Prevalence and possible causes of anemia in the elderly: a cross-sectional analysis of a large European university hospital cohort

Causes of macrocytic anemia among 628 patients: mean corpuscular volumes of 114 and 130 fL as critical markers for categorization

There have been no studies on the distribution of causes of macrocytic anemia with respect to mean corpuscular volume (MCV) cutoff values. We retrospectively investigated the causes of macrocytic anemia (MCV ≥100 fL) among 628 patients who visited the outpatient hematology clinic in Tohoku University Hospital. To ensure data validity, we also analyzed data from 307 patients in eight other hospitals in the Tohoku district. The leading causes of macrocytic anemia (number of patients, %) were myelodysplastic syndromes (121, 19.3 %), suspected bone marrow failure syndromes (BMF; 74, 11.8 %), aplastic anemia (51, 8.1 %), plasma cell dyscrasia (45, 7.2 %), and vitamin B12 deficiency (40, 6.4 %) in Tohoku University Hospital. We made three primary findings as follows. First, the most common cause of macrocytic anemia is BMF. Second, lymphoid and solid malignancies are also common causes of macrocytosis. Third, macrocytic anemia may be classified into three groups: Group 1 (megaloblastic anemia and medications), which can exceed MCV 130 fL; Group 2 (alcoholism/liver disease, BMF, myeloid malignancy, and hemolytic anemia), which can exceed MCV 114 fL; and Group 3 (lymphoid malignancy, chronic renal failure, hypothyroidism, and solid tumors), which does not exceed MCV 114 fL. These conclusions were supported by the results from eight other hospitals.

Myelodysplastic Syndromes in the Elderly: Treatment Options and Personalized Management

Myelodysplastic syndromes (MDS) are typical diseases of the elderly, with a median age of 68-75 years at initial diagnosis. Demographic changes producing an increased proportion of elderly in our societies mean the incidence of MDS will rise dramatically. Considering the increasing number of treatment options, ranging from best supportive care to hematopoietic stem cell transplantation (HSCT), decision making is rather complex in this cohort of patients. Moreover, aspects of the aging process also have to be considered in therapy planning. Treatment of elderly MDS patients is dependent on the patient's individual risk and prognosis. Comorbidities play an essential role as predictors of survival and therapy tolerance. Age-adjusted models and the use of geriatric assessment scores are described as a basis for individualized treatment algorithms. Specific treatment recommendations for the different groups of patients are given. Currently available therapeutic agents, including supportive care, erythropoiesis-stimulating agents (ESAs), immune-modulating agents, hypomethylating agents, and HSCT are described in detail and discussed with a special focus on elderly MDS patients. The inclusion of elderly patients in clinical trials is of utmost importance to obtain data on efficacy and safety in this particular group of patients. Endpoints relevant for the elderly should be integrated, including maintenance of quality of life and functional activities as well as evaluation of use of healthcare resources.

[Iron deficiency anemia and anemia of chronic disorders]

Hypochromic-microcytic anemias are characterized by a hemoglobin deficiency of the erythrocytes. The main reason for the insufficient hemoglobin synthesis is, with exception of thalassemia and a few other rare conditions, primarily a disorder of iron metabolism. Differential diagnostic considerations are focused on iron deficiency anemia, with approximately 80% the most common form of anemia worldwide. Iron deficiency anemia shows a particularly high prevalence in developing countries, but is also in industrialized Western countries the most common cause of anemia. Infants, toddlers, premenopausal or pregnant women, and elderly people are at particularly high risk of iron deficiency anemia. The most important differential diagnosis for iron deficiency anemia is the anemia of chronic disorders (ACD). This anemia is caused by a disturbance of iron utilization (functional iron deficiency), in which iron absorption and iron release, as a nonspecific defense mechanism, is blocked to restrict iron availability for the inflammatory process but also withhold iron from the erythropoiesis. ACD is not rare, but plays a significant role in hospitalized patients and in the elderly. The differentiation between ACD and iron deficiency anemia is highly important from a clinical point of view, due to different types of further management. The cause for iron deficiency should be clarified in each case, whereas the etiology for ACD is often obvious. The standard treatment of iron deficiency anemia is oral iron supplementation. Intravenous iron application is reserved for problem patients. The best treatment for ACD is the elimination of the underlying chronic disorder. In case of persistent ACD, red blood cell transfusions, erythropoietin, and intravenous iron are used therapeutically.

Readmission and mortality one year after acute hospitalization in older patients with explained and unexplained anemia - a prospective observational cohort study

BACKGROUND

Few studies have examined whether specific subtypes of anemia in older persons are more related to adverse outcomes such as hospital readmissions and death after acute hospitalization and post-acute care.

