From OncoLog, July/August 2006, Vol. 51, No. 7/8

DiaLog: Anemia in the Elderly

Elihu Estey, M.D., Professor, Department of Leukemia

A study in the April 2006 issue of the American Journal of Medicine (AJM) found that 24% of people over 65 years old were anemic, but it discouraged the practice of ascribing the cause of anemia simply to older age. (Anemia was defined as a hemoglobin level below 12 g/dl in women and 13 g/dl in men.) As a physician with an interest in myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML), I’m probably oversensitized to the possibility of these serious diagnoses in older patients with anemia, but the incidence of AML and MDS does rise significantly with age, and all physicians should be aware of this.

The AJM study showed that anemia increased the risk of death by 40%, after accounting for age, body mass index, kidney function, and other indicators of general health. Furthermore, deficits in cognition were much more frequent in people with anemia.

The AJM paper confirms the importance of diagnosing and managing anemia and points out that, although common, anemia is not normal in the elderly, i.e., most of the elderly are not anemic. Many conditions can cause anemia; these conditions run from the mundane (dietary folic acid deficiency) to the life-threatening (MDS and AML). Thus, the cause of anemia has a strong influence on mortality and should be routinely investigated, even in very old patients.

The starting point for diagnostic evaluation of anemia in the elderly is the patient history. This, for example, might indicate that the patient is taking a medicine that can cause anemia. Even non-prescription drugs such as ibuprofen can be responsible by causing blood loss from the gastrointestinal tract. The most important laboratory test is the reticulocyte count. A high count suggests that the cause of anemia is excessive destruction of red blood cells and that the bone marrow is responding appropriately to the anemia. Conversely, a low reticulocyte count suggests that marrow failure underlies the anemia. If a search for iron, B12, folic acid, or erythropoietin deficiency is unrevealing, examination of the bone marrow is in order.

MDS can be diagnosed when more than 5% of the cells are immature cells (blasts) or when there is a cytogenetic abnormality. When the blast count is from 10% to 20%, the distinction between MDS and AML is quite blurred; when it exceeds 20%, the diagnosis is AML. Because hematopathologists often differ in their identification of mild-to-moderate dysplasia, caution should be exercised in diagnosing MDS when the blast count is below 5%, when cytogenetic abnormalities are absent, and when only mild-to-moderate dysplasia is present. More sensitive and specific tests to diagnose MDS will almost certainly be based on the identification of genetic abnormalities.

For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.

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