|Year : 2014 | Volume
| Issue : 4 | Page : 190-194
A clinicohaematological profile of elderly patientsbeing investigated for anaemia in a tertiary care centre in north-west India
Anil Raina1, Ajay Kumar2, Aneeta Singh1, Geetika Gupta3, Pavan Malhotra2, Sunil K Raina4
1 Department of Pathology, Acharya Shri Chander College of Medical Sciences, Sidhra, Jammu and Kashmir, India
2 Department of Pharmocology, Acharya Shri Chander College of Medical Sciences, Sidhra, Jammu and Kashmir, India
3 Department of Physiology, Acharya Shri Chander College of Medical Sciences, Sidhra, Jammu and Kashmir, India
4 Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, Himachal Pradesh, India
|Date of Submission||27-Apr-2014|
|Date of Acceptance||21-Nov-2014|
|Date of Web Publication||25-Mar-2015|
Sunil K Raina
Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Tanda 176 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Background There are plenty of studies on prevalence of anaemia in high-risk groups such as pregnant and lactating women and children. Reliable data on the prevalence and causes of anaemia in the elderly population are not available, particularly in this region. Thus, the present study was carried out to profile anaemia in geriatric patients in our setup.
Objectives The aim of this study was to profile anaemia clinicohaematologically among elderly.
Materials and methods A total of 168 geriatric patients aged 65 years and above, male and female patients with haemoglobin less than 12 g/dl admitted in the Tertiary Care Hospital, were included in the study. Investigations were carried out, mainly haematological with supporting biochemical parameters, which included complete blood count, peripheral blood film examination, serum B12 and folate studies, bone marrow cytology, iron studies, liver and renal function tests, urine examination and radiological examination when required. Detailed clinical history, systemic examination and complete haematological, biochemical and radiological investigations were carried out when patients were being managed in the respective wards/units.
Results Various underlying pathologies encountered were nutritional deficiency anaemia (47.6%), anaemia of chronic disease (20.2%), bone marrow infiltration (8.3%), multiple myeloma (7.1%), myelodysplastic syndrome (4.8%), myelofibrosis (4.8%), acute myeloid leukaemia (3.6%), anaemia of renal disease (2.4%) and chronic lymphocytic leukaemia (1.2%). Anaemia associated with chronic diseases included cases of pulmonary tuberculosis, rheumatoid arthritis, bronchiectasis, pneumonia and ischaemic heart diseases, which predisposed the patient to greater morbidity.
Conclusion The incidence of anaemia is quite high among elderly patients, more so when associated with chronic diseases and malignancies. The major cause found is nutritional anaemia due to deficiency of iron, folic acid/vitamin B12 or dual deficiency. It is very important to diagnose the cause of anaemia by detailed investigations before initiating the required therapy. Egypt J Haematol 39:-0 © 2014 The Egyptian Society of Haematology.
Keywords: Anaemia, geriatric patients, Jammu region, nutritional, other causes
|How to cite this article:|
Raina A, Kumar A, Singh A, Gupta G, Malhotra P, Raina SK. A clinicohaematological profile of elderly patientsbeing investigated for anaemia in a tertiary care centre in north-west India. Egypt J Haematol 2014;39:190-4
|How to cite this URL:|
Raina A, Kumar A, Singh A, Gupta G, Malhotra P, Raina SK. A clinicohaematological profile of elderly patientsbeing investigated for anaemia in a tertiary care centre in north-west India. Egypt J Haematol [serial online] 2014 [cited 2020 Oct 21];39:190-4. Available from: http://www.ehj.eg.net/text.asp?2014/39/4/190/153943
| Introduction|| |
Anaemia is a key finding in the geriatric age group, more so in the lower socioeconomic strata. Elderly patients with anaemia and concomitant conditions such as heart failure or chronic renal failure are more prone to morbidity and mortality . Anaemia is often not only the first sign of an illness but also a signal to an underlying disease process . There occurs a continuous decrease in the volume of haematopoietic marrow, iron, vitamin B12 and folate levels with ageing. These changes only lead to a slight decrease in haematopoiesis as judged by cell counts and haemoglobin (Hb) level, except in individuals with significant deficiencies . According to WHO criteria, anaemia is present if the Hb level is below 13 g/dl in men and below 12 g/dl in women . The occurrence of anaemia in geriatric patients ranges from 8 to 44% in the different sections of population. Third National Health and Nutrition Examination Study (NHANES-III) of USA reported that as many as three million people aged 65 years and above are anaemic and that even mild anaemia when present is the cause of functional impairment and may lead to mortality as well. According to this study, 11% of men and 10.2% of women have been found to be anaemic. The underlying cause of anaemia identified in the study of elderly have been categorized into three groups:
- Nutritional deficiencies/blood loss anaemia (34%),
- Anaemia of chronic disease (32%) and
- Unexplained anaemia (34%). Nutrition deficiency anaemia, which accounted for one-third of cases, was attributed to iron deficiency/blood loss and vitamin B12 and folate deficiency.