METHODS

An observational prospective cohort study was conducted between 2011 and 2014. A total of 884 community-dwelling patients, ≥70 years of age were transferred from acute medical and orthopaedic hospital departments to a skilled nursing home where they were examined by comprehensive geriatric assessment and had laboratory tests taken for the investigation of anemia. They were divided into three major groups and compared; 1) no anemia (reference group), 2) explained anemia (renal insufficiency, iron deficiency, vitaminB12/folate deficiency or multifactorial anemia) and 3) unexplained anemia. The groups were compared, and association of anemia with hospital readmission and death was estimated by logistic regression analyses.

RESULTS

Compared to the patients with unexplained anemia (n=135), patients with explained anemia (n=275) had more often died (22 % vs. 14 %, p=0.05) and had more frequenlty been readmitted to hospital (39 % vs. 27 %, p=0.03). Compared to the patients without anemia (n=474), the patients with explained anemia had increased odds of hospital readmissions (OR = 1.54 (95 % CI: 1.05-2.25), p=0.03), while patients with unexplained anemia, (n=135), had neither increased odds of hospital readmissions, (OR=0.83, 95 % CI: 0.51-1.34, p=0.44) nor death (OR = 0.74, 95 % CI: 0.41-1.31, p=0.30), in adjusted regression analysis.

CONCLUSION

Since no increased risk of hospital readmissions or death was seen in older patients with unexplained anemia in the first year after acute hospitalization, no further invasive investigations might be necessary to investigate the cause of anemia in these patients. A close clinical follow up might be the best way to care for older patients with a mild and unexplained anemia.

Anemia in the frail, elderly patient

Anemia and frailty are two common findings in geriatric patients and have been shown to be associated with poor outcomes in this patient group. Recent studies have contributed to the growing evidence of a possible association with the age-related chronic inflammatory status known as “inflammaging”. These findings do not only give a better insight into the pathogenesis of anemia in frailty, but also offer new treatment options. The present article focuses on this assumed association between anemia, frailty, and inflammaging and summarizes current management options for anemia in frail patients.

Anemia in the Elderly: not Always what it Seems

Anemia in the elderly is a common but challenging clinical scenario. Here we describe the case of an older woman who presented with anemia and elevated inflammation markers. After a complete diagnostic work-up, a definite etiology of the anemia could not be found so eventually a bone marrow biopsy was performed and she was diagnosed with myelodysplastic syndrome. She responded well to erythropoietin treatment but her inflammation markers remained elevated thus a positron emission tomography was performed. It turned out that the patient suffered from giant cell artheritis and her anemia completely resolved after steroid treatment. Our case outlines that it is necessary to pay particular attention to anemia of inflammation, which could be due to several and often masked conditions. Myelodysplatic syndromes should be considered when other causes have been ruled out, but their diagnosis can be difficult and requires expertise in the field.

The European Hematology Association Roadmap for European Hematology Research: a consensus document

The European Hematology Association (EHA) Roadmap for European Hematology Research highlights major achievements in diagnosis and treatment of blood disorders and identifies the greatest unmet clinical and scientific needs in those areas to enable better funded, more focused European hematology research. Initiated by the EHA, around 300 experts contributed to the consensus document, which will help European policy makers, research funders, research organizations, researchers, and patient groups make better informed decisions on hematology research. It also aims to raise public awareness of the burden of blood disorders on European society, which purely in economic terms is estimated at €23 billion per year, a level of cost that is not matched in current European hematology research funding. In recent decades, hematology research has improved our fundamental understanding of the biology of blood disorders, and has improved diagnostics and treatments, sometimes in revolutionary ways. This progress highlights the potential of focused basic research programs such as this EHA Roadmap.The EHA Roadmap identifies nine 'sections' in hematology: normal hematopoiesis, malignant lymphoid and myeloid diseases, anemias and related diseases, platelet disorders, blood coagulation and hemostatic disorders, transfusion medicine, infections in hematology, and hematopoietic stem cell transplantation. These sections span 60 smaller groups of diseases or disorders.The EHA Roadmap identifies priorities and needs across the field of hematology, including those to develop targeted therapies based on genomic profiling and chemical biology, to eradicate minimal residual malignant disease, and to develop cellular immunotherapies, combination treatments, gene therapies, hematopoietic stem cell treatments, and treatments that are better tolerated by elderly patients.

Are plasma mineral levels related to antibody response to influenza vaccination in older adults?

INTRODUCTION

An effective immune response to vaccination may be related to nutritional status. This study examined the association of plasma mineral levels with hemagglutination inhibition (HI) titers produced in response to influenza vaccine in older adults.

