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      Anemia in the elderly: an important clinical problem

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          Abstract

          A paper written by Sgnaolin et al.(1) is published in this issue of the Revista Brasileira de Hematologia e Hemoterapia. The authors present a study about the frequency of anemia of 1058 people of 60 years old or more living in a community-based population in Porto Alegre, Brazil. Blood samples were taken from all participants and the hematological parameters [hemoglobin, mean cell volume (MCV), mean corpuscular hemoglobin concentration (MCHC) and red cell distribution width (RDW)] were analyzed. They observed a frequency of anemia of 12.8%, which was higher in women than in men. The majority of anemic patients presented with normocytic and normochromic anemia, but when they evaluated the erythrocyte morphology the anemic population had almost 10 times more microcytosis than the non-anemic subjects. This is a very important clinical problem as the frequency of anemia in this population can range from 10 to 30%. The large National Health and Nutrition Examination Survey (NHANES III) population study(2) showed that the prevalence of anemia increases directly with age; it is 10 to 11% in over 65-year olds and jumps to 26 to 30% in over 75-year olds and is a little higher in men(2- 4). The frequency of anemia can be even higher in patients followed in outpatient clinics due to the increase in different diseases these patients have. An abstract presented in the 2012 Brazilian Congress of Hematology by this author showed a frequency of 36.5% in 96 elderly patients with ages ranging from 65 to 92 years (mean: 76 years) followed in an outpatient clinic(5). The symptoms as dyspnea, angina and fainting are more intense in the elderly and the presence of comorbidities exacerbate the consequences of anemia in this population. It is relevant to comment that in the elderly, the lower the level of hemoglobin the higher the morbidity, mainly in those who have heart disease. It has been reported that the mortality of over 60-year-old patients, with myocardial infarction in an intensive care unit was higher when hemoglobin levels were lower. Moreover, the use of erythropoietin and transfusions in these patients reduced the mortality rate(6-9). Anemia significantly affects the daily performance of elderly patients. Some studies show that the capacity of walking, standing up, sitting or getting up from a chair and taking objects is severely impaired in anemic patients( 10,11). An assessment of the quality of life also shows the negative effects of anemia(12). The pathophysiology of anemia in these patients is, in the majority of cases, due to a hypoproliferative mechanism, although some of the cases are a result of blood loss, mainly associated to gastrointestinal neoplasms but some cases have a hemolytic origin. The causes of anemia in the elderly can be separated into three groups, each of them counting for about one third of the cases(2,4,13,14). The first is the group of chronic, particularly inflammatory and neoplastic, diseases. Anemia in these diseases is caused by the inhibition of the effect of erythropoietin in red cell precursors (interleukins such as interleukin-6 and Tumor Necrosis Factor)(4), or by blocking of iron in macrophage cells (role of hepcidin)(15) or even a reduction in the red cell lifespan. This affects the number of red cells and leads to normocytic or microcytic anemia with a low reticulocyte count. A second group is composed of patients who have "nutritional" anemia or anemia due to iron loss, reduced B12 vitamin absorption or folate deficiency. The main causes of iron losses are gastrointestinal, urinary or gynecologic diseases. It is essential to look for blood loss, because, in spite of the anemia being important, the cause of the blood loss will probably be more important(16-18). The levels of B12 and folate are frequently low in the elderly, but deficiency of the first vitamin only accounts for 1 to 2% of the cases of anemia, far less than those related to the iron loss(4,19,20). An even less important cause is folate deficiency, with a possible reason for this being alcohol abuse(4). The third group includes patients with anemia of unknown causes, which may be due to, among other things, the growing frequency of chromosomal abnormalities found in older people. This may explain the higher frequency of neoplasms of hematopoietic tissue in the elderly population such as the myelodysplastic syndromes( 21). It is important to note that anemia in the elderly is not normal! It is always necessary to investigate the cause and to at least try to reduce the consequences in these patients. In conclusion, as the number of over 60-year-old people is continuously growing in developed and developing countries, and because of the high prevalence, morbidity and mortality of anemia in this population, it is necessary for physicians in most areas to know the mechanisms, causes and management of anemic patients.

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          Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia.

          Clinicians frequently identify anemia in their older patients, but national data on the prevalence and causes of anemia in this population in the United States have been unavailable. Data presented here are from the noninstitutionalized US population assessed in the third National Health and Nutrition Examination Survey (1988-1994). Anemia was defined by World Health Organization criteria; causes of anemia included iron, folate, and B(12) deficiencies, renal insufficiency, anemia of chronic inflammation (ACI), formerly termed anemia of chronic disease, and unexplained anemia (UA). ACI by definition required normal iron stores with low circulating iron (less than 60 microg/dL). After age 50 years, anemia prevalence rates rose rapidly, to a rate greater than 20% at age 85 and older. Overall, 11.0% of men and 10.2% of women 65 years and older were anemic. Of older persons with anemia, evidence of nutrient deficiency was present in one third, ACI or chronic renal disease or both was present in one third, and UA was present in one third. Most occurrences of anemia were mild; 2.8% of women and 1.6% of men had hemoglobin levels lower than 110 g/L (11 g/dL). Therefore, anemia is common, albeit not severe, in the older population, and a substantial proportion of anemia is of indeterminate cause. The impact of anemia on quality of life, recovery from illness, and functional abilities must be further investigated in older persons.
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            Anemia is associated with disability and decreased physical performance and muscle strength in the elderly.

