In what extent anemia coexists with cognitive impairment in elderly: a cross-sectional study in Greece

Postoperative Hemodynamics of Total Knee Arthroplasty Unaffected by Cementless Approach under Contemporary Patient Blood Management Protocol: A Propensity Score-Matched Study

(1) Background: A cementless total knee arthroplasty (TKA) is a recent and an increasingly popular innovation that enhances porous fixation surfaces. However, the lack of cemented sealing of an exposed resected bone has raised concerns about the potential for greater blood loss. The goals of this study were to determine if a cementless approach impacts post-TKA hemodynamics and to identify risk factors for blood loss in instances of cementless (vs. cemented) TKAs under a contemporary patient blood management (PBM) protocol. (2) Methods: We recruited 153 consecutive patients undergoing unilateral TKAs between 2019 and 2023. All enrollees received cementless or cemented prostheses of the same design (cementless, 87; cemented, 66). After propensity score matching for demographics, there were 46 patients in each group. We then compared blood loss metrics (total [TBL] and estimated [EBL]), drainage volumes, hemoglobin (Hb) levels, and transfusion rates by group. (3) Results: Post-TKA hemodynamics (i.e., TBL, EBL, drainage, Hb level, and transfusion rate) of cementless (n = 46) and cemented (n = 46) TKA groups did not differ significantly. In addition, the proportions of patients with Hb drops > 3.0 g/dL were similar for the two groups. A logistic regression analysis revealed that only preoperative Hb and EBL during the early postoperative period were predictive of a substantial fall in Hb levels. The fixation method was not associated with Hb decline > 3.0 g/dL by postoperative Day 3. (4) Conclusion: The cementless TKA has no impact on customary post-TKA hemodynamics and is not associated with greater TKA-related blood loss when implementing a contemporary PBM protocol.

Intravenous Ferric Carboxymaltose Improves Response to Postoperative Anemia Following Total Knee Arthroplasty: A Prospective Randomized Controlled Trial in Asian Cohort

Background: Ferric carboxymaltose (FCM) is an intravenous (IV) high-dose iron that is effective in the treatment of iron deficiency anemia. This study was performed to determine whether postoperative FCM infusion is effective at improving hemoglobin (Hb) responders, Hb and iron profiles, and the patient’s quality of life (QOL). Methods: A total of 110 patients with postoperative anemia, defined by a Hb < 10 g/dL within 3 days of unilateral primary TKA, between June 2018 and February 2020 were randomized into either the FCM or Control group. On postoperative day 3, the FCM group (55 patients) received IV FCM while the Control group (55 patients) did not. The Hb responders (Hb increase ≥ 2 g/dL compared to baseline), Hb level, iron profiles (ferritin, total iron-binding capacity (TIBC), transferrin saturation (TSAT)), and EQ-5D scores were compared at weeks 2, 4, and 8. Results: The FCM group demonstrated a significantly greater number of Hb responders (p < 0.001) and a higher Hb level (p = 0.008) at 2 weeks postoperative than did the Control group. The FCM group recovered its preoperative Hb level between 4 and 8 weeks. In contrast, the Control group did not recover its preoperative level until 8 weeks. The FCM infusion group also had higher serum ferritin, iron and TSAT, and lower TIBC levels than those of the Control group between 2 and 8 weeks (all p < 0.001). However, there was no significant difference in the postoperative transfusion rate (p = 0.741) or EQ-5D score between the two groups (all p > 0.05). Discussion: In postoperative anemia following TKA, IV FCM increases the Hb response and improves Hb and iron metabolism variables, however, it does not affect the transfusion rate or QOL.

Association between platelet, white blood cell count, platelet to white blood cell ratio and sarcopenia in community-dwelling older adults: focus on Bushehr Elderly Health (BEH) program

BACKGROUND

Sarcopenia is a progressive age-related skeletal muscle disorder associated with harmful impacts on health. The present study aimed to investigate the relation between sarcopenia, platelet (PLT), white blood cell (WBC), and PLT to WBC ratio (PWR) due to the importance of early sarcopenia diagnosis.

METHODS

This cross-sectional study was conducted based on the second stage of the Bushehr Elderly Health (BEH) Program. Sarcopenia was defined based on the revised edition of the European Working Group on Sarcopenia in Older People (EWGSOP2) in accordance with the Iranian cut-off point. Univariate and adjusted multivariate logistic regression and linear regression were used to evaluate the associations.

RESULTS

The prevalence of sarcopenia among participants was 35.73%. PLT count and PWR were statistically higher in severe sarcopenic participants, while no differences were seen in WBC. In crude analysis, sarcopenia was not associated with quartiles of PLT, WBC, and PWR, while after adjusting for age, marital status, and sex, the association was seen in the fourth quartile of PLT and PWR [OR (95%CI) = 1.40 (1.08 to 1.81), p-value = 0.009 for PLT; OR (95%CI) =1.55 (1.20 to 2.00), p-value =0.001 for PWR]. This association remained significant in the fully adjusted model [OR (95%CI) =1.82 (1.20 to 2.78), p-value =0.005 for PLT; OR (95%CI) =1.57 (1.03 to 2.40), p-value =0.035 for PWR]. Among sarcopenia parameters, PLT count was more likely to be associated with handgrip strength and muscle mass. After stratifying the participants by gender, sarcopenia parameters were no longer statistically significant in men.

