Retrospective analysis of the prevalence and causes of anaemia in hospitalised elderly patients South African Family Practice is co-published by Medpharm Publications, NISC (Pty) Ltd and Cogent, Taylor & Francis Group S Afr Fam Pract ISSN 2078-6190 EISSN 2078-6204 © 2015 The Author(s) RESEARCH South African Family Practice 2015; 57(5):297–299 http://dx.doi.org/10.1080/20786190.2015.1071538 Open Access article distributed under the terms of the Creative Commons License [CC BY-NC-ND 4.0] http://creativecommons.org/licenses/by-nc-nd/4.0 Retrospective analysis of the prevalence and causes of anaemia in hospitalised elderly patients Anna M van Stadena* and Dirk JV Weicha aFaculty of Health Sciences, Department of Internal Medicine, University of the Free State, Bloemfontein, South Africa *Corresponding author, email: gninmvs@ufs.ac.za Introduction: Anaemia is common in the elderly. Little is known regarding anaemia in hospitalised elderly patients in South Africa. A retrospective study determined the prevalence and causes of anaemia in elderly patients hospitalised for acute medical problems. Methods: Patients with anaemia were identified from the computerised database of a geriatric unit. Laboratory tests and clini- cal information on these patients were reviewed to determine the cause of the anaemia defined according to the WHO criteria (haemoglobin level ≤ 12 g/l for women and ≤ 13 g/l men). Results: Of 759 consecutive geriatric patients, 236 (31.1%) were anaemic. The majority (n = 150; 63.6%) were female, with a mean age of 82.2 years. The male patients had a mean age of 80.8 years. The mean haemoglobin values were 10.7 g/l and 10.2 g/l for male and female patients, respectively. In 96 (40.7%) patients, the cause of anaemia could not be determined. Of the remaining 140 patients, 25.7% had anaemia of chronic disorders, 24.3% had iron deficiency anaemia and 13.6% had multiple causes. Conclusion: Approximately one-third of hospitalised elderly patients were anaemic on admission, although many were not adequately investigated. Chronic disorders and iron deficiency were the most common causes of anaemia. Keywords: anaemia, causes, elderly patients, hospitalised, retrospective Introduction Anaemia is a common problem in elderly patients that usually develops gradually, allowing the body to adapt. Its effects can be life threatening, particularly as part of various co-morbidities in geriatric patients, and it is therefore a difficult diagnostic and therapeutic dilemma for medical practitioners. In South Africa, the prevalence of anaemia was 13.9% in non-institutionalised subjects older than 64 years,1 although no study has yet been done on the prevalence and causes of anaemia in elderly hospitalised patients in this coun- try. Anaemia is an important sign of disease and an evaluation is almost always warranted to determine the underlying cause. It has been shown that anaemia defined according to the WHO criteria (haemoglobin level ≤ 13 g/dl in men and ≤ 12 g/dl in women) is associated with increased mortality in elderly community residents.2 The aim of this retrospective study was to determine the preva- lence and causes of anaemia in elderly patients hospitalised for acute medical problems in Universitas Academic Hospital, a tertiary healthcare facility in Bloemfontein, South Africa. Methods During a study period from January 1999 to July 2003, 791 consecu- tive patients were admitted to be hospitalised in the acute geriatric ward of Universitas Hospital (1 395 m above sea level). Patients’ data were captured in a computerised database. Haemoglobin investiga- tions were performed in 759 of these elderly patients. Of these 759 patients, a group with anaemia was identified. For patients admitted more than once, only data from the first admission were considered. The laboratory tests (full blood count, urea and electrolytes, serum iron level, serum transferrin, transferrin saturation, serum ferritin, serum vitamin B 12 level, erythrocyte folate concentration and bone marrow examination) and clinical information on these patients were reviewed to determine the cause of the anaemia. Anaemia was defined according to the WHO criteria (haemoglobin of ≤ 12 g/dl for women and < 13 g/dl for men).2 Iron deficiency was accepted as the cause of anaemia if the serum ferritin level was below 18  μg/l, or less than 45  μg/l in combination with a transferrin saturation of 8%,3 