1. State the World Health Organization criteria for defining anemia
and discuss issues related to this definition.
2. Compare the prevalence of anemia in a variety of subgroups in
persons over age 65.
3. Discuss the physical, cognitive, and economic impact of anemia
in the elderly.
4. Characterize the major causes of anemia in the geriatric
5. Explain laboratory tests and results useful in identifying the
cause of anemia in the elderly.
Demographic data combined with the results of recent studies
indicate that anemia is a significant health concern for our aging
population. As of 2006, more than 37 million people in the United States
are over age 65 with that number expected to reach 80 million by the
year 2050. (1,2) More than 10% of all individuals above age 65 have
anemia. Furthermore, the prevalence of anemia increases with age, making
our oldest seniors even more likely to develop anemia during their
lifetimes. (3) The significance of these facts led to a special
symposium, "Anemia and the Elderly: A Public Health Crisis in
Hematology', conducted at the 2005 meeting of the American Society
of Hematology. (4)
Although the presence of anemia may reflect an underlying or
undetected medical condition, anemia is also an independent risk factor
for morbidity and mortality in an array of disorders common to seniors,
including cancer, renal disease, and heart disease. (5) Furthermore,
anemia affects physical and mental functioning and interferes with the
ability to conduct activities of daily living, thus affecting quality of
life. Because the elderly, defined by the US Census Bureau as persons
over age 65, is the fastest growing segment of the US population, anemia
may be projected to have an increasing impact on our healthcare system.
In spite of these facts, anemia in elderly patients may be
over-looked in medical evaluations due to similarity of symptoms with
other disorders and lack of awareness of its prevalence. Diagnosis of
anemia and determination of its cause are highly dependent on the
results of clinical laboratory assays. Selecting appropriate laboratory
tests in an informed manner is an important consideration for quality
healthcare. Clinical laboratory scientists must be prepared to take the
lead in advising other health care providers on selection and
interpretation of relevant assays when anemia is a possibility.
DEFINING ANEMIA IN THE ELDERLY
Defining anemia in the elderly is important for clinical decision
making, yet what appears to be a simple matter is actually complicated
by current lack of consensus about appropriate reference intervals.
Traditionally, anemia in the general population has been defined by
criteria developed by the World Health Organization (WHO) in 1968. (6)
Anemia is defined for adult males and adult females as hemoglobin (HGB)
concentrations of < 130 g/L and < 120 g/L, respectively. This
seemingly straightforward definition may oversimplify what is actually a
more complex situation. The original data upon which the WHO criteria
are based were collected from a relatively small, non-elderly
population. Because some studies have demonstrated modest differences in
HGB between younger and older adults, there are questions about what
constitutes appropriate reference intervals for seniors. Several experts
have suggested it is time to abandon the outdated WHO standards for
newer definitions of anemia based on recent studies of the elderly. (5)
There is some evidence that blood HGB levels may decline slightly
with age. In a longitudinal study of elderly Swedes, mean HGB declined
from 140 to 138 g/L in healthy women and from 152 to 141 g/L in healthy
men between ages 70 and 88.7 Another study showed that although HGB
levels were slightly lower in hospitalized adults (mean age 70) than in
younger healthy controls (mean age 36), other RBC measures including
hematocrit (HCT), mean cell hemoglobin (MCH), and red cell distribution
width (RDW) were equivalent. Mean cell volume (MCV) was slightly but
significantly higher for geriatric patients than for younger controls.
When WHO anemia criteria were applied to the geriatric, hospitalized
population, 72% of patients were classified as anemic. When lower anemia
criteria (120 g/L for males and 115 g/L for females) were arbitrarily
applied to the same data, only 61% of the geriatric patients were
classified as anemic. Comparison of erythrocyte parameters of the newly
defined anemic geriatric group to the younger non-anemic controls
indicated no significant differences in HCT, MCH, RDW, or MCV' The
results of these studies suggest that HGB concentration may decline
slightly with age, and therefore reference intervals specific to
geriatric populations are needed. To apply WHO anemia criteria to people
of advanced age may, therefore, overestimate the number who are truly
anemic and may lead to unnecessary medical treatment.
