Anaemia in elderly patients.

Abstract

Dear Sir, We read with interest the article by Dr. Lippi et al. about the contribution of renal impairment to anaemia in elderly patients1. It was a well-designed study on a very interesting topic. However, in our experience, some points need additional development. Anaemia is a common condition in elderly patients and its prevalence increases with age. According to the third National Health and Nutrition Examination Survey (NHANES III) carried out in the United States, the prevalence of anaemia was 11% in community-dwelling men and 10.2% among women = 65 years of age2. Anaemia can impair quality of life as well as cognitive and physical functions and is a co-morbid condition that affects other diseases (e.g. heart disease, cerebrovascular insufficiency) and is even associated with a risk of death3. Thus, anaemia should not be accepted as a consequence of aging and must be explored. In our experience, elderly patients often have several associated co-morbid conditions, including renal insufficiency, and are commonly taking a variety of medications, some of which may contribute to anaemia. Thus, a sole aetiology of anaemia is frequently difficult to determine even after extensive investigations, including bone marrow examination4. Nevertheless, the aetiology of anaemia in the elderly can be identified (in approximately in 80%). In these cases, a significant proportion of elderly anaemic patients are presumed to have multiple causes of their anaemia (30–50%), often including renal impairment (not exclusively)3,4. The causes of anaemia in the elderly can be divided into three broad groups: (i) nutrient-deficiency anaemia, which is most often iron-deficiency anaemia; (ii) anaemia of chronic disease, perhaps better termed anaemia of chronic inflammation; and (iii) unexplained anaemia3. In the NHANES III study, 34% of all the cases of anaemia in elderly patients were caused by folate-, vitamin B12-, or iron-deficiency, alone or in combination (nutrient-deficiency anaemia), only 12% were associated with renal insufficiency, 20% were due to chronic diseases, and in 34% the cause remained unexplained (including myelodysplasia…) 2. About 60% of cases of nutrient-deficiency anaemia are associated with iron deficiency and most of those cases are the result of chronic blood loss from gastrointestinal lesions. The remaining cases of nutrient-deficiency anaemia are usually associated with vitamin B12 and/or folate deficiency and are easily treated. In Table I we have reported the aetiology of anaemia in 300 hospitalised patients =65 years old (personal communication at the French Congress of Internal Medicine, Aix-en-Provence, France; June 2001). Table I Aetiology of anaemia in 300 consecutive patients older than 65 years, hospitalised in a department of internal medicine in a tertiary reference centre (personal communication at the French Congress of Internal Medicine, Aix-en-Provence, France; June 2001). ... In our experience both vitamin B12 and folate deficiencies are common among the elderly, each occurring in at least 5% of the patients4. The Framingham study demonstrated a prevalence of 12% among elderly people living in the community3,4. In elderly patients, the aetiologies of cobalamin deficiency are primarily food-cobalamin malabsorption and pernicious anaemia and, more rarely, intake deficiency and malabsorption. In a cohort in which we followed more than 200 elderly patients with a proven nutrient deficiency, food-cobalamin malabsorption accounted for about 60% to 70% of the cases of cobalamin deficiency, while pernicious anaemia accounted for 15% to 25%. Food-cobalamin malabsorption is caused primarily by atrophic gastritis. Over 40% of patients over 80 years old have gastric atrophy that might or might not be related to H. pylori infection4. Many underlying conditions lead to anaemia in the elderly, but the most common are nutrient deficiencies, especially iron deficiency, folate (folic acid, vitamin B9) deficiency and vitamin B12 (cobalamin) deficiency3,4. In our opinion, recognition of these deficiencies (and thus screening for them) is a prerequisite of successful therapy. In fact, all these nutrient-deficiency anaemias are easily treated with nutrient replacement5.