Anemia and Other Hematological Problems

doi:10.1017/9781108942751.040

Chapter 40 - Anemia and Other Hematological Problems

from Section III - Care of the Elderly by Organ System

Published online by Cambridge University Press: 30 June 2022

Satish Shanbhag and

Rakhi P. Naik

Edited by

Jan Busby-Whitehead ,

Mary H. Palmer and

Jan Busby-Whitehead: Affiliation:
University of North Carolina, Chapel Hill
Samuel C. Durso: Affiliation:
The Johns Hopkins University, Maryland
Christine Arenson: Affiliation:
Thomas Jefferson University, Philadelphia
Rebecca Elon: Affiliation:
The Johns Hopkins University School of Medicine
Mary H. Palmer: Affiliation:
University of North Carolina, Chapel Hill
William Reichel: Affiliation:
Georgetown University Medical Center

Book contents

Get access

Summary

Hematologic abnormalities occur commonly in the elderly. The prevalence of anemia appears to increase with age and may be caused by various underlying etiologies, including iron deficiency, anemia of inflammation, or myelodysplastic syndrome. Thrombocytopenia due to underlying comorbidities, medications, or immune thrombocytopenia (ITP) may also occur. Hematologic malignancies such as chronic lymphocytic leukemia (CLL) and multiple myeloma also become more prevalent with age. A systematic approach to the evaluation of these hematologic abnormalities is imperative to help guide diagnosis and management. For acute or progressive conditions, a multidisciplinary team of both geriatricians and hematologists is essential to ensure proper diagnosis, frailty assessment, and initiation of appropriate therapies. Novel therapies for the various hematological malignancies are well tolerated, turning life-threatening illnesses into chronic disease that can be managed while preserving quality of life.

Keywords

anemia microcytic macrocytic hemolysis iron deficiency thrombocytopenia myelodysplastic syndrome hematologic malignancy myeloma leukemia

Information

Type: Chapter
Information: Reichel's Care of the Elderly
Clinical Aspects of Aging
, pp. 493 - 505

DOI: https://doi.org/10.1017/9781108942751.040 [Opens in a new window]

Publisher: Cambridge University Press

Print publication year: 2022

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Book purchase

Temporarily unavailable

References

Blanc, B, Finch, C, Hallberg, L, et al. Nutritional anaemia: Report of a WHO scientific group. WHO Tech Report Series. 1968; 405:5–37.Google Scholar

Zakai, NA, Katz, R, Hirsch, C, et al. A prospective study of anemia status, hemoglobin concentration, and mortality in an elderly cohort: The Cardiovascular Health Study. Arch Intern Med. 2005; 165:2214–2220.Google Scholar

Guralnik, JM, Eisenstaedt, RS, Ferrucci, L, Klein, HG, Woodman, RC. Prevalence of anemia in persons 65 years and older in the United States: Evidence for a high rate of unexplained anemia. Blood. 2004; 104:2263–2268.Google Scholar

Izaks, GJ, Westendorp, RG, Knook, DL. The definition of anemia in older persons. JAMA. 1999; 281:1714–1717.Google Scholar

Artz, AS, Thirman, MJ. Unexplained anemia predominates despite an intensive evaluation in a racially diverse cohort of older adults from a referral anemia clinic. J Gerontol A Biol Sci Med Sci. 2011; 66:925–932.CrossRef Google Scholar

Ferrucci, L, Semba, RD, Guralnik, JM, et al. Proinflammatory state, hepcidin, and anemia in older persons. Blood. 2010; 115:3810–3816.CrossRef Google Scholar PubMed

Adler, AS, Kawahara, TL, Segal, E, Chang, HY. Reversal of aging by NFkappaB blockade. Cell Cycle. 2008; 7:556–559.CrossRef Google Scholar PubMed

Chambers, SM, Shaw, CA, Gatza, C, Fisk, CJ, Donehower, LA, Goodell, MA. Aging hematopoietic stem cells decline in function and exhibit epigenetic dysregulation. PLoS Biol. 2007; 5:e201.CrossRef Google Scholar PubMed

Chambers, SM, Goodell, MA. Hematopoietic stem cell aging: Wrinkles in stem cell potential. Stem Cell Rev. 2007; 3:201–211.Google Scholar

Culleton, BF, Manns, BJ, Zhang, J, Tonelli, M, Klarenbach, S, Hemmelgarn, BR. Impact of anemia on hospitalization and mortality in older adults. Blood. 2006; 107:3841–3846.Google Scholar