CONCLUSION

This study showed that PLT and PWR were associated with sarcopenia after considering confounding factors, while this association was not seen in WBC. Moreover, results showed that gender had an important impact on sarcopenia parameters.

Haemoglobin Concentration and Cognitive Ability in the Aberdeen Children of the 1950s

Introduction

Haemoglobin concentrations decrease with age. Abnormally low and high haemoglobin concentrations are associated with reduced cognition; however, the evidence for these associations in cohort data is limited. This study aims to assess the relationship between haemoglobin concentration and cognition in a well-characterised cohort of older adults.

Methods

Two hundred and fifty-two healthy participants were drawn from the Aberdeen Children of the 1950s cohort, aged between 59 to 65 years. Participants underwent cognitive tests of processing speed, memory, verbal and nonverbal reasoning, and language ability and these were used to construct a global cognitive score, g, using principal component analysis. Haemoglobin concentration in the blood was measured concurrently. Hierarchical multiple regression models were constructed assessing the relationship between haemoglobin concentration and each cognitive measure and these were corrected for age, sex, education, C-reactive protein, hypertension, and body mass index.

Results

Significant linear association between haemoglobin concentration and nonverbal reasoning demonstrated that low haemoglobin levels are associated with lower scores. A quadratic relationship was found for haemoglobin concentration and immediate memory scores in which low and high haemoglobin levels were associated with lower scores.

Conclusions

Haemoglobin concentration was found to have a significant linear association with nonverbal reasoning scores and a significant quadratic association with memory scores. The results from this study help to understand the association between haemoglobin and different aspects of cognition.

Anemia and the Risk of Cognitive Impairment: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Cognitive impairment is one of the most common, burdensome, and costly disorders in the elderly worldwide. The magnitude of the association between anemia and overall cognitive impairment (OCI) has not been established.

OBJECTIVE

We aimed to update and expand previous evidence of the association between anemia and the risk of OCI.

METHODS

We conducted an updated systematic review and meta-analysis. We searched electronic databases, including EMBASE, PubMed, and Web of Science for published observational studies and clinical trials between 1 January 1990 and 1 June 2020. We excluded articles that were in the form of a review, letter to editors, short reports, and studies with less than 50 participants. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. We estimated summary risk ratios (RRs) with random effects.

RESULTS

A total of 20 studies, involving 6558 OCI patients were included. Anemia was significantly associated with an increased risk of OCI (adjusted RR (aRR) 1.39 (95% CI, 1.25-1.55; p < 0.001)). In subgroup analysis, anemia was also associated with an increased risk of all-cause dementia (adjusted RR (aRR), 1.39 (95% CI, 1.23-1.56; p < 0.001)), Alzheimer's disease [aRR, 1.59 (95% CI, 1.18-2.13; p = 0.002)], and mild cognitive impairment (aRR, 1.36 (95% CI, 1.04-1.78; p = 0.02)).

CONCLUSION

This updated meta-analysis shows that patients with anemia appear to have a nearly 1.39-fold risk of developing OCI than those without anemia. The magnitude of this risk underscores the importance of improving anemia patients' health outcomes, particularly in elderly patients.

Impact of Combined Photo-Biomodulation and Aerobic Exercise on Cognitive Function and Quality-of-Life in Elderly Alzheimer Patients with Anemia: A Randomized Clinical Trial

Purpose

Few data are available on the positive impact of photo-biomodulation (PBM) using low-level laser therapy as a complementary treatment for improving the cognitive function and optimizing the hemoglobin (Hb) level and oxygen carrying capacity in anemic elderly patients and consequently improving the quality-of-life. The present study aimed to evaluate a new, safe, and easy therapeutic approach to improve Alzheimer’s disease-related symptoms that interfere with the whole life activities and social interaction of elderly patients.

Patients and Methods

In this placebo-controlled clinical trial, 60 elderly patients suffering from anemia and mild cognitive dysfunction were randomly assigned into two equal groups to receive active or placebo low-level laser in addition to a moderate-intensity aerobic exercise over a 12-week period. Hb level as well as cognitive and functional tests were reassessed for any change after 12 weeks of intervention.

Results

By the end of this study, both groups showed significant improvements in Hb level, Montreal Cognitive Assessment Scale (MoCa – B basic), Quality-of-Life for Alzheimer’s Disease scale, and Berg Balance scale scores along with significant reduction in body mass index (BMI) and waist–hip ratio (WHR) (P<0.0001). The experimental group which received active low-level laser in addition to moderate-intensity aerobic exercise showed more significant results compared to the control group which received placebo low-level laser in addition to moderate-intensity aerobic exercise in all the measured outcomes (P<0.001).

Conclusion

Combined low-level laser therapy and moderate-intensity aerobic exercises are more effective in improving the cognitive function and quality-of-life of Alzheimer’s disease patients.

Clinical Trial Registration

www.ClinicalTrials.gov, identifier NCT04496778.

Anemia in Association with Cognitive Impairment: A Systematic Review and Meta-Analysis

BACKGROUND

Prevalence of both anemia and cognitive impairment tends to increase with age. Individual studies have recently shown that anemia could be associated with cognitive impairment.

OBJECTIVE

To investigate the association between anemia and cognitive impairment including dementia.

