Anemia, Fatigue, and Aging
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Aging is associated with a progressive decline in the functional reserve of multiple organ systems, and in personal and social resources.1 This combination leads to an impaired stress-coping ability. Although some changes of aging are unavoidable, many more may be delayed or prevented. Death is not preventable, but ideally, morbidity and disability may be delayed. “Compression of morbidity” is the main goal of geriatrics.2
Correction and prevention of anemia may play a role in compression of morbidity.3 Anemia is a cause of hypoxia, which limits the physical activity and impairs the synthesis of new proteins, leading to sarcopenia and increased disease susceptibility, which in turn, may lead to more anemia. This vicious cycle appears to be maintained by catabolic cytokines, which are a hallmark of aging and are associated with most geriatric syndromes, from dementia to osteoporosis to failure to thrive.4-8 In addition, anemia may be the first sign of lethal, but potentially curable, diseases including B12 deficiency or cancer of the digestive or urogenital tract. This article explores the implications of anemia in older patients and, in particular, in older cancer patients.
EPIDEMIOLOGY AND CAUSES OF ANEMIA IN OLDER AGE
The incidence and prevalence of anemia increase with age. The Third National Health And Nutrition Examination Survey (NHANES III) found a prevalence of anemia higher than 10% in individuals age 65 years and older.9 That prevalence increased with age, and was higher for African Americans, when compared with other ethnic backgrounds. Anemia was more common in older men than in older women, but this finding should be qualified. According to the World Health Organization (WHO), the normal hemoglobin values are 12 gm/dL or higher for women, and 13.0 gm/dL or higher for men. These values have been criticized since the publications of the Women’s Health and Aging Studies (WHAS), which demonstrated that in women age 65 years and older, hemoglobin levels lower than 13.5 gm/dL were associated with increased risk of mortality10 and functional impairment.11 If the average hemoglobin levels are the same in older men and postmenopausal women, the prevalence of anemia in NHANES III was similar for both sexes.
The Olmstead County studies demonstrated an age-related increase in incidence and prevalence of anemia.12 The prevalence of anemia was somewhat higher in Olmstead County, as this was a survey of the full population, including the sickest and oldest individuals. An Italian cross-sectional study showed a prevalence of anemia of 9.2% for individuals age 65 years and over, which increased with age.13 While the prevalence of anemia increased with age, the average concentration of hemoglobin remained stable in individuals age 85 years and over in all three studies, indicating that anemia is not an expected consequence of age.
The most common causes of anemia in older individuals in NHANES III and the Olmstead County study are shown in Table I. It is possible that more investigations might have revealed more specific causes for the so-called “anemias of unknown causes,” including early myelodysplasia and anemia of renal insufficiency.
Recent findings are germane to the discussion of the causes of anemia in older individuals:
• Incidence and prevalence of B12 deficiency increase with age.14,15 The most common cause of B12 deficiency is the inability to digest food containing B12 due to decreased gastric secretion of hydrochloric acid and of pepsin; this may be responsive to oral crystalline B12. In addition to anemia, B12 deficiency may be a cause of neurologic disorders, including dementia and posterior column lesions.16
• Seemingly, the main cause of iron deficiency is chronic bleeding from cancer, diverticuli, or angiodysplasia.
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