Zakai, NA, French, B, Arnold, AM, et al. Hemoglobin decline, function, and mortality in the elderly: The cardiovascular health study. Am J Hematol. 2013; 88:5–9.CrossRef Google Scholar PubMed

Dong, X, Mendes de Leon, C, Artz, A, Tang, Y, Shah, R, Evans, D. A population-based study of hemoglobin, race, and mortality in elderly persons. J Gerontol A Biol Sci Med Sci. 2008; 63:873–878.Google Scholar

Denny, SD, Kuchibhatla, MN, Cohen, HJ. Impact of anemia on mortality, cognition, and function in community-dwelling elderly. Am J Med. 2006; 119:327–334.CrossRef Google Scholar PubMed

Penninx, BW, Guralnik, JM, Onder, G, Ferrucci, L, Wallace, RB, Pahor, M. Anemia and decline in physical performance among older persons. Am J Med. 2003; 115:104–110.CrossRef Google Scholar PubMed

Penninx, BW, Pluijm, SM, Lips, P, et al. Late-life anemia is associated with increased risk of recurrent falls. J Am Geriatr Soc. 2005; 53:2106–2111.CrossRef Google Scholar PubMed

Chaves, PH, Semba, RD, Leng, SX, et al. Impact of anemia and cardiovascular disease on frailty status of community-dwelling older women: The Women’s Health and Aging Studies I and II. J Gerontol A Biol Sci Med Sci. 2005; 60:729–735.Google Scholar

Deal, JA, Carlson, MC, Xue, QL, Fried, LP, Chaves, PH. Anemia and 9-year domain-specific cognitive decline in community-dwelling older women: The Women’s Health and Aging Study II. J Am Geriatr Soc. 2009; 57:1604–1611.CrossRef Google Scholar PubMed

Zilinski, J, Zillmann, R, Becker, I, Benzing, T, Schulz, RJ, Roehrig, G. Prevalence of anemia among elderly inpatients and its association with multidimensional loss of function. Ann Hematol. 2014; 93(10):1645–1654.Google Scholar

Hong, CH, Falvey, C, Harris, TB, et al. Anemia and risk of dementia in older adults: findings from the Health ABC study. Neurology. 2013; 81:528–533.Google Scholar

Joosten, E, Ghesquiere, B, Linthoudt, H, et al. Upper and lower gastrointestinal evaluation of elderly inpatients who are iron deficient. Am J Med. 1999; 107:24–29.Google Scholar

Pang, WW, Schrier, SL. Anemia in the elderly. Curr Opin Hematol. 2012; 19:133–140.Google Scholar

Cook, JD, Flowers, CH, Skikne, BS. The quantitative assessment of body iron. Blood. 2003; 101:3359–3364.Google Scholar

Keel, SB, Abkowitz, JL. The microcytic red cell and the anemia of inflammation. N Engl J Med. 2009; 361:1904–1906.Google Scholar

Rector, WG Jr. Pica: Its frequency and significance in patients with iron-deficiency anemia due to chronic gastrointestinal blood loss. J Gen Intern Med. 1989; 4:512–513.Google Scholar

Moist, LM, Troyanov, S, White, CT, et al. Canadian Society of Nephrology commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD. Am J Kidney Dis. 2013; 62:860–873.CrossRef Google Scholar PubMed

Martin, A, Thompson, AA. Thalassemias. Pediatr Clin North Am. 2013; 60:1383–1391.CrossRef Google Scholar PubMed

Muncie, HL Jr, Campbell, J. Alpha and beta thalassemia. Am Fam Physician. 2009; 80:339–344.Google Scholar

Price, EA, Mehra, R, Holmes, TH, Schrier, SL. Anemia in older persons: Etiology and evaluation. Blood Cells Mol Dis. 2011; 46:159–165.Google Scholar

Corazza, F, Beguin, Y, Bergmann, P, et al. Anemia in children with cancer is associated with decreased erythropoietic activity and not with inadequate erythropoietin production. Blood. 1998; 92:1793–1798.Google Scholar

Weiss, G, Goodnough, LT. Anemia of chronic disease. N Engl J Med. 2005; 352:1011–1023.CrossRef Google Scholar PubMed

Artz, AS, Xue, QL, Wickrema, A, et al. Unexplained anaemia in the elderly is characterised by features of low grade inflammation. Br J Haematol. 2014; 167(2):286–269.Google Scholar

