Studies show that hemoglobin (Hb) levels progressively decline, as part of the aging process, leading to Hb levels in most elderly persons that are slightly lower than the lower limit of normal. Although anemia is viewed by most physicians as having no clinical significance and no independent effect on health, it has been shown to be associated with a number of health indicators. Several cross-sectional studies have found an association of anemia with a variety of physical and health issues in elderly persons. Some of these findings include diminished physical performance and muscular strength and increased risk of frailty and fall injury events.

In a prior study of elderly persons (65+) conducted in Italy, researchers found that the prevalence for dementia, cognitive impairment, functional disability, and health problems was greater in the oldest members of the elderly population. These findings prompted the authors to separate the population into a younger (65-84 years old) and older (85 +) cohort. The study described below, Health and Anemia, is an observational study of the younger cohort (65-84 years old) to determine the prevalence of dementia, cognitive impairment, functional disability, and health problems.

The objective of this cross-sectional study was to investigate the association of mild anemia with cognitive, functional, mood, and quality of life variables, using the Geriatric Depression Scale-10, Short-Form health survey (SF-12), and the Functional Assessment of Cancer Therapy-Anemia.

The study population was based on older individuals residing in the municipality of Biella, Piedmont, Italy on May 12, 2003. Among the 10,110 community dwelling residents, factors consisting of death, inability to contact, and refusal or inability to participate, resulted in a remainder of 4,501 individuals who agreed to take part in the study. Exclusion criteria led to a total study population of 547 non-anemic persons and 170 mild anemic persons. Mild grade anemia was defined as an Hb concentration between 10.0 and 11.9 g/dL in women and between 10.0 and 12.9 g/dL in men. Individuals with a Hb concentration below 10 g/dL were excluded. Possible differences based on demographic and clinical characteristics were controlled by comparing the study population to individuals, not included in the study. Univariate analyses and multivariable adjusted regressions were used to determine associations.

Results on almost all cognitive, functional, mood, and quality-of-life measures were significantly worse in mild anemic elderly persons. After controlling for various demographic and clinical confounders, analysis by multivariable logistic regression found mild anemia to be significantly associated with measures of selective attention and disease-specific quality-of-life measures (all fully adjusted p=0.046). Using the lower limit of normal Hb concentration according to WHO criteria, differences between mild anemic and non-anemic elderly persons tended to be increased on almost every variable. Results of the study are especially important, since mild anemia is typically overlooked in the elderly. Further studies using longitudinal and clinical trial designs would further increase our knowledge of potential risks of mild anemia in the elderly.

Association of mild anemia with cognitive, functional, mood and quality of life outcomes in the elderly: the "Health and Anemia" study. Lucca U, Tettamanti M, Mosconi P, Apolone G, Gandini F, Nobili A, Tallone MV, Detoma P, Giacomin A, Clerico M, Tempia P, Guala A, Fasolo G, Riva E. PLoS ONE. 2008;3(4):e1920.

NAAC Expert Commentary:
This cross-sectional study analyzed the impact of mild anemia on cognition, function, and quality of life among Italians from 65-84 years of age. The authors report that the presence of anemia showed an adverse association with most outcomes. Although statistical adjustment negated many of these associations, the adverse impact of anemia on disease-related quality of life persisted.

The limitations of cross-sectional association studies are well appreciated. Beyond this, methodology problems hinder drawing conclusions in this study. The excessive number of outcomes and multiple covariates used in adjustment runs the risk of both false negative and false positive findings. The statistical evaluation would also have benefited from interrogating hemoglobin (Hb) in 1 g/dL categories and assessing for trends. Data on Hb concentrations where outcomes are best (i.e. best quality of life or least functional impairment) provides insight into optimal Hb values.

Despite these limitations, the data reported herein are remarkably consistent to other published data. Prior studies on cognition and anemia have generally not been able to demonstrate an independent association between anemia and diminished cognition. Although not emphasized by the authors, the association of anemia to reduced quality of life in the physical aspects but not emotional components of the instruments may have been the most intriguing finding. This supports the concept that mild anemia could directly cause functional impairments and fatigue through reduced muscle oxygenation.

Last Modified: May 1, 2008