Update of nutrient-deficiency anemia in elderly patients

European Consensus on Malabsorption-UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN: Part 2: Screening, Special Populations, Nutritional Goals, Supportive Care, Primary Care Perspective

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. Patient's medical and pharmacological history are essential for identifying risk factors. Several examinations like endoscopy with small intestinal biopsies, non-invasive functional tests, and radiologic imaging are useful in diagnosing malabsorption. Due to its high prevalence, CD should always be looked for in case of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians have a central role in early detection of malabsorption and should be involved into multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving 10 scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

Anemia in Elderly Patients: Contribution of Renal Aging and Chronic Kidney Disease

Renal aging is a physiological process characterized by structural and functional changes in the kidneys. The presence of disorders or pathologies can exacerbate these age-related changes, potentially leading to organ dysfunction. Chronic kidney disease (CKD), a significant global public health issue, is particularly prevalent in the elderly and is often associated with the age-related decline in kidney function. Anemia is one of the most frequent complications of CKD and is also highly prevalent in the elderly. Mild anemia, often multifactorial, is the most common presentation. Understanding the mechanisms driving anemia in this population is crucial to ensure appropriate treatment. The primary etiologies include nutritional deficiency, anemia of unknown cause, and anemia of chronic diseases, including CKD. This review provides an in-depth exploration of the complex pathophysiological mechanisms underlying anemia in elderly patients with CKD.

Vitamin B12 Deficiency in Pernicious Anemia: A Hemolytic Anemia Mimic

Vitamin B12 deficiency can lead to a wide range of clinical symptoms and may resemble hemolytic anemia due to ineffective red blood cell production and hemolysis occurring within the bone marrow. Identifying this deficiency as a possible cause of hemolysis is essential to prevent misdiagnosis, especially when distinguishing it from thrombotic microangiopathy. We present a case involving a 60-year-old woman with a history of hypertension and type 2 diabetes who came in with symptoms of generalized weakness, dizziness, nausea, and abdominal pain. Laboratory tests showed pancytopenia, macrocytosis, and signs of hemolysis. Further investigation confirmed a severe vitamin B12 deficiency linked to pernicious anemia. After starting weekly intramuscular cyanocobalamin injections for the first month and then switching to monthly injections for four months post-discharge, her blood parameters showed significant improvement. This underlines the vital role of timely diagnosis and following established treatment protocols. This case emphasizes the importance of considering vitamin B12 deficiency as a reversible cause of hemolysis. It highlights the need to differentiate it from more serious hematologic disorders such as thrombotic microangiopathy to ensure proper management.

A Real-Time Web-Based Intervention with a Multicomponent Group-Based Program for Older Adults: Single-Arm Feasibility Study

Background/Objective: Frailty is a growing public health challenge in Japan's rapidly aging population, where 28.8% are aged ≥ 65. While multicomponent interventions have shown potential in preventing frailty, traditional face-to-face programs face accessibility challenges. This study evaluated the feasibility and short-term changes of an online multicomponent intervention on frailty-related factors among community-dwelling older adults. Methods: In this single-arm feasibility study, 132 participants (mean age 75.7; standard deviation 4.8 years, 65.2% women) completed a six-week online intervention combining exercise, nutrition education, cognitive activities, and the Coimagination Method to foster social connections, meeting weekly for 75 min sessions in groups of up to 10 participants. Results: The intervention demonstrated feasibility with a 96.4% retention rate and a 94.0% average participation rate. While no significant changes were observed in physical activity levels, autonomic nervous system indicators, or cognitive function, carotenoid scores and hemoglobin concentration improved significantly, with more pronounced improvements among women than men. Conclusions: This study demonstrates the high feasibility of online multicomponent interventions for older adults and suggests potential benefits for nutritional status markers, particularly among women. These findings indicate a promising and accessible approach to frailty prevention, though randomized controlled trials with longer intervention periods and direct frailty assessments are required to establish effectiveness conclusively. Study Trial registration: UMIN Clinical Trials Registry (UMIN000053089).

Prevalence of anaemia, iron, and vitamin deficiencies in the health system in the Republic of Ireland: a retrospective cohort study

BACKGROUND

Anaemia is a common but treatable condition that predicts adverse clinical outcomes. However, standards of anaemia management vary considerably.

AIM

To estimate the prevalence of anaemia and extent of screening for common underlying causes in the healthcare system in the Republic of Ireland.

DESIGN & SETTING

We conducted a retrospective cohort study of 112 181 adult patients, aged ≥18 years, who had a full blood count performed in 2013, using data from the National Kidney Disease Surveillance System.

METHOD

The prevalence of anaemia was determined across demographic and clinical subgroups, according to World Health Organization (WHO) definitions. The proportion screened for iron, vitamin B12, and folate deficiency was determined within a 3-month follow-up period and the corresponding prevalence for each deficiency determined.

RESULTS

The overall prevalence of anaemia was 12.0% (95% confidence interval [CI] = 11.8% to 12.2%) and was higher in women than men (13.2% versus 10.5%, P<0.001). Anaemia increased with advancing age (33.4% for those aged >75 years) and worsening kidney function (8.2%, 10.9%, 33.2%, and 63.8% for each estimated glomerular filtration rate [eGFR] categories >90, 60-89, 30-59 and <30 ml/min/1.73 m², respectively, P<0.001). After 3-months' follow-up, the proportion screened for iron deficiency was 11.2% based on transferrin saturation and 33.7% using serum ferritin. Screening for folate and B12 deficiency was 17.6% and 19.8%, respectively. Among screened patients, the prevalence of iron deficiency, B12, and folate deficiency was 37.0%, 6.3%, and 5.8%, respectively.