The prevalence of blood loss/iron deficiency along with concomitant presence of chronic disease state in the said age group warrants right diagnosis and treatment, knowing the inadequacy of present diagnostic methods for detecting iron deficiency anaemia . Age-related effects on cellular DNA and cytotoxic drugs are the cause of clonal haematopoietic diseases such as leukaemia, lymphoma and myeloma, contributing to the cause of anaemia. Haematopoietic growth factors such as erythropoietin, certain vitamins/minerals such as copper, cobalt and manganese are involved in the process of haematopoiesis and maintenance of normal Hb level.
| Materials and methods|| |
A total of 168 geriatric patients of age 65 years and above, male and female patients with geriatric level anaemia (Hb < 12 g/dl) admitted in a Tertiary Care Hospital, were included in the study. Among the 168 patients, 92 were male and 76 were female patients. Informed and written consent from these patients after explaining the importance of investigations was taken. A detailed physical and systemic examination, clinical history, family history, drug history and history of chronic diseases were recorded before going for detailed relevant investigations.
The investigations mainly haematological with supporting biochemical parameters were estimated, which included complete blood count, peripheral blood film examination, iron studies, serum B12 and folic acid levels, bone marrow cytology, liver and renal function tests, urine examination and radiological examination, when required.
Complete blood count
Complete blood count included the following: Hb level; total erythrocyte count; red cell indices such as mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH) and mean corpuscular haemoglobin concentration (MCHC); and white cell indices such as total leucocyte count (TLC) and differential leucocyte count, as well as platelet count, packed cell volume, reticulocyte count and corrected TLC. All investigations were carried out on an automated cell counter (XS-800i63591Analyse APL00-13; Sysmex Corporation, Kobe, Japan) . The erythrocyte sedimentation rate (ESR) was determined using Westergren's method, and the differential leucocyte count in the case of morbid conditions like leukaemia was confirmed using Leishman's stain and subsequently studied under a microscope using an oil immersion lens .
Bone marrow examination
Bone marrow aspiration, trephine biopsy, marrow section and staining of slides were carried out following standard protocol .
Iron studies included serum iron, total iron binding capacity (TIBC) and serum ferritin levels. Plasma iron saturation (%) were calculated using the following standard formula:
Seruminon × 100TIBC
- Serum vitamin B12 and folic acid levels were estimated by means of the Cobase-411 (HITACHI) automated analyser.
- Urine examination, including routine, microscopic and examination for Bence Jones proteins, was also carried out to investigate for multiple myeloma .
- Liver function tests and renal function tests were performed using Siemens Dimension AR automated analyser.
Radiography of the chest, flat bones and skull, ultrasonography of abdomen, computed tomographic scan and MRI were carried out when required.
The patients were investigated thoroughly to diagnose the underlying disease. This included endoscopy of the upper gastrointestine, mammography, prostatic specific antigen estimation and serum rheumatoid factor.
In this study of 168 elderly patients with anaemia, a final diagnosis was made on the basis of clinical history, physical examination and various investigations such as haematological, biochemical or other investigations, and various causes of anaemia were found [Table 1].
The clinical symptoms of the elderly patients with anaemia in this study are presented in [Table 2]. Pallor and generalized weakness were seen in all patients, whereas dyspnoea, fever and pedal oedema were seen in 88.1, 61.9 and 53.6% cases, respectively. Fever was seen in patients with leukaemia, tuberculosis, respiratory tract infections and carcinoma. Massive organomegaly was seen in patients with myelofibrosis, moderate hepatosplenomegaly in patients with acute myeloid leukaemia, mild to moderate hepatosplenomegaly in patients with megaloblastic anaemia, rheumatoid arthritis and tuberculosis. Bone tenderness is a feature of acute leukaemia, multiple myeloma, carcinomatous marrow deposits and myelofibrosis. Bleeding occurred in patients with leukaemia, malignancy, gastric erosions and haemorrhoids. Lymphadenopathy was associated with cases of chronic lymphocytic leukaemia, tuberculosis and carcinoma. Jaundice was seen in patients with megaloblastic anaemia and joint pains in case of rheumatoid arthritis. Nearly 50% of anaemia patients required blood transfusion and the majority of them received multiple units of blood.