or when no iron was detected in a bone marrow aspirate. The criteria of Cartwright and Lee4 were slightly modified to identify anaemia of chronic disorders, which included low serum iron (less than 13 μmol/l), low transferrin (less than 2 g/l), transferrin saturation 10–25% and serum ferritin level above 100 μg/l,5 or the condition was diagnosed on bone marrow aspiration. If the results of the iron study tests were abnormal but did not fit all the criteria of either iron deficiency anaemia or anaemia of chronic disorders, the results were deemed equivocal. Vitamin B 12 deficiency anaemia was diagnosed if the serum vita- min B 12 level was low (less than 211 ng/l), associated with macro- cytosis (mean corpuscular haemoglobin > 98 fl). Folate deficien- cy anaemia was diagnosed if the erythrocyte folate level was low (less than 186 μg/l) combined with macrocytosis. The diagnosis of haematological malignant conditions was based on examina- tions of the bone marrow aspirate and biopsy. Renal disease was accepted as the cause of anaemia if the patient was known to have chronic renal failure, or had small kidneys on ultrasound exam- ination and the results of the iron studies, serum vitamin B 12 levels and erythrocyte folate levels were normal. Approval to conduct the study was obtained from the Ethics Com- mittee of the Faculty of Health Sciences, University of the Free State (UFS), Bloemfontein (reference number 153/99). Results According to information from the computerised database, anae- mia was the main reason for admission in 20.5% (162/791) of the patients admitted to the Geriatric Unit during the study period. For 759 (96.0%) of these patients, haemoglobin readings were available. Patients with no information on haemoglobin level were excluded. mailto:gninmvs@ufs.ac.za 298 S Afr Fam Pract 2015 ; 57(5):297–299 Female patients represented 67.7% (n = 514) of the total group of patients included in the study. The mean age of male (n = 245) and female (n = 514) patients was 79.9 years and 81.4 years, respectively. The distribution of the haemoglobin levels of these patients (n = 759) is shown in Figure 1. Two hundred and thirty-six (31.1%) patients were found to be anaemic, of which 150 (63.6%) were female with a mean age of 82.1 years (range 65–96 years) and 86 (36.4%) male, with a mean age of 80.8 years (range 65–97 years). The mean haemoglobin value of the anaemic men was 10.7 ± 2 g/dL (median 11.0 g/dl) and that of the women was 10.2 ± 1.8 g/dl (median 10.6 g/dl). The distribu- tion of the haemoglobin levels of the anaemic patients (n = 236) is shown in Figure 2. No mean corpuscular volume (MCV) values were recorded for two patients. As shown in Table 1, the majority of the 236 geriatric patients with information on MCV values had normocytic anaemia (n = 158; 66.9%). In 96 (40.7%) of the anaemic patients, insufficient special investigations were performed to determine a cause of anaemia. The underlying cause of anaemia could therefore be determined in 140 patients with complete special investigations, of whom 36 (25.7%) and 34 (24.3%), respectively, had either anaemia of chronic disorders or iron deficiency anaemia. Results with regard to the cause of anaemia are summa- rised in Table 1. Of the 36 patients with anaemia of chronic disorders, nine (25.0%) had a proven malignancy and eight (22.2%) patients had acute or chronic infections. The mortality rate in the total study group of 791 patients hospi- talised in the Geriatric Unit was 16.6% (n = 131),6 and in the anaemic group it was 18.0% (27/150) for female and 18.6% (16/86) for male patients, confirming that anaemia is associated with a slightly increased mortality rate in geriatric hospitalised patients.2 Discussion Anaemia is very common in elderly hospitalised patients, with a prevalence ranging from 2.9% to 66.3%.7−12,13 In our study, the condition was often not adequately investigated, with 40.7% of patients not having sufficient laboratory investigations to determine the specific type of anaemia. Possible causes for not pursuing these investigations could be death, obvious other serious pathology, such as metastatic carcinoma or severe dementia, and ignorance of the correct work-up of anaemia. The majority of our patients had a mild normocytic anaemia, the most likely cause in these cases being anaemia of chronic disease, which was confirmed with special investigations in 36 cases. Many