Feature Articles

Anemia is Common for Elderly Residents in Long-Term Care Facilities

February 18, 2010

Caregiver and elderly woman

In the U.S., about 50% of nursing home residents have anemia, as do about 10% of all adults over age 65.1-3

Anemia in the Elderly

In the United States, roughly 10% of adults over the age of 65 are considered to be anemic, defined by hemoglobin levels below 12 g/dL for women and below 13 g/dL for men.1 Anemia is more common for elderly adults for a variety of reasons, including nutritional deficiencies, iron deficiency anemia caused by intestinal bleeding, and the presence of chronic inflammatory diseases like cancer, chronic kidney disease and rheumatoid arthritis. Natural hormonal changes involving testosterone and erythropoietin can also lead to lower hemoglobin levels in both men and women.

Also common is the occurrence of unexplained anemia in the elderly (UAE). Anemia which cannot be attributed to a cause is seen in about one-third of elderly patients. “Over the age of 70 more and more patients have unexplained anemia,” said Dr. William Ershler, Senior Investigator at the National Institute on Aging of the National Institutes of Health. Although unexplained anemia of the elderly is common in the elderly, he believes that, “It’s not so much that it’s unexplained, but that its cause is complex and multi-factorial.”

Multiple factors working together to cause anemia is more common in the elderly who may have several chronic conditions, persistent inflammation, and possible nutritional deficiencies at the same time. This can make it much harder for caregivers and medical staff to determine what is causing an elderly patient’s anemia, but that doesn’t mean anemia is a normal consequence of aging or that it should go untreated.

“The casual observer may think it’s difficult to find a cause, but there are correctable causes of anemia that can be treated safely,” notes Dr. Ershler. To learn more about the causes of anemia in the elderly and UAE, read our information handout Anemia & Aging and the feature article Anemia is Not a Normal Consequence of Aging.

Monitoring for Frailty

Signs of increasing frailty can indicate declining overall health and should be monitored by regularly measuring or assessing a patient's:

  • Grip strength
  • Walking speed
  • Lean body mass
  • Bone mass
  • Ability to perform daily activities
  • Ability to completing mental tasks
  • Ability to remain independent

The Frail Elderly in Long-Term Care

A ten percent prevalence of anemia in elderly people may seem high, but elderly residents in long-term care are even more likely to have anemia. In fact, large health studies in nursing homes have shown that about 50% of residents have anemia, and sometimes even more when the average age of study participants was over 80 years.2,3 Increased prevalence of anemia relates to the fact that residents in long-term care facilities are generally less independent, more physically impaired and more frail than elderly people still residing in the community. Reduced physical ability and dependence on care are sometimes requirements for admittance into care facilities.

Definition of Terms
Sarcopenia: The processs of losing muscle mass and strength due to old age or lack of physical activity

Osteopenia: A natural process in which bones become thinner and may eventually lead to osteoperosis

“Not all frail patients are in long-term care, but a majority of long-term care patients are considered frail by standard measures,” observes Dr. Andrew Artz, a hematologist concentrating in hematologic disorders in geriatric patients at the University of Chicago. Frailty is a general physical characteristic that is used to describe reduced physical strength and can be determined in various ways. Measurements of grip strength, walking speed, lean body mass, bone mass and even mental awareness are often included in assessments of frailty. Questionnaires of daily activities, mental acuity and independence are also administered to evaluate frailty.

Frailty is associated with worse health outcomes and anemia. Also, the more frail a patient has become, the more likely they are to have anemia. Because of this association, Dr. Ershler recommends that caregivers and health professionals caring for elderly residents watch for health trends which indicate frailty and which may be related to, or caused by anemia.

Indications of frailty are also tough to catch because they can also come on slowly and are frequently attributed to the normal physical decline of old age. Some signs to look out for are reduced grip strength, considerable weight loss, reductions in walking speed and overall strength. Two physical processes that directly lead to frailty are sarcopenia and osteopenia, which are the biological processes that lead to reductions in lean body mass and bone mass. Both of these deteriorations can reduce an elderly patient’s strength and many times leads to falls and bone fractures, further progressing the likelihood of more health complications and an increased risk for anemia.