All patients in this study had mild (9-12 g%), moderate (6-9 g%) or severe (<6 g%) degree anaemia [Table 3]. Packed cell volume was also lower in all the 168 elderly patients and ranged from 10.7 to 40% [Table 3].
|Table 3: Haemoglobin levels and PCV values in elderly patients (n = 168)|
Click here to view
Total erythrocytic count ranged from 1.1 to 4 million/mm3 of blood; lowest (1.1×106/mm3) count was recorded in a patient with carcinomatous marrow deposits.
MCV, MCH and MCHC values varied from case to case and were normal, increased or decreased, as shown in [Table 4]. The lowest MCV value was 57.6 fl in a patient with iron deficiency anaemia, whereas the highest value was 122.0 fl in a patient with megaloblastic anaemia. The MCH values were less than 20 pg in patients with iron deficiency anaemia and greater than 32 in patients with megaloblastic anaemia. The MCHC values varied over a wide range, from as low as 25 g% in a case of iron deficiency to 33 g% in a case of megaloblastic anaemia.
|Table 4: Mean cell volume and mean cell haemoglobin concentration in elderly patients|
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Reticulocyte count was normal in 64.3% of cases, increased in 26.2% (myelodysplastic syndrome, myelofibrosis, bleeding disorders, some cases of iron and dual deficiency anaemia) and decreased in 9.5% of cases (megaloblastic anaemia). The count increased after treatment with haematinics or blood transfusion. Lowest count was seen in severe cases of megaloblastic anaemia. TLC was normal in 57.1% of cases, increased in 26.2% and decreased in 16.7% of cases. Increased count was seen in cases of various infections, leukaemia and myelodysplastic syndrome. Reduced count was seen in cases of megaloblastic anaemia and metastatic carcinoma of bone marrow. Platelet count was more than 4 lakh in 20.2% of cases, 1.5-4 lakh in 60.7%, 1-1.5 lakh in 12%, 0.5 lakh in 9.5% and 0.1-0.5 lakh in 8.3% of cases. Increased platelet count was seen in cases of iron deficiency, underlying infections and bleeding cases. Decreased count was seen in patients with severe megaloblastic anaemia, acute leukaemia and metastatic bone marrow disease. ESR was elevated in all cases of anaemia. It was more than 100 mm in the first hour in 23.8% of cases, 51-100 mm in the first hour in 42.9% and 10-50 mm in the first hour in 33.3% of cases. It was highly elevated in multiple myeloma, metastatic marrow disease, carcinoma, acute leukaemia and tuberculosis. The majority of patients with anaemia had ESR in the range of 51-100 mm in the first hour. Red blood cell (RBC) morphology with blood smear showed a predominantly macrocytic blood picture in patients with megaloblastic anaemia, myelodysplastic syndrome and myelofibrosis. Microcytic hypochromic predominance was seen in patients with iron deficiency anaemia. Dysmorphic blood picture was seen in patients with dual deficiency anaemia. Rouleaux formation was observed in anaemic patients with chronic disease and multiple myeloma.
Bone marrow aspiration cytology and trephine biopsy
Different causes of anaemia, such as nutritional (iron, folic acid/vitamin B12 or dual deficiency) or those of chronic diseases/bone marrow neoplastic pathology, which had a reflection in the cytological changes in bone marrow, were diagnosed on the basis of cytological changes.
Iron study was conducted on 80 patients with nutritional anaemia. Serum ferritin was found low in 49 patients with iron and dual deficiency anaemia. Increased value was observed in 28 cases of anaemia of chronic diseases, whereas three cases had normal value. The serum ferritin levels were below 15 mg/l in patients with iron deficiency anaemia, whereas patients with chronic disease had serum ferritin levels greater than 300 mg/l.
Other investigations carried out for diagnosing the cause of anaemia included those for the presence of albumin and Bence Jones proteins in cases of multiple myeloma, for increased levels of urea and creatinine in patients with cerebrospinal fluid, and for upper gastrointestinal bleeding by endoscopy, and confirmation of cases of carcinoma, myelophthisic and chronic disease anaemia by radiological observation made on radiography, ultrasonography, computed tomographic scan, MRI and mammography. Carcinoma and lymphoma were confirmed by cytological and histopathological examination, prostate cancer by prostatic specific antigen estimation, rheumatoid arthritis by rheumatoid factor estimation and megaloblastic and dual deficiency anaemia by vitamin B12 and folic acid estimation.
| Discussion|| |
Anaemia is a condition that indicates decreased oxygen-carrying capacity of blood due to reduced concentration of Hb or RBC count. The haematopoietic machinery, which works in the bone marrow, is primarily involved in the formation of cellular components of blood, including RBCs. Endogenous components such as iron, vitamin B12, folic acid, trace elements (copper, cobalt, manganese), along with growth factors such as G-CSF and erythropoietin contribute to the organized functioning of bone marrow. As such, any derangement in the process of this machinery, either due to deficiency of inputs or due to chronic diseases of bone marrow, leads to anaemia, particularly in the geriatric group.