METHODS

Two of the authors systematically searched PubMed, EMBASE, and the Cochrane library to retrieve observational studies reporting a relationship between anemia and cognitive impairment from 1964 to July 10, 2019. Case-control and cohort studies were included, and odds ratios (ORs) or relative risks (RRs) with 95% confidence intervals (CIs) for the risk of cognitive impairment were calculated using a random-effects model.

RESULTS

In total, 16 observational studies including eight case-control studies and eight cohort studies were included in the final analysis. Anemia was significantly linked to cognitive impairment (OR or RR 1.51; 95% CI: 1.32-1.73) in a random-effects meta-analysis, albeit with medium heterogeneity (I2 = 47.8%). Meta-estimates of dementia from prospective population-based cohort studies were similar (RR 1.46; 95% CI: 1.22-1.76) without substantial heterogeneity (I2 = 23.2%).

CONCLUSION

Our meta-analysis indicates that anemia is associated with cognitive impairment. Further prospective research is warranted to determine the cause-effect relationship of anemia with cognitive impairment and whether treatment of anemia might reduce the risk of dementia.

Does anemia affects cognitive functions in neurologically intact adult patients: Two year cross sectional study at rural tertiary care hospital

Background:

The anemia not only negatively affects physical function but also the cognition, mood, and quality of life in adult patients due to hypoxic condition as per its severity. This study has been planned to investigate the cross-section association of anemia with cognitive function in neurologically intact patients.

Methods:

In this study, a total 200 subjects were enrolled out of which 100 were cases and 100 age and sex matched controls. Mini-mental status examination (MMSE) and short portable mental status questionnaire (SPMSQ) scales were used to assess cognition in all the subjects.

Results:

This study showed that there was a significant correlation between the anemia and the cognitive skills in the neurologically intact patients.

Conclusion:

The cognitive functions were strongly related to hemoglobin levels as seen by low MMSE score and higher SPMSQ error in those with low hemoglobin levels compared with those with higher hemoglobin levels.

Prevalence, Comorbidity and Investigation of Anemia in the Primary Care Office

Background

Anemia has a myriad of causes and its prevalence is growing. Anemia is associated with increased all-cause hospitalization and mortality in community-dwelling individuals above age 65 years. Our aim was to determine the prevalence and severity of anemia in adult patients in our primary care office and to determine the relationship between anemia and medical comorbidities.

Methods

Electronic medical records of 499 adult patients in our suburban internal medicine office were reviewed who had had at least one hemoglobin value and did not undergo moderate to high-risk surgery in the preceding 30 days.

Results

About one-fifth (21.1%) of the patients had anemia. The mean age of patients with anemia was 62.6 years. Among all patients with anemia, 20.3% were males and 79.6% were females. Of these patients, 60.1% had mild anemia (hemoglobin 11 - 12.9 g/dL) and 39.8% had moderate anemia (hemoglobin 8 - 10.9 g/dL). For every year of increase in age, there was 1.8% increased odds of having anemia. African-American race had 5.2 times greater odds of having anemia than the Caucasian race. Hispanic race had 3.2 times greater odds of having anemia compared to the Caucasian race. Patients with anemia had a greater average number of comorbidities compared to patients without anemia (1.74 and 0.96, respectively; P < 0.05). There was a statistically greater percentage of patients with essential hypertension, hypothyroidism, chronic kidney disease, malignancy, rheumatologic disease, congestive heart failure, and coronary artery disease in the anemic population as compared to the non-anemic population. Of the patients, 41% with mild anemia and 62% with moderate anemia underwent additional diagnostic studies. Of the patients, 14.8% had resolution of anemia without therapy in 1 year, 15.7% were on iron replacement therapy, and 6.5% were on cobalamin therapy. No specific etiology of anemia was found in 24% of patients.

Conclusion

A higher prevalence of anemia was associated with advancing age, African-American and Hispanic ethnicity, and comorbidities, such as essential hypertension, hypothyroidism, chronic kidney disease, malignancy, rheumatologic disease, congestive heart failure, and coronary artery disease. It is important to be aware of the demographic factors and their relationship to anemia in primary care.

Associations Between Neurocognitive Impairment and Biomarkers of Poor Physiologic Reserve in a Clinic-Based Sample of Older Adults Living with HIV

Data from a cross-sectional study of a clinic-based sample of older people living with HIV (PLWH; n = 100) were used to examine associations between biomarkers of physical health and neurocognitive impairment (NCI). In this sample, anemia, chronic kidney disease (CKD) stages 4-5, and hypocalcemia were associated with impairment in executive functioning or processing speed. Furthermore, participants with anemia were more likely to have CD4+ T cell counts <200 cells/mm³ (χ² [1] = 19.57, p < .001); hypocalcemia (χ² [1] = 17.55, p < .001); and CKD 4-5 (χ² [2] = 10.12, p = .006). Black and Hispanic participants were more likely to be anemic compared to other races and ethnicities (χ² [3] = 12.76, p = .005). Common medical conditions (e.g., anemia, hypocalcemia, CKD) should be investigated as potential contributors to NCI in older PLWH. Additionally, laboratory testing in racial/ethnic minority PLWH may help inform NCI screening.