CONCLUSION

The burden of anaemia in the healthcare system is substantial especially for older patients and those with advanced kidney disease. Low screening rates for iron, B12, and folate deficiency are common and warrant quality improvement initiatives.

Prospective changes in anemia are associated with the incidence and persistence of sarcopenia among older Mexican adults

Background

Low hemoglobin levels are a significant biomarker in the prognosis of sarcopenia. Anemia and sarcopenia are frequent and disabling conditions in the older adult population, but little is known about the role of anemia in the onset and progression of sarcopenia. This study aimed to determine whether prospective changes in anemia are associated with the incidence and persistence of sarcopenia.

Methods

Data come from the second and third waves (2014, 2017) of the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) in Mexico. SAGE-Mexico is a dynamic cohort with national representativeness, including a follow-up sample and new enrollments. For this study, 1,500 older adults (aged 50 or above) with measurements in both waves were included. Sarcopenia was defined as having low muscle quantity and either/both slow gait speed and weak handgrip strength. Anemia was defined according to hemoglobin concentrations, adjusted for altitude, as recommended by the WHO, <120 g/L for women and <130 g/L for men. Multinomial logistic regression was used to estimate the association between anemia and prospective changes in sarcopenia.

Results

The baseline prevalence of anemia was 17.4%, and that of sarcopenia was 12.1%. The incidence and persistence of anemia were 10.6% (95% CI: 7.3-15.0%) and 6.9% (95% CI: 4.7-9.8%), respectively, and for sarcopenia, they were 5.3% (95% CI: 3.7-7.7%) and 9.2% (95% CI: 6.4-13.0%), respectively. Incident anemia was associated with incident (RRR = 3.64, 95% CI: 1.18-11.19) but not with persistent (RRR = 0.75, 95% CI: 0.18-3.20) sarcopenia. Persistent anemia was significantly associated with persistent (RRR = 3.59, 95% CI: 1.14-11.27) but not incident (RRR = 1.17, 95% CI: 0.30-4.54) sarcopenia.

Conclusion

Changes in anemia are significantly associated with incident and persistent sarcopenia. Primary actions to promote a healthy diet rich in antioxidants, high-quality proteins, and micronutrients, as well as moderate physical activity and maintaining a healthy weight, are crucial for the aging population to delay the deleterious effects of anemia and sarcopenia.

Vitamin B status and its impact in post-menopausal women: A review

Menopause is an age-related naturally occurring phenomenon in women. Women generally attain menopause between the 40-58 years of age, during which they undergo several physiological changes that have an impact on their daily activities. The deficiency of B vitamins occurs mainly due to the dietary pattern, absorption and blood loss which may leads to health problems such as cognitive decline, osteoporosis, physical and mental imbalance.  This review evaluated the published evidence on the vitamin B status and its impact in post-menopausal women. Selected data sources were searched for relevant literature (2010-2020) and included as per the set criteria using Prisma guidelines. The NIH quality questionnaire tool was used to rate the articles. Finally eleven articles were included for full length review having reports on the impact of B vitamins on bone loss, cognitive decline and physical activity. Existing evidences show that there is no association between B vitamins and bone loss. Very few studies are available which concluded association of B vitamin with cognitive decline and physical health.  More studies are required to address this research gap.

Anemia of geriatric patients

Anemia is a common finding in the elderly. Approximately 10 percent of the elderly suffers from anemia. Anemia per se is an independent factor of mortality in older patients regardless its cause. Frailty is also frequent in geriatric patients. That means that there is a decreased reserve capacity to react to different stress factors including anemia. The frequent presence of heart failure and also impaired cerebrovascular circulation makes more difficult to tolerate anemia in older age.

Anemia is a symptom, finding and treating the underlying cause is also important.

Treatment always depends on clinical findings: the more severe the symptoms, the more important to treat them. Severity of anemia depends not only the underlying cause, degree of anemia, co-morbidities and frailty of the patients, but also the speed of its development. Sudden blood loss due to an accident is less well tolerated than the same degree of anemia due to B12 deficiency.

Main causes of anemia in the elderly include nutritional deficiencies, chronic diseases, tumors, and certain hematological malignancies such as chronic lymphocytic leukemia, multiple myeloma, myelodysplastic syndrome.

The influence of anaemia on pressure ulcer healing in elderly patients

Anaemia is a common and multifactorial blood disorder in elderly individuals. This condition may be a significant barrier to pressure ulcers healing as it is associated with a decreased level of oxygen being supplied to body tissues. Some nutritional deficiencies such as iron, vitamin B12 and folate may also cause anaemia and have a negative impact on pressure ulcer healing. An increased iron demand in hard-to-heal pressure ulcers is a significant factor associated with the risk of anaemia of chronic disease in elderly patients. Anaemia screening and correction may need to be considered as well as iron supplementation if required in pressure ulcer prevention and management.

High anemia prevalence in Korean older adults, an advent healthcare problem: 2007-2016 KNHANES

BACKGROUND

Anemia is associated with high morbidity and mortality in older people. However, the prevalence and characteristics of anemia in older individuals are not fully understood, and national data on these aspects in older Korean adults are lacking. This study aimed to evaluate the prevalence and characteristics of anemia in older adults using data from the Korea National Health and Nutrition Examination Survey (KNHANES), which is a nationwide cross-sectional epidemiological study conducted by the Korean Ministry of Health and Welfare.

