anemia in the elderly patient (a geriatrician’s pov) mcgill 66th family medicine refresher mon....
DESCRIPTION
Objectives 1.To review common causes of anemia* in the elderly, and general investigations & management for these –Not “normal aging” –1° vs. 2° screening 2.To consider the risks:benefits of anemia* work up / treatment in the very / frail elderly –Individualized approach –Primum no nocere… (* Chronic anemia)TRANSCRIPT
Anemia in the elderly patient(a geriatrician’s POV)
McGill 66th Family Medicine RefresherMon. Nov. 23rd 2015
Workshop A-02 @11h00Workshop C-11 @16h00
Wendy Chiu, MD.CM, FRCPCMcGill Division of Geriatric [email protected]
Disclosure
• No conflicts of interest to declare
Dammit, Jim – I’m a geriatrician,
not a hematologist!
Objectives1. To review common causes of anemia* in the
elderly, and general investigations & management for these
– Not “normal aging”– 1° vs. 2° screening
2. To consider the risks:benefits of anemia* work up / treatment in the very / frail elderly
– Individualized approach– Primum no nocere…
(* Chronic anemia)
What is it?• Definition – Hb (g/L)
– WHO: Men < 130, women < 120– Differences by sex, ethnicity, age…
• ↑ Prevalence (>65yo)– Community-dwelling ~10%– Hospitalized ~25%– LTC ~50%
-but-• NOT “NORMAL AGING”
– No age adjustment Prognosis with Hb > WHO definition
hospitalization/death @Hb Men ?140-170, Women ?130-150
– But not EBM to Tx for this (e.g. Epo, transfusion)
Why do I care? Prognostic factor:
– ↑ Morbidity (esp. CVD) & Mortality– ↑ Hospitalization rate & LOS– (-) Functional impact
• Loss of autonomy• Falls (& fall injuries)• Cognitive decline
Quality of life• Fatigue
Causes?• 1/3 Nutritional
– Esp. iron deficiency• 1/3 Chronic inflammation
– “Anemia of chronic disease”• 1/3 “Unknown”
– Undiagnosed MDS?– Age-associated predispositions? (but not N aging?!)
• Renal function• Stem cells• Androgens• Chronic inflammation
1/3 Nutritional deficiencies Iron (30% of all anemias)
– Blood loss (heme) >> low intake
B12 (5-10%)– Before hematologic, neurologic effects
• Macrocytosis = late finding• Neurological symptoms irreversible
Folate• N/S since flour fortification
1/3 “Anemia of chronic disease”• Cytokines (IL-6, TNF-alpha, etc.)
Epo production Iron use (hepcidin) – “functional iron deficiency”
Absorption GI tract Release from bone marrow
• “Chronic diseases”– OK: Cancer, autoimmune, chronic infection
• But: DM2? HTN? Atherosclerosis? OA??– +/- “Normal aging” +/- “body habitus” (↑ fat)
• Associated with ↑ inflammatory markers…
1/3 Unexplained anemia (“NYD”)• MDS (undiagnosed pathology)• Epo-related (production, action)?
– Blunted Epo sensitivity/response• “Age-associated”?
– Co-morbidities (esp. CKD)
• “Age-associated” changes? CrCl– ↑ Inflammation (see ACD) Androgens
• Prostate CA Rx anti-testosterone : Hb 10-20 g/L Stem cells (quantity, quality)
“Mixed” anemias – e.g.
• Consider medication side effects - e.g.
– Bone marrow suppression• Chemotherapy, immunosuppressants - Hydroxyurea• Anti-epileptics - Phenytoin
– Hemolysis• e.g. Antibiotics (e.g. pen, ceph, nitrofurantoin, levoflox)
– Blood loss (chronic)• NSAIDs, anti-coagulants
• R/o EtOH abuse (chronic)– Nutritional, bleed (cirrhotic), direct RBC toxicity
(macrocytosis), etc.
Diagnosis - Clinical• 1° screening (asymptomatic)*
– PHE not EBM, but…– “Baseline Hb”
• 2° screen (symptomatic, case finding)– Symptoms/signs specific causes (e.g. CRC, RA)– “Gen det” (failure to thrive)* – e.g.
• Fatigue, weakness• Weight loss, anorexia• Exertional dyspnea; Pallor• Poor concentration / memory problems• Falls, gait / balance problems
– PMHx– Rx review – incl. EtOH
Diagnosis: Laboratory - CBC• Mean corpuscular volume (MCV)
: Microcytic• e.g. iron, thalassemia
– ↑: Macrocytic• e.g. B12, EtOH, Rx (e.g. anti-epileptics)
– Normocytic – e.g. ACD, MDS• NB: early on, all can be normocytic…
• Red-cell distribution width (RDW)– NB: MCV = average RDW = range– “Normal”: See MCV– ↑RDW: R/o mixed anemia
• Response to blood loss, supplement, “recovering marrow”
Labs – Other heme• Reticulocyte count
– Absolute count (lab’s N range), < 2% retics– “Normal” or (i.e. not ↑): R/o bone marrow dysfunction
• Peripheral smear (“qualitative” RBC, associated findings) – e.g.– RBC
• Schistocytes (hemolysis), dacrocytes (myelofibrosis), rouleux formation (myeloma)
– WBC• Hyperlobulated nuclei ( B12), circulating plasma cells (myeloma)
– Platelets• True thrombocytopenia
• Bone marrow biopsy... – e.g.– Iron stores– Myelodysplasia / fibrosis– Marrow “replacement” (cancer, solid or heme)
UpToDate.com – Approach to the Adult Patient with Anemia
Labs – specific causes – e.g.