Iron biology, immunology, aging, and obesity: four fields connected by the small peptide hormone hepcidin

Iron status and immune response become impaired in situations that involve chronic inflammation, such as obesity or aging. Little is known, however, about the additional burden that obesity may place on the iron status and immune response in the elderly. This question is relevant given the rising numbers of elderly obese (BMI >30 kg/m(2)) individuals and the high prevalence of iron deficiency worldwide. Iron is necessary for proper function of both the innate and adaptive immune system. Hepcidin, a peptide hormone that regulates cellular iron export, is essential for the maintenance of iron homeostasis. Therefore, since immune cells require iron for proper function hepcidin may also play an important role in immune response. In this review, we summarize the evidence for hepcidin as a link between the fields of gerontology, obesity, iron biology, and immunology. We also identify several gaps in knowledge and unanswered questions pertaining to iron homeostasis and immunity in obese populations. Finally, we review studies that have shown the impact of weight loss, focusing on calorie restriction, iron homeostasis, and immunity. These studies are important both in elucidating mechanistic links between obesity and health impairments and identifying possible approaches to target immune impairment and iron deficiency as comorbidities of obesity.

Serum folate and B12 levels in association with cognitive impairment among seniors: results from the VELESTINO study in Greece and meta-analysis

OBJECTIVE

To summarize existing evidence on the effect of serum folate and vitamin B12 levels on cognitive impairment among elders via a meta-analysis, also including unpublished data from a cross-sectional study of seniors ( > 65 years) residing in Velestino, Greece.

METHOD

Serum measurements and Mini-Mental State Examination (MMSE) assessments were available for 593 Velestinians. In addition, 12 studies availing data on folate blood levels (N = 9,747) and 9 on B12 (N = 8,122) were identified following a search algorithm; pooled effect estimates were derived.

RESULTS

Cognitive impairment (MMSE < 24) among Velestenians was associated with lower education level in both genders; decreased social activity, depressive symptoms and low folate levels in males; older age in females. Meta-analyses showed an adverse effect of low-folate levels on cognition (OR: 1.66, 95% CI: 1.40-1.96); B12 was nonsignificantly associated (OR: 1.11, 95% CI: 0.88-1.40).

DISCUSSION

Low folate levels are associated with cognitive impairment of seniors; underlying pathophysiological mechanisms should be further explored.

Association of vitamin D deficiency and anemia in a hospitalized geriatric population: denutrition as a confounding factor

This study aimed to investigate the association between vitamin D deficiency and anemia in a hospitalized geriatric population. An observational study, at the acute care geriatric unit of Brest Hospital, France, was conducted among 226 patients aged ≥70 years consecutively hospitalized between January 22, 2010 and August 9, 2010. Vitamin D and hemoglobin levels were measured. Vitamin D deficiency was defined as a 25(OH)D level <50 nmol/L and anemia as defined by the World Health Organization. After adjustment for albuminemia, anemia was not significantly associated with vitamin D deficiency (odds ratio (OR) = 1.37; 95 % confidence interval (CI) = 0.72-2.6). But anemia was significantly associated with hypoalbuminemia (OR = 2.08; 95 % CI = 1.11-3.91). Denutrition reflected by hypoalbuminemia could be a possible confounding factor in the previously described association between anemia and vitamin D deficiency.

Reporting new cases of anaemia in primary care settings in Crete, Greece: a rural practice study

BACKGROUND

Early diagnosis of anaemia represents an important task within primary care settings. This study reports on the frequency of new cases of anaemia among patients attending rural primary care settings in Crete (Greece) and to offer an estimate of iron deficiency anaemia (IDA) frequency in this study group.

METHODS

All patients attending the rural primary health care units of twelve general practitioners (GPs) on the island of Crete for ten consecutive working days were eligible to participate in this study. Hemoglobin (Hb) levels were measured by portable analyzers. Laboratory tests to confirm new cases of anaemia were performed at the University General Hospital of Heraklion.

RESULTS

One hundred and thirteen out of 541 recruited patients had a low value of Hb according to the initial measurement obtained by the use of the portable analyzer. Forty five (45.5%) of the 99 subjects who underwent laboratory testing had confirmed anaemia. The mean value of the Hb levels in the group with confirmed anaemia, as detected by the portable analyzer was 11.1 g/dl (95% Confidence Interval (CI) from 10.9 to 11.4) and the respective mean value of the Hb levels obtained from the full blood count was 11.4 g/dl (95% CI from 11.2 to 11.7) (P = 0.01). Sixteen out of those 45 patients with anaemia (35.6%) had IDA, with ferritin levels lower than 30 ng/ml.

CONCLUSION

Keeping in mind that this paper does not deal with specificity or sensitivity figures, it is suggested that in rural and remote settings anaemia is still invisible and point of care testing may have a place to identify it.

Iron deficiency can cause cognitive impairment in geriatric patients

OBJECTIVES

Deficiency of iron, which plays an important role in oxygen transport and storage, may lead to cerebral hypoxia and cognitive decline. This relationship which was studied in children and adults was not evaluated in the elderly. The objective of this study is to examine the effect of iron deficiency on cognitive function in the elderly.

DESIGN, SETTING, PARTICIPANTS

This is a cross-sectional study conducted in a geriatric medicine outpatient clinic of a university hospital. Consecutive 2009 patients admitted to Geriatric Medicine outpatient clinic were examined and 622 patients who fulfilled the inclusion criteria were enrolled in the study.

MEASUREMENTS

Comprehensive geriatric assessment, cognitive assessment and laboratory analysis including blood count, iron, total iron binding capacity, ferritin, and transferrin saturation were performed.

