Treatment options for anemia in the elderly

Anemia in patients receiving anticancer treatments: focus on novel therapeutic approaches

Anemia is common in cancer patients and impacts on quality of life and prognosis. It is typically multifactorial, often involving different pathophysiological mechanisms, making treatment a difficult task. In patients undergoing active anticancer treatments like chemotherapy, decreased red blood cell (RBC) production due to myelosuppression generally predominates, but absolute or functional iron deficiency frequently coexists. Current treatments for chemotherapy-related anemia include blood transfusions, erythropoiesis-stimulating agents, and iron supplementation. Each option has limitations, and there is an urgent need for novel approaches. After decades of relative immobilism, several promising anti-anemic drugs are now entering the clinical scenario. Emerging novel classes of anti-anemic drugs recently introduced or in development for other types of anemia include activin receptor ligand traps, hypoxia-inducible factor-prolyl hydroxylase inhibitors, and hepcidin antagonists. Here, we discuss their possible role in the treatment of anemia observed in patients receiving anticancer therapies.

Anemia in Elderly Patients-The Impact of Hemoglobin Cut-Off Levels on Geriatric Domains

Background: The primary aim of this study was to evaluate the impact of anemia—according to the WHO criteria—on cognitive performances, mood, functional and nutritional status, and comorbidities in a population of subjects aged 65 years or older. The secondary aim of this study was to understand if different hemoglobin cut-off levels are associated with a variation of the mentioned domains’ impairment. Methods: We designed a cross-sectional study, including subjects aged 65 or more consecutively evaluated in an outpatient setting from July 2013 to December 2019. A sum of 1698 subjects met the inclusion criteria. They were evaluated with: MMSE and CDT (cognitive assessment), GDS (mood), BADL, IADL, PPT, and POMA (autonomies), MNA (nutritional status), and CIRS (comorbidities). Results: According to the WHO criteria, non-anemic patients reported significantly better performances than the anemics in BADL (p < 0.0001), IADL (p = 0.0007), PPT (p = 0.0278), POMA (p = 0.0235), MNA, CIRS TOT, CIRS ICC, and CIRS ISC (p < 0.0001). The same tendency has been found by considering the 12 g/dL- and the 13 g/dL-cut-off level in the whole population. The multivariate analysis showed that, considering the 12 g/dL-cut-off level, age (OR: 1.03, p = 0.0072), CIRS (OR: 1.08, p < 0.0001), and gender (OR: 0.57, p = 0.0007) were significant regressors of anemia, while considering the 13 g/dL-cut-off level, age (OR: 1.04, p = 0.0001), POMA (OR: 1.03, p = 0.0172), MNA (OR = 0.95, p = 0.0036), CIRS (OR: 1.17, p < 0.0001), ICC (OR = 0.83, p = 0.018), and gender (OR = 0.48, p < 0.0001) were significant regressors of anemia, while the other CGA variables were excluded by the model (p > 0.01). Conclusions: Our study showed that anemia negatively impact on geriatric people’s general status, regardless of which hemoglobin cut-off level is considered. It also highlighted that hemoglobin concentrations < 13 g/dL, regardless of gender, have an association with the impairment of the affective-functional-nutritional state as well as an increase in comorbidities; therefore, it should be pursuable to consider the elderly person “anemic” if Hb < 13 g/dL regardless of gender.

The impact of intravenous iron supplementation in elderly patients undergoing major surgery

BACKGROUND

Age and preoperative anaemia are risk factors for poor surgical outcome and blood transfusion. The aim of this study was to examine the effect of iron supplementation in iron-deficient (ID) elderly patients undergoing major surgery.

METHOD

In this single-centre observational study, patients ≥ 65 years undergoing major surgery were screened for anaemia and ID. Patients were assigned to the following groups: A^- (no anaemia); A^-,ID⁺,T⁺ (no anaemia, iron-deficient, intravenous iron supplementation); A⁺ (anaemia); and A⁺,ID⁺,T⁺ (anaemia, iron-deficient, intravenous iron supplementation).

