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approximately 80% of elderly patients.9
The most common causes of anaemia
in the elderly are chronic disease
(Mrs K) and iron deficiency (Mrs B).
Anaemia of chronic disease is the
single most common form of anaemia
in the elderly; about one-quarter of
community-dwelling elderly people
with anaemia have underlying anaemia
of chronic disease.5,8,9 Serum ferritin
is the most useful test to differentiate
iron deficiency anaemia from anaemia
of chronic disease, typically being
low (< 100 μg/L) in iron deficiency
anaemia and normal in anaemia of
chronic disease.5,9 Although serum
ferritin levels between 15 and 100 μg/L
are moderately predictive of iron
deficiency anaemia, patients with levels
in this range may have iron deficiency
anaemia, anaemia of chronic disease,
or both. If it is important to determine
which is present or if the patient does
not respond to iron therapy, a bone
marrow biopsy might be necessary to
measure iron stores directly.9
Anaemia of chronic disease is observed
in many conditions, including
malignancy, chronic infections, chronic
inflammatory conditions, congestive
heart failure and diabetes mellitus.
Often the extent of the anaemia is linked
to the severity of the underlying illness.
It is thought to result from an increase
in pro-inflammatory cytokines that
contribute to impaired erythropoiesis
by interfering with both the production
and biological activity of erythropoietin.
Ageing may be associated with a similar
phenomenon, with dysregulation of pro-
inflammatory cytokines, most notably
interleukin-6, which may negatively
impact haematopoiesis, either by
inhibition of erythropoietin production
or interaction with erythropoietin
receptors.8 Anaemia of chronic disease
can occur in the presence of other causes
of anaemia, including iron deficiency,
which may cause difficulties in
confirming the diagnosis in the elderly.
There is no specific therapy for anaemia
of chronic disease except to manage
or treat the underlying disorder. Iron
therapy is generally of no benefit.9
In the elderly, iron deficiency anaemia is
most often the result of chronic GI blood
loss caused by oesophagitis, peptic
ulcer, colon cancer or pre-malignant
polyps, diverticula or non-steroidal
anti-inflammatory drugs. Iron deficiency
anaemia is rarely the result of dietary
deficiency in industrialised countries.8
In addition to treating the cause of
bleeding, iron supplementation should
be initiated for the treatment of the
anaemia.9 The usual recommended
therapy is ferrous sulfate 325 mg 1 tablet
once or twice daily.10 A haemoglobin
level no higher than 12 g/dL in women
and 13 g/dL in men should be a safe
starting therapeutic target.3
• Common adverse effects of oral iron
include GI pain, nausea, vomiting,
diarrhoea, constipation, and
• To minimise GI adverse effects, iron
supplements may be taken with food,
but this may reduce bioavailability.
Reducing the amount of iron taken in
each dose, or reducing the frequency
from twice daily to once daily, may
also improve GI tolerability.
• Vitamin C does not increase
absorption of iron supplements
but may increase absorption of iron
• Beware of drug interactions with oral
iron (e.g. tetracyclines, quinolones, and
• Patients unable to tolerate oral iron
supplements may require parenteral
• Monitor haemoglobin for response to
therapy. Expect haemoglobin to rise by
about 2 g/dL over 3--4 weeks.
• If no response is detected in a month,
review diagnosis and consider non-
adherence or coexisting problems
(e.g. ongoing occult GI bleeding).
• Once haemoglobin concentration
is normal, continue treatment for a
further three months to replenish
• Avoid unnecessary long-term use of
Pharmacists have an important role in
detecting and managing anaemia in the
elderly. Elderly patients should be advised
that fatigue, weakness and breathlessness
are not necessarily normal parts of
ageing and referred on to their general
practitioner for further investigation. The
provision of counselling to optimise oral
iron therapy may also avoid the need for
more invasive parenteral therapy.
1. Kheir F, Haddad R. Anemia in the elderly. Dis Mon. 2010;
2. Steensma DP, Tefferi A. Anemia in the elderly: how should we
define it, when does it matter, and what can be done? Mayo
Clin Proc. 2007; 82(8):958--66.
3. Spivak JL. Anemia in the elderly: time for new blood in old
vessels? Arch Intern Med. 2005; 165(19):2187--9.
4. Beyer I, Compte N, Busuioc A, et al. Anemia and transfusions
in geriatric patients: a time for evaluation. Hematology. 2010;
5. Gabrilove J. Anemia and the elderly: clinical considerations. Best
Pract Res Clin Haematol. 2005; 18(3):417--22.
6. Lipschitz D. Medical and functional consequences of anemia in
the elderly. J Am Geriatr Soc. 2003; 51(3 Suppl):S10--3.
7. Levin A, Singer J, Thompson CR, et al. Prevalent left ventricular
hypertrophy in the predialysis population: identifying
opportunities for intervention. Am J Kidney Dis. 1996;
8. Eisenstaedt R, Penninx BW, Woodman RC. Anemia in the elderly:
current understanding and emerging concepts. Blood Rev.
9. Smith DL. Anemia in the elderly. Am Fam Physician. 2000;
10. Australian Medicines Handbook Pty Ltd. Australian Medicines
Handbook Drug Choice Companion: Aged Care, 3rd ed.
Table 1. Anaemia in the elderly:
• Anaemia is very common in the
elderly and its prevalence increases
with age: it occurs in approximately
10% of people aged 65 years or older.
• It is associated with increased
mortality and poorer health-related
quality of life, regardless of the
• Anaemia can lead to cardiovascular
and neurological complications,
such as congestive heart failure and
impaired cognitive function.
• Anaemia is always the consequence
of another disorder, and correction of
the underlying disorder is the most
• While iron deficiency is a common
cause of anaemia in older individuals,
it is rarely the result of dietary
deficiency in developed countries.
• Iron deficiency anaemia is most often
the result of chronic gastrointestinal
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