Evaluation of anemia as comorbidity in elderly subjects aged 65 years and above admitted to hospital for other medical problems

INTRODUCTION

Anemia in the elderly is an emerging problem that is associated with poor health-related quality of life, decreased cognition and functional ability, increased risk of fall, infections, and increased morbidity and mortality regardless of the underlying cause of low hemoglobin (Hb).^[1] However, many physicians continue to neglect the significance of anemia as a serious clinical condition in the elderly, while decreased Hb was previously largely considered as a normal consequence of aging. There is now evidence that anemia has a substantial negative impact on previously existing comorbidities, signifies an underlying disease, and is associated with poor clinical outcome, which adversely affects morbidity and mortality. Hence, anemia is recognized as a significant and independent contributor to morbidity, mortality, and frailty in the elderly patients regardless of the underlying causes.^[1] Failure to evaluate geriatric anemia can result in delayed diagnosis of an easily treatable condition and increased chance of hospital readmission rate and increased mortality up to 1 year after hospitalization.^[2] There has been a progressive statistical increase in the number of elderly in recent years; thus, anemia in the elderly patients is an emerging global health problem and requires allocation of health-care resources.^[3]

Aging by itself is unlikely to cause anemia, but changes that occur commonly during aging increases the risk of anemia, thus explaining the association of anemia with old age. These include (a) poor nutrition, (b) reduced ability to absorb essential nutrients, (c) decreased reserve of hematopoietic factors, (d) reduced erythropoiesis, (e) increased frequency of inflammatory process, and (f) gastrointestinal loss of blood.^[4] These factors make the elderly more prone to developing anemia and micronutrient deficiencies which affect erythropoiesis. Rectification of any of these abnormalities contributes significantly to overall improved outcome with respect to physiological parameters as well as quality of life.^[5]

According to Hb cutoff levels defined by the World Health Organization, Hb <12 g/dL for females and Hb <13 g/dL for males is defined as anemia. The third National Health and Nutrition Examination Survey (NHANES) (1988–1994) (NHANES III), overall, 11.0% of men and 10.2% of women aged 65 and older were anemic and the prevalence of anemia was >20% among those aged 85 and older.^[4] Anemia is an independent predictor of poor outcomes with many diseases, especially in the elderly. Despite the high prevalence of anemia in elderly and its impact on their quality of life, very few studies have examined the effect of anemia in elderly patients in India. Hence, this study is undertaken with the following objectives.

1. To find out the proportion of anemia in the elderly aged 65 years and above admitted to hospital for other medical problems.

2. To determine the association between sociodemographic variables, other comorbidities, and anemia in the elderly aged 65 years and above.

MATERIAL AND METHODS

This present hospital-based analytical cross-sectional study was conducted by Departments of General Medicine and Allied Specialties at Malabar Medical College Hospital and Research Centre, Calicut. The study was conducted for period of 1 year in patients admitted with other medical disorders who are aged 65 years and above and they were evaluated for anemia.

RESULTS

Among 236 elderly patients, recruited in the study, 154 (65.3%) were anemic and the remaining 82 (34.7%) were not anemic [Figure 1]. There was no significant association between age and gender of the elderly patients and their anemia status [Table 1].

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Figure 1:

Anemia status in elderly patients (n = 236).

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Out of 236 study subjects in this study, 179 patients (75.8%) had at least one comorbidities such as coronary artery disease (CAD), chronic respiratory illness, renal diseases, arthritis, liver diseases, gastrointestinal diseases, cardiovascular accidents, carcinomas, diabetes, and hypertension. All these comorbidities except diabetes and hypertension had shown to be significantly associated with anemic status of the elderly patients [Table 2].

DISCUSSION

Anemia is a significant health problem in elderly patients requiring hospitalization due to its impact on the clinical outcome of the individual. Anemia is highly prevalent in elderly population, which is often overlooked due to coexisting multiple comorbidities in the elderly. In elderly patients, determining the underlying etiology is difficult due to multiple comorbidity.^[7] This is an important shortfall because even mild anemia can compromise a patient’s well-being and survival, regardless of the underlying cause.^[8] Since anemia is associated with significant morbidity, mortality, and frailty in hospitalized geriatric population, understanding the association between the various comorbidities and anemia is crucial for active intervention to reduce morbidity and mortality and to improve the survival and quality of life in the elderly age group. Hence, this study is undertaken to know the prevalence of anemia among elderly patients and its association with other comorbidities.

Among 236 study subjects, 154 (65.3%) patients were found to be anemic. A study done by Steensma and Tefferi^[8] among elderly patients in prospective study at France showed similar results, whereas another study done by Guralnik et al.^[4] and Tettamanti et al.^[9] among elderly subjects showed a low prevalence of anemia in elderly patients. This variation may be due to the fact difference in the study settings at hospitals in comparison with the community-based studies among elderly.^[10]

Among 236 study subjects in this study, 179 patients (75.8%) had comorbidities such as CAD, chronic respiratory infection, renal disease, arthritis, liver disorders, gastrointestinal disorders, cerebrovascular accidents, and carcinoma. These comorbidities were statistically associated with anemia in the study subjects (P < 0.05). This finding insists on screening for these comorbidities in elderly patients presenting with anemia and vise versa screening for anemia among those presenting with other comorbidities.

In the present study, out of 236 participants, 26 patients (11%) had chronic renal failure with anemia. Similar results were shown in the study by Chaves et al., revealed that 13.2% of patients had anemia due to chronic renal failure.^[11] Anemia due to chronic renal disease has impact on mortality and prolonged hospitalization.^[12] Anemia is due to reduced erythropoietin production. A serum creatinine clearance <60 mL/min is a known risk factor for anemia. Non-steroidal anti-inflammatory drugs (NSAIDs) and anti-platelet drugs are known risk factor for elderly anemia.^[13] The findings of the present study substantiated the above mentioned statement by showing that comorbidities such as chronic arthritis (NSAID use) and cardiovascular disease/CAD (anti-platelet drugs use) were significantly associated with anemia in elderly patients.

In the present study, of the total 85 diabetes patients, 54 patients (63.5%) were anemic. The present study does not show any association between diabetes and anemia status of elderly patients. Although there is no statistically significant association between diabetes and anemia, due to high prevalence of anemia among diabetic patients, it shows the importance of screening all diabetes patients at ward setting for anemia.

Malignancies, particularly hematological malignancies, due to their nature of destruction of blood cells are commonly associated with anemia. Out of 17 cancer patients, 5 (4 with hematological malignancy) patients presented with anemia This finding is not concurrent with the study done by Prakash et al.^[14] who revealed that 18% of the cases had hematological malignancy. The prevalence of hematological malignancy could have been higher, if bone marrow examination had been done in all 154 anemic patients. A study done by Ludwig^[15] showed that anemia (63%) is the most common presentation in patients with underlying hematological malignancy.

Very few studies have examined the effect of anemia in elderly patients in India. It is hospital-based cross-sectional study, temporarily cannot be maintained.

The study findings cannot be generalized due to smaller sample size.

CONCLUSION

This study concludes that, anemia was highly prevalent among hospitalized elderly patients and it is highly associated with other comorbid conditions. Hence, all elderly patients admitted for other comorbid illness needs to be screened for anemia and those who were found to be anemic should be initiated on appropriate treatment for anemia. Vice versa, all anemic elderly patients should be evaluated for underlying chronic morbidities.