Anemia in the elderly patient(a geriatrician’s POV)

McGill 66th Family Medicine RefresherMon. Nov. 23rd 2015

Workshop A-02 @11h00Workshop C-11 @16h00

Wendy Chiu, MD.CM, FRCPCMcGill Division of Geriatric Medicinewendy.chiu@muhc.mcgill.ca

Disclosure

• No conflicts of interest to declare

Dammit, Jim – I’m a geriatrician,

not a hematologist!

Objectives1. To review common causes of anemia* in the

elderly, and general investigations & management for these

– Not “normal aging”– 1° vs. 2° screening

2. To consider the risks:benefits of anemia* work up / treatment in the very / frail elderly

– Individualized approach– Primum no nocere…

(* Chronic anemia)

What is it?• Definition – Hb (g/L)

– WHO: Men < 130, women < 120– Differences by sex, ethnicity, age…

• ↑ Prevalence (>65yo)– Community-dwelling ~10%– Hospitalized ~25%– LTC ~50%

-but-• NOT “NORMAL AGING”

– No age adjustment Prognosis with Hb > WHO definition

hospitalization/death @Hb Men ?140-170, Women ?130-150

– But not EBM to Tx for this (e.g. Epo, transfusion)

Why do I care? Prognostic factor:

– ↑ Morbidity (esp. CVD) & Mortality– ↑ Hospitalization rate & LOS– (-) Functional impact

• Loss of autonomy• Falls (& fall injuries)• Cognitive decline

Quality of life• Fatigue

Causes?• 1/3 Nutritional

– Esp. iron deficiency• 1/3 Chronic inflammation

– “Anemia of chronic disease”• 1/3 “Unknown”

– Undiagnosed MDS?– Age-associated predispositions? (but not N aging?!)

• Renal function• Stem cells• Androgens• Chronic inflammation

1/3 Nutritional deficiencies Iron (30% of all anemias)

– Blood loss (heme) >> low intake

B12 (5-10%)– Before hematologic, neurologic effects

• Macrocytosis = late finding• Neurological symptoms irreversible

Folate• N/S since flour fortification

1/3 “Anemia of chronic disease”• Cytokines (IL-6, TNF-alpha, etc.)

Epo production Iron use (hepcidin) – “functional iron deficiency”

Absorption GI tract Release from bone marrow

• “Chronic diseases”– OK: Cancer, autoimmune, chronic infection

• But: DM2? HTN? Atherosclerosis? OA??– +/- “Normal aging” +/- “body habitus” (↑ fat)

• Associated with ↑ inflammatory markers…

1/3 Unexplained anemia (“NYD”)• MDS (undiagnosed pathology)• Epo-related (production, action)?

– Blunted Epo sensitivity/response• “Age-associated”?

– Co-morbidities (esp. CKD)

• “Age-associated” changes? CrCl– ↑ Inflammation (see ACD) Androgens

• Prostate CA Rx anti-testosterone : Hb 10-20 g/L Stem cells (quantity, quality)

“Mixed” anemias – e.g.

• Consider medication side effects - e.g.

– Bone marrow suppression• Chemotherapy, immunosuppressants - Hydroxyurea• Anti-epileptics - Phenytoin

– Hemolysis• e.g. Antibiotics (e.g. pen, ceph, nitrofurantoin, levoflox)

– Blood loss (chronic)• NSAIDs, anti-coagulants

• R/o EtOH abuse (chronic)– Nutritional, bleed (cirrhotic), direct RBC toxicity

(macrocytosis), etc.

Diagnosis - Clinical• 1° screening (asymptomatic)*

– PHE not EBM, but…– “Baseline Hb”

• 2° screen (symptomatic, case finding)– Symptoms/signs specific causes (e.g. CRC, RA)– “Gen det” (failure to thrive)* – e.g.

• Fatigue, weakness• Weight loss, anorexia• Exertional dyspnea; Pallor• Poor concentration / memory problems• Falls, gait / balance problems

– PMHx– Rx review – incl. EtOH

Diagnosis: Laboratory - CBC• Mean corpuscular volume (MCV)

: Microcytic• e.g. iron, thalassemia

– ↑: Macrocytic• e.g. B12, EtOH, Rx (e.g. anti-epileptics)

– Normocytic – e.g. ACD, MDS• NB: early on, all can be normocytic…

• Red-cell distribution width (RDW)– NB: MCV = average RDW = range– “Normal”: See MCV– ↑RDW: R/o mixed anemia

• Response to blood loss, supplement, “recovering marrow”

Labs – Other heme• Reticulocyte count

– Absolute count (lab’s N range), < 2% retics– “Normal” or (i.e. not ↑): R/o bone marrow dysfunction

• Peripheral smear (“qualitative” RBC, associated findings) – e.g.– RBC

• Schistocytes (hemolysis), dacrocytes (myelofibrosis), rouleux formation (myeloma)

– WBC• Hyperlobulated nuclei ( B12), circulating plasma cells (myeloma)

– Platelets• True thrombocytopenia

• Bone marrow biopsy... – e.g.– Iron stores– Myelodysplasia / fibrosis– Marrow “replacement” (cancer, solid or heme)

UpToDate.com – Approach to the Adult Patient with Anemia

Labs – specific causes – e.g.