• Iron– Serum ferritin ( mg/L) < 10, < 50, > 100, ?50-100– Response to Tx (↑Hb, ↑ retics)
• B12– < 200 pM (geriatricians at least…)
• No folate (serum or RBC) unless macrocytosis NYD• Creatinine, eGFR (CrCl)
– SPEP – Anemia + CKD +/- “back pain” (“OP” / VBC fractures)• TSH
– DDx “gen det” +/- anemia• CRP• Hemolysis
– Smear, LDH, indirect bili, serum haptoglobin, plasma free Hb
What to do about it?• Remove Rx if ADR
– PPI?• Treat/manage contributing co-morbidity(s)• 1/3 Nutritional
– B12 supplementation• Oral vs. IM
– Iron supplementation• Ideal: 150-200 mg/day elemental iron
– E.g. Iron SO4 300mg = 65 mg eFe hence TID constipating!
– 65mg eFe adequate to replace most check Hb @3 months– IV iron if intolerant PO? risk ADR (e.g. allergic), cost
• + Vitamin C? + dietary sources
• Investigation for blood (iron) loss• “Invasive”
– G’scope– C’scope MSSS C’scope referral (triage) form
» vs. CT “virtual” C’scope same prep» vs. PillCam? TBA» vs. Ba’enema Sn & Sp, same prep
• “Non-invasive”– FIT (iFOBT)
» No more gFOBT (guaic)– Fecal DNA testing? TBA– Serum CEA no
• AbN finding in any of above C’scope -- so…?
NB: “Goals of therapy”1º screening: Life expectancy
2º screening: Surgical risk, QoL
FIGURE 1 . Operative mortality among nursing home residents and non-institutionalized elderly Medicare enrollees, by procedure type. Ann Surg, Dec 2011; 254(6):921-6.
What to do, cont.
• 1/3 ACD, 1/3 UA (NYD)– Consider MDS
• Refractory anemia, other cytopenias– BM Bx vs. only when need Tx? (e.g. PRBC)
– “Treatments” – not EBM, do not recommend• Epo? – threshold Hb 100-120, risks (OFF LABEL)• IV iron? - “functional iron deficiency” (OFF LABEL)
– Transfusion – threshold, mortality, QoL (Sx)• Recent RCTs no benefit “liberal” vs. “restrictive”
transfusion older pt post-hip # ORIF, ICU
• MDS, UA (“NYD”) cont.– Experimental
• Hepcidin-targeted Tx?– IL-6 induces liver synthesis hepcidin
(-) iron absorption GI tract(-) release stored iron from BM macrophages= “relative [functional] iron-deficiency”
• NB: Tx goal = Symptom relief• Albeit under-reporting/-recognition, non-specific…
– Typically Hb > 100• NB: mortality Rx Epo to make Hb > 120
“Take-home” messages x3:(NB: geriatrician’s POV!)
1. Hb <120 merits investigation (M & F)– Investigation =
• Note other cell lines on CBC– If abN, consider Hematology consult
• Do medication review– Incl. EtOH
• Review PMHx for co-morbidities than may cause or contribute to anemia – e.g.– CKD, autoimmune disease, past CA, PUD
–Investigation cont.• Check other bloods as could change
management– Iron or B12 deficiency
» sB12 <200Vit. B12 1200μcg PO DIE
» sFerritin: Probably OK if >100, definite if < 10Iron SO4 300mg PO DIE x3 months
–Chronic kidney disease (creatinine)» If abN, check SPEP» If SPEP abN, consider Heme consult
–Hypothyroidism (TSH)
2. If iron deficient, consider also:
• Risks:benefits of major abdominal surgery– Colectomy = potentially curative– Surgical risk, co-morbidities (type, severity),
QOL, life expectancy– Bowel prep - supportive needs?
• Patient preference / informed decision– Incl. symptoms for palliation?
• If “a go” C’scope directly– MSSS triage level P3
3. If none of the above, “monitor”• i.e. likely ACD, UA…
– Further investigation unlikely to change management beyond underlying co-morbidities
• F/u CBC ?Q6 months ?PRN symptoms– Symptoms can be insidious, vague (“getting old”)– NB: not EBM
• Hb < 100 or symptomatic– Consider further investigation and/or Tx for QoL
e.g. Heme consult for BM Bx Dx MDS periodic PRBC transfusions
• Case study: Mrs. R
• Suggested readings:ASH Special Symposium: Anemia in the Elderly.Am Soc Hemato 2005.http://asheducationbook.hematologylibrary.org/content/2005/1/528.short
Anemia in the older adult.UpToDate.com
– Free access via CMA website