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Anemia is prevalent in the aging population. Several

observational population-based studies have demonstrat-

ed decreasing hemoglobin (Hb) levels with advancing

age1 as well as high rates of anemia in community-

dwelling elderly individuals.2 Unfortunately, even as it is

common, the level of its recognition as an important clin-

ical entity in certain individuals may be relatively low.

Anemia is rarely an admitting diagnosis3 and cases classi-

fied according to standard definitions may not be treated

at all.4 However, emerging data support more vigilance

and possibly higher rates of treatment for anemia in

elderly individuals. This article will discuss the rationale

for i n c reased awareness of anemia, the consequences of a n e-

mia, and potential etiologies that increase risk of adverse events.

A summary of potential signs and symptoms of anemia

(Figure 1) reveals that many of the body’s systems may be

adversely affected.5 Central nervous system signs of ane-

mia include fatigue, vertigo, depression, and low cogni-

tive function. Gastrointestinal symptoms may include

anorexia and nausea. Vascular changes may cause low

skin temperature and pallor, and there may also be

immune system effects, such as impaired T-cell and

macrophage function. Of particular concern are the effects

of the relationships among anemia, chronic kidney dis-

ease (CKD), and cardiovascular disease.

As discussed in Section I, anemia may be implicated in

several nursing home quality indicators, such as rates of

cognitive impairment, rates of decline in mobility, rates of

decline in activities of daily living, and rates of bedfast

residents.6 Thus, the finding of even mild anemia in an

elderly nursing home patient may be a good reason to

pursue the cause and consider an intervention. The

National Kidney Foundation (NKF) recommends that a

workup for anemia be initiated if Hb is less than 12 g/dL.

More than one method is available to assess anemia and

renal function7 in the elderly, and the specificity for our

population at risk continues to be debated ( Tables 1 and 2).

The basic laboratory parameters are useful in identifying

the etiology of anemia and potential for meaningful ther-

apy. In elderly patients, blood loss and nutritional defi-

ciency must be ruled out. After that, look for a multifacto-

I I . A n e m i a — Why It Is ImportantEric G. Tangalos, MD, FACP, AGSF, CMD

Figure 1: Signs and symptoms of anemia.5 Adapted from Semin Oncol.1998;25(suppl 7):2–6.

Table 1: Basic laboratory evaluation.

Table 2: Kidney function assessment.7

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6

rial etiology based on problems with erythropoesis. As the

molecular basis of anemia is better understood, the roles

of erythropoietin deficiency and erythropoietin resistance

associated with chronic or occult kidney disease are

assuming more importance as primary causes of anemia

in elderly patients. Anemia due to CKD can have debili-

tating effects on the patient by producing lethargy, weak-

ness, and cardiac symptoms.8

In long-term care settings, significant rates of age-related

decline in renal function have been observed. In a recent

study from Canada, nearly 40% of the residents in 87

long-term care facilities had a glomerular filtration rate

(GFR) less than 60 mL/min/1.73m2.9 The strength of the

link between rates of renal insufficiency and anemia is

also becoming clearer. A recent study in a health mainte-

nance organization of more than 220,000 adult patients

with elevated serum creatinine levels showed that as

serum creatinine rose, the risk of anemia and the severity

of anemia increased.10 Also, in a nationwide analysis of

patients who became eligible for renal dialysis due to end-

stage renal disease, 51% had anemia and only 20% of

these patients had received treatment for it before begin-

ning dialysis.11

As discussed in Section III, recent research has demon-

strated that anemia of CKD is a significant risk factor for

increased morbidity and mortality due to cardiovascular

events.12 Abnormal GFR was specifically implicated as an

independent risk factor for death from any cause, cardio-

vascular events, and hospitalization in a large (n = 1.1 mil-

lion) diverse population of adults from an integrated

health care delivery system.13

Anemia and GFR abnormalities have been associated,

independently and additively, with increased risk of mor-

tality in patients who undergo percutaneous coronary

interventions.14 Evidence is emerging on the impact of cor-

recting even mild anemia in patients with congestive

heart failure (CHF). In an open-label uncontrolled study,

179 diabetic and nondiabetic patients with severe resistant

CHF and mild anemia were treated with erythropoietin

and iron therapy for an average of 11.8 months. During

the treatment, significant improvements in heart function,

symptoms, and hospitalization rates were observed com-

pared with baseline measurements (Table 3).15 Progression

of renal failure (shown by changes in serum creatinine

levels and creatinine clearance) was also tracked. During

the treatment, significant improvement in heart function,

symptoms, and hospitalization rates were observed com-

pared with baseline measurements (Table 3), and progres-

sion of renal failure was slower during the intervention

period than during an equal period before intervention.15

The decreased rate of hospitalization should be of partic-

ular interest to the long-term care community, for whom

transitions of care will be important quality indicators.

Many laboratories now routinely report creatinine clear-

ance rates, and GFR can be calculated through a number

of medical software programs found on hand-held per-

sonal digital assistants using either the Modification of

Diet in Renal Disease or the Cockcroft-Gault equation

(Table 2). The NKF has produced a treatment algorithm

Table 3: Anemia correction may improve cardiac function and reducehospitalizations.*15 Adapted and reprinted with permission fromNephrol Dial Transplant. 2003;18:141-146.

*179 Diabetic and nondiabetic congestive hearth failure patients

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for anemia associated with CKD (Figure 2) that further

helps initiate an evaluation that will improve manage-

ment of these patients.16

The link associating anemia and CKD is becoming more

important to our practice. This combination of conditions

is a common marker for frailty and a serious problem for

the elderly. Anemia of CKD contributes to morbidity and

mortality that is especially associated with cardiovascular

disease. Correction of even mild anemia in elderly

patients may have multiple benefits. Clinically meaning-

ful outcomes for this population at risk still need to be

studied.

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