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Evidence has shown that anemia prevalence increases as patients grow older, but it and its effect on quality of life should not be considered an inevitability of old age. This is especially true for patients in long-term care facilities who are many times more likely to have anemia than their community-dwelling counterparts. In fact, approximately half of elderly residents in long-term care have anemia. This article discusses the frequency of anemia, the effect it can have on elderly patients in long-term care, and emphasizes the importance of proper and thorough evaluation.

Commonality of Anemia in Long-Term Care

As people grow older, average hemoglobin levels steadily decline and rates of anemia increase for reasons that are not entirely known.^1,2 This general trend eventually results in 10% of adults over the age of 65 in the United States being anemic – as defined by the World Health Organization as a hemoglobin concentration <12 g/dL for women and <13 g/dL for men.^3,4 For patients in long-term care facilities, this increased prevalence is even more pronounced with roughly half of residents possessing anemia. Two multi-institutional studies of long-term care patients reported 48% and 60% prevalence rates of anemia for populations of 900 residents median aged 79 years and 6,200 residents median aged 83 years, respectively.^5,6

Despite higher prevalence rates, recognition of anemia in long-term care residents may not always keep pace. For instance, only 2.4% of nursing home residents from a 1999 national survey had been diagnosed with anemia.⁷ 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.⁸

Also of consideration when caring for elderly patients is that unlike children, adolescents and adults, elderly men are more likely to have anemia than women. The shift in prevalence between gender is largely a result of the end of menstrual blood loss for women and the differing Hb definition of anemia of <12 g/dL and <13 g/dL for women and men, respectively.² Additionally, people of African and Mediterranean decent have a higher risk of anemia due at least in part to biologic differences that on average cause them to have a lower Hb level. In one study, the median Hb level for elderly patients of African decent had been approximately 0.8 g/dL lower than their Caucasian counterparts.^9,10

Associated Risks of Anemia in the Elderly

The direct effects of anemia may not always be clear, but the presence of anemia has been associated with a wide variety of physical and mental impairments, other chronic conditions and increased mortality. How anemia is related to each of the following ailments is not always clear, but the detrimental association warrants careful consideration by medical professionals caring for elderly patients in long-term care.

Symptoms – For many elderly patients with mild to moderate anemia there might be few if any recognizable anemia-related symptoms like fatigue, dizziness or a reduction in concentration that can be attributed to anemia. Sometimes, even the symptoms that have manifested may have done so slowly enough that their onset has not garnered the attention of caregivers or the patient themselves. If Hb levels continue to drop and anemia worsens however, symptoms typically become more pronounced. Close monitoring and documentation of symptoms by medical staff is important for patients in long-term care.

Frailty and Falls – The decline in physical ability as people get older is an undeniable fact of nature. As noted by Dr. Andrew Artz, a hematologist concentrating in hematologic disorders in geriatric patients at the University of Chicago, “Not all frail patients are in long-term care, but a majority of long-term care patients are considered frail by standard measures.” Frailty and reduced physical mobility can, in concert with anemia, leave many elderly patients at-risk for falls and consequent injuries thereafter. In one study, falls occurred in 30% of anemic individuals compared to 13% of non-anemic individuals.¹¹ Strong associations have also been demonstrated between anemia and other measures of reduced physical ability such as sarcopenia, strength and mobility.¹ Additionally, some physical impairments correlate with decreases in Hb level, even above the threshold for anemia.

Functional Dependence – A reduction in mobility and the ability to perform daily tasks can have a significant effect on an elderly patient’s quality of life. Studies have demonstrated that reductions in Hb levels below 13.5 g/dL can lead to the inability to perform instrumental activities of daily life, resulting in functional dependence and potentially serious social and health consequences for patients over age 65.¹² Analysis of dependency in long-term care reported 51% of functionally dependent residents were anemic and 12% of non-dependent residents had anemia.^13,14

Cognitive Impairment – At any age, anemia may be associated with trouble concentrating or performing mental tasks. For elderly patients, the presence of anemia has been correlated with reduced cognition and dementia. As forgetfulness and other mental stumbles are common as we get older, serious lapses should not be overlooked as possibly being contributed to by anemia.

Morbidity and Mortality – Prolonged anemia can have detrimental effects to cardiovascular health. It is associated with myocardial infarction, worse outcomes following an infarct, and the presence of left ventricular hypertrophy (LVH).^15-17 In a variety of settings, including elderly populations, anemia is associated with increased mortality.^1,10 For instance, in a chart review of over 40,000 patients in long-term care, documented anemia correlated with one-year mortality.⁸

Despite the litany of reports demonstrating the association anemia has with a variety of serious maladies, clinical evidence proving that treating anemia is beneficial remains absent. “There is a an urgent need to establish whether correction of anemia in these settings may reverse or delay the manifestations that can shorten a person's life, compromise their quality of life, and increase the cost of management,” commented Dr. Lodovico Balducci, Chief of the Division of Geriatric Oncology, Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center & Research Institute.

Causes of Anemia in Elderly

Multiple factors can often contribute to anemia diagnosed in elderly patients, with about two-thirds of cases being attributed to chronic conditions and nutritional deficiencies. In up to one-third of instances, a definite cause for anemia cannot be identified.¹³ “In elderly persons the etiology of anemia differs sufficiently from younger adults to warrant considering anemia in elderly persons as a distinct entity,” commented Dr. Artz.

Elderly patients often suffer from multiple chronic comorbidities and it is not surprising that the anemia of chronic disease (ACD) is a common cause of geriatric anemia. Characterized by low serum iron and adequate iron stores, ACD appears to be primarily related to inflammation, and usually develops in the presence of disorders such as chronic infections, malignancy, autoimmune and inflammatory disorders.¹⁸ Chronic kidney disease (CKD) and the associated reduced erythropoietin production is a common cause of anemia in long-term care residents, and had been reported as high as 43% of residents on one study.^6,14

Nutritional deficiencies of iron, folate or vitamin B12 are the cause of anemia in one-third of patients over 65 years of age.¹⁹ Reports have shown that approximately 20-40% of long-term care residents will have iron deficiency.^20-22 Although deficiencies are prevalent, they are not as common in long-term care residents as with younger patients. Some of the reason for reduced deficiencies may be attributed to regimental doses of vitamins and supplements provided by some care facilities.

More information about the causes of anemia in the elderly can be found in the article Tracking and Treating Anemia in Elderly Patients and the Anemia Monograph chapter Anemia & Aging.

Maintaining Quality of Life

Anemia is a common problem in long-term care residents but it should not be accepted as a normal consequence of aging. Clinicians should be aware that anemia in elderly persons is associated with poorer quality of life, significant morbidities, and increased mortality.

Dr. Balducci emphasizes for clinicians that, “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.”

References

1. Artz AS. Anemia and the frail elderly. Semin Hematol. 2008 Oct;45(4):261-66. Link.
2. Artz AS, Ershler WB. Anemia in Elderly Persons. EMedicine. Link. Accessed: December 15, 2009.
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4. World Health Organization. Worldwide Prevalence of Anaemia 1993-2005: WHO Global Database on Anaemia. Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell Link.
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Last Updated: February 24, 2009