METHODS

Data from a total of 62,825 participants of the 2007-2016 KNHANES were compiled and analyzed to investigate differences in participant characteristics and potential risk factors for anemia. Differences in clinical characteristics of participants were compared across subgroups using the chi-square test for categorical variables and independent t-test for continuous variables. Univariate and multivariate analyses using logistic regression were performed to identify related clinical factors.

RESULTS

The prevalence of anemia was higher in the population aged ≥65 years than in the younger population. Anemia was also more prevalent among females than among males, but this difference was not significant in people aged > 85 years. Being underweight, receiving a social allowance, living alone, and having comorbidities such as hypertension, rheumatoid arthritis, diabetes mellitus (DM), cancer, and chronic renal failure (CRF) were more common among older adults with anemia than among the population without anemia. In univariate and multivariate analyses, older age, female sex, underweight, and presence of comorbidities including rheumatoid arthritis, DM, cancer, and CRF were associated with an increased risk of anemia.

CONCLUSIONS

This study revealed that age, female sex, underweight, and the presence of comorbidities such as rheumatoid arthritis, DM, cancer, and CRF were associated with an increased risk of anemia in older Korean adults. Further study on causal relationships between anemia and other variables in the older population is necessary.

Comparison of nutrient intakes by nutritional anemia and the association between nutritional anemia and chronic diseases in Korean elderly: Based on the 2013-2015 Korea National Health and Nutrition Examination Survey Data

BACKGROUND/OBJECTIVES

The elderly are reported to have a high prevalence of nutritional anemia when they have lower intakes of nutrients or chronic diseases. This study was conducted to compare nutritional status according to nutritional anemia and to determine associations between nutritional anemia and chronic diseases in Korean elderly.

MATERIALS/METHODS

This study utilized data on 3,258 elderly aged ≥ 65 years gathered during the 6th Korea National Health and Nutrition Examination Survey 2013-2015. Subjects were divided into nutritional anemia (NA) group (n = 415) and non-NA group (n = 2,843) by hemoglobin concentration. Nutrient intakes were assessed using dietary intake data obtained using the 24-hour recall method. The odds ratios (ORs) for nutritional anemia by chronic diseases were determined. Statistical analysis was performed using SPSS Ver. 23.0.

RESULTS

Of 3,258 subjects, 12.7% had nutritional anemia. Intakes of potatoes, pulses, and mushrooms by males and potatoes, fruits, meats, eggs, and seafood by females were significantly lower in NA group than in non-NA group. The proportion of the subjects whose intakes of protein, vitamin A, vitamin B1, vitamin B2, niacin, and iron less than estimated average requirement (EAR) were significantly higher in NA group compared to non-NA group. After adjusting for age, the number of family members, energy intake, and alcohol drinking, ORs for nutritional anemia in the subjects with diabetes and myocardial infarction or angina pectoris were significantly higher by 1.74 times and 1.59 times as compared to the subjects without those diseases, respectively. However, ORs for nutritional anemia in the subjects with obesity, abdominal obesity, and hypertriglyceridemia were significantly lower by 0.64 times, 0.60 times, and 0.59 times as compared to the subjects without those diseases, respectively.

CONCLUSIONS

The results of this study suggested that nutritional management should be done to enable the Korean elderly to consume foods with high hematopoietic nutrients density to prevent nutritional anemia. Korean elderly need to make regular efforts to check for nutritional anemia.

Magnitude of Anemia in Geriatric Population Visiting Outpatient Department at the University of Gondar Referral Hospital, Northwest Ethiopia: Implication for Community-Based Screening

Objective

This study is aimed at assessing the magnitude and its associated factors of anemia in geriatric population visiting outpatient department at the University of Gondar referral hospital, northwest Ethiopia.

Method

A cross-sectional study was conducted among elder patients in Gondar town, North Gondar District, in May 2013. A total of 200 randomly selected geriatric population participated in the study. Summary statistics were computed and presented in tables and figure. Both bivariate and multivariable binary logistic regression were fitted to identify associated factors. A P value < 0.05 was considered as statistically significant.

Result

The median age of the study participants was 65 years (Interquartile range (IQR): 8 years). The prevalence of anemia in the geriatric patients was 54.5% (n = 109), of which 61.5% (n = 67) were males. Mild type anemia was predominant, 55.96% (n = 61). Geriatric patients with an elevated erythrocyte sedimentation rate (AOR = 9.04, 95% CI: 4.2–19.7) and who are vegetarians (AOR = 2.2, 95% CI: 1.03–4.71) were at high risk of developing anemia.

Conclusion

The magnitude of anemia was high in geriatrics. Mild anemia was the predominant type. Vegetarians and geriatrics with elevated erythrocyte sedimentation rate were more likely to develop anemia. Hence, early diagnosis and management of anemia have paramount importance to prevent adverse outcomes in geriatrics.

Magnitude and Correlates of Anemia in Elderly Women of a Resettlement Colony of Delhi

BACKGROUND

Anemia of any degree contributes significantly to morbidity and mortality and has a significant effect on the quality of life of elderly women. Despite its clinical importance, anemia in the elderly women is underrecognized.

OBJECTIVES

The objective of this study was to assess the magnitude and correlates of anemia in elderly women of a resettlement colony of Delhi.