RESULTS

Mean age of the study group was 72.5±6.5 and 439 (70.6%) were women. MMSE scores were moderately and significantly correlated with iron levels (r=0.33, p<0.001) and transferrin saturation (r=0.32, p<0.001). Transferrin saturation was significantly lower in the patients with dementia (p=0.040). It was found that patients with iron deficiency had lower MMSE scores (p<0.001) and this relationship was also present in patients without anemia (p=0.004).

CONCLUSION

The results of this study revealed a negative influence of iron deficiency on cognitive function and this influence was independent from the presence of anemia. As iron deficiency can be easily diagnosed and treated, detecting its effect on cognitive function is of importance. Screening for iron deficiency and initiating appropriate treatment should be a routine part of comprehensive geriatric assessment.

Efficacy and safety of iron supplementation for the elderly patients undergoing hip or knee surgery: a meta-analysis of randomized controlled trials

BACKGROUND

Anemia is a frequent co-morbidity in the elderly patients undergoing hip or knee surgery and is often associated with poor clinical outcomes. Mild to moderate anemia is often treated with intravenous or oral iron supplementation. However, the efficacy and safety of iron supplementation in treating anemia for the elderly patients undergoing hip or knee surgery remains controversial.

METHODS

Only prospective, randomized studies that compared iron supplementation with no iron supplementation in the elderly patients undergoing hip or knee surgery were included. Six studies met the inclusion criteria: the target population consisted of patients undergoing hip or knee surgery treated with iron supplementation; the study was a published randomized trial. Each outcome measure tested was assessed for heterogeneity. If significant heterogeneity was present for more than 75%, data from the studies were not combined. If there was no significant heterogeneity (less than 40%), a weighted mean difference (WMD) or combined relative risk was calculated using a fixed effects model, while a random effects model was applied when heterogeneity was within 40% to 75%.

RESULTS

Our meta-analysis demonstrated the increase of hemoglobin level in patients undergoing hip or knee surgery with iron supplementation. However, no significant difference on the length of hospital stay, morbidity, 1-mo mortality, the infection rate, the rate and volume of allogeneic blood transfusions, and the adverse drug effects was found between the patients with iron treatment and those without.

CONCLUSION

Our meta-analysis suggested that iron supplementation was safe and effective in treating anemia for the elderly patients undergoing hip or knee surgery.

Hemoglobin concentration and cognitive impairment in the renal REasons for Geographic And Racial Differences in Stroke (REGARDS) Study

BACKGROUND

There is growing interest in determining the degree of anemia, which is clinically significant. The goal of this study was to determine the association between hemoglobin concentration and cognitive impairment in a large sample of U.S. adults.

METHODS

We used cross-sectional data from 19,701 adults participating in the REasons for Geographic And Racial Differences in Stroke study. Cognitive impairment was defined as a score of 4 or less on the six-item screener. Hemoglobin was analyzed in 1 g/dL increments relative to the World Health Organization (WHO) threshold (<13 g/dL for men and <12 g/dL for women).

RESULTS

The mean hemoglobin concentration was 13.7 ± 1.5 g/dL. The prevalence of cognitive impairment increased from 4.3% among individuals with a hemoglobin >3 g/dL above the WHO threshold to 16.8% for those with a hemoglobin ≥2 g/dL below the WHO threshold. After adjustment for demographics, chronic health conditions, health status, and inflammation, the association between reduced hemoglobin and cognitive impairment was attenuated and no longer significant, including among those with hemoglobin ≥2 g/dL below the WHO threshold (odds ratio 1.39, 95% confidence interval = 0.94-2.04). A test for linear trend was of borderline significance (p value = .06). For 94% of the sample within 2 g/dL of the WHO threshold, there was no relationship between hemoglobin concentration and the odds of cognitive impairment. The associations did not differ by sex and race.

CONCLUSIONS

Within a large sample of community-dwelling adults, there was no significant association between hemoglobin concentration and cognitive impairment after multivariable adjustment.

[Cognitive impairment and chronic kidney disease: which links?]

Ageing of the population leads to an increase of cognitive disorders and chronic renal failure incidence. Compared to the general population, prevalence of cognitive impairment is more important in renal failure patients, especially in dialyzed patients. No direct link has been established between renal failure and cognitive impairment. The care of older and older patients and the high frequency of vascular risk factors, in particular hypertension and diabetes, partially explain the prevalence of vascular dementia and Alzheimer disease in this population. Other factors as the anemia, phosphocalcic metabolism disorders facilitate the cognitive impairment. The present work reviews the links existing between chronic renal failure and cognitive impairment.

Anemia and the risk of non-vertebral fractures: the Tromsø Study

In this longitudinal study of 5,286 persons, men with anemia had a 2.15 higher risk of non-vertebral fractures than men with high hemoglobin levels. Women with anemia had no increased fracture risk.

INTRODUCTION

Low hemoglobin levels are associated with several risk factors for fractures such as low physical function, impaired cognition, and low bone mass. The aim of this population-based, prospective study was to examine whether anemia predicts non-vertebral fractures.

METHODS

A total of 5,286 inhabitants from the municipality of Tromsø, Norway (2,511 men and 2,775 women), 55-74 years old at baseline, were followed for mean 8.3 years. Measurements of hemoglobin, mean corpuscular volume, height, weight, blood pressure, blood lipids, serum creatinine, and bone mineral density and questionnaire information concerning smoking and drinking habits, physical activity, prevalent diseases, and use of medication was collected before start of follow-up. Non-vertebral fractures were registered during follow-up.

