Anemia in the Hospitalized Elderly

Hospitalist Best PracticeJ Rush Pierce Jr, MD, MPH

February 29, 2012

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

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 negLab: Hgb = 13.3, MCV = 85, glucose = 225, creat = 1.0

Q1 Should he be evaluated for anemia?

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 it’s probably dilution due to the fluids he received.

Q2 Do you agree?

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?

Defining anemia in elderly

(Hgb, g/dL)

Men Women

PowerChart < 14.5 < 12.0

Williams (US populations, does not include elderly) < 14.0 < 12.3

WHO (world populations, does not include elderly) < 13.0 < 12.0

NHANES III/Kaiser-Scripps (Caucasian race, age > 60 yr ) < 13.2 < 12.2

Prevalence of anemia in elderly

• Prevalence– NHANES III (>64 yrs) – 11% (~1 % Hgb below 10)– NHANES III (>84 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

Etiology of anemia in elderly

NHANES III (1988-1994)• 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)

Stanford study (2006-2010)• 35% = unexplained• 22% = hem malignancy

including myelodysplasia• 12% = iron def• 11% = chemotherapy • 6% = chronic inflam dz• 4% = renal dz• 10% = other

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 < 80• Leukopenia, thrombocytopenia, macrocytosis

frequently seen with myelodysplasia

Iron deficiency in the elderly

• Importance of diagnosing iron deficiency in elderly (Gastroenetrol Clin Biol 2007:31:169)– 111 hospitalized pts > 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

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 it’s probably dilution due to the fluids he received.

Q2 Do you agree?

Hospital acquired anemia

Causes of dilution anemia

• Acute blood loss with crystalloid replacement• Pregnancy• Plasma exchange/plt transfusion (mostly kids)• “Sports anemia” (<1.0 g/dL)• Venous sample drawn from vein with infusion

Anemia and CAP

BMC Pulm Med 2010; 10:15

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?

Transfusion for anemia in the elderly

• 428 pts post post-CABG (1999)– 428 pts, transfuse Hgb <8 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 < 7) vs “liberal” strategy (transfusion if Hgb < 10)

– Mortality less in restrictive group if APACHE < 21 (6% vs 16%) & if younger than 55 yrs (6% vs 13%)

– No diff if clinically significant heart dz (20% vs 23%)

FOCUS (Functional Outcomes in Cardiovascular Patients Undergoing

Surgical Hip Fracture Repair) Trial

• Perioperative patients with cardiovascular disease and > 50 yrs

• Transfuse if Hgb < 10 vs < 8• NHLBI sponsored, multiple centers, 2016 pts

FOCUS Trial

Recommended consensus practice

1. Consider anemia in hospitalized elderly if Hgb < 13.2 in males and < 12.2 in females

2. Consider referral to GI, elderly patients with iron deficiency anemia

3. In the absence of significant ongoing blood loss, transfusion will be generally reserved for elderly with sxs of anemia or Hgb < 8

4. Change Adult Admit order set, so that the default lab draw is “once” rather than “daily for 4 days”