Allen, LA, Felker, GM, Mehra, MR, et al. Validation and potential mechanisms of red cell distribution width as a prognostic marker in heart failure. J Card Fail. 2010; 16:230–238.Google Scholar

Roy, CN. Anemia of inflammation. Hematology Am Soc Hematol Educ Program. 2010; 2010:276–280.Google Scholar

Merchant, AA, Roy, CN. Not so benign haematology: Anaemia of the elderly. Br J Haematol. 2012; 156:173–185.Google Scholar

Goodnough, LT, Levy, JH, Murphy, MF. Concepts of blood transfusion in adults. Lancet. 2013; 381:1845–1854.Google Scholar

Finch, CA, Lenfant, C. Oxygen transport in man. N Engl J Med. 1972; 286:407–415.Google Scholar

Kazmi, WH, Kausz, AT, Khan, S, et al. Anemia: An early complication of chronic renal insufficiency. Am J Kidney Dis. 2001; 38:803–812.Google Scholar

Erslev, AJ. Erythropoietin. N Engl J Med. 1991; 324:1339–1344.Google Scholar

Donnelly, S, Shah, BR. Erythropoietin deficiency in hyporeninemia. Am J Kidney Dis. 1999; 33:947–953.CrossRef Google Scholar PubMed

Ma, JZ, Ebben, J, Xia, H, Collins, AJ. Hematocrit level and associated mortality in hemodialysis patients. J Am Soc Nephrol. 1999; 10:610–619.CrossRef Google Scholar PubMed

Fernandez-Rodriguez, AM, Guindeo-Casasus, MC, Molero-Labarta, T, et al. Diagnosis of iron deficiency in chronic renal failure. Am J Kidney Dis. 1999; 34:508–513.Google Scholar

Phrommintikul, A, Haas, SJ, Elsik, M, Krum, H. Mortality and target haemoglobin concentrations in anaemic patients with chronic kidney disease treated with erythropoietin: A meta-analysis. Lancet. 2007; 369:381–388.Google Scholar

Andres, E, Loukili, NH, Noel, E, et al. Vitamin B12 (cobalamin) deficiency in elderly patients. CMAJ. 2004; 171:251–259.CrossRef Google Scholar PubMed

Carmel, R. How I treat cobalamin (vitamin B12) deficiency. Blood. 2008; 112:2214–2221.Google Scholar

Nimo, RE, Carmel, R. Increased sensitivity of detection of the blocking (type I) anti-intrinsic factor antibody. Am J Clin Pathol. 1987; 88:729–733.Google Scholar

Eussen, SJ, de Groot, LC, Clarke, R, et al. Oral cyanocobalamin supplementation in older people with vitamin B12 deficiency: A dose-finding trial. Arch Intern Med. 2005; 165:1167–1172.Google Scholar

Ades, L, Itzykson, R, Fenaux, P. Myelodysplastic syndromes. Lancet. 2014; 383:2239–2252.Google Scholar

Will, B, Zhou, L, Vogler, TO, et al. Stem and progenitor cells in myelodysplastic syndromes show aberrant stage-specific expansion and harbor genetic and epigenetic alterations. Blood. 2012; 120:2076–2086.Google Scholar

Anttila, P, Ihalainen, J, Salo, A, Heiskanen, M, Juvonen, E, Palotie, A. Idiopathic macrocytic anaemia in the aged: molecular and cytogenetic findings. Br J Haematol. 1995; 90:797–803.Google Scholar

Greenberg, PL, Tuechler, H, Schanz, J, et al. Revised international prognostic scoring system for myelodysplastic syndromes. Blood. 2012; 120:2454–2465.Google Scholar

Zeidan, AM, Linhares, Y, Gore, SD. Current therapy of myelodysplastic syndromes. Blood Rev. 2013; 27:243–259.Google Scholar

Gehrs, BC, Friedberg, RC. Autoimmune hemolytic anemia. Am J Hematol. 2002; 69:258–271.Google Scholar

Crisp, D, Pruzanski, W. B-cell neoplasms with homogeneous cold-reacting antibodies (cold agglutinins). Am J Med. 1982; 72:915–922.Google Scholar

Berentsen, S. Cold agglutinin-mediated autoimmune hemolytic anemia in Waldenstrom’s macroglobulinemia. Clin Lymphoma Myeloma. 2009; 9:110–112.Google Scholar

Berentsen, S, Ulvestad, E, Langholm, R, et al. Primary chronic cold agglutinin disease: A population based clinical study of 86 patients. Haematologica. 2006; 91:460–466.Google Scholar

