Review
Anaemia in the elderlyLa anemia del anciano

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Abstract

Anaemia is common in the elderly and is associated with an increased risk of physical, functional, and cognitive impairment, hospitalization and mortality. Although it is unknown whether anaemia is a causal factor or a subrogated marker of worse health status, its correction can improve the patients’ physical and functional capacity. Detection, classification, and treatment of anaemia should be a priority for the health system. The main causes of anaemia in the elderly are nutritional deficiencies and chronic disease, with or without kidney failure, although some cases are of indeterminate origin. Medical history and physical examination help to clarify its aetiology. A diagnostic algorithm based on data from the lab allows anaemia classification with a therapeutic orientation. Supplements of iron and maturation factors, as well as erythropoiesis-stimulating agents, constitute the mainstay of treatment, along with that of the underlying disease, whereas red blood cell transfusion should be reserved for severe cases.

Resumen

La anemia es frecuente en los ancianos y se asocia con un mayor riesgo de deterioro físico, funcional y cognitivo, hospitalización y mortalidad. Aunque desconocemos si es un factor causal o un marcador subrogado de un peor estado de salud, su corrección puede mejorar la capacidad física y funcional. Su detección, su clasificación y su tratamiento deberían ser objetivos prioritarios para el sistema de salud. Sus principales causas son las deficiencias nutricionales y las enfermedades crónicas, con y sin insuficiencia renal, aunque algunas son de origen desconocido. La historia clínica y la exploración física ayudan a aclarar su etiología. Un algoritmo diagnóstico basado en los datos del laboratorio permite su clasificación con orientación terapéutica. Los suplementos de hierro y factores madurativos y los agentes estimuladores de la eritropoyesis constituyen la base del tratamiento, junto con el de la enfermedad de base, reservándose la transfusión de hematíes para los casos graves.

Introduction

The average life expectancy has increased drastically over the last century (from ≈60 years in 1900 to ≈80 years in 2015) and is estimated to increase further in the future.1 In the European Union, the proportion of individuals ≥80 years will triple between 2011 and 2060.2 With age there is an inevitable deterioration of the organic functionality (ageing) that eventually leads to death. Age is also a risk factor for common processes, whether diagnosed or not, such as cardiovascular disease, cancer, diabetes or Alzheimer's disease, which increase the risk of mortality.1

Factors responsible for the phenotypic changes leading to the loss of physiological reserve, organic failure and reduction of the functionality have a role in the ageing process. The sum of these factors would give rise to the clinical features in the elderly: frailty, anaemia, malnutrition and poor immune response.1 Whether anaemia is an independent risk factor for functional impairment, a surrogate marker of a worse health status or simply an additional comorbidity, is something that we still do not know.

A better understanding of the molecular basis of ageing would facilitate the development of interventions that, if applied early, could prevent, delay, alleviate or even reverse some of the diseases related to ageing, thereby gaining years of independent living. That is, we would not only add “years to life”, but also “life to years”.

Section snippets

Definition and prevalence of anaemia in the elderly

According to the World Health Organization (WHO), the concentration of haemoglobin (Hb) that defines the presence of anaemia in the elderly would be <13 g/dl in men and <12 g/dl in women.3 With these definitions, between 1993 and 2005 anaemia affected 24% of the world's elderly (164 million individuals), although with important regional differences.4 However, there are authors who question its validity in the elderly, in whom an Hb value near the lower limit of normality could be associated with

Consequences of anaemia in the elderly

Anaemia reduces physical capacity and muscle strength in the elderly, decreasing mobility and quality of life.16 In addition, it increases the risk of fatigue, depression, dementia, hospitalization (due to exacerbations of intercurrent disease, falls) or admission to nursing homes (due to exacerbation of functional deterioration) and mortality (especially if accompanied by other disorders such as heart or kidney failure, high blood pressure or diabetes).17, 18 In a meta-analysis of 24 studies

Causes of anaemia in the elderly

Anaemia in the elderly usually has a multifactorial origin; all pathophysiological mechanisms are possible and many of them are simultaneous. In the NAHNES III study, nutritional deficiencies were responsible for 34% of the cases, while chronic diseases, with and without renal failure, accounted for another 33%.7 In 33% of cases, it was not possible to identify the aetiology (unexplained anaemia in the elderly [UAE]).7 The high prevalence of UAE (25–45%) in large epidemiological studies on

Diagnosis of anaemia in the elderly

Anaemia in the elderly is usually mild-moderate and the onset of symptoms is insidious, so its clinical symptoms are not normally very helpful for diagnosis. Decreased physical activity, fatigue, weakness and dyspnoea can be attributed to the ageing process or the worsening of intercurrent diseases; not so the pallor reflected by low levels of Hb (<9 g/dl). It is often a casual finding in laboratory tests requested for any other cause (e.g., preoperative laboratory tests, health examinations).

Treatment of anaemia in the elderly

Healthy elderly do not have to suffer anaemia, rather, they should have levels that are close to the lower limit of normal. Therefore, it is very common for anaemia to be of mixed aetiology, depending on the comorbidities, and its treatment must be etiological (or, failing that, pathophysiological). Iron and maturation factor supplementation and erythropoiesis stimulating agents (ESA) form the basis of treatment, together with that of the underlying disease, with red blood cell transfusion

Conclusions

  • Anaemia in the elderly is common, increases with age and is an independent risk factor for greater morbidity and mortality in this population.

  • There is no consensus on the level of Hb that defines the presence of anaemia in the elderly, nor on what is the “healthy level of Hb” in these individuals, according to their age and comorbidity.

  • The correct classification of anaemia in the elderly can be complicated due to the presence of multiple comorbidities, it requires persistence and yet it is not

Conflict of interest

The authors declare no conflict of interest.

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    Please cite this article as: Gómez Ramírez S, Remacha Sevilla ÁF, Muñoz Gómez M. La anemia del anciano. Med Clin (Barc). 2017;149:496–503.

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