Anemia in elderly patients ≥65 years of age: a hospital-based cross-sectional study

E Kadhiravan; Agalya Devi; Reenaa Mohan; R Sindhuri; Shiek Abdula; D S. Karthika Devi

doi:10.4103/jiag.jiag_57_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 19 | Issue : 1 | Page : 19-23

Anemia in elderly patients ≥65 years of age: a hospital-based cross-sectional study

E Kadhiravan¹, Agalya Devi², Reenaa Mohan³, R Sindhuri⁴, Shiek Abdula⁵, D S. Karthika Devi³
¹ Department of Nephrology, Indira Gandhi Medical College and Research Institute, Puducherry, India
² Department of Pathology, Sri Lakshmi Narayana Institute of Medical Sciences, Puducherry, India
³ Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
⁴ Shri Sathya Sai Medical College and Research Institute, Chengalpattu District, Tamil Nadu, India
⁵ Department of Nephrology, Srinivasa Medical College and Hospital, Trichy, Tamil Nadu, India

Date of Submission	13-Oct-2022
Date of Decision	24-Dec-2022
Date of Acceptance	31-Dec-2022
Date of Web Publication	17-Mar-2023

Correspondence Address:
Reenaa Mohan
Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital, Kalitheerthalkuppam, Madagadipet, Puducherry - 605 107
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiag.jiag_57_22

Abstract

Introduction: Anemia in elderly patients of any degree contributes significantly to morbidity and mortality and has a significant effect on the quality of life. Despite of high prevalence, very few studies have examined the effect of anemia in elderly patients in India. Hence, this study is undertaken to know the prevalence and clinicopathological pattern of anemia in elderly patients. Objectives: 1. To estimate the prevalence of anemia in the elderly aged 65 years and above. 2. To determine the severity, clinicohematological patterns, and causes of anemia in the elderly aged 65 years and above. Materials and Methods: A hospital-based descriptive cross-sectional study was done. The study was conducted for 1 year; during this period, elderly patients aged 65 years and above admitted for other medical conditions were recruited in the study using consecutive sampling technique until the desired sample size of 236 was achieved and they were evaluated for anemia. Among them with hemoglobin cutoff value <13 g% for men, <12 g% for women were further evaluated to known the cause of anemia and its clinicohematological pattern. Ethical committee approval was obtained. Data were analyzed using SPSS Software version 23.0. Results: The mean age of the participants was 73.9 ± 7.4 (standard deviation [SD]) years. Majority, 53.8%, of the participants were males. Among the 236 elderly patients, recruited in the study 65.3% were anemic and among them 44.2 had mild anemia and 37% had moderate anemia. Mean hemoglobin value of the participants was 10.7 ± 2.83 SD and it ranged from 3 to 16.3 g/dl. There was no significant difference in the hematological parameters between male and female elderly patients in the study. The main cause of anemia was found to be due to chronic diseases followed by iron-deficiency anemia. Conclusion: This study concludes that anemia was highly prevalent among elderly patients and most of them had identifiable and treatable etiology. Hence, all elderly patients with anemia should be evaluated properly for underlying etiology and treated accordingly to reduce the mortality and morbidity in elderly patients with multiple comorbidities.

Keywords: Anemia, elderly, hemoglobin, pattern of anemia

How to cite this article:
Kadhiravan E, Devi A, Mohan R, Sindhuri R, Abdula S, Devi D S. Anemia in elderly patients ≥65 years of age: a hospital-based cross-sectional study. J Indian Acad Geriatr 2023;19:19-23

How to cite this URL:
Kadhiravan E, Devi A, Mohan R, Sindhuri R, Abdula S, Devi D S. Anemia in elderly patients ≥65 years of age: a hospital-based cross-sectional study. J Indian Acad Geriatr [serial online] 2023 [cited 2023 Apr 2];19:19-23. Available from: http://www.jiag.com/text.asp?2023/19/1/19/371904

Introduction

Anemia in the elderly is an emerging problem that is associated with poor health-related quality of life, decreased cognition and functional ability, increased risk of fall, infections, and increased morbidity and mortality regardless of the underlying cause of low hemoglobin (Hb).^[1] Hence, anemia is recognized as a significant and independent contributor for morbidity, mortality, and frailty in the elderly patients regardless of the underlying causes.^[1] Failure to evaluate geriatric anemia can result in delayed diagnosis of easily treatable condition and increased chance of hospital readmission rate and increased mortality up to 1 year after hospitalization.^[2] A progressive statistical increase in number of elderly, thus anemia in the elderly patient is an emerging global health problem and requiring allocation of health care resources.^[3]

Aging by itself is unlikely to cause anemia, but changes that occur commonly during aging increases the risk of anemia, thus explaining the association of anemia with old age include (a) Poor nutrition, (b) Reduced ability to absorb essential nutrients, (c) Decreased reserve of hematopoietic factors, (d) Reduced erythropoiesis, (e) Increased frequency of inflammatory process, (f) Gastrointestinal loss of blood.^[4] These factors make the elderly more prone to developing anemia and micronutrient deficiencies which affect erythropoiesis. Rectification of any of these abnormalities contributes significantly to overall improved outcome with respect to physiological parameters as well as quality of life.^[5]

According to Hb cutoff levels defined by the World Health Organization <12 g/dL for females, <13 g/dL for males is defined as anemia. The third National Health and Nutrition Examination Survey (1988–1994) (NHANES III), overall, 11.0% of men and 10.2% of women aged 65 and older were anemic and the prevalence of anemia was >20% among those aged 85 and older.^[4] Anemia is an independent predictor of poor outcomes with many diseases, especially in the elderly.

