Causes Of Low Haemoglobin In The Elderly – Anemia is a common condition in adults 60 years of age and older. Because of the demographic growth of this population and the morbidity and mortality associated with anemia, primary care physicians should be familiar with the diagnosis and management of anemia in the elderly.

Low-dose formulations of iron (15 mg of elemental iron) can be effective for the treatment of suspected iron deficiency anemia and have a lower risk of adverse effects than standard preparations.

Causes Of Low Haemoglobin In The Elderly

Causes Of Low Haemoglobin In The Elderly

Anemia was previously defined as a hemoglobin level of less than 12 g per dL (120 g per L) in women and less than 13 g per dL (130 g per L) in men.

Serum Erythropoietin Level In Anemia Of Elderly With Unclear Etiology

These values ​​and reference ranges remained static until recently, when cohort studies such as the third National Health and Nutrition Examination Survey suggested that this definition needed to be adjusted due to variation in normal levels. of hemoglobin with age, sex, and black race (values ​​for different ethnicities are not available). A revised definition that may better reflect these differences is proposed (Table 1).

The overall prevalence of anemia is 17% in the elderly (7% to 11% of community-dwelling elderly, 47% of nursing home residents, and 40% of hospitalized patients).

Most of these patients have mild anemia (hemoglobin level of 11 g per dL [110 g per L] or more), but even mild anemia is independently associated with increased morbidity and mortality.

A prospective cohort analysis of 3,758 patients 65 years of age and older found that new-onset anemia and decreased hemoglobin levels with or without anemia were associated with increased mortality ( hazard ratios of 1.39 [95% confidence interval (CI), 1.15 to 1.69] and 1.11 [95% CI, 1.04 to 1.18], respectively, per 1 g per dL decrease in hemoglobin).

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A 2016 British prospective cohort study of 220 patients with an average age of 83.6 years found that anemia was associated with increased all-cause mortality one year after hospitalization.

After adjusting for comorbid conditions, anemia in community-dwelling older adults is associated with decreased performance and decreased mobility, balance, and ability to rise from a chair.

In general, one-third of elderly patients with anemia have nutritional deficiencies, which include iron deficiency due to subsidiary causes (eg, bowel malignancy), one-third have chronic inflammation or chronic kidney disease (CKD), and one-third have an unknown cause.

Causes Of Low Haemoglobin In The Elderly

Recognizing the clinical signs and symptoms of anemia is an important first step. However, some patients will be asymptomatic, and the diagnosis will occasionally be based on incidental laboratory findings. In acute presentations, patients will have symptoms secondary to volume loss, such as dizziness, syncope, and hypotension. Chronic anemia may be asymptomatic but in severe cases shows symptoms related to decreased oxygen-carrying capacity, such as weakness, fatigue, shortness of breath, and worsening of comorbid conditions such as angina, failure of heart, CKD, and chronic obstructive pulmonary disease. These conditions are more common in older patients and can cause many of the same clinical symptoms as anemia; thus, a high clinical suspicion should be maintained.

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In addition to clinical manifestations, risk factors for anemia should guide the diagnosis. Risk factors more common in elderly patients include chronic alcohol use, malnutrition, CKD, liver disease, myelodysplastic disorders, gastrointestinal bleeding, cancer, androgen deficiency, and age-related decline in stem cell proliferation. . The clinical history should focus on identifying these risk factors, as well as symptoms that may suggest a particular condition. Melena, hematochezia, and unintentional weight loss may indicate gastrointestinal bleeding. Recurrent skin infections may be a sign of immunocompromise indicative of myelodysplastic syndrome.

Once anemia is suspected, a complete blood count with differential should be obtained. If the results indicate anemia, further studies are needed to evaluate the underlying cause and to guide treatment. The mean corpuscular volume is used to classify anemia as microcytic (less than 80 fL), normocytic (80 to 100 fL), or macrocytic (greater than 100 fL), and allows for a more specific and tailored analysis.

Microcytic and normocytic anemia are most common in adults. Although microcytic anemia is usually associated with iron deficiency, and normocytic with chronic disease or unknown causes, there is significant overlap between the manifestations of these diseases. Iron deficiency anemia occurs in 11% to 57% of patients with colorectal cancer and may be the presenting symptom in 15%.

A level below 19 ng per mL (43 pmol per L) is highly suggestive of iron deficiency anemia (positive likelihood ratio [LR+] = 41), but this condition may be present in patients with higher level (LR+ = 3.1 in patients with serum ferritin of 45 ng per mL [101 pmol per L] or less).