            To examine the association between anemia and disability, physical performance, and muscle strength in older persons. Cross-sectional. Community-dwelling older persons in the Chianti area in Italy. A total of 1,156 persons aged 65 and older participating in the InChianti Study ("Invecchiare in Chianti," i.e., Aging in the Chianti Area). Anemia was defined according to World Health Organization criteria as a hemoglobin concentration below 12 g/dL in women and below 13 g/dL in men. Disability in six basic and eight instrumental activities of daily living was assessed. Physical performance was assessed using the short physical performance battery (4-m walk, balance, and chair stands), which yields a summary performance score ranging from 0 to 12 (high). Muscle strength was determined using knee extensor and handgrip strength assessments. Overall, 11.1% of the men and 11.5% of the women had anemia. After adjustment for age, sex, body mass index, Mini-Mental State Examination score, creatinine level, and presence of various comorbid conditions, anemic persons had more disabilities (1.71 vs 1.04, P=.002) and poorer performance (8.8 vs 9.6, P=.003) than persons without anemia. Anemic persons also had significantly lower knee extensor strength (14.1 vs 15.2 kg, P=.02) and lower handgrip strength (25.3 vs 27.1 kg, P=.04) than persons without anemia. Further adjustment for inflammatory markers (interleukin-6, C-reactive protein, tumor necrosis factor-alpha) did not change these associations. Anemia is associated with disability, poorer physical performance, and lower muscle strength. Further research should explore whether treating anemia has a beneficial effect on the functional status of older persons.
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              Anemia is common in heart failure and is associated with poor outcomes: insights from a cohort of 12 065 patients with new-onset heart failure.

              Although previous work has suggested that anemia is associated with an increased mortality in selected patients with congestive heart failure (CHF), little is known about the prevalence and predictors of anemia, or whether anemia is an independent prognostic factor in unselected, community-based patients with CHF. We analyzed a population-based cohort of patients with new-onset CHF from a database of patients discharged from 138 acute-care hospitals in Alberta, Canada, between April 1993 and March 2001. Logistic regression, Kaplan-Meier survival analyses, and Cox proportional hazards model were used. Among the 12 065 patients with CHF (median age 78 years), 17% had anemia, 58% of whom had anemia of chronic disease. After adjustment for clinical and demographic variables, patients with anemia were more likely to be older (odds ratio [OR] 1.01 per year) and female (OR 1.2 [95% confidence interval 1.1 to 1.3]) and to have a history of chronic renal insufficiency (OR=3.2 [95% confidence interval 2.8 to 3.6]), or hypertension (OR 1.3 [95% confidence interval 1.2 to 1.5]). Hazard ratios for mortality, adjusting for covariates, were 1.34 (1.24 to 1.46) in anemic patients, and 1.36 (1.23 to 1.50) in those patients with anemia of chronic disease. In this large cohort of community-dwelling patients with CHF, anemia is common and an independent prognostic factor for mortality. Further research into the mechanisms of anemia in CHF and randomized controlled trials to test whether correction of anemia improves prognosis in CHF are needed.
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                Author and article information

                Journal
                Rev Bras Hematol Hemoter
                Rev Bras Hematol Hemoter
                Rev Bras Hematol Hemoter
                Revista Brasileira de Hematologia e Hemoterapia
                Associação Brasileira de Hematologia e Hemoterapia
                1516-8484
                1806-0870
                2013
                : 35
                : 2
                : 87-88
                Affiliations
                Faculdade de Ciências Médicas e da Saúde, Pontifícia Universidade Católica de São Paulo – PUC-SP, Sorocaba, SP, Brazil
                Author notes
                Corresponding author: Marcelo Gil Cliquet, Faculdade de Ciências Médicas e da Saúde, Pontifícia Universidade Católica de São Paulo - PUC-SP, Praça Dr. José Ermírio de Moraes, 290, 18030-095 Sorocaba, SP, Brazil, mmcliquet@ 123456uol.com.br
                Article
                10.5581/1516-8484.20130026
                3672115
                23741183
                1de5377c-a7d0-40aa-8f4e-817f159e739d

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 February 2013
                : 14 March 2013
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                Hematology
                Hematology

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