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Anemia Associated with Higher Risk of Death in the Elderly

	Hemoglobin is the most important component of red blood cells. It is composed of a protein called heme, which binds oxygen. In the lungs, oxygen is exchanged for carbon dioxide. Abnormalities of an individual's hemoglobin value can indicate defects in red blood cell balance. Both low and high values can indicate disease states.

Earlier study found anemia in senior citizens doubled risk of physical decline

Oct. 24, 2005 – A study in today’s Archives of Internal Medicine says elderly people with anemia are at an increased risk of death. Another study, reported in SeniorJournal.com in July of 2003, said anemia doubles the risk that an older person will develop serious physical decline. Clearly, anemia is a condition that needs treatment for the healthy survival of many senior citizens.

Increasing evidence also indicates that anemia is common in the elderly population, but few studies have assessed the association of anemia with clinical outcomes, such as illness and death, according to background information in the article published by the Archives of Internal Medicine.

Anemia is defined by the World Health Organization (WHO) as a hemoglobin concentration of less than 12 g/dL (grams per one tenth liter) for women and less than 13 g/dL for men.

Neil A. Zakai, M.D., of the University of Vermont College of Medicine, Burlington, compared the association of hemoglobin concentration and anemia status with subsequent death over the course of eleven years in elderly adults living in four U.S. communities.

Hemoglobin concentrations were determined for participants recruited between 1989 and 1993. Participants were contacted biannually; telephone and clinic examinations were conducted alternately. Deaths were reviewed and classified as cardiovascular or noncardiovascular. Complete follow-up was available through June 2001 for this analysis.

Hemoglobin concentration was analyzed in two ways: by dividing the participants' baseline hemoglobin into five equal levels and by the WHO criteria for anemia.

Based on the WHO criteria for anemia, 498 individuals were anemic on enrollment (8.5 percent of the 5,797 included in the analysis), the researchers report.

The hemoglobin concentration for the 1,205 individuals in the lowest fifth was higher than the WHO criteria for anemia, and 41.3 percent of these 1,205 people did qualify as anemic by WHO standards.

"In this elderly cohort, the prevalence of anemia was 7.0 percent among white and 17.6 percent among black individuals," the authors write.

"After 11.2 years of follow-up, lower hemoglobin concentrations were associated with increased mortality risk, independent of many potentially confounding factors. The magnitude of this association was similar whether the lowest quintile [fifth] of hemoglobin or the WHO criteria for anemia was used; however, the number of participants was much larger when considering the lowest quintile of hemoglobin concentration."

Another finding of the study was that there was also elevated mortality among those in the highest hemoglobin quintile, even after extensive adjustment for other factors.

"In conclusion, a lower hemoglobin concentration was independently associated with mortality in this elderly cohort," the authors write.

"The bottom hemoglobin quintile defined a larger group at risk than anemia status based on WHO criteria. Future areas of investigation should determine the optimal hemoglobin value that defines an abnormal concentration in elderly individuals, study the causes of low hemoglobin concentrations in elderly individuals and how these relate differentially to outcomes, evaluate the causes of increased mortality in individuals with low and high hemoglobin concentrations, and assess whether treatment of low hemoglobin in the general population reduces mortality."

The Archives of Internal Medicine is a peer-reviewed journal published by the American Medical Association. (Arch Intern Med. 2005; 165: 2214-2220)

This research was supported by contracts from the National Heart, Lung, and Blood Institute, Bethesda, Md. Dr. Cushman has received research funding in the form of a subcontract with the University of Alabama funded by Amgen; the project is not related to this article.

Editorial: Anemia in the Elderly - Time for New Blood in Old Vessels?

In an accompanying editorial, Jerry L. Spivak, M.D., of The Johns Hopkins University School of Medicine, Baltimore, Md., writes, "The four articles in this issue of the Archives usefully highlight and advance our conceptions of the cause of anemia in the elderly and anemia's health-related impact.

“Anemia, of course, is always the consequence of another disorder, and correction of the underlying disorder is the most effective means of alleviating the anemia. However, anemia in the majority of the elderly is caused by conditions such as chronic renal insufficiency, chronic inflammation, cancer, or bone marrow failure, some of which are actually an aftermath of the aging process and most of which defy correction.

“It is now also well established that anemia frequently exacerbates the illness causing it, while having its own independent adverse effects."

"What remains to be determined is whether pharmacologic correction of anemia . can slow disease progression, reduce morbidity [illness], improve quality of life, and prolong survival, and whether there is a favorable cost-benefit ratio to society for such improvements," Dr. Spivak continues.

"Recent failed attempts to answer these questions in the setting of renal failure or cancer indicate that this will not be an easy task, but the prospect of a doubling in the number of elderly persons over the next 25 years indicates that it is a task that cannot be ignored or deferred."

The Archives of Internal Medicine is a peer-reviewed journal published by the American Medical Association. (Arch Intern Med. 2005; 165: 2187-2189.)

Anemia Risk Factors by MayoClinic.com

These are factors that place seniors at increased risk of anemia:

Poor diet. Anyone — young or old — whose diet is consistently low in iron and vitamins, especially folate, is at risk of anemia. Your body needs iron and vitamins to produce sufficient numbers of red blood cells.

Intestinal disorders. Having an intestinal disorder that affects the absorption of nutrients in the small intestine — such as Crohn's disease or celiac disease — puts you at risk of anemia. Surgical removal of or surgery to the parts of the small intestine where nutrients are absorbed can lead to nutrient deficiencies and anemia.

Chronic conditions. For example, if you have cancer, kidney or liver failure, or another chronic condition, you may be at risk of what's called anemia of chronic disease. These conditions can lead to a shortage of red blood cells. Slow, chronic blood loss from an ulcer or other source within the body can deplete your body's store of iron, leading to iron deficiency anemia.

Family history. If your family has a history of an inherited anemia, you also may be at increased risk of the condition.

Certain infections, blood diseases and autoimmune disorders, exposure to toxic chemicals, and the use of some medications can affect red blood cell production and lead to anemia. Other people at risk of anemia are people with diabetes, people who are dependent on alcohol (alcohol interferes with the absorption of folic acid) and people who adhere to a strict vegetarian diet, who may not get enough iron or vitamin B-12 in their diet.

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