Two major causes of anemia in the elderly are anemia of chronic disease and nutritional deficiencies. Approximately up to 33% of anemia in elderly remains unexplained and their pathophysiology is not understood.^[6]

Despite high prevalence, very few studies have examined the effect of anemia in elderly patients in India. Hence, this study is undertaken to know the prevalence anemia in elderly patients, association between anemia and comorbidities, the hematological types and possible etiology and the impact of anemia as a comorbid state in an elderly population.

Objectives

To estimate the prevalence of anemia in the elderly aged 65 years and above
To determine the severity, clinicohematological patterns, and causes of anemia in the elderly aged 65 years and above.

Materials and Methods

Study setting and participants

The present study was a descriptive cross-sectional study, conducted in elderly patients aged 65 years and above in department of general medicine, Malabar Medical College Hospital and Research Centre, Calicut, admitted for medical conditions other then anemia.

Sample size and sampling

Based on the findings of the study done in South India by Shrivastava et al.^[7] (prevalence of anemia in elderly people is 68.5%) and the allowable error as 6.5%, at 95% confidence interval (CI), the sample size was calculated to be 197 and with 20% nonresponse rate, the final sample size was 236 (calculated using Open Epi software version 3.01). Patients >65 years of age admitted for other medical problems in medicine ward during the study period and were willing to participate in the study were consecutively selected until the desired sample size of 236 was achieved. Those patients identified with anemia based on the Hb level (<13 g% for men, <12 g% for women.^[8] were further evaluated for etiology, severity and clinicohematological pattern of anemia.^[9] Patients who were known case of anemia and on treatment, patients on iron and folic acid therapy, and those who received blood transfusion in the last 1 month were excluded from the study.

Data collection

The study was cleared by the Institutional Ethical Committee of Malabar Medical College Hospital and Research Centre, Calicut. After obtaining written informed consent from the participants, the data were collected using pretested semi-structured questionnaire. The participants were subjected to clinical examination, followed by investigations as per standard guidelines. The following list of investigations were done for the participants: complete blood count with peripheral smear and reticulocyte count, renal function test (blood urea, serum creatinine), blood glucose, chest X-ray PA view, urine and stool examination (occult blood loss and microscopy), direct Coombs test, iron studies (serum ferritin, TIBC and serum iron), and liver function test. Bone marrow examination (aspiration/trephination biopsy) was done in patients with history and examination suggestive of malignancy, abnormal peripheral smear, and unexplained anemia. Hb electrophoresis done in patients suspected multiple myeloma, sickle cell disease, thalassemia). Sickling test, Osmotic fragility test, Indirect Coombs test when hemolysis suspected. Serum B12/Folate assay done in patients suspected of nutritional deficiency and peripheral smear showing macrocytic picture.

The diagnosis of anemia of chronic disease is difficult as both serum iron and transferrin concentration may be low. The term has been used haphazardly without precise diagnosis of the etiology in many cases. However, laboratory parameters like increased or normal iron store level may be used to help in diagnosis. In this study, patients with low level circulating serum iron in the presence of increased iron stores (normal or increased serum ferritin >100 ng/mL, transferrin saturation >25% and <50% and decreased total iron binding capacity (<250 μg/dL)^[10] were diagnosed to had anemia of chronic disease.

Statistical analysis of data

The data were entered using Microsoft excel 2010 and analyzed in SPSS Software version 23.0 (Developed by IBM company have headquaters in chicago, developed in 1968). Discrete variables such as grading and causes of anemia and peripheral smear examination results were presented as frequency and percentages. Mean and standard deviation (SD) and median and interquartile range were used to summarize the findings of hematological parameters. For variables that do not follow normal distribution like white blood cell, Platelet count and Reticulocyte count, Mann–Whitney U test was used and for all other variables Student's t-test was used to find out if there was any statistically significant difference in hematological parameters between male and female elderly patients. Statistically significant level was fixed at <0.05.

Results

As per [Table 1], 66.4% of the participants were in the age group of 65–74 years, whereas the remaining 43.6% were more than or equal to 75 years of age. The mean age of the participants was 73.9 ± 7.4 (SD) years. Majority, 53.8% of the participants, were male.

Table 1: Baseline characteristics of the participants (n=236)

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The mean Hb value of the participants was 10.7 ± 2.83 (SD) and it ranged from 3 to 16.3 g/dl. As per [Table 2], there was no statistically significant difference in the hematological parameters between male and female elderly patients in the study.

