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ANEMIA IN THE ELDERLY
Special Considerations Regarding
Management
Canadian Multicentre Anemia Symposium
22 Anemia A!areness "ee#
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Anemia in t$e Elderly
Anemia in the elderly is not part of normal aging.
Anemia is common & increases with each
successive decade.
Prevalence 10-45 with an incidence !etween 10-15
per 1000.
"igher in men than women of any given ageand in Afro-Americans.
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Anemia in t$e Elderly
Special Considerations
#ultifactorial often with multiple medical pro!lems& polypharmacy.
$nset of symptoms is usually insidious & fre%uently
nonspecific.
Anemia in the elderly has increased conse%uences.
'( indices often unrelia!le.
#yelosuppression more common & severe.
)uality of life issues may !e more pronounced.
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Anemia in t$e Elderly
Time o% Diagnosis
Annual medical e*amination +
$nset of acute medical pro!lem ,
ollow up of a chronic medical pro!lem
ollowing admission to hospital +5
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Anemia in t$e Elderly
#ultiple diagnoses 5/
o diagnosis 1+
ingle diagnosis /0
Anemia of chronic disease 10
#alnutrition
2nfection 4
Postoperative !leeding /Alcohol 1
2ron deficiency 1
Modified from Principles of Geriatric Medicine and Gerontology 4th
ed. 1999
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Anemia in t$e Elderly
Anemia o% C$ronic Disease
Most common cause o% anemia in $ospitali&ed patients'
Anemia correlates !it$ se(erity o% underlying disease'
Serum eryt$ropoietin le(els may )e inappropriately lo!'
Response to eryt$ropoietin administration (aria)le'
In selected diseases *e'g' Myeloma+ RA+ CR,- responses to
eryt$ropoietin possi)le !it$ serum le(els . 2 /0L *N+ 12 32-'
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Anemia in t$e Elderly
Diseases Associated !it$ Anemia o% C$ronic Disease
Acute in%ections Malignancy
C$ronic in%ections #etastatic carcinoma
3u!erculosis "ematologic malignancies
2nfective endocarditis euemia
(hronic urinary tract infection ymphoma
(hronic fungal infection #yeloma
C$ronic in%lammatory disorders C$ronic renal insu%%iciency
$steoarthritis Hypot$yroidism
heumatoid disease 4rotein5energy malnutrition (ollagen vascular disease
Polymyalgia rheumatica
Acute and chronic hepatitis
6ecu!itus ulcer
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Anemia in t$e Elderly
Anemia o% C$ronic Disease4at$ogenesis
2mpairment of iron utili7ation
2nhi!ition of erythropoeisis
'lunted response to erythropoietin
educed '( survival
4ossi)le %unctional adaptation o% innate immune system
2ron se%uestration as a micro!icidal strategy
Altered macrophage responses
Cyto#ine mediated
3h1 - 28 3, 1
3h9 : 2-48 2-108 2-;
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Anemia in t$e Elderly
Iron De%' ACD
erum iron educed educed
32'( 2ncreased educed
3ransferrin saturation educed ormal
erum ferritin educed ormal or2ncreased
Plasma transferrin receptor 2ncreased ormal
3ransferrin receptor < ferritininde*
"igh ow
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Anemia in t$e Elderly
Sensiti(ity 6 Speci%icity o% Serum ,erritin in Iron De%iciency Anemia
Serum %erritin
*ug per L- Sensiti(ity *7- Speci%icity *7-
Li#eli$oodratio8
. 2 9: ;1
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Anemia in t$e Elderly
>12 de%iciency o%ten unrecogni&ed in t$e elderly
3ypical signs & symptoms of '19 deficiency often not present.
$nly a!out ;0 of pts. with '19 def are anemic.
'19 deficiency accounts for anemia in 5-10 of elderly patients.
2nade%uate a!sorption occurs in 10-/0 of pts. with partial gastrectomy.
Pernicious anemia undiagnosed in 9 of healthy individuals over ;0 yrs.
eurologic symptoms may precede anemia.
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Anemia in t$e Elderly
Neurological presentation o% >12 de%iciencyParesthesias of fingers & toes
educed vi!ration sense =95;-"7> & proprioception
Ata*ia =(om!ined system disease>
Perversion of taste & smell
$ptic atrophy
6ementia8 #emory oss & 6epression
?#egalo!lastic #adness@ : Paranoid chi7ophrenia
pecific #2 a!normalities
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Anemia in t$e Elderly
?itamin >12 de%iciencyerum '19 levels do not relia!ly predict tissue deficiency.
erum or urine methylmalonic acid & serum homocystiene
more relia!le indicators of tissue '19 levels.
creening in elderly if serum '19 9;0 pmol
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Anemia in t$e Elderly
Myelodysplastic *MDS- Syndromes
Most cases occur )et!een @59 years'
MDS may represent up to 37 o% anemia in elderly'
1' Ine%%ecti(e $ematopoiesis'
- Anemia present in =597 o% cases'- Neutropenia in 37 o% cases o%ten !it$ monocytosis'
- T$rom)ocytopenia in 237 o% cases'
2' Clonal E(olution
- 15:7 de(elop AML'
- C$romosome a)normalities in :7 o% casesTrisomy =
3 6 ; deletions *CS,s-
112< *MLL gene-
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Anemia in t$e Elderly
Myelodysplastic Syndromes
Supporti(e care remains maBor treatment approac$
: Trans%usions+ Amicar+ Anti)iotics
/npro(en t$erapies
: Trans%usions des%erral administration'
: Epo 5CS, Dana&ol'
Eperimental t$erapies
: Immune t$erapies AT+ CSA+ T$alidomide
: C$emot$erapy anti5CD
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Anemia in t$e Elderly
Indications %or >one Marro!
9 or more cell lines affected
#onoclonal gammopathy
2ndeterminate iron status
euoerythro!lastic peripheral smear
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Anemia in t$e Elderly
4otential Areas o% ,uture Researc$
Etiology 6 treatment o% myelodysplastic syndrome'
Nutritional )ene%its o% L5carnitine'
Regulation o% eryt$ropoiesis'
Com)ination gro!t$ %actor t$erapy'
Tools %or ,atigue 6 FGL assessments'
E%%ects o% anemia on sur(i(al 6 t$erapy responses in cancer'
Immunomodulatory 6 neurocogniti(e e%%ects o%
eryt$ropoietin'
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Canadian Multicentre AnemiaSymposium
22 Anemia A!areness "ee#
!!!'anemiainstitute'org
Supported by an unrestricted educational grant from Janssen-Ortho nc.
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