Data from the Women's Health and Aging Study were used to
evaluate the clinical appropriateness of the WHO anemia criteria by
investigating the relationship between HGB concentration and mobility
function in female participants age [greater than or equal to] 65.
Although a consistent trend of improvement in mobility performance was
found to correspond to increasing HGB levels, the study authors noted
that even at low-normal HGB concentrations (12-13 g/dL), there was an
adverse effect on mobility, leading the authors to question the
appropriateness of the WHO definition of anemia for an older population.
In a second study by the same authors, it was found that higher HGB
levels were associated with lower risk of mortality for disabled women
age [greater than or equal to] 65, and that even in the low-normal
range, there was an increased risk of mortality. (10) Results of both
studies raise concerns about the appropriateness of using WHO criteria
when evaluating the elderly for anemia, in this case suggesting that the
number clinically affected by anemia may be underestimated.
In support of the WHO criteria, a 10-year longitudinal study of
community-based residents in the Netherlands found that anemia as
defined by WHO criteria was associated with increased mortality risk for
persons aged 85 and older. The mortality risk increased with lower HGB
concentrations, and mortality from infectious and malignant diseases was
higher in persons with anemia as defined by WHO criteria." The
authors of this study concluded that the WHO criteria for defining
anemia are appropriate for the elderly and that low HGB concentrations
may indicate underlying disease.
To date, revised criteria for defining anemia in the elderly have
not been adopted and the WHO criteria are still widely used. Some
clinical laboratories may use HGB reference intervals stratified by age,
including a separate category for elderly patients.
EPIDEMIOLOGY OF ANEMIA IN THE ELDERLY
Anemia has been shown to be a common disorder in the elderly, and
its prevalence increases with age. Data from the Third National Health
and Nutrition Examination Survey 1988-1994 (NHANES III) revealed that
11.0% of non-institutionalized men and 10.2% of women over age 65 are
anemic as defined by WHO anemia criteria. (3) Other studies confirm
these findings or show that the prevalence may be even higher,
especially in certain subgroups of the elderly.
The incidence of anemia was studied in 618 Minnesota residents aged
[greater than or equal to] 65. Using WHO criteria for anemia, the rate
for men was 9.0% and the rate for women was 6.9%. In 75% of cases,
anemia was detected in conjunction with hospitalization, but reason for
admission was attributed to anemia in only nine percent of subjects,
leading the authors to conclude that the prevalence of anemia is four to
six times higher than is suspected clinically." Other studies have
similarly documented a higher prevalence of anemia in elderly men than
in women. This finding is in contrast to anemia prevalence for younger
age groups. In persons < 55, anemia is more common in women than men.
There is also an increasing prevalence of anemia with advancing
age. In community dwelling men aged [greater than or equal to] 85, the
prevalence of anemia was found to be 44.4%. Furthermore, the prevalence
of anemia in community dwelling females is greater than the prevalence
in patients referred to a medical center, suggesting that anemia may be
unrecognized in a substantial portion of elderly persons. (13) Anemia is
especially common in nursing home residents. In a study of 900 residents
of skilled-nursing homes, 48% were found to be anemic by WHO criteria.
The mean age of participants in this study was 79 years. (14)
In an analysis of data from the Cardiovascular Health Study (CHS),
prevalence of anemia was found to be higher in Black than White
community dwellers age [greater than or equal to] 65. Using WHO
criteria, anemia was present in 7.0% of whites and 17.6% of black
participants. (15) In the NHANES III study, the prevalence of anemia was
found to be 27.8% in elderly Black Americans residing in the community.
Variation in prevalence rates among studies may be attributed to
differing criteria for defining anemia, differences in populations
studied, or other variables.