MATERIALS AND METHODS

A community-based, cross-sectional study for the duration of 1 year was conducted among 512 geriatric women (≥60 years). Demographic characteristics, dietary assessment, and behavioral risk factors were determined by interview, and the participants underwent physical examination followed by hemoglobin estimation by HemoCue. Anemia was defined using the WHO criteria of hemoglobin <12 g/dl. Chi-square test was employed to study the association between sociodemographic factors and anemia followed by multivariate regression analysis.

RESULTS

The prevalence of anemia was 79.9% according to the WHO criteria of hemoglobin <12 g/dl in females. Age, education, marital status, financial dependence, diagnosed chronic disease, diet, calorie intake, history of worm infestation, and body mass index (BMI) were significantly associated with anemia on univariate analysis. In multivariate analysis, age, marital status, financial dependence, diagnosed chronic disease, diet, calorie intake, and BMI were significant explanatory variables for anemia.

CONCLUSION

Our study points out high prevalence of and some of the major factors associated with anemia in elderly women. The need of the hour is to include our elderly women under the gamut of National Anemia Prophylaxis Program.

Upper and lower gastrointestinal endoscopies in patients over 85 years of age: Risk-benefit evaluation of a longitudinal cohort

After age 85, upper and lower gastrointestinal (GI) endoscopy may be indicated in 5% to 10% of inpatients, but the risk-benefit ratio is unknown. We studied patients older than 85 years undergoing upper and lower GI endoscopy.We analyzed a retrospective cohort of inpatients older than 85 years between 2004 and 2012, all explored by upper and complete lower GI endoscopy. Initial indications, including iron deficiency anemia (IDA), other anemias, GI bleeding, weight loss, and GI symptoms, were noted, as were endoscopy or anesthesia complications, immediate endoscopic diagnosis, and the ability to modify the patients' therapeutics. Deaths and final diagnosis for initial endoscopic indication were analyzed after at least 12 months.We included 55 patients, 78% women, with a median age, reticulocyte count, hemoglobin, and ferritin levels of 87 (85-99), 56 (24-214) g/L, 8.6 (4.8-12.9) g/dL, and 56 (3-799) μg/L, respectively. IDA was the most frequent indication for endoscopy (60%; n = 33). Immediate diagnoses were found in 64% of the patients (n = 35), including 25% with GI cancers (n = 14) and 22% with gastroduodenal ulcers or erosions (n = 12). Cancer diagnosis was associated with lower reticulocyte count (45 vs. 60 G/L; P = .02). Among the 35 diagnoses, 94% (n = 33) led to modifications of the patients' therapeutics, with 29% of the patients deciding on palliative care (n = 10). No endoscopic complications lead to death. Follow-up of >12 months was available in 82% (n = 45) of the patients; among these patients, 40% (n = 27) died after an average 24 ± 18 months. Cancer diagnosis was significantly associated with less ulterior red cell transfusion (0% vs. 28%; P = .02) and fewer further investigations (6.7% vs. 40%; P = .02).Upper and complete lower GI endoscopy in patients older than 85 years appears to be safe, and enables a high rate of immediate diagnosis, with significant modifications of therapeutics. GI cancers represented more than one-third of the endoscopic diagnoses.

Factors Associated with Anemia in the Institutionalized Elderly

As a common problem in long-term care facilities (LTCFs), anemia affects 25–63% of the elderly. The aim of the present study was to describe the prevalence and characteristics of anemia and its associated factors in the institutionalized elderly. The cross-sectional study was carried out with three hundred thirteen individuals aged ≥ 60 years, of both genders, living in long-term care facilities for the elderly in Salvador, Bahia, Brazil. Poisson regression (PR) with robust variance estimates was used to assess the factors related to anemia. The prevalence of anemia was 38%. Mild anemia was predominant in both genders (male: 26.8%; female: 21.1%), as normocytic and normochromic anemia, with no anisocytosis (69.75%). Anemia was associated with thinness (PR: 1.68; 95% CI: 1.04–2.72) and with moderate (PR: 1.98; 95% CI: 1.07–3.63) and total (PR: 2.61; 95% CI: 1.34–5.07) dependence in the final model. Severe dependence exhibited borderline significance (PR: 1.94; 95% CI: 1.00–3.77). The prevalence of anemia was high in the institutionalized elderly in both genders, with characteristics suggesting chronic diseases as the causal factor, and the frequency of occurrence was higher in thinness elderly with moderate to total dependence.

[Iron deficiency in the elderly]

Anemia is a common diagnosis in the geriatric population, especially in institutionalized and hospitalized elderly. Most common etiologies for anemia in elderly people admitted to a geriatric ward are iron-deficiency anemia and anemia associated with chronic disease. Determination of serum ferritin is the most used assay in the differential diagnosis, despite low sensitivity and moderate specificity. New insights into iron homeostasis lead to new diagnostic assays such as serum hepcidin, serum transferrin receptor and reticulocyte hemoglobin equivalent.Importance of proper diagnosis and treatment for this population is large since there is a correlation between anemia and morbidity - mortality. Anemia is usually defined as hemoglobin less than 12 g/dl for women and less than 13 g/dl for men. There is no consensus for which hemoglobinvalue an investigation into underlying pathology is obligatory. This needs to be evaluated depending on functional condition of the patient.

Systematic review and meta-analysis: what is the evidence for oral iron supplementation in treating anaemia in elderly people?

BACKGROUND

Oral iron supplementation is used widely in older people despite observational studies suggesting it is ineffective.

OBJECTIVE

The aim of this systematic review was to determine if oral iron therapy is effective in elderly people with iron deficiency anaemia.

