12/1/2017 Comprehensive Review of Clinical  Laboratory Tests for Investigating  the Etiology of Anemia in the  Elderly.  December 15, 2017  Dennis J Chapron MS, RPh Medication Safety Pharmacist Saint Francis Hospital and Medical Center Hartford, CT  06105 Dennis J Chapron reports no real or  potential conflicts of interest  relevant to this lecture. 1 12/1/2017 At the conclusion of this knowledge‐based  activity, the participant will be able to: • Compare the kinetic vs the morphological approach  for identifying the cause of anemia.  • Discuss the laboratories tests used to investigate and  differentiate anemia due to nutrient deficiency, blood  loss, hemolysis, chronic inflammation, renal failure  and marrow failure. • Describe the physiological mechanisms that maintain  adequate nutrients for red cell production and how  diseases and medications adversely affect these  mechanisms.   WHO Definition of Anemia • In woman: hemoglobin concentration below 12 gm/dl. • In men: hemoglobin concentration below 13 gm/dL 2 12/1/2017 Hematocrit Approx 3 x Hgb Plasma Packed RBCs Anemia Severity Scale • Mild anemia – Hgb >10<12 • Moderate anemia ‐ Hgb >8≤10 • Severe anemia ‐ ≤8 3 12/1/2017 Estimated Anemia Prevalence in the  Elderly  Based on WHO definition  • 12% in those living in the community • 40% in those admitted to the hospital • 47% in nursing home residents  Hematologica 2014;99:1127 Some Disorders Associated with a High Prevalence of Anemia in the Elderly • Chronic upper and lower GI bleeding • Chronic inflammatory disorders • Heart failure • Cancer • Debility • Chronic renal failure • Unintentional weight loss 4 12/1/2017 Anemia is Often an Important Sign of an Underlying Pathological Process • Anemia is common in the elderly. • Anemia impacts morbidity • Anemia impacts mortality Am Fam Phys Sept 2010 5 12/1/2017 Anemia Morbidity/Mortality and QOL Anemia Disease M/M and QOL 6 12/1/2017 Anemia and the Elderly • Anemia in the elderly is due to a  primary underlying disease and is  not related to aging. Look for the  problem behind the problem. Anemia: Problems in Diagnosis and Treatment • Not recognized (not in problem list) • Recognized but not investigated • Recognized, investigated (at least partially), but failure to treat or considered not worth treating. • Recognized, investigated and treated suboptimally 7 12/1/2017 Types and Prevalence of Anemia  Observed in Geriatric Populations  • Anemia of chronic inflammation – 20% • Iron deficiency anemia – 17% • Vitamin B‐12 or folate deficiency – 15% • Chronic kidney disease – 9% • Kidney disease with inflammation – 5% • Unexplained anemia – 34%  NHANES III –Blood 2004;104:2263 2 Conceptual Views of Anemia  Etiology  8 12/1/2017 Kinetic Approach Steady-state [hemoglobin] PRODUCTION RATE [Hgb] = -------------------------------- CLEARANCE DJ Chapron Kinetic Approach Bone marrow Nutritional PRODUCTION RATE [Hgb] = -------------------------------- CLEARANCE Bleeding Hemolysis DJ Chapron 9 12/1/2017 Hematology –Basic Principles and Practices  2013  Chronic inflammation Hemolysis MDS/Ca Bone marrow RBCs EP Kidney Bleeding Iron, B-12, folate DJ Chapron 10