Anemia in the Hospitalized Elderly

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Anemia in the Hospitalized Elderly

• Hospitalist Best Practice
• J Rush Pierce Jr, MD, MPH
• February 29, 2012

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Agenda

• Case
• Brief Literature review
• Special clinical considerations regarding anemia
  in elderly
• Hospital acquired anemia
• Transfusion for anemia in hospitalized elderly
• Discussion about consensus practice

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Case Q1

• 78 year old white man admitted with CAP.
• PMHx diabetes, HTN, CAD, h/o CABG, GERD
• Meds metformin, lovastatin, lisinopril, ASA,
  clopidogrel, pantoprazole.
• PE 135/76, 105, 38.4, RR 20, SaO2 88 RA 60
  kg. Sternotomy scar, signs of consolidation right
  base,
• guaiac neg
• Lab Hgb 13.3, MCV 85, glucose 225, creat
  1.0
• Q1 Should he be evaluated for anemia?

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Case Q2

• Two days later his Hgb is 11.2. You ask the
  intern why she thinks the Hgb has fallen by 2.1
  g/dL. She says its probably dilution due to the
  fluids he received.
• Q2 Do you agree?

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Case Q3

• On day 3, he falls going to the toilet and
  fractures his hip. He undergoes surgical repair.
  On the second post-operative day he is doing
  well. Hgb 8.2. Your resident suggests
  transfusing the patient because he has CAD and is
  going to start ambulation.
• Q3 Do you agree?

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Defining anemia in elderly
(Hgb, g/dL) (Hgb, g/dL)
Men Women
PowerChart lt 14.5 lt 12.0
Williams (US populations, does not include elderly) lt 14.0 lt 12.3
WHO (world populations, does not include elderly) lt 13.0 lt 12.0
NHANES III/Kaiser-Scripps (Caucasian race, age gt 60 yr ) lt 13.2 lt 12.2
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Prevalence of anemia in elderly

• Prevalence
• NHANES III (gt64 yrs) 11 (1 Hgb below 10)
• NHANES III (gt84 yrs) 20/26 (F/M)
• Observational studies show anemia in elderly
  assoc with poorer functional ability, impaired
  cognitive function, depressed sxs, poorer quality
  of life and increased mortality

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Etiology of anemia in elderly

• NHANES III (1988-1994)

• Stanford study (2006-2010)

• 1/3 nutritional (50 of these were iron def)
• 1/3 chronic dz (CRF most common)
• 1/3 unexplained (50 of these had some features
  of early myelodysplasia)

• 35 unexplained
• 22 hem malignancy including myelodysplasia
• 12 iron def
• 11 chemotherapy
• 6 chronic inflam dz
• 4 renal dz
• 10 other

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Evaluation of anemia in elderly

• Anemias in elderly often due to more than one
  etiology
• B12 absorption impaired with atrophic gastritis,
  H pylori infection, PPI use
• Only 4/26 pts with iron def in Stanford study had
  MCV lt 80
• Leukopenia, thrombocytopenia, macrocytosis
  frequently seen with myelodysplasia

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Iron deficiency in the elderly

• Importance of diagnosing iron deficiency in
  elderly (Gastroenetrol Clin Biol 200731169)
• 111 hospitalized pts gt 74 yrs with Fe def anemia
• 68 had bleeding source found on EGD/coloscopy
• 28 had colon cancer
• 5 had UGI malignancy
• Diagnosis
• Ferritin may be falsely elevated due to
  malignancy, so some advocate using higher cut-off
  (50)
• Some had advocated using sTfR/log ferritin ratio

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Case Q2

• Two days later his Hgb is 10.9. You ask the
  intern why she thinks the Hgb has fallen has
  fallen by 2.1 g/dL and she says its probably
  dilution due to the fluids he received.
• Q2 Do you agree?

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Hospital acquired anemia
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Causes of dilution anemia

• Acute blood loss with crystalloid replacement
• Pregnancy
• Plasma exchange/plt transfusion (mostly kids)
• Sports anemia (lt1.0 g/dL)
• Venous sample drawn from vein with infusion

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Anemia and CAP
BMC Pulm Med 2010 1015
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Case Q3

• On day 3, he falls going to the toilet and
  fractures his hip. He undergoes surgical reapir.
  On the second post-operative day he is doing
  well. Hgb 8.2. Your resident suggests
  transfusing the patient because he has CAD and is
  going to start ambulation.
• Q3 Do you agree?

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Transfusion for anemia in the elderly

• 428 pts post post-CABG (1999)
• 428 pts, transfuse Hgb lt8 vs usual care
• No diff in morbidity, mortality, fatigue
• TRICC (Transfusion Requirements in Critical Care)
  Trial (1999)
• 838 pts randomized to restrictive strategy
  (transfusion if Hgb lt 7) vs liberal strategy
  (transfusion if Hgb lt 10)
• Mortality less in restrictive group if APACHE lt
  21 (6 vs 16) if younger than 55 yrs (6 vs
  13)
• No diff if clinically significant heart dz (20
  vs 23)

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FOCUS (Functional Outcomes in Cardiovascular
Patients Undergoing Surgical Hip Fracture Repair)
Trial

• Perioperative patients with cardiovascular
  disease and gt 50 yrs
• Transfuse if Hgb lt 10 vs lt 8
• NHLBI sponsored, multiple centers, 2016 pts

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FOCUS Trial
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Recommended consensus practice

• Consider anemia in hospitalized elderly if Hgb lt
  13.2 in males and lt 12.2 in females
• Consider referral to GI, elderly patients with
  iron deficiency anemia
• In the absence of significant ongoing blood loss,
  transfusion will be generally reserved for
  elderly with sxs of anemia or Hgb lt 8
• Change Adult Admit order set, so that the default
  lab draw is once rather than daily for 4 days