RESULTS

A total of 235 men and 641 women sustained a new non-vertebral fracture. One SD lower value of hemoglobin was associated with a 1.27 higher risk of fracture in men (p < 0.001, after multiple adjustments) and 1.08 (p = 0.07) in women. Men with anemia (hemoglobin levels <13 g/dL) had a 2.15 higher risk of non-vertebral fractures than men with high levels (15.2-18.8, g/dL) whereas women with anemia (hemoglobin levels <12 g/dL) had no increased fracture risk.

CONCLUSION

Anemia is associated with non-vertebral fractures in men but not in women.

Cobalamin deficiency, hyperhomocysteinemia, and dementia

INTRODUCTION

Although consensus guidelines recommend checking serum B12 in patients with dementia, clinicians are often faced with various questions: (1) Which patients should be tested? (2) What test should be ordered? (3) How are inferences made from such testing? (4) In addition to serum B12, should other tests be ordered? (5) Is B12 deficiency compatible with dementia of the Alzheimer's type? (6) What is to be expected from treatment? (7) How is B12 deficiency treated?

METHODS

On January 31st, 2009, a Medline search was performed revealing 1,627 citations related to cobalamin deficiency, hyperhomocysteinemia, and dementia. After limiting the search terms, all abstracts and/or articles and other references were categorized into six major groups (general, biochemistry, manifestations, associations and risks, evaluation, and treatment) and then reviewed in answering the above questions.

RESULTS

The six major groups above are described in detail. Seventy-five key studies, series, and clinical trials were identified. Evidence-based suggestions for patient management were developed.

DISCUSSION

Evidence is convincing that hyperhomocysteinemia, with or without hypovitaminosis B12, is a risk factor for dementia. In the absence of hyperhomocysteinemia, evidence is less convincing that hypovitaminosis B12 is a risk factor for dementia. B12 deficiency manifestations are variable and include abnormal psychiatric, neurological, gastrointestinal, and hematological findings. Radiological images of individuals with hyperhomocysteinemia frequently demonstrate leukoaraiosis. Assessing serum B12 and treatment of B12 deficiency is crucial for those cases in which pernicious anemia is suspected and may be useful for mild cognitive impairment and mild to moderate dementia. The serum B12 level is the standard initial test: 200 picograms per milliliter or less is low, and 201 to 350 picograms per milliliter is borderline low. Other tests may be indicated, including plasma homocysteine, serum methylmalonic acid, antiparietal cell and anti-intrinsic factor antibodies, and serum gastrin level. In B12 deficiency dementia with versus without pernicious anemia, there appear to be different manifestations, need for further workup, and responses to treatment. Dementia of the Alzheimer's type is a compatible diagnosis when B12 deficiency is found, unless it is caused by pernicious anemia. Patients with pernicious anemia generally respond favorably to supplemental B12 treatment, especially if pernicious anemia is diagnosed early in the course of the disease. Some patients without pernicious anemia, but with B12 deficiency and either mild cognitive impairment or mild to moderate dementia, might show some degree of cognitive improvement with supplemental B12 treatment. Evidence that supplemental B12 treatment is beneficial for patients without pernicious anemia, but with B12 deficiency and moderately-severe to severe dementia is scarce. Oral cyanocobalamin is generally favored over intramuscular cyanocobalamin.

Relationship between anaemia and cognitive functions in elderly people

BACKGROUND

The primary goal of the present study was to investigate the effects of anaemia on the cognitive functions and daily living activities in elderly people.

METHODS

This sectional study was performed using 180 elderly people. Face-to-face interviews and questionnaires were conducted to evaluate daily activities. To evaluate cognitive functions we used the Folstein's Mini-Mental State Examination (MMSE).

RESULTS

The mean age of the anaemic group and the nonanaemic group were 76.0+/-11.7 and 72.5+/-15.2 years, respectively. The average haemoglobin level among the anaemic population was 10.4 g/dL compared with 13.6 g/dL among the nonanaemic population; a statistically significant difference. There was more impairment in functional status (Katz ADL) (6.8+/-4.3 vs 9.3+/-3.7) and cognition (MMSE) (17.9+/-6.4 vs 21.7+/-6.7) in anaemic than nonanaemic groups, respectively. Albumin and body mass index were lower and the percentage of two or more comorbidities was higher in anaemic group compared to the nonanaemic group, which was a statistically significant variation. The anaemic group was more dependent in terms of bathing, dressing, toileting and transferring.

CONCLUSION

In the elderly anaemic group, the dependency for daily activities that require physical effort was higher compared to the nonanaemic group. The MMSE score in the elderly anaemic group was lower than subjects who had normal haemoglobin levels. We conclude that anaemia may impair cognitive functions and some daily living activities in the elderly.