Not Just Tiredness, It Could Be Anemia

Symptoms of Anemia
  • Fatigue
  • Weakness
  • Dizziness
  • Pale skin
  • Brittle nails
  • Chest pain
  • Coldness of hands or feet
  • Trouble breathing
  • Irregular heartbeat
  • Depression

Anemia-related symptoms and signs of frailty can be tough to notice when they progress gradually. For instance, some patients with mild anemia (9.5-13.0 g/dL) may not show any symptoms, and patients with moderate anemia (8.0-9.5 g/dL) might not personally notice any fatigue or weakness.4 Symptoms of anemia can include tiredness, fatigue, weakness, dizziness, shortness of breath, or depression. With anemia, patients may also have pale skin, brittle nails, chest pain, a coldness in the hands or feet, or an irregular heartbeat.

Documenting signs and symptoms is essential in the effort to notice long-term deteriorations of strength or physical ability. This is often an area where tracking and communication regarding anemia can be improved by caregivers, healthcare professionals or family members caring for the elderly. In many facilities, recognition and documentation of anemia is far behind prevalence rates of 50%. For instance, only 2.4% of nursing home residents from a 1999 national survey had been diagnosed with anemia.5 Another study of over 43,000 nursing home residents reported only 18.8% of residents 65 years and older had an anemia diagnosis recorded in their chart.6

Anemia is diagnosed through a hemoglobin or hematocrit test administered by a healthcare professional. Most facilities require that this test be performed as part of a complete blood count (CBC) test at least once every year, and some experts recommend that it should be performed more regularly if the patient is showing symptoms of anemia or signs of reduced physical ability because of worsening frailty.

“It's important to remember that many forms of anemia are reversible, and consequently anemia in adult long-term care facilities should be thoroughly investigated,” said Dr. Lodovico Balducci, Chief of the Division of Geriatric Oncology, Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center & Research Institute.

Ershler quoteTreating Anemic Elderly

Diagnosing and treating anemia in older adults and in the frail elderly is generally similar to anemia management for adults and children. Most important is the need to find the ultimate cause of why a patient’s hemoglobin level has declined. Some treatments that help raise the hemoglobin level – like transfusion or iron supplementation – can be helpful to a patient in the short term, but might ignore a larger more serious problem.

“Correcting anemia without treating the underlying condition can allow the problem to progress,” said Dr. Ershler, explaining that, “The best approach is to find out why they are anemic and treat the cause.” Anemia can be a symptom of several serious conditions seen in the elderly, including blood loss from the gastrointestinal tract, some forms of cancer, and even chronic kidney disease. Treating a patient’s specific condition can reduce the effect that the condition is having on the body and often times can raise hemoglobin levels over time.

The type of treatment most appropriate for each patient depends on what is causing their anemia. For instance, iron supplements are commonly used to raise hemoglobin levels for many types of anemic patients, however it is not effective when anemia is caused by chronic inflammation. Thus finding the right cause and using the precise treatment for that cause will yield the best results for managing anemia. Family members and caregivers should talk with a patient’s doctor and medical staff about their symptoms and known chronic conditions to determine how best to treat their anemia. Information about different types of anemia treatments are available in the Caregiver and womanarticles:

Improving Quality of Life

Anemia is a common problem for elderly patients and especially for residents in long-term care facilities. However, anemia should not be accepted as a normal consequence of aging, and it often times can be accurately diagnosed and treated. Reducing the symptoms of anemia and treating underlying conditions which are often its cause may improve a patient’s quality of life.

“Anemia should be on the mind when caring for all patients in the long-term care facility,” said Dr. Ershler. “From medical directors, to nursing staff to caregivers and family members; the awareness of anemia is important system wide.” Working together we can improve the lives of elderly patients with anemia.


  1. Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood 2004;104:2263-68. Link.
  2. Artz AS, Fergusson D, Drinka PJ, Gerald M, Gravenstein S, Lechich A, Silverstone F, Finnigan S, Janowski MC, McCamish MA, Ershler WB. Prevalence of anemia in skilled-nursing home residents. Arch Gerontol Geriatr. 2004 Nov-Dec;39(3):201-06. Link.
  3. Robinson B, Artz AS, Culleton B, Critchlow C, Sciarra A, Audhya P. Prevalence of anemia in the nursing home: contribution of chronic kidney disease. J Am Geriatr Soc. 2007 Oct;55(10):1566-70. Link.
  4. Elesevier Oncology. Guide to Oncology Drugs and Regimens 2006. Link.
  5. Jones A. The National Nursing Home Survey: 1999 summary. National Center for Health Statistics. Vital Health Stat 13(152). 2002. (PDF)
  6. van Dijk PT, Mehr DR, Ooms ME, Madsen R, Petroski G, Frijters DH, et al. Comorbidity and 1-year mortality risks in nursing home residents. J Am Geriatr Soc 2005;53:660-65. Link.