DATA SOURCES

MEDLINE, EMBASE and The Cochrane Library databases were searched from inception to 23 January 2014.

STUDY SELECTION

Randomised controlled trials comparing oral iron with no iron supplementation or placebo and measuring the change in haemoglobin levels in elderly patients with anaemia were included. Titles and abstracts were reviewed and publications were screened by both authors independently to exclude articles that did not satisfy the inclusion criteria.

STUDY APPRAISAL AND SYNTHESIS

Risk of bias was systematically assessed independently by both authors using the Cochrane risk of bias tool. Data on the increase in haemoglobin level after therapy was either collected from original publications or by contacting the corresponding authors. Length of hospitalisation, mortality and adverse effect data were also analysed.

RESULTS

A total of 6,163 citations were screened, but only three studies (a total of 440 participants with a mean age ranging between 70 and 83 years) met the inclusion criteria. Meta-analysis showed oral iron supplementation increased haemoglobin levels more than placebo or no treatment after 4-6 weeks of treatment (mean difference 0.35 g/dL, 95 % CI 0.12-0.59, p = 0.003). There were no statistically significant differences in adverse effects, length of hospitalisation or mortality.

LIMITATIONS

Only one of the three studies was specific to older people and all studies involved patients in orthopaedic settings. The mean age of participants was different, and the dosage and frequency of ferrous sulphate differed.

CONCLUSION

Oral iron raises haemoglobin levels in elderly people with iron deficiency anaemia by 0.35 g/dL after 4-6 weeks, but it is unclear if this results in tangible health benefits.

Parameters influencing in-hospital mortality in patients hospitalized in intensive cardiac care unit: is there an influence of anemia and iron deficiency?

We investigated the incidence and prognostic value of anemia as well as of the iron status in non-selected patients admitted to an intensive cardiac care unit (ICCU). 392 patients (mean age 70 ± 13.8 years, 43% women), 168 with acute coronary syndromes (ACS), 122 with acute decompensated heart failure, and 102 with other acute cardiac disorders were consecutively, prospectively assessed. The biomarkers of iron status-serum iron concentration (SIC), total iron binding capacity (TIBC), and transferrin saturation (TSAT) together with standard clinical, biochemical and echocardiographic variables-were analyzed. In-hospital mortality was 3.8% (15 patients). The prevalences of anemia (according to WHO criteria), and iron deficiency (ID) were 64 and 63%, respectively. The level of biomarkers of iron status, but not anemia, was lower in patients who died (p < 0.05). Anemia was less frequent in patients with ACS as compared to the remaining ICCU population (p = 0.019). The analysis by logistic regression indicated the highest risk of death for age [odds ratio (OD) 1.38, 95% CI 1.27-1.55], SIC (OR 0.85, 95% CI 0.78-0.94), TIBC (OR 0.95, 95% CI 0.91-0.98), left ventricle ejection fraction (OR 0.85, 95% CI 0.77-0.93), as well as hospitalization for non-ACS (OR 0.25, 95% CI 0.14-0.46), (p < 0.05). The risk of death during hospitalization tended to increase with decreasing levels of TIBC (p = 0.49), as well as with the absence of ACS (p = 0.54). The incidence of anemia and ID in heterogeneous ICCU patients is high. Parameters of the iron status, but not anemia per se, independently influence in-hospital mortality. The prevalence of anemia is higher in non-ACS patients, and tends to worsen the prognosis.

Cobalamin deficiency in the elderly: aetiology and management: a study of 125 patients in a geriatric hospital

INTRODUCTION

Cobalamin deficiency is frequent in elderly patients and the main aetiologies are food-cobalamin malabsorption and pernicious anaemia. The aim of our retrospective study was to identify the causes and methods of management of cobalamin deficiency at Nice geriatric university hospital.

METHODS

A retrospective monocentric study was conducted over 14 months at Nice geriatric hospital, which included patients with cobalamin deficiency having received supplementation. The clinical and paraclinical data, etiological diagnosis, treatment and follow-up modalities were analyzed retrospectively.

RESULTS

We studied 125 elderly patients whose median age was 85.5 ± 7 years. The etiological diagnosis was food-cobalamin malabsorption for 72 patients (57.6 %), nutritional cobalamin deficiency for 15 patients (12 %), pernicious anaemia for 12 patients (9.6 %) and there was no etiological diagnosis for 26 patients (20.8 %). Concerning cobalamin therapy, 111 patients (88.8 %) received oral therapy and 14 (11.2 %) intramuscular therapy. Vitamin B12 levels increased significantly after supplementation (p<0.001) but cobalamin administration varied according to the diagnoses (p<0.001) and was less effective in patients with dementia (p=0.04) and food-cobalamin malabsorption.

CONCLUSION

Our study showed the importance of food-cobalamin malabsorption in etiological diagnosis in accordance with the literature, but also the non-negligible share of nutritional cobalamin deficiency. Mainly oral cobalamin supplementation was used in our study with a significant increase in vitamin B12 levels. An oral cobalamin regimen is proposed for elderly patients with cobalamin deficiency but with no severe neurological signs.

The changing of serum vitamin B12 and homocysteine levels after gastrectomy in patients with gastric cancer: do they associate with clinicopathological factors?