CONSEQUENCES OF ANEMIA IN THE ELDERLY
Although in the majority of cases anemia in the elderly is mild,
its impact on morbidity, mortality, and healthcare costs is significant.
Several studies have implicated anemia as an independent risk factor for
a variety of clinical conditions and other adverse outcomes in community
dwelling adults, hospitalized patients, and residents in long term care
In a study of 17,030 community dwelling adults age [greater than or
equal to] 66, anemia defined as HGB < 110g/L was associated with
increased risk of hospitalization and death over a three year period.
Anemia was associated with first hospitalization for all causes and with
hospitalization attributed to cardiovascular causes. A five-fold
increased risk of mortality was found for study participants with HGB
levels < 110 g/L. (16) A similar association between low HGB and
increased mortality risk was observed in the Cardiovascular Health
Study. (15) In both studies, data was adjusted to control for other
co-morbid conditions common to older adults, thus confirming that anemia
is an independent risk factor. Anemia was shown to be an independent
predictor of death and major adverse clinical events among elderly
patients with stable symptomatic coronary artery disease. Anemic
patients in this study were more likely than non anemic patients to be
older and more likely have chronic renal failure and diabetes. 17 Anemia
in community dwelling adults [greater than or equal to]65 was associated
with an increased number of hospitalizations, more days spent in the
hospital, and increased mortality rates. (18)
Anemia also negatively affects physical and neurologic functions.
Anemia is associated with physical disability related to activities of
daily living, inferior physical performance, and decreased muscle
strength in community dwellers age [greater than or equal to] 65.
Performance measures showing decrements in anemic elders included
standing balance, repetitive sitting and rising from a chair, and
walking eight feet.' In women aged 70 to 80, mobility difficulty
increased with declining HGB levels. In hospitalized patients who had
recently undergone hip fracture surgery, those with HGB values < 100
g/L were less able to walk independently post-operatively and anemia
interfered with post-operative rehabilitation. (20) Anemia has also been
shown to increase the risk of falls in older adults living in the
community, those who are hospitalized, and those in long-term care
facilities. (21) Anemia was found to be an independent risk factor for
delirium in hospitalized geriatric males. Depression and cognitive
impairment are frequently reported by elderly patients with anemia. (23)
Anemia in the elderly has economic impact. Untreated anemia in
elderly patients with predialysis chronic kidney disease was associated
with a significant increase in costs of medical care when compared to
the cost of care for patients without anemia. (24) Costs of anemia
include the direct costs of laboratory tests, treatment, and management
of the patient with anemia. Because of the association of anemia with
other medical conditions and with physical and cognitive impairment, the
costs of anemia-related effects must also be considered. As the number
of elderly in our society increases, so will the number of persons at
risk for anemia and the healthcare expenditures needed for anemia
ETIOLOGY OF ANEMIA IN THE ELDERLY
Anemia in the elderly can be attributed to a variety of causes
including anemia of chronic disease (anemia of inflammation),
nutritional deficiencies, renal disease, acute or chronic blood loss,
hemolytic disorders, and others. In some studies, anemia in a
significant subset of subjects is attributed to unknown or unexplained
The third National Health and Nutrition Examination Survey
1988-1994 (NHANES III) provided data for a comprehensive study of the
prevalence of anemia and its causes. (3) A HGB assay was performed as a
screening test for anemia on 4,199 non institutionalized adults aged
[greater than or equal to] 65, and tests used to classify the cause of
anemia were performed (or calculated) on a subset of 2,096 participants.
Additional tests included serum iron (SI), total iron-binding capacity
(TIBC), transferrin saturation (TS), serum ferritin (SF), folate,
cobalamin ([B.sub.12]), C-reactive protein (CRP), serum creatinine,
creatinine clearance, glucose, rheumatoid factor, and hepatitis C
antibody. Anemia was defined according to the WHO criteria of <120
g/L HGB for women and <130 g/L HGB for men. Based on results of
laboratory data and information collected from a personal interview,
causes of anemia were determined. Approximately one-third of anemia in
the study group was attributed to deficiencies of iron, [B.sub.12], or
folate with deficiencies of iron accounting for half of these cases.
