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.