CKD associates with cognitive decline

Cognitive impairment and chronic kidney disease (CKD) will become increasingly prevalent in the aging US population. Although evidence exists that CKD is a risk factor for cognitive decline, longitudinal studies are limited and largely have excluded ethnically diverse populations. The Northern Manhattan Study includes a population-based, prospective, stroke-free cohort. We assessed global cognitive function annually using the modified Telephone Interview for Cognitive Status (TICS-m) and estimated kidney function using Cockcroft-Gault creatinine clearance (CCl), Modification of Diet in Renal Disease estimated GFR (eGFR), and serum creatinine (sCr). We examined the association between CKD and change in TICS-m scores over time, adjusting for sociodemographic and vascular risk factors. Of 2172 subjects (mean age 71.5 yr, mean follow-up 2.9 yr), 59% were Hispanic, 20% were black, and 63% were women. Participants with a CCl <60 ml/min and those with a CCl between 60 and 90 ml/min performed significantly worse on the TICS-m over time than those with a CCl >90 ml/min, adjusting for potential confounders. Our results were similar when we used eGFR or sCr to estimate kidney function. In conclusion, decreased kidney function associates with greater cognitive decline, even in those with mild CKD. Kidney disease may represent a novel mechanism leading to cognitive impairment and a target for early intervention.

Albumin, hemoglobin, body mass index, cognitive and functional performance in elderly persons living in nursing homes

The aim of this study is to produce the relation between cognitive and functional performance and some biochemical parameters in elderly population. So, we searched for the correlation between the activities of daily living (ADL), mini-mental state examination (MMSE) and body weight, age, hemoglobin, albumin, serum sodium level of 180 elderly people in five nursing homes. Face-to-face interviews and questionnaires were applied to evaluate ADL. To evaluate the cognitive function we used the MMSE. The average age of 180 people contacted was 71.5+/-5.1 (+/-S.D.), ranging 65-91 years; 112 of them were women (62.2%), 68 were men (37.8%). Of these elderly people, 25% had no medically diagnosed illnesses, whereas 17 of them (9.4%) were bedridden. There was a positive correlation between ADL and hemoglobin, albumin, body weight, cognitive function parameters and a negative one with age and serum sodium. There was a positive correlation between cognitive functions and hemoglobin, body weight, ADL and a negative one with serum sodium. Hemoglobin concentrations indicating anemia were observed in 30% of subjects, 3.9% of them had hyponatremia and 26.7% displayed a hypernatremia. There was a positive correlation between cognitive and physical function scores and hemoglobin, albumin levels in elderly patients. These results suggest that restoration of hemoglobin and albumin levels could improve cognitive and physical functional status in the elderly population.

Albumin, haemoglobin, BMI and cognitive performance in older adults

OBJECTIVES

to examine the relationships between serum albumin, haemoglobin and body mass index (BMI) with cognitive performance among community-living older adults.

METHOD

design--population-based cross-sectional study; setting--local community in Southeast Region of Singapore; subjects--Chinese older adults aged 55 and above (N = 2, 550); measurements--serum albumin, haemoglobin, BMI and Mini-Mental State Examination (MMSE).

RESULTS

in multivariable analyses controlling for gender, age, education and vascular risk factors, low albumin in the bottom quintile (OR 2.04; 95% CI 1.22-3.41) and low haemoglobin in the bottom quintile (OR 1.56; 95% CI 1.00-2.47) and low BMI with chronic comorbidity (OR 1.73; 95%CI 1.02-2.95) were independently associated with poor cognitive performance (MMSE < or = 23). Among cognitively intact respondents (MMSE > or = 24), albumin concentration showed a significant inverse linear relationship with MMSE scores (P for trend =0.002).

CONCLUSION

low albumin, low haemoglobin and low BMI (in the presence of chronic comorbidity) are independently associated with poor cognitive performance in community-living older adults.

Vitamin B status and cognitive performance in preclinical and clinical Alzheimer's disease: data from the Kungsholmen Project

BACKGROUND/AIMS

The impact of vitamin B status on cognitive functioning in Alzheimer's disease (AD) is disputed. Using a population-based sample, we examined the associations of vitamin B(12) and folate with cognitive functioning in clinical (n = 44) and preclinical (n = 39) AD.

METHODS

The groups were subdivided in terms of low (<200 pmol/l) versus normal levels of B(12) and low (<13 nmol/l) versus normal folate levels. Participants were administered tests of verbal and nonverbal episodic memory, visuospatial abilities and verbal fluency.

RESULTS

As expected, the preclinical AD group performed better than the AD group across most cognitive tests. More interestingly, the effects of low vitamin B(12) and folate levels were negligible across all cognitive tests in clinical and preclinical AD.

CONCLUSION

These findings suggest that the influence of vitamin B deficiency on cognitive functioning is overshadowed by the neurodegenerative processes associated with AD.

Association between mild anemia and executive function impairment in community-dwelling older women: The Women's Health and Aging Study II

OBJECTIVES

To evaluate the relationship between mild anemia and executive function in community-dwelling older women.

DESIGN

Cross-sectional.

SETTING

Community-based.

PARTICIPANTS

High-functioning subjects participating in the baseline assessment of the Women's Health and Aging Study (WHAS) II, Baltimore, Maryland, 1994 to 1996. WHAS II eligibility criteria included aged 70 to 80, a Mini-Mental State Examination score of 24 or greater, and absence of advanced disability (difficulty in no more than 1 domain of physical function). Included in this study were 364 subjects with a hemoglobin concentration 10 g/dL or greater and known executive function status.

MEASUREMENTS

Trail Making Test (TMT) Parts B and A. Tertiles of time to complete each test were used to define best (bottom), intermediate, and worst (top) performance. Tertiles of the difference TMT-B minus TMT-A were calculated. Anemia defined as hemoglobin concentration less than 12 g/dL.

