A clinico‐pathological study of geriatric anemias

Abstract Introduction Anemia in the older age (e.g., >60 years) is a major health problem in India and many parts of the world since it signifies an underlying disease and is associated with poor clinical outcome like increased morbidity and affects health‐related quality of life. Since symptoms like fatigue or shortness of breath related to anemia could also be attributed to the aging process, anemia is often easily overlooked in the elderly. Aims and objectives Clinico‐hematological patterns and morphological types of anemia in older age (e.g. >60 years) are manifold, hence this study was undertaken to determine them and to know more about associated disorders. Materials and methodology The present study was conducted on a sample size of 1257 patients who were 60 years and above and clinically diagnosed as anemic. Routine haematological investigations including peripheral blood smear examination and complete hemogram were done. Special investigations like bone‐marrow examination and iron studies were done whenever required. Results Males (aged >60 years) were more affected than females (aged >60 years) and patients in the age group of 60–69 years were affected the most. The most common presenting symptom was generalized weakness. The most common morphological type was normocytic normochromic anemia, and chronic diseases were the commonest etiological factors. Conclusion In spite of modern diagnostic advances, geriatric anemias still remain under‐reported and inadequately investigated, necessitating evaluation of even mild anemias. Prompt diagnosis and definite categorization helps in appropriate management of anemias.

indicates that the maximum number of subjects (1013) were in the age group of 60-70 years, 179 subjects were in the age group of 71-80 years, and 65 were subjects in the age group of 80 years and above. Figure 1 shows that 52.6% subjects were male and 47.4% were female in the present study ( Figure 2).
In this study, non-specific symptoms were most commonly associated with anemia, followed by symptoms and signs of respiratory illness, gastrointestinal diseases, carcinoma, nutritional disorders, liver and renal diseases (Table 3).

Associated Factors
We observed in the present study that anemia due to chronic disease (54%) was the most common type followed by iron deficiency anemia (17%), anemia due to other nutritional deficiencies (12%), anemia due to blood loss (16%), and the least common was anemia due to hemolysis (1%).

| D ISCUSS I ON
In the present study, more males were found to be anemic as com- Joosten et al, 7 and Tay and Youong 8 in which females were more anemic (Tables 4 and 5).
In the present study, patients in the age group of 60-70 years were maximally affected, which is in concurrence with the studies by Amarneel et al, 6 Nisha et al, 9 and Kiran et al, 10 whereas in a study done by Geisel et al, 11 patients in the age group of 81-90 years were maximally affected (Table 6).
In the present study, the most common underlying cause of anemia is anemia of chronic disease. This finding is in concurrence with the studies by Guyatt et al 12  First, reduced EPO production that is too low to counteract anemia and a blunted response of erythroid progenitors to EPO represent essential underlying mechanisms.   well as reduced levels of estrogen and testosterone, seem to directly increase hepcidin expression. This helps in understanding why endocrine changes at menopause or andropause result not only in a constitutively increased presence of inflammatory mediators, but also in increased hepcidin levels.

TA B L E 2 Relation with symptoms and sign
Third, eryptosis, the phagocytosis of aging erythrocytes triggered by changes in their plasma membrane, is often discussed as a further hallmark in the development of AI. Recycling of aged and/ or damaged RBCs occurs under physiological conditions mainly in the spleen. It is well known that in distinct situations including inflammation, RBC numbers and Hb levels drop much faster than can be explained by a pure reduction in RBC production and Hb synthesis. In fact, translocation of phosphatidylserine to the membrane surface is a first step in this process. 15 It enables macrophages to engulf erythrocytes and ultimately eliminate them from circulation.
Lupescu et al showed that ROS production leads to a much higher frequency of phosphatidylserine-presenting erythrocytes in older than in younger patients. Other reports have shown that disorders that are quite common at advanced age, including dehydration, diabetes mellitus, or chronic heart disease, might also affect RBC stability (Table 7).
In the present study, the highest number of subjects are with Anemia in the elderly is a significant universal problem that is associated with poor clinical outcome. Though it is a critical issue that needs to be addressed on a priority basis, especially in developed countries, it is most often overlooked or sidelined owing to the more pressing and demanding diseases in the elderly.
In the elderly patients in whom anemia has a high prevalence, neither the hemoglobin threshold nor the identity of the disease causing anemia is easily established. This is an important shortfall because even mild anemia can compromise a patient's well-being and survival, regardless of the underlying cause. 16 Anemia due to chronic diseases is the most common form of geriatric anemia as observed in the present study. This study is concurrent with the study by Mauro Tettamanti et al (

| CON CLUS ION
Despite the fashionable diagnostic advances, geriatric anemia still remains under-reported and inadequately investigated, especially when mild, thereby necessitating evaluation of even mild anemias during this vulnerable population. Non-specific symptoms like fatigue and weakness should not be ignored or attributed to the normal aging process as it can be an important signal to the presence of anemia. Improved definitions of anemia and more detailed investigations like bone marrow aspiration and biopsy also help to define the subtypes of anemia, thereby facilitating prompt and accurate diagnosis to ensure appropriate patient management.

ACK N OWLED G EM ENTS
I Heartily thank Dr. Gauravi A Dhruva, Professor and head,

Department of Pathology, Pandit Dindayal Upadhyay Medical
College, Rajkot For her help, valuable advice and suggestions. Dr.
Rutvi Teli my colleague for writing assistance.

CO N FLI C T S O F I NTE R E S T
Nothing to disclose.