After total (TG) or distal subtotal gastrectomy (DG), patients are at high risk of vitamin B12 (vit-B12) deficiency, which results in elevation of homocysteine levels. The changing of serum vit-B12 and homocysteine levels in patients with gastric cancer is not well known. Seventy-two patients with gastric cancer who had undergone currative gastrectomy and 50 healthy controls were included. Serum vit-B12 and homocysteine levels were analyzed in gastric cancer patients. In addition, these parameters were compared with those of healthy control subjects. While serum vit-B12 levels in gastrectomized patients were significantly lower than that of healthy controls (221.8 ± 125.6 pg/mL vs. 309.9 ± 174.3 pg/mL, p = 0.002), homocysteine levels were significantly higher in patients with gastric cancer (14.2 ± 6.7 μmol/L vs. 12.5 ± 6.1 μmol/L, p = 0.016). Mean serum folate level was found to be high in healthy controls (7.3 ng/mL) compared to patients (9.2 ng/mL, p = 0.027). Out of 72 patients, 40 patients (55.6 %) with gastric cancer developed vit-B12 deficiency after gastrectomy. Vit-B12 deficiency was found to be related with gastrectomy type (p = 0.02) and homocysteine levels (p = 0.014). In patients who underwent TG, the incidence of vit-B12 deficiency was significantly higher compared with those with DG (67.5 vs. 32.5 %). In addition, serum vit-B12 level in patients with DG was significantly higher than that of patients with TG (248.3 ± 122.0 pg/mL vs. 200.8 ± 126.7 pg/mL, p = 0.041), whereas homocysteine levels were significantly lower in DG group compared with TG group (12.1 ± 6.1 μmol/L vs. 15.8 ± 6.9 μmol/L, p = 0.014). A logistic regression analysis showed that the extent of gastrectomy was found to be an independent factor for predicting the occurrence of vit-B12 deficiency (p < 0.001, odds ratio 1.38). Our results showed that cumulative vit-B12 deficiency rate was significantly higher after TG compared with that after DG, while homocysteine levels were significantly higher in TG group compared with DG group. The extent of gastrectomy was found to be an independent factor for predicting the occurrence of vit-B12 deficiency. Vit-B12 deficiency and hyperhomocysteinemia are imperious clinical situation for patients with gastric cancer after surgery. Hence, both preoperative and regular postoperative monitoring of vit-B12 and homocysteine levels for all gastrectomized patients with gastric cancer are important and necessary for early detection and prevention of vit-B12 deficiency and hyperhomocysteinemia as a risk factor for cardiovascular diseases.

Prevalence of vitamin B(12) depletion and deficiency in Liechtenstein

OBJECTIVE

Data about vitamin B(12) (B(12)) deficiency in the general population are scarce. The present study was performed to determine the prevalence of B(12) deficiency in the general population of the Principality of Liechtenstein, as well as to identify sub-populations potentially at high risk.

DESIGN

Retrospective study.

SETTING

Ambulatory setting, population of the Principality of Liechtenstein.

SUBJECTS

Seven thousand four hundred and twenty-four patients seeking medical attention whose serum samples were referred for routine work-up in an ambulatory setting were consecutively enrolled. Serum total B(12) was determined in all patients in this cohort. In addition, for a subgroup of 1328 patients, serum holotranscobalamin was also measured. Prevalence of B(12) deficiency was calculated. Further, multivariate logistical regression models were applied to identify covariates independently associated with B(12) deficiency and depletion.

RESULTS

Nearly 8% of the general population was suffering from either B(12) depletion or deficiency. The ratio between B(12) depletion and deficiency was 2:1 for all age ranges. Pathological changes were detected predominantly in older people. Female gender was a significant predictor of B(12) depletion. In the cohort, nearly 40% exhibited either depletion or deficiency of B(12).

CONCLUSIONS

B(12) depletion and deficiency are common in Liechtenstein, a Central European country. The measurement of biochemical markers represents a cost-efficient and valid assessment of the B(12) state. When a deficiency of B(12) is diagnosed at an early stage, many cases can be treated or prevented, with beneficial effects on individual outcomes and subsequent potential reductions in health-care costs.

[Gender aspects of malnutrition and associated sequelae. Prevention and therapy]

Malnutrition is related to a range of secondary complications. The prevalence of many of these sequelae is higher in elderly women than in men, thus resulting in a higher level of impairment and reduced quality of life. Multiple factors lead to the development of malnutrition and socioeconomic causes, such as poverty among the elderly and isolation, are more common in elderly women. The age-associated loss of muscle mass is more pronounced in women than in men and the risk of developing sarcopenia and frailty is increased. The prevalence of sarcopenic obesity is higher in women than in men. Malnutrition increases the risk of osteoporosis and about 80 % of all osteoporosis patients are women. Furthermore, low serum levels of vitamin D correlate more closely to a poorer cognitive outcome in elderly women than they do in men. The prevention, early diagnosis and therapy of malnutrition is of great clinical importance, particularly to preserve physical functional capacity and thus quality of life in elderly women.

Management of anemia of inflammation in the elderly

Anemia of any degree is recognized as a significant independent contributor to morbidity, mortality, and frailty in elderly patients. Among the broad types of anemia in the elderly a peculiar role seems to be played by the anemia associated with chronic inflammation, which remains the most complex form of anemia to treat. The origin of this nonspecific inflammation in the elderly has not yet been clarified. It seems more plausible that the oxidative stress that accompanies ageing is the real cause of chronic inflammation of the elderly and that the same oxidative stress is actually a major cause of this anemia. The erythropoietic agents have the potential to play a therapeutic role in this patient population. Despite some promising results, rHuEPO does not have a specific indication for the treatment of anemia in the elderly. Moreover, concerns about their side effects have spurred the search for alternatives. Considering the etiopathogenetic mechanisms of anemia of inflammation in the elderly population, an integrated nutritional/dietetic approach with nutraceuticals that can manipulate oxidative stress and related inflammation may prevent the onset of this anemia and its negative impact on patients' performance and quality of life.

