Anemia in the Elderly

Abstract

Anemia affects a substantial fraction of the elderly population, representing a public health problem that is predicted to further increase in coming years because of the demographic drive. Being typically mild, it is falsely perceived as a minor problem, particularly in the elderly with multimorbidity, so that it often remains unrecognized and untreated. Indeed, mounting evidence indicates that anemia in the elderly (AE) is independently associated with disability and other major negative outcomes, including mortality. AE is generally multifactorial, but initial studies suggested that etiology remains unexplained in near one-third of cases. This proportion is consistently declining due to recent advances highlighting the role of several conditions including clonal hematopoiesis, “inflammaging,” correctable androgen deficiency in men, and under-recognized iron deficiency. Starting from a real-world case vignette illustrating a paradigmatic example of anemia in an elderly patient with multimorbidity, we review the main clinical and pathophysiological aspect of AE, giving some practical insights into how to manage similar cases.

Iron deficiency

“…The diagnosis of absolute iron deficiency is also challenging in the elderly; proposed cutoffs between .30 and ,100 mg/L are based on small studies. 37,38 This supports the need for well-designed prospective clinical trials and development of biomarkers for tissue iron deficiency.…”

“…37 Iron deficiency accounts for ;30% of cases, resulting from low intake, reduced absorption (atrophic gastritis, use of proton pump inhibitors), gastrointestinal blood losses (antithrombotic drugs, angiodysplasia, peptic ulcer, hemorrhoids, and even colorectal cancer). Unfortunately, being obscured by comorbidities, it often remains undiagnosed, 38 while even mild anemia worsens the outcome of associated disorders and influences mortality. 39 Patients with chronic kidney disease (CKD) are prone to absolute iron deficiency because of reduced absorption 40 and blood loss at dialysis, at an estimated rate of up to 2 to 3 g per year.…”

“…56 The stable carbohydrate shell of the latter compounds prevents free iron release, a feature that increases their safety. 56 The highdose schedule avoids repeated hospital visits (eg, for patients with reduced mobility, such as the elderly, for whom oral therapy can be particularly disturbing) 38 and is convenient when a fast recovery is needed (such as in the second and third trimesters of pregnancy or in postpartum anemia 87 and the prevention of repeated cycles of therapy [eg, in heavy uterine bleeding]). 88 In addition to the prompt Hb increase, this protocol rapidly reconstitutes stores, 89 making the advantages (single access, accelerated recovery, limited need for blood tests) outweigh the disadvantages (cost, invasiveness, risk of reactions).…”

Prevalence and Causes of Anemia in Hospitalized Patients: Impact on Diseases Outcome

“…In the remaining patients, a chronic disease was the most common cause of anemia, including chronic kidney disease. However, in none of our patients, serum IL6, that upregulates Hepcidin [34], was tested even if iron deficiency related to Hepcidin increase in "inflammaging" [4] is implicated not only in anemia but also in other age-associated conditions. Many cases of anemia, often severe, were considered multifactorial, while IDA and other were less common.…”

“…The most common cause of anemia in the world is iron deficiency (IDA); in contrast, in elderly patients (>65 years of age), multifactorial anemia (chronic kidney disease, nutritional deficiency, occult hemorrhages, gastrointestinal blood loss, use of antithrombotic drugs, ineffective erythropoiesis,) [4] and anemia related to chronic diseases (CDA) have a higher prevalence [2,3], though in some cases the condition may remain unexplained: on a whole, 40% of hospitalized and 47% of institutionalized patients are anemic [5]. Elderly patients with anemia have a reduced physical performance [6], reduced muscle strength leading to a higher incidence of falling [7], to more frequent hospitalizations [8], and to an increased risk of death [9][10][11][12].…”