search for underlying cause starts concurrently. Tackling the underlying cause can prevent, in some cases, the need for repeated blood transfusions. 

In patients who fail to produce red cells due to marrow pathologies, they may require up to two to four pints of blood monthly. 

Iron overload is a big problem once patients receive more than 20 pints of blood and chelating therapy is necessary to prevent complications of iron overload such as congestive heart failure, diabetes mellitus etc. 

Good oral chelating agents such as exjade (deferasirox) are now available but the long term cost of using oral chelating agent is formidable. 

Why is more research into anaemia in the ageing population needed? 

We need to have better epidemiological data for health planning purposes. 
There are significant physiological changes in ageing that may affect red cell production. These would include the fact that bone marrow becomes less cellular with ageing and the whole host of hormonal changes that occur as we grow older. 

Erythropoietin injections are effective in patients with chronic renal failure and perhaps some MDS patients, but we would like more data on its efficacy, plus pharmacoeconomics study to delineate its use as it is an expensive treatment. 
The intricate issue of drug interactions needs to be addressed in elderly patients. We now have better understanding of anaemia of chronic disorders (ACD) with the discovery of hepcidin. 

Hepcidin production is stepped up by inflammatory cytokines (a result of chronic infections, chronic immune stimulation or malignancy) and it in turn stops ferroportin from being released from iron stored in the body. Some diseases such as MDS is more common in the elderly while AML is hard to treat in elderly folks – we urgently need more novel agents and better treatment strategies. 

Take home messages 

Anaemia is a common and growing problem in the ageing populations. It is not a normal consequence of ageing and should be recognised as such and the underlying cause(s) elucidated. 

Untreated geriatric anaemia is associated with increased mortality and decreased body functions. Careful clinical evaluation and simple basic tests suffice in most cases in investigating anaemia in the elderly. 

More research is required to tackle the problem of anaemia in ageing populations so that we can improve the overall management strategy. 

• This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. 

The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Assoc Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my 

The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. 

The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article. 

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