Iron deficiency was attributed to blood loss or nutritional deficiency.
Another third of subjects had anemia of inflammation, anemia of chronic
renal disease, or both. One-third of cases were classified as
unexplained anemia. Most cases of anemia were mild; only 2.8% of women
and 1.6% of men had HGB values [less than or equal to] 110 g/L.
In a study of 60 anemic nursing home residents, 23.3% had iron
deficiency anemia, 13.3% had anemia of chronic disease, and 10.0% had
anemia of renal insufficiency. Other causes were found for 8.3% of
residents and 45.9% of causes were listed as idiopathic. (26) In a
larger study of 481 residents of a multilevel geriatric institution, a
high prevalence of anemia was found (31.4%). The most common causes were
anemia of chronic disorders (65.6%), anemia of chronic renal failure
(13.2%), and anemia due to deficiencies of iron, folate, or [B.sub.12]
(4%). In only 15% of cases was the cause unknown. Anemia was considered
to be mild in over half of the cases. (27) The differences in results
for these studies may be due to variations in methods, average age of
subjects, or clinical settings.
Anemia of chronic disease (ACD), also referred to as anemia of
inflammation, is clearly responsible for many cases of anemia observed
in the elderly. ACD is more common in the elderly than in any other age
group. (28) The occurrence of ACD-associated diseases including cancer,
autoimmune disorders, kidney disease, and acute and chronic infections,
increases with advancing age. Protein calorie malnutrition is another
cause of ACD. ACD develops when there is acute or chronic immune
activation. The impact of pro-inflammatory cytokines such as
interleukin-1 (IL-1), interleukin-6 (IL-6), and tissue necrosis factor
[alpha] (TNF-[alpha]), on erythropoiesis includes alterations in iron
homeostasis, production of erythroid progenitors and erythropoietin
(EPO), and red cell survival, thus causing anemia by several mechanisms.
(29) Anemia of renal disease is considered to be a distinct form of
anemia, and is typically due to decreased EPO production.
Nutritional deficiencies also occur in the elderly and are
responsible for some cases of anemia. Mild, preclinical cobalamin
(vitamin B12) deficiency is common, affecting 5%-30% of the elderly. The
risk of cobalamin deficiency increases with age, but not all persons
with cobalamin deficiency develop megaloblastic anemia. In the elderly,
the deficiency arises most commonly from inability to split cobalamin
from foods, making it unavailable for transport by intrinsic factor.
Folate deficiency can develop from dietary insufficiencies or alcohol
abuse. Due to widespread use of food additives and dietary supplements,
folate levels in the general population have risen significantly, and
folate deficiency is no longer considered common in the elderly. (28)
Iron deficiency is more common in younger women than in postmenopausal
women. Iron deficiency in elderly women and men is most likely a result
of gastrointestinal or genitourinary bleeding rather than inadequate
dietary intake. Iron deficiency anemia may exist concurrently with ACD
or megaloblastic anemia in some patients.
The underlying mechanisms by which idiopathic or unexplained anemia
develops in the elderly are incompletely understood. It is possible that
some aspect of the process of aging alone may contribute to the
development of anemia, leading to speculation about the existence of
"anemia of aging". However, hematopoiesis in healthy elderly
persons who are not subjected to hematopoietic stress is similar to
hematopoiesis in healthy younger adults. Hematopoietic precursors remain
normal in number, and cell counts in the peripheral blood do not change
with advancing age in healthy adults.
It may be that the elderly have impairment in the hematopoietic
system that results in reduced capacity to deal with hematopoietic
stress. Elderly anemic patients fail to show increases in erythrocyte
progenitors and reticulocytes as would be expected in younger anemic
patients. (30) A longitudinal analysis of EPO levels in healthy adults
initially without anemia demonstrated that EPO levels increase with age.