Causes Of Anemia In Older Adults

Iron deficiency anemia is less likely in patients with serum ferritin levels of 46 to 100 ng per mL (103 to 225 pmol per L), although it cannot be ruled out. In these patients, the serum transferrin receptor-ferritin index can be used to distinguish between iron deficiency anemia and other types. (There is an online calculator for registered users at index of more than 1.5 supports the diagnosis of iron deficiency anemia. Fecal occult blood testing should be performed to assess gastrointestinal blood loss, and endoscopic evaluation should be strongly considered for patients with iron deficiency anemia. or where occultation is identified, taking into account factors such as the patient’s comorbidities and the risk of complications.

If iron deficiency anemia is excluded, anemia of chronic disease is the most likely cause of microcytic or normocytic anemia. In elderly patients, anemia of chronic disease is often caused by CKD, which can be assessed using serum creatinine and the glomerular filtration rate. Further evaluation based on clinical presentation is necessary for patients in whom iron deficiency anemia and CKD are excluded. Testing should begin with a peripheral blood smear and reticulocyte count, with further testing based on the results of these tests.

If the serum ferritin level is more than 100 ng per mL, or if macrocytic anemia is detected, the most likely cause changes to other etiologies. A peripheral blood smear and reticulocyte count are the first steps in the diagnosis of macrocytic anemia. Abnormalities in the peripheral blood smear should prompt consideration of a myelodysplastic syndrome or malignancy, and hematologic consultation is required. A high reticulocyte count (reticulocyte index greater than 2%) is associated with increased bone marrow production of red blood cells and is associated with hemolysis, hypersplenism, or recent blood loss (Figure 2).

Causes Of Low Haemoglobin In The Elderly

Or folate deficiency. These deficiencies may occur with chronic alcoholism, or they may be the result of malabsorption due to diet or surgery.

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The diagnosis can be made when serum cobalamin levels are markedly low (less than 100 pg per mL [74 pmol per L]); High levels of methylmalonic acid and homocysteine ​​​​are more sensitive for the diagnosis of vitamin B

Treatment of anemia is ultimately guided by the underlying diagnosis. This article focuses on treatment in the outpatient setting for the most common etiologies in elderly patients. Hospital admission and blood transfusion should be considered if there is concern for significant anemia (hemoglobin level less than 7 to 8 g per dL [70 to 80 g per L]) or if the patient have symptoms.

When formulating a treatment plan, the underlying cause of anemia must be considered, as should any comorbidities. The primary care physician should discuss the potential benefits and harms of treatment with the patient and caregivers.

Iron replacement therapy can be used as a treatment, as well as a diagnostic discriminator. Initiating therapy with oral agents is reasonable as long as there is no concern for malabsorption and the patient is informed about potential adverse effects. These drugs should not be taken with food because of the potential for reduced absorption, but they can be taken after meals to reduce adverse gastrointestinal effects. Medications that decrease gastric acid secretion may also decrease absorption and should not be taken at the same time.

Pdf) Prognostic Relevance Of Normocytic Anemia In Elderly Patients Affected By Cardiovascular Disease

Classically, oral therapy with 325 mg of ferrous sulfate three times per day is recommended to achieve 100 to 200 mg of elemental iron daily. However, this regimen is associated with a high rate of adverse effects, including dark or black stools (up to 91%), abdominal discomfort (up to 70%), diarrhea (up to 70%), nausea and vomiting (up to 67%), and constipation (up to 23%).

Although there are only limited studies in adults, new evidence shows that lower doses of iron and less frequent dosing may be equally effective while reducing the risk of adverse effects.

Liquid elemental iron in doses as low as 15 mg per day, given with orange juice to enhance absorption, may be effective while minimizing adverse effects. Liquid formulations also allow for easy dose titration. There are no specific guidelines for the length of therapy, but recommendations generally advise continuing for three to six months when hemoglobin and serum ferritin are normal, which usually occurs after six to eight weeks of oral therapy.

Causes Of Low Haemoglobin In The Elderly

This may be especially necessary in patients at risk of malabsorption with oral dosing (eg, patients who have undergone bariatric surgery, gastrectomy, gastrojejunostomy, or other small bowel surgery). In these patients, parenteral therapy can be considered a first-line option due to its effectiveness and significant reduction in adverse effects. Parenteral iron is also possible

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