Table 2: Summary of hematological parameters in study subjects (n=236)

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Based on [Table 3], Out of 236 elderly people who participated in the study, 154 (65.3%) presented with anemia. Among 154 patients with anemia, majority 68 (44.2%) had mild anemia, followed by moderate anemia in 57 (37%) participants. Nearly one-fifth of the elderly people suffered from severe anemia. Of 154 anemic elderly patients, 77 (50%) showed normocytic normochromic anemia in their peripheral smear and 70 (45.5%) revealed features of microcytic hypochromic anemia.

Table 3: Prevalence, severity and peripheral blood smear patterns of anemia in elderly patients aged ≥65 years

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Among 154 anemic patient in the study,majority of them 76 (29.4%) had chronic disease and iron deficiency was found in 42 (27.3%) patients.It was found 9 (5.8%) had anemia due to post hemorrhage, 5 (3.2%) had nutitional deficiency other than iron and 4 (2.6%) of them had hematological malignancy.wherase in 18 (11.7%) of the patients the cause of anemia remains unexplained [Table 4].

Table 4: Causes of anemia in elderly patients (n=154)

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Discussion

Principal findings of the study

The present study was undertaken to find out etiology, the grading of anemia, and peripheral smear patterns in elderly patients. This study also tries to find out the difference in the hematological parameters related to anemia between males and females. In this study, most of the patients presented with mild anemia, 44.8% (69 patients). This finding concurrent with the study done by Alwar et al., (54.23%)^[11] and Dharmarajan et al.^[12] who reported that mild anemia is the most prevalent anemia in the geriatric age group. Mild anemia should not be accepted as the normal response to the aging phenomenon, as it is associated with reduced quality of life, increased morbidity and mortality in geriatric age group.^[10] Therefore, underlying etiology must be identified in all patients presenting with anemia to facilitate appropriate medical therapy.

Comparison with other studies

From the NHANES III study reported, three common causes for anemia in the elderly population, which include (1) anemia associated with chronic illness/inflammation or chronic renal failure, (2) anemia due to blood loss/nutritional deficiencies, and (3) unexplained anemia. In the present study, anemia of chronic disease among the study subjects was found to be 49.4% (76 patients) was the most common form of geriatric anemia followed by iron deficiency anemia in 27.3% (42 patients), unexplained anemia in 11.7% (18 patients), posthemorrhagic in 5.8% (nine patients), nutritional deficiency in3.2% (five patients), and hematological malignancy in 2.6% (four patients). Ferrucci et al.^[13] reported that 33% had anemia due to chronic disease, 22% had iron deficiency anemia and in 23% of the patients cause of anemia remains unexplained. Vitamin B12-folate deficiency was found in 8% patients. Other studies^[10] have also reported similar findings to our study in elderly anemia patients.^[10] A study conducted by Tettamanti et al.^[14] also reported similar findings. Hence, this study reports anemia due to chronic disease is the predominant cause of anemia in elderly when compared with nutritional deficiency. However, both anemia of chronic disease and iron-deficiency anemia, are two important causes for anemia in hospitalized elderly patients.

In this study, 27.3% (42 patients) had iron-deficiency anemia and 3.2% (five patients) had Vitamin B12-folate deficiency. A study done by Chaves et al.^[15] reveals similar findings stating 16.6% patients had reported to have iron deficiency anemia. Hence, iron-deficiency anemia is the most common form of nutrient deficiency anemia in elderly.

Chronic blood loss is the most common etiology behind iron deficiency anemia.^{[10],[11],[12]} Hence, our study also reports the use of screening tests such as endoscopy, colonoscopy, and other cancer screening test to identify the underlying causes and coexisted malignant and premalignant gastrointestinal lesion. Estimation of serum Ferritin help us to confirm the diagnosis of iron deficiency anemia without a need for invasive techniques like bone marrow examination.^[13] High prevalence of iron deficiency anemia in elderly emphasis the need to initiate the preventive public health measure in geriatric population.

In this study, four patients (2.6%) had both iron and B12/folate deficiency suggestive of multiple nutrient deficiency in elderly population. Vitamin B12 deficiency have neuro-psychiatric manifestation even in patients with moderate anemia, this proves there is a need for investigation for other causes of nutrient deficiency, even if one form of nutrient deficiency is established.^[14] Similar findings were noted in study done by Ferrucci et al.^[13] In the present study, normocytic normochromic anemia was the most prevalent morphological type of anemia followed by microcytic hypochromic anemia in both sexes findings of our study are in concordance with study done by Tettamanti et al.,^[14] Elis et al.,^[16] and Shrivastava et al.^[7]

This study have made an attempt to further evaluate the underlying cause of anemia, Hence proper treatment was provided. Since the elderly patients were enrolled from the hospital setting, the results might not reflect the true status of anemia among elderly patients in the community.

Implication of the study

This study's findings imply the need for protocol for management of anemia in geriatric population. All elderly patients with anemia need proper evaluation for underlying etiology and treated accordingly.

Conclusion

This study concludes that anemia was highly prevalent among hospitalized elderly patients, of which most of them had identifiable and treatable causes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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