The increase may reflect normal compensation for subclinical bleeding,
increased red cell turnover, or increased resistance of red cell
precursors to EPO in which case the EPO is an effort to maintain optimal
HGB levels. The rate of EPO increase was greater for persons who
remained healthy during the study than it was for persons who developed
diabetes or hypertension. Study participants who developed diabetes or
hypertension and anemia during the study showed a significantly
diminished EPO response, and were thus unable to compensate for the
anemia. (31) Increases in pro-inflammatory cytokines, including IL-6,
IL-1, and TNF-[alpha], have been observed in healthy elderly persons.
It is also possible that some cases of unexplained anemia in the
elderly result from unrecognized inflammatory conditions. Before
attributing the cause to "anemia of aging", it may be
beneficial to rule out subclinical conditions associated with ACD in a
geriatric patient. Myelodysplastic syndromes are also a cause of anemia
in persons typically over age 50 and should be considered when
accompanied by dysplasia and cytopenia in leukocytes or platelets.
Anemia may also be a presenting feature in patients with chronic or
acute leukemias which are seen in older persons. It is unlikely that
other causes of anemia such as hemoglobinopathies, thalassemia, and
inherited red cell defects will be initially diagnosed in older adults
as they are often sufficiently severe to be recognized in much younger
individuals. A complete discussion of all possible causes of anemia is
beyond the scope of this article. For more detailed information, the
reader may wish to consult a hematology reference book. (33)
DETECTING ANEMIA IN THE ELDERLY
In many elderly persons, the onset of anemia is gradual. Most
anemic adults are asymptomatic until HGB fall below 80 g/L, although
elderly patients may be symptomatic at HGB levels of 100 g/L, especially
if cardiac reserves are impaired. (34) Because they may adjust their
daily activities to accommodate for physiologic changes, the elderly may
be unaware of symptoms. When symptoms associated with anemia such as
fatigue, dyspnea, mental confusion, depression, disorientation, or
weakness are reported to a health care provider, they may be attributed
to aging alone if the patient is elderly. Although pallor, especially in
the conjunctiva, can be a useful diagnostic clue to anemia, there are no
other clinical signs specific to anemia. For these reasons, it is easy
to overlook anemia in geriatric patients. (35) In addition, symptoms of
anemia may be masked by those of comorbidities. In some cases, providers
may fail to appreciate the clinical significance of a mild anemia in the
elderly patient. (36)
An abnormally low HGB may be the first clue that the elderly
patient is anemic, but it is interesting to note that current practice
guidelines do not recommend anemia screening for asymptomatic elderly
patients. Routine anemia screening by HGB and hematocrit (HCT) are not
recommended for patients age [greater than or equal to] 65 in guidelines
issued by the Institute for Clinical Systems Improvement, citing lack of
supporting evidence for a recommendation. (37) Screening of asymptomatic
adults for anemia is not included in the Recommendations of the US
Preventive Services Task Force (38) and is not recommended by the
American Academy of Family Physicians .31 Preoperative testing for
anemia is only recommended for patients with severe comorbidities such
as cardiovascular or renal disease prior to major surgeries. (40) The
National Kidney Foundation recommends annual testing for anemia in
patients with chronic kidney disease. (41)
Although screening guidelines are lacking, some providers may test
for anemia in healthy patients or in those with diagnosed clinical
conditions as part of regular health assessments. Some researchers and
geriatric specialists believe that anemia is often poorly recognized and
managed, and that routine screening of older individuals for anemia
should be considered. (36) When anemia is documented, the cause should
be thoroughly investigated in order to initiate appropriate and timely
treatment. (42) Treatment may slow disease progression and prevent it
from worsening, thus improving patient outcomes. (43)
DETERMINING CAUSES OF ANEMIA
Although anemia testing begins with reviewing HGB and HCT values, a
complete blood count (CBC) is typically performed on an automated
