Anemia and its impact on function in nursing home residents: what do we know?

Anemia in nursing homes, proton pump inhibitors and prescribing cascade of antianemic drugs

PURPOSE

Some medications can cause anemia through their effect on gastrointestinal function, such as proton pump inhibitors and H2-antagonists, and on the risk of bleeding, such as anticoagulants and antiplatelet agents. The main aim of this study is to evaluate how anemia is related with the most commonly used drugs in a large sample of NH residents.

METHODS

This retrospective cross-sectional multicenter study was conducted in a sample of Italian long-term care NHs distributed throughout the country.

RESULTS

In all, 2602 NH residents recruited from 27 Italian long-term NHs (mean age ± SD: 88.4 ± 8.5) and 441 (16.9%) had a diagnosis of anemia. The unadjusted model showed a significant relation with PPI (OR 1.71, 95% CI 1.39-2.11, p < 0.0001). This relation was maintained in the model adjusted for age, sex, CKD, atrophic gastritis, peptic ulcer and rheumatic disease (OR 1.61, 95% CI 1.31-1.99, p < 0.0001). PPI users were also at higher risk of being treated with antianemic drugs-iron supplements, folate, vitamin B12 and erythropoietin (OR 2.03, 95% CI 1.67-2.48, p < 0.0001)-even if they did not have anemia (OR 1.94, 95% CI 1.55-2.42, p < 0.0001).

CONCLUSION

Proton pump inhibitors are associated with anemia in NH residents. PPIs are also related with an increased probability of receiving drugs to treat anemia, such as iron supplements, folate or cyanocobalamin and erythropoietin, as the effect of a prescribing cascade. Optimization of PPI prescription is needed to avoid adverse events and promote rational drug prescription.

Hematopoiesis, Inflammation and Aging-The Biological Background and Clinical Impact of Anemia and Increased C-Reactive Protein Levels on Elderly Individuals

Anemia and systemic signs of inflammation are common in elderly individuals and are associated with decreased survival. The common biological context for these two states is then the hallmarks of aging, i.e., genomic instability, telomere shortening, epigenetic alterations, loss of proteostasis, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion and altered intercellular communication. Such aging-associated alterations of hematopoietic stem cells are probably caused by complex mechanisms and depend on both the aging of hematopoietic (stem) cells and on the supporting stromal cells. The function of inflammatory or immunocompetent cells is also altered by aging. The intracellular signaling initiated by soluble proinflammatory mediators (e.g., IL1, IL6 and TNFα) is altered during aging and contributes to the development of both the inhibition of erythropoiesis with anemia as well as to the development of the acute-phase reaction as a systemic sign of inflammation with increased CRP levels. Both anemia and increased CRP levels are associated with decreased overall survival and increased cardiovascular mortality. The handling of elderly patients with inflammation and/or anemia should in our opinion be individualized; all of them should have a limited evaluation with regard to the cause of the abnormalities, but the extent of additional and especially invasive diagnostic evaluation should be based on an overall clinical evaluation and the possible therapeutic consequences.

Transfusion at the border of the "intention-to-treat", in the very aged person and in palliative care: A debate

In both palliative care and in the very aged person i.e. at the end of life, transfusion aims at bringing supportive care; it has indeed no intention to treat. It can occasionally be compassionate as to bring oxygen to a patient or a resident in nursing home wishing to enjoy some exercise or entertainment. Transfusion in this condition is not consensual, for reasons that are medical and/or societal. The present essay aims at discussing the main options to provide transfusion in such extreme, though non-exceptional, conditions.

Multiple Micronutrients, Including Zinc, Selenium and Iron, Are Positively Associated with Anemia in New Zealand Aged Care Residents

Anemia is a significant comorbidity for older adults not fully attributable to iron deficiency. Low-grade inflammation and other micronutrient deficiencies also contribute. This cross-sectional study examined the relationships between nutrient and non-nutrient factors with hemoglobin and anemia in 285 residents (>65 years) of 16 New Zealand aged-care facilities. Blood samples were analyzed for hemoglobin, ferritin, sTfR, hepcidin, zinc, selenium, and interleukin-6 (IL-6), (with ferritin, sTfR, zinc and selenium adjusted for inflammation). Linear regression models examined the relationships between micronutrient biomarkers (iron, zinc, selenium, vitamin B-12 and D), age, sex, and health factors with hemoglobin. Thirty-two percent of participants exhibited anemia, although <2% had either depleted iron stores or iron deficiency. Plasma zinc and selenium deficiencies were present in 72% and 38% of participants, respectively. Plasma zinc and total body iron (TBI) were positively associated (p < 0.05) with hemoglobin, while gastric acid suppressing medications, hepcidin, and interleukin-6 were inversely associated. These relationships were maintained after the application of anemia cut-offs. These findings emphasize the importance of considering multiple micronutrient deficiencies as risk factors for anemia.

The impact of treatment for iron deficiency and iron deficiency anemia on nutritional status, physical performance, and cognitive function in geriatric patients

OBJECTIVE

Iron deficiency in older people is common and affects physical and cognitive performance. The effects of iron deficiency on nutrition and cognitive status are well established. However, there are few studies demonstrating the impact of iron deficiency treatment on functional and cognitive outcomes in the geriatric population. The aim of this study was to determine whether iron replacement treatment was associated with an improvement in the nutritional, cognitive, and functional status of older patients with iron deficiency (ID) and iron deficiency anemia (IDA).

METHODS

Geriatric patients with iron deficiency and iron deficiency anemia presenting to the geriatric clinic were included in the study. Comprehensive geriatric assessment (CGA) and blood samples to investigate iron deficiency were performed at baseline and 6 month later. 81 patients were included in the study and were evaluated at follow-up in the 6th month. The CGA included the following tests: the Katz Index of Independence in Activities of Daily Living Scale (Katz ADL), the Lawton-Brody Instrumental Activities of Daily Living Scale (IADL), the Mini-Mental State Examination (MMSE), and the Mini Nutritional Assessment Short-Form (MNA-SF), as well as the assessments of hand grip strength and walking speed.

RESULTS

Of the 81 participating patients, 69.1% were women and 30.9% were men. The mean age was 76.8 ± 7.28 years. Follow-up after iron supplementation treatment was performed with a mean of 6.23 ± 1.58 months. Improvements occurred in the following geriatric and laboratory assessments: Lawton-Brody (IADL), MNA-SF, MMSE, hand grip strength, and walking speed evaluations and the levels of hemoglobin, iron, total iron-binding capacity, transferrin saturation, and ferritin.

CONCLUSIONS

It was shown that iron replacement treatment has a positive impact on functional and cognitive status and nutritional parameters in older patients with ID and IDA.

[Gender aspects of malnutrition and associated sequelae. Prevention and therapy]

Malnutrition is related to a range of secondary complications. The prevalence of many of these sequelae is higher in elderly women than in men, thus resulting in a higher level of impairment and reduced quality of life. Multiple factors lead to the development of malnutrition and socioeconomic causes, such as poverty among the elderly and isolation, are more common in elderly women. The age-associated loss of muscle mass is more pronounced in women than in men and the risk of developing sarcopenia and frailty is increased. The prevalence of sarcopenic obesity is higher in women than in men. Malnutrition increases the risk of osteoporosis and about 80 % of all osteoporosis patients are women. Furthermore, low serum levels of vitamin D correlate more closely to a poorer cognitive outcome in elderly women than they do in men. The prevention, early diagnosis and therapy of malnutrition is of great clinical importance, particularly to preserve physical functional capacity and thus quality of life in elderly women.