Anaemia has been found to occur in both men and women above 65 years of age. A definite cause or causes are associated with anaemia in this age group. Evidently, anaemia in old age is not due to the physiological process of ageing; rather it is associated with a disease process seen in old age. This finding of ours is in consonance with the findings reported earlier ,. It is important that anaemia in elderly patients be investigated to find the aetiology before initiating the treatment, as this state has a definite cause. In addition to anaemia, elderly patients often suffer from conditions such as heart failure. It has been reported that anaemia can adversely affect the cardiovascular function of such patients and result in lower Hb levels, predisposing to mortality ,. Deterioration in cognition , disability, poor physical performance and lower muscle strength have also been reported .
For definite diagnosis of the cause of anaemia, routine investigations to study the clinical profile, haematological, bone marrow and cytological studies, and biochemical, radiological and other investigations are warranted. In our study covering the elderly population residing in the urban, periurban and rural areas belonging to different socioeconomic strata of population, nutritional deficiency anaemia was the major cause in 47.6% of cases followed by anaemia of chronic disease in 20.2% of cases, marrow infiltration in 8.3%, multiple myeloma in 7.1%, myelodysplastic syndrome in 4.8%, myelofibrosis in 4.8%, acute myeloid leukaemia in 3.6%, anaemia of renal disease in 2.4% and anaemia due to chronic lymphocytic leukaemia in 1.2% of cases.
Nutritional deficiency anaemia was largely seen in patients of low socioeconomic background or in those residing in old-age homes, with their diets deficient in green leafy vegetables and nonvegetarian diets. Other contributing factors were chronic blood loss due to ulcers/haemorrhoids. The nutritional deficiency anaemia included deficiency of iron, vitamin B12 and/or folic acid or dual deficiency. Among these, iron deficiency anaemia occurred more frequently, followed by vitamin B12/folic acid deficiency. Other causes recorded were anaemia of chronic diseases including pathologies of bone marrow and kidney .
| Conclusion|| |
The highlight of the present study conducted on elderly patients in Jammu, covering urban, periurban and rural areas of both poor and affluent backgrounds, is that the incidence of anaemia is quite high among elderly patients, more so when associated with chronic diseases and malignancies. The early diagnosis of anaemia is beneficial in the geriatric age group, as from the aetiopathogenesis and results of our study we infer that malignancy happens to be the second most common cause (29.8%) of anaemia, after nutritional anaemia (47.6%), followed by anaemia due to chronic disease (22.6%). Therefore, the anaemic conditions in all elderly patients need to be investigated thoroughly for exact diagnosis before initiating any kind of therapeutic intervention.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Ezekowitz JA, McAlister FA, Armstrong PW. Anemia is common in heart failure and is associated with poor outcomes: insights from a cohort of 12 065 patients with new-onset heart failure. Circulation
Freedman ML, Marcus DL. Anemia and the elderly: is it physiology or pathology? Am J Med Sci
Beutler E, Litchman MA, Coller BS, Kipps TJ, Seligsohn U. Williams haematology. 5th ed. USA: McGraw-Hill Publication
Smith DL. Anemia in the elderly. Am Fam Physician 2000; 62
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
Dacie JM, Lewis SM. Practical haematology. 9th ed.. New York: Churchill Livingstone Publication
Sood R. Medical laboratory technology: methods and interpretation. 5th ed. New Delhi: Jaypee Brothers Medical Publishers; 1999.
Douglas S. Management and treatment of anaemia in elderly. Clinical geriatrics
Kosiborod M, Smith GL, Radford MJ, Foody JM, Krumhoiz HM. The prognostic importance of anaemia in patients with heart failure. Am J Med
Denny SD, Kuchibhatla MN, Cohen HJ. Impact of anemia on mortality, cognition, and function in community-dwelling elderly. Am J Med
Pennix BW, Pahor M, Cesari M, Corsi AM, Woodman RC, et al. Anaemia is associated with disability and decreased physical performance and muscle strength in the elderly. J Am Geriatr Soc
Salive ME, Cornoni-Huntley J, Guralnik JM, Phillips CL, Wallace RB, Ostfeld AM, Cohen HJ. Anemia and hemoglobin levels in older persons: relationship with age, gender, and health status. J Am Geriatr Soc
[Table 1], [Table 2], [Table 3], [Table 4]