Anemia Express Report

Based on Data Presented at a Breakfast Symposium held during the 36th Annual Meeting & Exhibition of the American Society of Consultant Pharmacists, November 10, 2005, Boston, Massachusetts.

Publication date: 2005-12-31

Anemia in Long-term Care: Impact and Management

This report was reviewed for medical and scientific accuracy by Michael J. Germain, MD, FCCM, Associate Professor of Medicine, Tufts University; Medical Director, Renal Transplantation, Baystate Medical Center, Western New England Renal and Transplant Associates; Springfield, Massachusetts.

Expert Commentary

T.S. Dharmarajan, MD, FACP, AGSF, Chairman, Department of Medicine; Chief, Division of Geriatrics; Director, Geriatric Medicine Fellowship Program; Our Lady of Mercy Medical Center, Bronx, New York; Professor of Medicine, New York Medical College, Valhalla, New York

Anemia is common in older subjects and its prevalence increases with age.^1-3 The association between increased incidence of anemia and aging has led to speculation that anemia may be a normal consequence of aging, and thus, under-diagnosed. This rationale has resulted in the acceptance of anemia as an “innocent bystander” of the aging process, but the evidence suggests that anemia is not so innocent. Manifestations of anemia include lethargy, fatigue, insomnia, dyspnea, decreased aerobic capacity, impaired cognition, depression, functional decline, an increase in falls, and cardiovascular complications (left ventricular hypertrophy, angina, heart failure), amongst others. Moreover, anemia results in significant hospitalization, morbidity and mortality, ⁴ with an adverse impact on health care economics. ^5,6 Despite the prevalence of anemia, few clinical studies have systematically examined functional, clinical, and economic outcomes in elderly patients with anemia.

Aging by itself is unlikely to be the basis for anemia; rather patients should be investigated for the timely diagnosis of disease process. ⁷ A decline in hematopoietic reserve and the occurrence of cytokine dysregulation with altered sensitivity to erythropoietin may play roles. ⁷ The role of hepcidin, a hepatic hormone, which alters ferrokinetics, has recently received attention. ⁸

Even the definitions of anemia are controversial, particularly with respect to the validity of gender specific criteria. The National Kidney Foundation recommends that hemoglobin be maintained between 11 g/dL and 12 g/dL in patients with anemia of chronic kidney disease, regardless of gender. ⁹ But the generally accepted definition of anemia is from the World Health Organization (WHO) that defines anemia as hemoglobin values of <12 g/dL in women and <13 g/dL in men. ¹⁰ According to the Third National Health and Nutrition Examination Survey (NHANES III), ¹¹ 34.3% of anemia in individuals over 65 years of age may be caused by nutritional deficiencies (involving iron, folate, vitamin B₁₂ or combinations), with 32.1% by non-nutritional causes (renal insufficiency, chronic inflammation, or a combination of chronic disease and chronic inflammation), and 33.6% of unexplained etiology.

Once a diagnosis of anemia is made, one should proceed to look for an etiology; in cases where a specific etiology is identified, several safe and effective treatment options are available for treatment of anemia. Where possible, management is directed at the cause. In nutritional anemia, in addition to looking for a cause, iron, folate and vitamin B₁₂ (cyanocobalamin) replacement are treatment options.

In chronic kidney disease, erythropoiesis-promoting therapies (epoetin alfa, darbepoetin alfa) are available. The benefits of treatment with erythropoiesis-stimulating agents in chronic kidney disease and several other causes of anemia of chronic disease include a decrease in blood transfusions and improved exercise capacity, cognitive function, and quality of life.^12-15 The National Kidney Foundation has published clinical practice guidelines for the evaluation and treatment of anemia in chronic kidney disease.^9,16

In long-term care skilled nursing facilities, the manifestations, consequences and implications of anemia present a challenge for the management of th