Anemia and mortality in older persons: does the type of anemia affect survival?

Anemia is a common condition among community-dwelling older adults. The present study investigates the effect of type of anemia on subsequent mortality. We analyzed data from participants of the Third National Health and Nutrition Survey who were aged ≥50 and had valid hemoglobin levels determined by laboratory measurement. Anemia was defined by World Health Organization criteria. 7,171 subjects met our inclusion criterion. Of those with anemia (n = 862, deaths = 491), 24% had nutritional anemia, 11% had anemia of chronic renal disease, 26% had anemia of chronic inflammation, and 39% had unexplained anemia. We found an overall relative risk (RR) for mortality of 1.8 (p < 0.001) comparing those with anemia to those without, after adjusting for age, sex, and race. After we controlled for a number of chronic medical conditions, the overall RR was 1.6. Compared to persons without anemia, we found the following RRs for the type of anemia: nutritional (2.34, p < 0.0001), chronic renal disease (1.70, p < 0.0001), chronic inflammation (1.48, p < 0.0001), and unexplained (1.26, p < 0.01). Anemia is common although not severe in older non-institutionalized adults. When compared with non-anemic older adults, those with nutritional anemia or anemia due to chronic renal disease have the highest mortality risk.

Not so benign haematology: anaemia of the elderly

Developed countries, such as the United Kingdom, are experiencing a change in demographics resulting in the largest proportion of adults over 65 years of age that our health systems have ever experienced. As such, haematologists must be prepared to evaluate and treat anaemia in a more complicated patient population, but sufficient evidence-based guidelines are lacking. Critical next steps that must be taken to ensure the best care of this population include the determination of appropriate haemoglobin concentrations for older adults in light of age, gender, race, and comorbidities; the development of interventional trials that address physical performance outcomes in addition to haemoglobin targets; and translational studies which address the molecular pathogenesis of anaemia in older adults with the most advanced scientific approaches.

Thyroid hormone abnormalities and frailty in elderly patients with chronic kidney disease: a hypothesis

Thyroid hormones play a crucial role in the metabolic activities of adults, affecting almost every organ system. All types of thyroid diseases are encountered in the elderly. As symptoms and signs of thyroid diseases may overlap with what is considered to be "normal aging," the presence of a thyroid disorder may go undiagnosed in the elderly. This potential problem is further compounded in elderly patients with chronic kidney disease (CKD), where the presence of an underlying hormonal problem such as hypothyroidism may be erroneously attributed to multiple comorbidities, the aging process, or the kidney disease. Frailty is being recognized as a contributing factor to the poor outcomes (hospitalization and high mortality) in elderly patients with CKD. Predisposing factors leading to frailty in elderly with CKD such as increased inflammatory markers, anemia, low testosterone, sarcopenia, and depression are associated with thyroid hormonal abnormalities. These associations are remarkable and raise the question of whether routine monitoring and screening for thyroid hormone changes in elderly CKD patients might be helpful in identifying reversible causes of frailty. In this review, we will focus on the associations between thyroid hormone abnormalities and the predisposing factors of frailty in elderly patients with CKD. If a cause-effect relationship of thyroid hormone abnormalities and factors predisposing to frailty in CKD patients is established, identification and treatment of thyroid abnormalities in this population would assume increased importance.

[Anemia in the elderly]

Anemia is a common disorder in the elderly and is associated with increased morbidity and mortality. In elderly subjects, in whom anemia is highly prevalent, there are several aspects, such as a hemoglobin at a level which should concern us limit, or identifying its causes, that are not easy to establish. This review focuses on knowing what is considered to be normal hemoglobin levels in adults and the common causes and potential consequences of anemia in elderly patients. It provides a diagnostic algorithm and an approach to treatment that addresses new treatments such as parenteral iron drugs and erythropoiesis-stimulating agents.

Relationship between anaemia and cognitive functions in elderly people

BACKGROUND

The primary goal of the present study was to investigate the effects of anaemia on the cognitive functions and daily living activities in elderly people.

METHODS

This sectional study was performed using 180 elderly people. Face-to-face interviews and questionnaires were conducted to evaluate daily activities. To evaluate cognitive functions we used the Folstein's Mini-Mental State Examination (MMSE).

RESULTS

The mean age of the anaemic group and the nonanaemic group were 76.0+/-11.7 and 72.5+/-15.2 years, respectively. The average haemoglobin level among the anaemic population was 10.4 g/dL compared with 13.6 g/dL among the nonanaemic population; a statistically significant difference. There was more impairment in functional status (Katz ADL) (6.8+/-4.3 vs 9.3+/-3.7) and cognition (MMSE) (17.9+/-6.4 vs 21.7+/-6.7) in anaemic than nonanaemic groups, respectively. Albumin and body mass index were lower and the percentage of two or more comorbidities was higher in anaemic group compared to the nonanaemic group, which was a statistically significant variation. The anaemic group was more dependent in terms of bathing, dressing, toileting and transferring.

CONCLUSION

In the elderly anaemic group, the dependency for daily activities that require physical effort was higher compared to the nonanaemic group. The MMSE score in the elderly anaemic group was lower than subjects who had normal haemoglobin levels. We conclude that anaemia may impair cognitive functions and some daily living activities in the elderly.

