University of Alabama at Birmingham
School of Medicine
Anemia in the Elderly

Anemia is a common clinical problem in the elderly- studies have shown a high
prevalence of anemia in hospitalized older subjects, institutionalized older
individuals and patients attending geriatric clinics.

In general, the population incidence of anemia is 2% while in oldest old (>85yrs)
it is 13%per year.

Hemoglobin of 12gm/dl is considered the lower limit of normal for elderly men
and women. The workup for anemia in the aged population is similar to that in
younger adults.

Hypoproliferative anemias form the majority of anemias in the elderly with
anemias of chronic disease composing the most common etiology. In younger
people iron deficiency anemia is the common cause. Multiple myeloma should be
considered in elderly persons with anemia, hypercalcemia, and bone pain.

Blood loss and anemia associated with protein energy malnutrition represent the
other prevalent causes of hypoproliferative anemias in elderly. Frequent causes of
blood loss in the elderly include drugs (aspirin) and bleeding due to a neoplasm.
Angiodysplasia of the large bowel and diverticular disease are also frequent
causes but should be considered only after a neoplasm has been excluded.

Ineffective erythropoiesis with macrocytosis in aged persons commonly occurs
from B12 or folate deficiency. Cobalamine deficiency in the elderly is not only
due to Pernicious Anemia but also from food-cobalamine malabsorption –which
is not detected by the Schilling test. High-dose (i.e., 1 mg) oral B12 effectively
treats the deficiency regardless of the cause. Thus, there is less need to perform
Schilling tests. Major causes of ineffective erythropoiesis and microcytosis are
thalassemia and sideroblastic anemias.

Acquired Sideroblastic anemia is primarily a condition of elderly. The disorder is
a consequence of impaired heme synthesis characterized by the presence of iron
deposits in the mitochondria of normoblasts.

Myelodysplastic syndromes are a group of stem cell disorders characterized by
disordered hematopoesis, which occur primarily in older adults. The median age
at presentation is 66 years and is characterized by 1) macrocytic anemia, 2)
modest leucopenia, 3) normal or increased platelet counts, 4) marrow erythroid
hypoplasia or hyperplasia and 5) female preponderance. Treatment is supportive.
University of Alabama at Birmingham
School of Medicine

Autoimmune hemolytic anemia is the most common cause of hemolysis in elderly
persons. The etiology is rarely identified in younger adults while in elders; it is
commonly associated with lymphoproliferative disorders (e.g., non-Hodgkin’s
lymphoma or CLL), collagen vascular diseases and drug ingestions.

The presence of multiple pathologies frequently makes the evaluation of anemia
difficult in older persons. Clinical judgment is critically important in deciding
how aggressive the workup for anemia ought to be.
References
1. Anemia and aging: an overview of clinical, diagnostic and biological issues.
J.Blood Rev 2001; 15: 9 – 18.
2. Anemia in the elderly, J Am Fam Phys 2001; 62:
3. Vitamin B12 deficiency in the elderly: current dilemmas. J.Am Clin Nutri
1997; 66: 741 – 9.
4. Anemia. In Principles of Geriatrics, 3rd Ed eds: Hazzard.1996
Supported by a grant from the Association of American Medical Colleges and the John A. Hartford
Foundation.