Smyth, SS, McEver, RP, Weyrich, AS, et al. Platelet functions beyond hemostasis. J Thromb Haemost. 2009; 7:1759–1766.Google Scholar

Williamson, DR, Albert, M, Heels-Ansdell, D, et al. Thrombocytopenia in critically ill patients receiving thromboprophylaxis: frequency, risk factors, and outcomes. Chest. 2013; 144:1207–1215.CrossRef Google Scholar PubMed

Mendes, FD, Suzuki, A, Sanderson, SO, Lindor, KD, Angulo, P. Prevalence and indicators of portal hypertension in patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol. 2012; 10:1028,33.e2.Google Scholar

Sheikh, MY, Raoufi, R, Atla, PR, Riaz, M, Oberer, C, Moffett, MJ. Prevalence of cirrhosis in patients with thrombocytopenia who receive bone marrow biopsy. Saudi J Gastroenterol. 2012; 18:257–262.Google Scholar

Aster, RH. Pooling of platelets in the spleen: Role in the pathogenesis of “hypersplenic” thrombocytopenia. J Clin Invest. 1966; 45:645–657.Google Scholar

Peck-Radosavljevic, M, Zacherl, J, Meng, YG, et al. Is inadequate thrombopoietin production a major cause of thrombocytopenia in cirrhosis of the liver? J Hepatol. 1997; 27:127–131.Google Scholar

Kuwana, M, Okazaki, Y, Ikeda, Y. Splenic macrophages maintain the anti-platelet autoimmune response via uptake of opsonized platelets in patients with immune thrombocytopenic purpura. J Thromb Haemost. 2009; 7:322–329.Google Scholar

Frederiksen, H, Schmidt, K. The incidence of idiopathic thrombocytopenic purpura in adults increases with age. Blood. 1999; 94:909–913.Google Scholar

Neunert, C, Lim, W, Crowther, M, et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011; 117:4190–4207.Google Scholar

Cines, DB, Blanchette, VS. Immune thrombocytopenic purpura. N Engl J Med. 2002; 346:995–1008.Google Scholar

Provan, D, Stasi, R, Newland, AC, et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010; 115:168–186.Google Scholar

Surveillance, Epidemiology, and End Results Program (SEER) Stat Fact Sheet: Myeloma. National Cancer Institute. http://seer.cancer.gov/statfacts/html/mulmy.html. Accessed on 01/14/2014.Google Scholar

DeSantis, CE, Lin, CC, Mariotto, AB, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014; 64:252–271.Google Scholar

Kyle, RA, Gertz, MA, Witzig, TE, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc. 2003; 78:21–33.Google Scholar

Katzmann, JA, Clark, RJ, Abraham, RS, et al. Serum reference intervals and diagnostic ranges for free kappa and free lambda immunoglobulin light chains: Relative sensitivity for detection of monoclonal light chains. Clin Chem. 2002; 48:1437–1444.Google Scholar

Kyle, RA, Therneau, TM, Rajkumar, SV, et al. Prevalence of monoclonal gammopathy of undetermined significance. N Engl J Med. 2006; 354:1362–1369.CrossRef Google Scholar PubMed

Rajkumar, SV, Kyle, RA, Therneau, TM, et al. Serum free light chain ratio is an independent risk factor for progression in monoclonal gammopathy of undetermined significance. Blood. 2005; 106:812–817.Google Scholar

Rajkumar, SV, Dimopoulos, MA, Palumbo, A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet. 2014: 15; e538–e548.Google Scholar

Richardson, PG, Weller, E, Lonial, S, et al. Lenalidomide, bortezomib, and dexamethasone combination therapy in patients with newly diagnosed multiple myeloma. Blood. 2010; 116:679–686.Google Scholar

Cancer Facts and Figures. American Cancer Society. www.cancer.org/research/cancerfactsstatistics/allcancerfactsfigures/index. Accessed on 07/30/2014.Google Scholar

Rai, KR, Sawitsky, A, Cronkite, EP, Chanana, AD, Levy, RN, Pasternack, BS. Clinical staging of chronic lymphocytic leukemia. Blood. 1975; 46:219–234.Google Scholar

Bailey, C, Richardson, LC, Allemani, C, et al. Adult leukemia survival trends in the United States by subtype: A population-based registry study of 370,994 patients diagnosed during 1995–2009. Cancer. 2018; 124:3856–3867.Google Scholar