Vitamin B12 and older adults

PURPOSE OF REVIEW

To review the prevalence, causes and functional significance of vitamin B12 deficiency in vulnerable subpopulations including older adults and the developing embryo.

RECENT FINDINGS

It is becoming increasingly recognized that the susceptibility to vitamin B12 deficiency may change throughout the life cycle, with the developing embryo and older adults exhibiting elevated risk. Recent data implicate low vitamin B12 status as a risk factor for birth defects resulting from improper neural tube development. The potential for vitamin supplementation and/or food fortification to ameliorate the risk of deficiency in these subpopulations is discussed.

SUMMARY

The prevalence and impact of vitamin B12 deficiency varies throughout the life cycle, with older adults and potentially the developing embryo having the greatest risk and susceptibility. Additional research is needed to develop effective public health interventions that address the unique causes of this nutritional deficiency, which differ among at-risk subpopulations.

Corpus predominant gastritis: what does it mean?

PURPOSE OF REVIEW

To summarize this year's relevant literature on the causes and mechanisms of autoimmune gastritis.

RECENT FINDINGS

It is increasingly recognized that parietal cell antibodies, previously assumed exclusive to autoimmune gastritis, are associated with Helicobacter pylori infection. Successful H. pylori eradication with antibiotic treatment decreases antiparietal cell antibodies. Interestingly, vitamin B(12) deficiency, previously associated with autoimmune gastritis, is increasingly described in the elderly, irrespective of H. pylori status. Autoimmune gastritis that mostly affects patients of Scandinavian descent, was reported this year from China, and corpus predominant gastritis (autoimmune associated) was reported from Japan. It is difficult to evaluate the role played by genetics, increased use of proton pump inhibitors, and H. pylori infection, as current patient work-up does not regularly include screening for parietal cell and intrinsic-factor antibodies. As these clinicopathologic changes are seen in both H. pylori-positive patients, and in H. pylori-naïve patients, the debate continues for mechanisms involved in H. pylori-naïve patients.

SUMMARY

The clinical features commonly associated with autoimmune gastritis are increasingly seen in the elderly, irrespective of H. pylori status. Though some patients are genetically predisposed, long-term proton pump inhibitor use increases the prevalence of clinicopathologic features irrespective of genetic tendency.

[Update of oral vitamin B12]

OBJECTIVE

The objective of this review is to evaluate the usefulness of oral cobalamin (vitamin B12) treatment.

MATERIAL AND METHOD

PubMed was systematically searched for English and French articles published from January 1990 to January 2007.

RESULTS

Prospective randomized studies (n = 3), a systematic review by the Cochrane group (n = 1) and prospective studies in well-determined population (n = 5) provide evidence that oral cyanocobalamin therapy may adequately treat cobalamin deficiency in elderly patients. However, the current literature may not suggest a strategy in terms of the form (hydroxy- or cyanocobalamin), frequency and duration of the treatment.

CONCLUSION

This present review confirms the previously reported efficacy of oral cyanocobalamin treatment in elderly patients.

Anaemia in the elderly

Anaemia is highly prevalent in elderly populations, particularly in long term care facilities and geriatric wards. Even mild anaemia is associated with adverse health outcomes. Although senescence is considered to be a contributing factor, underlying pathology always has to be thoroughly explored. The most frequent etiologies of anaemia in the elderly are anaemia of chronic disease/inflammation; iron, folate and cobalamin deficiency; and myelodysplastic syndrome. Multiple concomitant etiologies are frequently present. The diagnostic workup is straightforward, not very invasive and should be done systematically. Nutrient deficiencies require complete workup and cure. Anaemia of chronic disease/inflammation ideally is taken care of by treating the underlying disease. If this is not possible and if glomerular filtration rate is significantly decreased, treatment with erythropoietin should be considered. Most cases of myelodysplastic syndrome will benefit from supportive care, but a specific subgroup responds particularly well to oral thalidomide analogues. Transfusions should be avoided.

Update on oral cyanocobalamin (vitamin B12) treatment in elderly patients

The objective of this review is to evaluate the usefulness of oral cobalamin (vitamin B12) treatment in elderly patients. PubMed was systematically searched for English and French articles published from January 1990 to January 2007. Prospective randomized studies (n=3), a systematic review by the Cochrane group (n=1) and prospective studies in a well defined population (n=5) provide evidence that oral cobalamin therapy may adequately treat cobalamin deficiency in elderly patients. However, the current literature does not suggest a strategy in terms of the form (hydroxy- or cyanocobalamin), frequency and duration of the treatment. This review confirms the previously reported efficacy of oral cobalamin treatment in elderly patients. Oral cobalamin treatment avoids the discomfort, inconvenience and cost of monthly injections.

Cobalamin deficiency in elderly patients: a personal view

Cobalamin (vitamin B12) deficiency is particularly common in the elderly (>65 years of age) but is often unrecognized because its clinical manifestations are subtle; however, they are also potentially serious, particularly from a neuropsychiatric and hematological perspective. In the elderly, the main causes of cobalamin deficiency are pernicious anemia and food-cobalamin malabsorption. Food-cobalamin malabsorption syndrome is a disorder characterized by the inability to release cobalamin from food or its binding proteins. This syndrome is usually caused by atrophic gastritis, related or unrelated to Helicobacter pylori infection, and long-term ingestion of antacids and biguanides. Management of cobalamin deficiency with cobalamin injections is currently well documented but new routes of cobalamin administration (oral and nasal) are being studied, especially oral cobalamin therapy for food-cobalamin malabsorption.