patients admitted to a geriatric unit usually suffer from multiple medical conditions, and it is likely that doctors might not have thought it necessary to further investigate patients with mild normocytic anaemia, of which the cause would most likely be anaemia of chronic disorders. The prevalence of anaemia in our study (31.1%) was higher than in similar studies done in Belgium7 and Israel,8 reporting a preva- lence of 24% and 14.4%, respectively. Our findings were similar to results reported from studies in Iceland (36.7%)11 and Italy (38.6%),12 but substantially lower than studies from Germany (66.3%)9 and France (65%).10 This variation in the prevalence of anaemia in hospitalised elderly patients can be related to a number of factors, including the setting of the study, the health status of the studied population, the age and gender of the subject population, the criteria used to define anaemia, and ageing trends in different countries. Since anaemia defined by WHO criteria is associated with an increased mortality rate in elderly persons and is often the marker of serious underlying disease such as cancer, we feel that further investigations in anae- mic elderly individuals are warranted, even in the case of mild anaemia. 2 4 6 8 10 12 14 16 18 P E R C E N TA G E O F P A TI E N TS HAEMOGLOBIN LEVEL (g dl−1)) 19 .1– 20 .0 0.0 – 4.0 4.1 – 5.0 5.1 – 6.0 6.1 – 7.0 7.1 – 8.0 8.1 – 9.0 9.1 – 10 .0 10 .1– 11 .0 11 .1– 12 .0 12 .1– 13 .0 13 .1– 14 .0 14 .1– 15 .0 15 .1– 16 .0 16 .1– 17 .0 17 .1– 18 .0 18 .1– 19 .0 Male, n = 245 (normal range 14.0–18.0 g dL−1) Female, n = 514 (normal range 12.0–16.0 g dL−1) Figure 1: Distribution of haemoglobin levels of hospitalised geriatric patients (n = 759) 5 10 15 20 25 30 P E R C E N TA G E O F P A TI E N TS HAEMOGLOBIN LEVEL (g dl−1)) 0.0 – 4.0 4.1 – 5.0 5.1 – 6.0 6.1 – 7.0 7.1 – 8.0 8.1 – 9.0 9.1 – 10 .0 10 .1– 11 .0 11 .1– 12 .0 12 .1– 13 .0 Male, n = 86 (normal range 14.0–18.0 g dL−1) Female, n = 150 (normal range 12.0–16.0 g dL−1) Figure 2: Distribution of haemoglobin levels of hospitalised geriatric patients with anaemia (n = 236) Table 1: Red cell morphology and cause of anaemia in elderly hospitalised patients Frequency Percentage Red cell morphology (n = 236) Normocytic 158 66.9 Microcytic 54 22.9 Macrocytic 22 9.3 No results 2 0.8 Underlying cause (n = 140) Anaemia of chronic disorders 36 25.7 Iron deficiency 34 24.3 Vitamin B12 and folate deficiency 10 7.1 Haematologic malignancy or pre-malignancy 10 7.1 Post-haemorrhagic anaemia 9 6.4 Chronic renal failure 4 2.9 Miscellaneous haematological conditions 4 2.9 Multiple causes 19 13.6 Equivocal iron study results 14 10.0 Retrospective analysis of the prevalence and causes of anaemia in hospitalised elderly patients 299 Several studies on hospitalised elderly, anaemic patients found anaemia of chronic disorders and iron deficiency anaemia to be the most common causes of anaemia in this particular group of patients,7−15 supporting the finding that in approximately 50% of patients in our study anaemia could be attributed to either one of these two causes. We had 14 patients with equivocal iron studies where it was not possible to diagnose with certainty either iron deficiency or anae- mia of chronic disorders. An example would be a finding of a fer- ritin value between 45 and 100 μg/l with a transferrin saturation level of less than 8%. These cases should have been assessed by means of bone marrow aspiration to distinguish between the two conditions, as the investigation and treatment of these condi- tions differ completely. In conclusion, our future plan is to draft a protocol for the investi- gation of anaemia in elderly persons. We also recommend that a prospective study on anaemia should be done to identify and treat the underlying causes in both elderly community residents and hospitalised patients. Acknowledgements – Dr H. Badenhorst for assistance with the evalu- ation of results, and Dr Daleen Struwig for technical and editorial preparation of the manuscript. 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Does anaemia matter? Anaemia, morbidity, and mortality in older adults: need for greater recognition. Geriatrics. 2005;60:22–9. 15. Smith DL. Anaemia in the elderly. Am Fam Physician. 2000;62:1565–72. Received: 11-03-2015 Accepted: 07-07-2015 http://dx.doi.org/10.1155/2014/932486 Introduction Methods Results Discussion Anchor 5 Anchor 6 References