instrument. Other useful tests for anemia evaluation included in the CBC
are erythrocyte count, mean cell volume (MCV), mean cell hemoglobin
(MCH), mean cell hemoglobin concentration (MCHC), reticulocyte count
(RET), red cell distribution width (RDW), and a microscopic examination
of erythrocytes on a Wright stained blood smear. Erythrocyte indices
(MCV, MCH, and MCHC) are useful for classifying anemia based on red cell
size and HGB content, thus providing a first step in determining cause
of anemia. Other parts of the CBC such as the leukocyte concentration,
leukocyte differential and morphology, and platelet concentration may be
helpful in evaluating patients for other conditions causing anemia such
as myelodyplastic syndromes or leukemia. (44) A new measurement, the
reticulocyte hemoglobin (CHr), is reported by some hematology analyzers
when RET counts are ordered. CHr has been shown to be an early indicator
of developing iron deficiency, before HGB levels decline. (45)
Confirmatory tests for investigating the possible cause of anemia
in an elderly patient include serum iron (SI), total iron binding
capacity (TIBC), transferrin saturation (TS), serum ferritin (SF),
soluble transferrin receptor (sTR), cobalamin, and folate. These tests
are important when a deficiency of iron, cobalamin, or folate is
suspected and in some cases of anemia due to other causes. The sTR assay
is helpful in differentiating iron deficiency anemia from anemia of
chronic disease. A bone marrow examination is ordered if leukemia,
myelodysplastic syndrome, or aplastic anemia is suspected but is not
needed for assessing iron status.
For cost effectiveness, selection of confirmatory tests should
proceed based on information gained from the CBC, physical examination,
and patient history. Useful algorithms for evaluating anemia in the
elderly appear in the references. (35,42)
The following sections include brief descriptions of key laboratory
findings for the most common causes of anemia in elderly patients. For
more information on these disorders or other causes of anemia, the
reader should consult a hematology reference book. (33)
ANEMIA OF CHRONIC DISEASE
Anemia of chronic disease (ACD) is usually characterized as
normocytic and normochromic, although in about one-third of patients,
the anemia is microcytic and hypochromic. It is usually mild, with
typical HGB and HCT levels ranging from 90 to 110 g/L. (46) A decreased
serum iron, low to normal TIBC, normal or increased SF, and normal TfR
are typical in ACD and are useful in differentiating ACD from iron
deficiency. The RET is usually decreased and TS is normal or low in ACD.
(47) There is no specific treatment for ACD in general, and the anemia
usually resolves with effective treatment for the underlying disorder.
ACD due to cancer and rheumatoid arthritis may respond favorably to
treatment with EPO. ACD and IDA may be found in combination. In this
situation, interpretation of confirmatory tests is difficult.
Anemia of renal disease
Anemia of renal disease is considered a category of anemia distinct
from ACD. HGB concentration begins to decrease when the level of blood
urea nitrogen rises above 30 mg/dL. The anemia is typically normocytic
and normochromic, and HGB levels are between 50 and 80 g/L.
Poikilocytosis is moderate to severe with burr cells, acanthocytes, and
schistocytes present. RET counts are decreased. (48) Other useful assays
include tests of renal function such as creatinine, urea nitrogen, and
the urinalysis. EPO is used to treat anemia of renal disease. When
patients are treated with hemodialysis, bleeding and loss of iron or
folate may result in anemia due to other causes.
Iron deficiency anemia
Anemia due to iron deficiency (IDA) is microcytic and hypochromic,
especially once the HGB level falls below 100 g/L. In severe cases,
elliptocytes may accompany microcytes and hypochromic red cells on blood
films. Typically HGB and HCT are somewhat lower than seen in ACD.
Because other anemias, most notably the thalassemias, are also
characterized by low MCV, MCH, and MCHC, additional tests are needed for
confirmation of IDA. Low SI, TS, and SF combined with elevated RDW, TIBC
and sTR are typical for IDA and are needed to differentiate it from ACD
and thalassemia. Ferritin is an especially sensitive marker for emergent
iron deficiency and will be decreased before full-blown anemia develops.