METHODS

Prior to (Day 0) and 21 (range = 19-28) days after receiving the 2013-14 influenza vaccine, 109 adults ages 51-81 years, provided blood samples. Serum samples were tested for HI activity against the A/H1N1 and A/H3N2 2013-2014 vaccine virus strains. Plasma minerals were collected in zinc-free tubes and assayed by inductively coupled plasma mass spectrometry. HI titers were reported as seroprotection (≥1:40) and seroconversion (≥ 4-fold rise from Day 0 (minimum HI = 1:10) to Day 21). Both HI titers and mineral values were skewed and thus log2 transformed. Magnesium (Mg), phosphorus (P), zinc (Zn), copper (Cu), iron (Fe), potassium (K) and the Cu to Zn ratio were tested. Logistic regression analyses were used to determine the associations between mineral levels and seroconversion and seroprotection of HI titers for each influenza A strain.

RESULTS

Participants were 61% white, 28% male, 39% diabetic, and 81% overweight/obese with a mean age of 62.6 y. In logistic regression, Day 21 A/H1N1 seroprotection was associated with P and Zn at Day 21(P < 0.05). Seroconversion of A/H1N1 was associated with Day 21 Cu, P, and Mg (P < 0.03). Day 21 A/H3N2 seroprotection and seroconversion were associated with Day 21 P (P < 0.05).

CONCLUSIONS

Phosphorus was associated with seroprotection and seroconversion to influenza A after vaccination; these associations warrant additional studies with larger, more diverse population groups.

Increased prevalence and incidence of anemia among adults in transforming rural China: two cross-sectional surveys

Background

Anemia remains one of the serious nutrition-related diseases in China, but data on incidence of anemia were less available, especially in rural area which are experiencing rapid urbanization. Out study aimed to estimate both the prevalence and incidence of anemia in transforming rural China.

Methods

We conducted a combined study of rural adults 18–64 years of age with a repeated cross-sectional component (4456 in 2006 and 2184 in 2008) and a cohort component (1424) in rural Deqing, China. Anemia was diagnosed based on blood hemoglobin levels using the hemiglobincyanide (HiCN) method according to both the World Health Organization (WHO) and Chinese criteria. The prevalence and incidence of anemia and their 95 % confidential intervals (95 % CI) were calculated.

Results

The prevalence of anemia based on the WHO criteria was 51.5 % in 2006 and 53.7 % in 2008, and the 2-year cumulative incidence was 42.1 %. Of the cases, over 95 % had mild anemia. The prevalence was much lower when the Chinese criteria was used. Both the prevalence and incidence were higher in women than in men and significantly increased with age in men. In both sexes, the incidence sharply increased after 45 years of age.

Conclusion

Our study showed a high prevalence and incidence of anemia among adults in rural Deqing, China. Monitoring and intervention were needed urgently, especially among individuals over 45 years of age.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2671-8) contains supplementary material, which is available to authorized users.

Anemia in prospective blood donors deferred by the copper sulphate technique of hemoglobin estimation

Background

Patients who require transfusion as part of their clinical management have the right to expect sufficient blood to be available to meet their needs and to receive the safest blood possible. Donor deferrals (disqualification) lead to loss of precious blood donors and blood units available for transfusion purposes. It is believed that a large majority of donor deferrals are due to temporal and correctable causes such as anemia in developing countries. It is therefore important to determine anemia among donor population to inform decision-making on the type of measures to be taken to reduce deferrals due to anemia. The aim of the study was to determine anemia in prospective blood donors deferred by the copper sulphate technique of hemoglobin estimation. This, to provide information that would help plan a future strategy for donor recruitment and management.

Methods

Three (3) ml of venous blood samples were collected from the study subjects into EDTA anticoagulant tubes. The hemoglobin levels and red cell indices were measured using Sysmex hematology analyser. A thin blood film was prepared and stained using Leishman stain and then observed under the light microscope.

Results

The prevalence of anemia among the total deferred patients (538) was 17.1 %. Four different types of anemia were found among the subjects. These were normocytic normochromic (46.74 %), microcytic hypochromic (42.39 %) normocytic hypochromic (8.70 %), and microcytic normochromic anemia (2.17 %).

Conclusion

The study showed that a significant number of the prospective blood donors deferred for having low hemoglobin by the copper sulphate method turned out to have anemia by the standard method of diagnosis. Prevalence of anemia among apparently healthy blood donors was therefore higher than expected. Measures must therefore be taken to address this in order not to lose potential blood donors due to a correctable and preventable cause such as anemia.