RESULTS

Of 4,381 patients screened at the anaemia walk-in clinic, 2,381 (54%) patients were ≥ 65 years old and 2,191 cases were included in analysis. The ID prevalence was 63% in patients with haemoglobin (Hb) < 8 g/dl, 47.2% in patients with Hb from 8.0 to 8.9 g/dl, and 44.3% in patients with Hb from 9 to 9.9 g/dl. In severely anaemic patients, an Hb increase of 0.6 (0.4; 1.2) and 1.2 (0.7; 1.6) g/dl was detected with iron supplementation 6-10 and > 10 days before surgery, respectively. Hb increased by 0 (-0.1; 0) g/dl with iron supplementation 1-5 days before surgery, 0.2 (-0.1; 0.5) g/dl with iron supplementation 6-10 days before surgery, and 0.2 (-0.2; 1.1) g/dl with supplementation > 10 days before surgery (p < 0.001 for 1-5 vs. 6-10 days). Overall, 58% of A⁺,ID⁺,T⁺ patients showed an Hb increase of > 0.5 g/dl. The number of transfused red blood cell units was significantly lower in patients supplemented with iron (0 (0; 3)) compared to non-treated anaemic patients (1 (0; 4)) (p = 0.03). Patients with iron supplementation > 6 days before surgery achieved mobility 2 days earlier than patients with iron supplementation < 6 days.

CONCLUSIONS

Intravenous iron supplementation increases Hb level and thereby reduces blood transfusion rate in elderly surgical patients with ID anaemia.

Unexplained anemia of aging: Etiology, health consequences, and diagnostic criteria

BACKGROUND

Up to 15% of people aged 60 and over are anemic, and the prevalence of anemia increases with age. In older men and women, anemia is associated with increases in the risk of death and all-cause hospitalization, poor functional capacity, quality of life, and depression.

METHODS AND RESULTS

We reviewed the literature describing anemia in aging populations, focusing on the specific diagnostic criteria of anemia and potential causes in older men and women. Even after extensive etiologic workup that involves careful medical history, physical examination, laboratory measurements, and additional studies such as bone marrow biopsy, anemia of aging is unexplained in up to 40% of older patients with anemia. As a result, treatment options remain limited.

CONCLUSIONS

The prevalence of unexplained anemia of aging (UAA; also called unexplained anemia of the elderly, UAE), its deleterious impacts on health, physical function, and quality of life, and the lack of effective treatment or therapy guidelines represent a compelling unmet clinical need. In this review and consensus document, we discuss the scope of the problem, possible causes of UAA, diagnostic criteria, and potential treatment options. Because even mild anemia is strongly linked to poor clinical outcomes, it should receive clinical attention rather than simply being considered a normal part of aging.

Anemia in older adults as a geriatric syndrome: A review

Anemia, a frequently occurring condition in older patients, has no standard definition; however, in most studies, it is defined as hemoglobin level <12 and <13 g/dL in women and men, respectively. Approximately 10% of older adults living in the community have anemia. The prevalence of anemia is significantly correlated with advanced age and male sex. Anemia is associated with falls, frailty and other negative outcomes, including early mortality. However, there remains little consensus regarding whether anemia treatment favorably affects these adverse outcomes. Therefore, this article reviews the prevalence of anemia, and provides updates on its common causes and treatments in older adults. While excluding well-established hematopoietic diseases, the etiology of anemia in older adults has been grouped into four categories: (i) nutritional deficiency; (ii) inflammation; (iii) clonal hematopoiesis; and (iv) "unexplained anemia," when there is no clear mechanism to account for the anemia. Recently, clonal leukocytes were detected in a considerable number of older individuals. The number of somatic mutations in blood leukocytes increases with age; however, single mutations of DNMT3A, TET2 and ASXL1 are not correlated with the presence of unexplained anemia in older adults. With an increased understanding of anemia etiology and the availability of innovative anti-anemic drugs, future studies that evaluate the causes and benefits of treatment are required. Geriatr Gerontol Int 2021; 21: 549-554.