Surveillance, Epidemiology, and End Results Program (SEER) Fast Stats 2014. National Cancer Institute. http://seer.cancer.gov/faststats/selections.php. Accessed on 07/30/2014.Google Scholar

Mauro, FR, Foa, R, Cerretti, R, et al. Autoimmune hemolytic anemia in chronic lymphocytic leukemia: Clinical, therapeutic, and prognostic features. Blood. 2000; 95:2786–2792.Google Scholar

Diehl, LF, Ketchum, LH. Autoimmune disease and chronic lymphocytic leukemia: autoimmune hemolytic anemia, pure red cell aplasia, and autoimmune thrombocytopenia. Semin Oncol. 1998; 25:80–97.Google Scholar

Delgado, J, Nadeu, F, Colomer, D, Campo, E. Chronic lymphocytic leukemia: from molecular pathogenesis to novel therapeutic strategies. Haematologica. 2020; 105:236000.Google Scholar

Deininger, MW, Shah, NP, Altman, JK, et al. Chronic Myeloid Leukemia, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2020; 18:1385–1415.Google Scholar

Surveillance, Epidemiology, and End Results Program (SEER) Cancer Statistics Reviews (CSR) 1975–2011. National Cancer Institute. http://seer.cancer.gov/csr/1975_2011. Accessed on 07/30/2014.Google Scholar

Sorror, ML, Sandmaier, BM, Storer, BE, et al. Long-term outcomes among older patients following nonmyeloablative conditioning and allogeneic hematopoietic cell transplantation for advanced hematologic malignancies. JAMA. 2011; 306:1874–1883.Google Scholar

Ania, BJ, Suman, VJ, Sobell, JL, Codd, MB, Silverstein, MN, Melton, LJ 3rd. Trends in the incidence of polycythemia vera among Olmsted County, Minnesota residents, 1935–1989. Am J Hematol. 1994; 47:89–93.Google Scholar

Baxter, EJ, Scott, LM, Campbell, PJ, et al. Acquired mutation of the tyrosine kinase JAK2 in human myeloproliferative disorders. Lancet. 2005; 365:1054–1061.Google Scholar

Marchioli, R, Finazzi, G, Specchia, G, et al. Cardiovascular events and intensity of treatment in polycythemia vera. N Engl J Med. 2013; 368:22–33.Google Scholar

Landolfi, R, Marchioli, R, Kutti, J, et al. Efficacy and safety of low-dose aspirin in polycythemia vera. N Engl J Med. 2004; 350:114–124.Google Scholar

Passamonti, F. How I treat polycythemia vera. Blood. 2012; 120:275–284.Google Scholar

Mesa, RA, Silverstein, MN, Jacobsen, SJ, Wollan, PC, Tefferi, A. Population-based incidence and survival figures in essential thrombocythemia and agnogenic myeloid metaplasia: An Olmsted County Study, 1976–1995. Am J Hematol. 1999; 61:10–15.Google Scholar

Beer, PA, Erber, WN, Campbell, PJ, Green, AR. How I treat essential thrombocythemia. Blood. 2011; 117:1472–1482.CrossRef Google Scholar

Cortelazzo, S, Finazzi, G, Ruggeri, M, et al. Hydroxyurea for patients with essential thrombocythemia and a high risk of thrombosis. N Engl J Med. 1995; 332:1132–1136.Google Scholar

Harrison, CN, Campbell, PJ, Buck, G, et al. Hydroxyurea compared with anagrelide in high-risk essential thrombocythemia. N Engl J Med. 2005; 353:33–45.Google Scholar

Gisslinger, H, Gotic, M, Holowiecki, J, et al. Anagrelide compared with hydroxyurea in WHO-classified essential thrombocythemia: The ANAHYDRET Study, a randomized controlled trial. Blood. 2013; 121:1720–1728.Google Scholar

Harrison, C, Kiladjian, JJ, Al-Ali, HK, et al. JAK inhibition with ruxolitinib versus best available therapy for myelofibrosis. N Engl J Med. 2012; 366:787–798.Google Scholar

Verstovsek, S, Mesa, RA, Gotlib, J, et al. A double-blind, placebo-controlled trial of ruxolitinib for myelofibrosis. N Engl J Med. 2012; 366:799–807.CrossRef Google Scholar PubMed

Accessibility standard: Unknown

Why this information is here

This section outlines the accessibility features of this content - including support for screen readers, full keyboard navigation and high-contrast display options. This may not be relevant for you.

Accessibility Information

Accessibility compliance for the HTML of this chapter is currently unknown and may be updated in the future.