What Causes Low Hemoglobin In The Elderly

What Causes Low Hemoglobin In The Elderly – Anemia is a common disease in adults 60 years and older. Due to the demographic growth of this population and the morbidity and mortality associated with anemia, primary care physicians should be familiar with the evaluation and management of anemia in the elderly.

A formula with a low amount of iron (15 mg of elemental iron) can effectively treat anemia suspected of iron deficiency and with a lower risk of adverse effects than the standard preparation.

What Causes Low Hemoglobin In The Elderly

What Causes Low Hemoglobin In The Elderly

Anemia has historically been 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.

Pdf) Anaemia In The Elderly

These values ​​and reference levels remained constant until recently, when studies in groups such as the third national health and nutrition survey suggested that this definition must be adjusted due to differences in normal hemoglobin levels with age, sex, and black race (values ​​for different ethnic groups do not exist). A revised definition that may better reflect these differences has been proposed (Table 1).

The overall prevalence of anemia is 17% in the elderly (7% to 11% of elderly in the community, 47% of those in nursing homes, and 40% in hospital patients).

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

A prospective cohort analysis of 3,758 patients aged 65 years and older found that new-onset anemia and decreased hemoglobin levels with or without anemia were associated with increased mortality (hazard ratio 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).

Impaired Iron Recycling From Erythrocytes Is An Early Hallmark Of Aging

A 2016 UK cohort study of 220 patients with a mean age of 83.6 years found that anemia was associated with increased all-cause mortality one year after admission.

After adjusting for confounding factors, anemia in community-dwelling adults was associated with functional decline and decreased mobility, balance, and the ability to get up from a chair.

Overall, one-third of elderly patients with anemia have nutritional deficiencies, including iron deficiency due to secondary causes (such as colon cancer), one-third have chronic inflammation or chronic kidney disease (CKD), and one-third have symptoms. I don’t know the cause.

What Causes Low Hemoglobin In The Elderly

Recognizing the clinical signs and symptoms of anemia is an important first step. However, some patients will have no symptoms, and the diagnosis will sometimes be based on incidental laboratory findings. In acute presentation, patients will have symptoms secondary to volume loss, such as lightheadedness, syncope, and hypotension. Chronic anemia may not show symptoms but in severe cases there are symptoms related to reduced oxygen carrying capacity, such as weakness, fatigue, shortness of breath, and severe conditions such as angina, heart failure, CKD, and chronic obstructive pulmonary disease. These conditions are common in elderly patients and may cause many of the same clinical symptoms as anemia; Therefore, a high clinical suspicion must be maintained.

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In addition to clinical manifestations, risk factors for anemia should guide the evaluation. Common risk factors in older 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 indicate a particular condition. Melena, hematochezia, and unintentional weight loss may indicate gastrointestinal bleeding. Recurrent skin infections may be an immune symptom that suggests myelodysplastic syndrome.

When anemia is suspected, a complete blood count with differential should be obtained. If the results indicate anemia, further studies are needed to assess the underlying cause and recommend treatment. The average 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 appropriate evaluation.

Microcytic and normocytic anemias are most common in adults. Although microcytic anemia is associated with iron deficiency, and normocytic with chronic or unknown diseases, there is a great overlap between the manifestations of these diseases. Iron deficiency anemia occurs in 11% to 57% of patients with colon cancer and may be symptomatic in 15%.

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

Anemia In The Elderly: Clinical Implications And New Therapeutic Concepts

Iron deficiency anemia is less likely in patients with a serum ferritin level of 46 to 100 ng per mL (103 to 225 pmol per L), although it cannot be ruled out. In these patients, the receptor-ferritin index of serum transferrin can be used to distinguish between iron deficiency anemia and other types. (Online calculator available for registered users at https://online.epocrates.com/medCalc/TransferrinReceptorIndex.htm?activeMedCalcName=Transferrin%20Receptor-Ferritin%20Index%20for%20Diagnosis%20of%20Iron%0Anemia%20deficiency). An index of more than 1.5 supports the diagnosis of iron deficiency anemia. Fecal occult blood test should be performed to evaluate gastrointestinal blood loss, and endoscopic evaluation should be strongly considered for patients with iron deficiency anemia or occult blood, considering various factors such as patient comorbidities and the risk of complications.

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

If the ferritin level in the serum is higher than 100 ng per mL, or if macrocytic anemia is identified, it is most likely the cause of the change in other etiologies. A peripheral blood smear and reticulocyte count is the first step in the evaluation of macrocytic anemia. Peripheral blood test abnormalities should be considered myelodysplastic syndrome or malignancy, and hematologic consultation is warranted. A high reticulocyte count (reticulocyte index greater than 2%) is associated with an increase in bone density of red blood cells and is associated with hemolysis, hypersplenism, or recent blood loss (Figure 2).

What Causes Low Hemoglobin In The Elderly

Or folate deficiency. These deficiencies can occur with chronic alcoholism, or they can 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 lower (less than 100 pg per mL [74 pmol per L]); Elevated levels of methylmalonic acid and homocysteine ​​are more sensitive for the diagnosis of vitamin B deficiency.

Treatment of anemia is ultimately recommended by early diagnosis. This article focuses on treatment in the outpatient setting for the most common etiologies in elderly patients. Hospitalization and transfusion should be considered if significant anemia is suspected (hemoglobin level less than 7 to 8 g per dL [70 to 80 g per L]) or if the patient is symptomatic.

When creating a treatment plan, the underlying cause of anemia should be considered, as well as other diseases. Primary care physicians should discuss the benefits and risks of treatment with patients and caregivers.

Iron replacement therapy can be used as a treatment, as well as a differential diagnosis. Initiating oral agent therapy is reasonable as long as there are no concerns about malabsorption and the patient is informed of potential adverse effects. These drugs should not be taken with food due to the potential for reduced absorption, but they can be taken after a meal to reduce adverse effects on the gastrointestinal tract. Drugs that reduce gastric acid secretion can also reduce absorption and should not be taken at the same time.

Iron Deficiency Symptoms

Classically, oral therapy with 325 mg of ferrous sulfate three times a day is recommended to achieve 100 to 200 mg of 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 the elderly, new evidence shows that low doses of iron and less frequent doses may be equally effective while reducing the risk of adverse effects.

Liquid iron in doses as low as 15 mg per day, given with orange juice to increase absorption, can be effective while minimizing adverse effects. The liquid formula also allows for easy dose titration. There are no specific guidelines for the duration of treatment, but general guidelines recommend continuing for three to six months when hemoglobin and serum ferritin levels normalize, which usually occurs after six to eight weeks of oral treatment.

What Causes Low Hemoglobin In The Elderly

This may be especially necessary in patients at risk of malabsorption with oral doses (eg, patients undergoing bariatric surgery, gastrectomy, gastrojejunostomy, or other small bowel surgery). In these patients, parenteral therapy can be considered as the first choice due to its effectiveness and a significant reduction in adverse effects. Parenteral iron may be

Iron Deficiency Anemia: Symptoms, Causes, Diagnosis, And Treatment

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