Anaemia

Anaemia is a risk factor for increased falls, frailty, decreased cognition, hospitalisation, morbidity and mortality.

Anaemia is defined by the World Health Organisation as:
A haemoglobin of less than 120 g per L in women and less than 130 g per L in men
Consider anaemia in residents who have:

• Pallor
• Fatigue
• Dyspnoea or shortness of breath
• Headache
• Restless leg syndrome
• Symptoms of blood loss e.g. rectal bleeding
• Worsening or new onset angina
• Diffuse alopecia or hair loss
• Tachycardia
• Syncope

Red flags in anaemic residents need to be considered in the context of the residents life trajectory and expressed choices.

Red flags include:

A. Severe anaemia < 70g / L in symptomatic resident

B. Potentially life-threatening complications of anaemia:

• Haemodynamic compromise: hypotension, pallor, cold clammy skin, tachycardia, dyspnoea
• Secondary angina (chest pain) or heart failure
• Acute confusion or altered level of consciousness
• Syncope or pre-syncope

C. Persistent or severe abdominal or back pain

D. Acute bleeding, particularly in those on oral anticoagulants or anti-platelet agents

• GI bleeding may present with any of: haematemesis (vomiting of blood) OR rectal bleeding OR melaena (black, tarry stools) OR severe back or abdominal pain (abdominal aortic aneurysm)
• Epistaxis unresponsive to digital pressure on the nose cartilage for 10 minutes or posterior nasal bleeding or haemoptysis
• Macroscopic haematuria or vaginal bleeding
• Traumatic bleeding

A. Symptoms of:

• Anaemia (see Definition of, and when to suspect, anaemia - practice point 1)
• Underlying cause:
  • Bleeding: Gastrointestinal, ENT, vaginal or traumatic bleeding or haematuria, severe abdominal / back pain
  • Underlying coagulation disorder: Excessive bruising
  • Haemolysis: Jaundice and dark urine
  • Haematological malignancy: Night sweats or weight loss
  • Chronic Diseases that may be associated with anaemia of chronic disease
  • Recurrent infections: Pancytopenia

B. Dietary history including alcohol intake

C. Medications or supplements that:

• Cause haemolysis: e.g. penicillin, levodopa, cephalosporins, NSAIDs, clopidogrel
• Increase bleeding risk e.g. anticoagulants, antiplatelet agents, NSAIDs, corticosteroids, bisphosphonates, ginkgo
• Affect folate levels or metabolism e.g. alcohol, phenytoin, methotrexate, trimethoprim-sulfamethoxazole
• Decrease B12 absorption e.g. metformin, colchicine, proton pump inhibitors, histamine blockers
• Suppress the bone marrow e.g. azathioprine, methotrexate, hydroxyurea

D. Examination findings:

• Haemodynamic instability
• Conjunctival pallor
• Clinical signs of heart failure
• Iron deficiency: koilonychia (spoon-shaped nails), angular cheilitis (inflammation of corners of mouth), glossitis (inflamed tongue) and diffuse alopecia (thinning hair), clinical evidence of bleeding, abdominal masses
• Haemolysis: jaundice, enlarged spleen
• Underlying malignancy or aplastic anaemia: abnormal bruising, petechiae, lymphadenopathy, enlarged spleen pancytopenia or coagulopathy: petechiae, bruising, spontaneous bleeding e.g. epistaxis, haematuria

Reticulocyte count high (>2 per cent)

Mean corpuscular volume (MCV): normal or elevated

• Cause: Post-haemorrhage
  • Prevalence: 5-10 per cent
  • Peripheral smear: Polychromasia due to increased reticulocyte count
  • Other: Iron studies initially normal in acute haemorrhage
• Cause: Haemolysis
  • Prevalence: Uncommon
  • Peripheral smear: Spherocytes, fragments of blood cells
  • Other: Iron studies normal in acute haemolysis; may be reflective of iron deficiency in chronic haemolysis; haemoglobinuria; elevated bilirubin, lactate dehydrogenase (LDH) and reduced haptoglobin

Reticulocyte count normal or low (<2 per cent)

Mean corpuscular volume (MCV): Low MCV (<80fL)

• Cause: Iron deficiency
  • Prevalence: 15 – 30 per cent
  • Peripheral smear: Pencil cells, tear drop cells in severe iron deficiency
  • Other: Serum iron low, total iron binding capacity high, ferritin low; haemoglobin normalises with trial of iron replacement

Mean corpuscular volume (MCV): Normal or low MCV

• Cause: Anaemia of chronic disease
  • Prevalence: 30 – 45 per cent
  • Peripheral smear: Burr cells in uraemia; Spur cells in liver disease / renal failure
  • Other: Evidence of renal impairment, liver or hypothyroidism, elevated inflammatory markers; iron studies may show low iron, low total iron binding capacity and ferritin > 100 microg/L

Mean corpuscular volume (MCV): High MCV (>100fL)

• Cause: Vitamin B12 and / or folate deficiency
  • Prevalence: 5 – 10 per cent
  • Peripheral smear: Oval macrocytes, hyper-segmented neutrophils; if severe: teardrop poikilocytes and red cell fragments
  • Other: B12 / red cell folate levels low
• Cause: Myelodysplastic syndrome
  • Prevalence: 5 per cent
  • Peripheral smear: Tear drop cells, oval macrocytosis; hypogranular or hypolobulated neutrophils; blast cells; giant or hypogranular platelets, Pappenheimer bodies, presence of a minor population of hypochromic microcytic cells = dimorphic smear
  • Other: Cytopenias

Recognition of the deteriorating resident pathway

1. Goodnough LT, Schrier SL. Evaluation and management of anemia in the elderly. Am J Hematol. 2014;89(1):88-96.
2. World Health Organization. Indicators and Strategies for Iron Deficiency and Anemia Programmes. Report of the WHO/UNICEF/UNU Consultation. Geneva, Switzerland, 1993.
3. Abid SA, Gravenstein S, Nanda A. Anemia in the Long-Term Care Setting. Clin Geriatr Med. 2019;35(3):381-9.
4. Joosten E. Strategies for the laboratory diagnosis of some common causes of anaemia in elderly patients. Gerontology. 2004;50(2):49-56.
5. Gastrointestinal Expert Groups, Therapeutic Guidelines: Gastrointestinal Melbourne: Therapeutic Guidelines limited; 2016.
6. Smith DL. Anemia in the elderly. Am Fam Physician. 2000;62(7):1565-72.
7. Bain BJ. Diagnosis from the blood smear. N Engl J Med. 2005;353(5):498-507.