The CHr is also a useful marker, with low levels seen in developing iron
deficiency. Because IDA in elderly adults is most commonly a result of
iron loss due to chronic gastrointestinal bleeding, treatment includes
stopping the blood loss and replacing iron with oral supplements.
Ferritin levels may be periodically re-ordered to assess the efficacy of
treatment. EPO is not typically used to treat IDA.
Megaloblastic anemia (MA) is macrocytic and normochromic with
numerous morphologic abnormalities evident in erythrocytes, including
macroovalocytes, Howell-Jolly bodies, and basophilic stippling. MCV is
usually >I 10 fL RDW is elevated and RET is normal or decreased.
Hypersegmentation of neutrophils is an early and common indicator of MA,
and pancytopenia is typical. Assays for serum cobalamin and serum folate
are needed to document deficiencies of one or both as a cause of MA.
Other relevant laboratory tests include assays for methylmalonic acid,
antibodies to parietal and gastric cells, bilirubin, lactic
dehydrogenase, and homocysteine. (49) Treatment consists of cobalamin or
folate replacement, and additional laboratory tests are needed to
monitor the effectiveness of therapy.
Other causes of macrocytosis include alcoholism, liver disease, and
reticulocytosis. Usually MCV is less elevated in these conditions than
in MA. An elevated MCV should not be ignored as it can indicate the
presence of these clinical conditions, especially unsuspected alcohol
abuse. Elevated RET are a key feature of hemolytic anemias and severe
blood loss. A complete discussion of macrocytic anemias is beyond the
scope of this article, and the reader should consult a hematology
reference book for more information. (33)
The prevalence of anemia is high in people over age 65 in the US
and is especially common among the eldest seniors, men, and African
Americans. Several studies have shown that anemia is an independent risk
factor for morbidity and mortality and may impair physical and cognitive
function and quality of life for senior citizens. Early diagnosis and
treatment of anemia can improve health outcomes in several medical
conditions. (43) Detecting the presence of anemia and identifying its
cause depends on information provided by the clinical laboratory, thus
ordering the correct tests is important. With our rapidly aging US
population, the overall incidence and impact of anemia on the healthcare
system is expected to increase.
In spite of a large number of relevant studies performed to date,
unanswered questions about anemia in the elderly remain. They include:
* Should the healthy elderly be routinely screened for anemia?
* What reference intervals should be used to evaluate seniors for
the presence of anemia?
* Does an "anemia of aging" exist and if so, how should
it be managed?
* What is the most cost effective use of laboratory tests to
evaluate anemia and determine its cause?
* How can health care providers become more aware of the prevalence
and causes of anemia in elderly patients?
ABBREVIATIONS: ACD = anemia of chronic disease; CBC = complete
blood count; CHr = reticulocyte hemoglobin; EPO = erythropoietin; HGB =
hemoglobin; HCT = hematocrit; IDA = iron deficiency anemia; MA =
megaloblastic anemia; MCV = mean cell volume; MCH = mean cell
hemoglobin; MCHC = mean cell hemoglobin concentration; RDW = red cell
distribution width; RET = reticulocyte count; SI = serum iron; sTR =
serum transferrin receptor;TIBC = total iron binding capacity; TS =
INDEX TERMS: anemia; anemia of chronic disease; elderly; iron
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Rebecca J Laudicina PhD is professor, Clinical Laboratory Science,
Department of Allied Health Sciences, The University of North Carolina
at Chapel Hill, Chapel Hill NC.
Address for Correspondence: Rebecca J Laudicina PhD, Division of
Clinical Laboratory Science, 4110 Bondurant Hall, CB#7145, The
University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7145.
(919) 843-4350. Rebecca_Laudicina@med.unc.edu
Rebecca J Laudicina PhD is the Focus: Anemia in Selected
Populations guest editor.