• Iron– Serum ferritin ( mg/L) < 10, < 50, > 100, ?50-100– Response to Tx (↑Hb, ↑ retics)

• B12– < 200 pM (geriatricians at least…)

• No folate (serum or RBC) unless macrocytosis NYD• Creatinine, eGFR (CrCl)

– SPEP – Anemia + CKD +/- “back pain” (“OP” / VBC fractures)• TSH

– DDx “gen det” +/- anemia• CRP• Hemolysis

– Smear, LDH, indirect bili, serum haptoglobin, plasma free Hb

What to do about it?• Remove Rx if ADR

– PPI?• Treat/manage contributing co-morbidity(s)• 1/3 Nutritional

– B12 supplementation• Oral vs. IM

– Iron supplementation• Ideal: 150-200 mg/day elemental iron

– E.g. Iron SO4 300mg = 65 mg eFe hence TID constipating!

– 65mg eFe adequate to replace most check Hb @3 months– IV iron if intolerant PO? risk ADR (e.g. allergic), cost

• + Vitamin C? + dietary sources

• Investigation for blood (iron) loss• “Invasive”

– G’scope– C’scope MSSS C’scope referral (triage) form

» vs. CT “virtual” C’scope same prep» vs. PillCam? TBA» vs. Ba’enema Sn & Sp, same prep

• “Non-invasive”– FIT (iFOBT)

» No more gFOBT (guaic)– Fecal DNA testing? TBA– Serum CEA no

• AbN finding in any of above C’scope -- so…?

NB: “Goals of therapy”1º screening: Life expectancy

2º screening: Surgical risk, QoL

FIGURE 1 . Operative mortality among nursing home residents and non-institutionalized elderly Medicare enrollees, by procedure type. Ann Surg, Dec 2011; 254(6):921-6.

What to do, cont.

• 1/3 ACD, 1/3 UA (NYD)– Consider MDS

• Refractory anemia, other cytopenias– BM Bx vs. only when need Tx? (e.g. PRBC)

– “Treatments” – not EBM, do not recommend• Epo? – threshold Hb 100-120, risks (OFF LABEL)• IV iron? - “functional iron deficiency” (OFF LABEL)

– Transfusion – threshold, mortality, QoL (Sx)• Recent RCTs no benefit “liberal” vs. “restrictive”

transfusion older pt post-hip # ORIF, ICU

• MDS, UA (“NYD”) cont.– Experimental

• Hepcidin-targeted Tx?– IL-6 induces liver synthesis hepcidin

(-) iron absorption GI tract(-) release stored iron from BM macrophages= “relative [functional] iron-deficiency”

• NB: Tx goal = Symptom relief• Albeit under-reporting/-recognition, non-specific…

– Typically Hb > 100• NB: mortality Rx Epo to make Hb > 120

“Take-home” messages x3:(NB: geriatrician’s POV!)

1. Hb <120 merits investigation (M & F)– Investigation =

• Note other cell lines on CBC– If abN, consider Hematology consult

• Do medication review– Incl. EtOH

• Review PMHx for co-morbidities than may cause or contribute to anemia – e.g.– CKD, autoimmune disease, past CA, PUD

–Investigation cont.• Check other bloods as could change

management– Iron or B12 deficiency

» sB12 <200Vit. B12 1200μcg PO DIE

» sFerritin: Probably OK if >100, definite if < 10Iron SO4 300mg PO DIE x3 months

–Chronic kidney disease (creatinine)» If abN, check SPEP» If SPEP abN, consider Heme consult

–Hypothyroidism (TSH)

2. If iron deficient, consider also:

• Risks:benefits of major abdominal surgery– Colectomy = potentially curative– Surgical risk, co-morbidities (type, severity),

QOL, life expectancy– Bowel prep - supportive needs?

• Patient preference / informed decision– Incl. symptoms for palliation?

• If “a go” C’scope directly– MSSS triage level P3

3. If none of the above, “monitor”• i.e. likely ACD, UA…

– Further investigation unlikely to change management beyond underlying co-morbidities

• F/u CBC ?Q6 months ?PRN symptoms– Symptoms can be insidious, vague (“getting old”)– NB: not EBM

• Hb < 100 or symptomatic– Consider further investigation and/or Tx for QoL

e.g. Heme consult for BM Bx Dx MDS periodic PRBC transfusions

• Case study: Mrs. R

• Suggested readings:ASH Special Symposium: Anemia in the Elderly.Am Soc Hemato 2005.http://asheducationbook.hematologylibrary.org/content/2005/1/528.short

Anemia in the older adult.UpToDate.com

– Free access via CMA website