RESULTS

The percentage of subjects in the worst TMT-B, TMT-A, and TMT-B minus TMT-A performance tertile was highest for those with anemia. Prevalent anemia substantially increased the likelihood of performing worst (as opposed to best) on the TMT-B (odds ratio (OR) = 5.2, 95% confidence interval (CI) = 1.3-20.5), TMT-A (OR = 4.8, 95% CI = 1.5-15.6), and TMT-B minus TMT-A (OR = 4.2, 95% CI = 1.0-17.2), even after controlling for age, education, race, prevalent diseases, and relevant physiological and functional parameters.

CONCLUSION

This study provides preliminary evidence in support of the hypothesis that mild anemia might be an independent risk factor for executive function impairment in community-dwelling older adults. Whether such an association is causal or noncausal remains to be determined.

Impact of anemia on mortality, cognition, and function in community-dwelling elderly

PURPOSE

To explore the impact of varying hemoglobin levels on mortality, function, and cognition in a representative population of older persons.

METHODS

Participants in this prospective cohort study included 1 744 men and women, aged 71 years or older, from a random household sample living in Durham and surrounding counties in North Carolina. Hemoglobin levels were obtained from participants at baseline in 1992. Functional status was measured at the 4-year follow-up interview using Katz and instrumental activities of daily living. Cognition was measured using the Short Portable Mental Status Questionnaire (SPMSQ). Death was determined by search of the National Death Index, and all deaths through 2000 are included.

RESULTS

Using World Health Organization (WHO) criteria, the prevalence of anemia was 24%. There was a strong racial difference with an odds ratio, adjusted for age, education, estimated glomerular filtration rate and comorbidity of 3.0 (95% CI, 2.3-3.9) in African Americans compared with Caucasians. The risk ratio for 8-year mortality was 1.7 (95% CI, 1.5-2.0) for anemic subjects (P = .0001) and did not differ by sex or race. Anemia was strongly associated with poorer physical function (P = .0001) and cognitive function (P = .0001), and predicted decreases in both over a 4-year period.

CONCLUSIONS

In an elderly community-based population, anemia is more prevalent in African Americans and is independently associated with increased mortality over 8 years for both races and sexes. Anemia also is a risk factor for functional and cognitive decrease.

Anemia in the elderly: current understanding and emerging concepts

Anemia is currently defined by the World Health Organization (WHO) as a hemoglobin (Hb) level <13 g/dL in men and <12 g/dL in women. While estimates vary widely, nearly one quarter of community-based octagenerians and one half of the chronically ill elderly have Hb levels that satisfy a diagnosis of anemia according to these criteria. A growing body of evidence has linked adverse events with even "mild" anemia or low-normal Hb in the elderly. Recent studies suggest strongly that aging is associated with dysregulation of pro-inflammatory cytokines, most notably interleukin-6 (IL-6), which may negatively impact hematopoiesis, either by inhibition of erythropoietin (EPO) production or interaction with EPO receptors. Anemia in older individuals is associated with a very wide range of complications, including increased risk for mortality, cardiovascular disease, cognitive dysfunction, longer hospitalization for elective procedures and comorbid conditions, reduced bone density, and falls and fractures. Not surprisingly, anemia also has a significant effect on quality of life (QOL) in the elderly. Most anemia in older individuals results from iron deficiency, chronic inflammation, or chronic kidney disease, or it may be unexplained. Future research on anemia in the elderly should focus on the age-related physiologic changes underlying this condition and whether anemia correction can reduce anemia-associated risks, and improve QOL.

Chronic kidney disease and cognitive impairment in the elderly: the health, aging, and body composition study

Previous studies suggest a link between chronic kidney disease (CKD) and cognitive impairment. Whether the longitudinal course of cognitive impairment differs among people with or without CKD is unknown. Data collected in 3034 elderly individuals who participated in the Health, Aging, and Body Composition study were analyzed. Cognitive function was assessed with the Modified Mini-Mental State Exam (3MS) at baseline and then 2 and 4 yr after baseline. Cognitive impairment was defined as a 3MS score <80 or a decline in 3MS >5 points after 2 or 4 yr of follow-up among participants with baseline 3MS scores > or =80. Participants with CKD, defined as an estimated GFR (eGFR) <60 ml/min per 1.73 m2, were further divided into two eGFR strata. Unadjusted mean baseline 3MS scores and mean declines in 3MS scores over 4 yr were significantly more pronounced for participants with lower baseline eGFR. More advanced stages of CKD were associated with an increased risk for cognitive impairment: Odds ratio (OR) 1.32 (95% confidence interval [CI] 1.03 to 1.69) and OR 2.43 (95% CI, 1.38 to 4.29) for eGFR 45 to 59 ml/min per 1.73 m2 and <45 ml/min per 1.73 m2, respectively, adjusted for case mix, baseline 3MS scores, and other potential confounders. CKD is associated with an increased risk for cognitive impairment in the elderly that cannot be fully explained by other well-established risk factors. Studies aimed at understanding the mechanism(s) responsible for cognitive impairment in CKD and efforts to interrupt this decline are warranted.

Medical and functional consequences of anemia in the elderly

Anemia is a common problem in the elderly, accounting for significant morbidity and mortality in this population. It also has a negative effect on quality of life. Recent findings have shown that anemia can lead to cardiovascular and neurological complications, such as congestive heart failure and impaired cognitive function. In addition, anemia has been implicated in functional impairment and falls. Available data have shown that the successful management of this condition will not only improve patients' quality of life, but may also prevent the anemia from worsening.