1. Anemia in the Hospitalized Elderly Hospitalist Best Practice J Rush Pierce Jr, MD, MPH February 29, 2012

2. Agenda Case Brief Literature review – Special clinical considerations regarding anemia in elderly – Hospital acquired anemia – Transfusion for anemia in hospitalized elderly Discussion about consensus practice

3. Case Q1 78 year old white man admitted with CAP. PMHx: diabetes, HTN, CAD, h/o CABG, GERD Meds : metformin, lovastatin, lisinopril, ASA, clopidogrel, pantoprazole. PE : 135/76, 105, 38.4, RR 20, SaO2 88% RA; 60 kg. Sternotomy scar, signs of consolidation right base, guaiac neg Lab: Hgb = 13.3, MCV = 85, glucose = 225, creat = 1.0 Q1 Should he be evaluated for anemia?

4. Case Q2 Two days later his Hgb is 11.2. You ask the intern why she thinks the Hgb has fallen by 2.1 g/dL. She says it’s probably dilution due to the fluids he received. Q2 Do you agree?

5. Case Q3 On day 3, he falls going to the toilet and fractures his hip. He undergoes surgical repair. On the second post-operative day he is doing well. Hgb = 8.2. Your resident suggests transfusing the patient because he has CAD and is going to start ambulation. Q3 Do you agree?

6. Defining anemia in elderly (Hgb, g/dL) MenWomen PowerChart< 14.5< 12.0 Williams (US populations, does not include elderly)< 14.0< 12.3 WHO (world populations, does not include elderly)< 13.0< 12.0 NHANES III/Kaiser-Scripps (Caucasian race, age > 60 yr )< 13.2< 12.2

7. Prevalence of anemia in elderly Prevalence – NHANES III (>64 yrs) – 11% (~1 % Hgb below 10) – NHANES III (>84 yrs) – 20%/26% (F/M) Observational studies show anemia in elderly assoc with poorer functional ability, impaired cognitive function, depressed sxs, poorer quality of life and increased mortality

8. Etiology of anemia in elderly NHANES III (1988-1994) 1/3 = nutritional (50% of these were iron def) 1/3 = chronic dz (CRF most common) 1/3 = unexplained (50% of these had some features of early myelodysplasia) Stanford study (2006-2010) 35% = unexplained 22% = hem malignancy including myelodysplasia 12% = iron def 11% = chemotherapy 6% = chronic inflam dz 4% = renal dz 10% = other

9. Evaluation of anemia in elderly Anemias in elderly often due to more than one etiology B12 absorption impaired with atrophic gastritis, H pylori infection, PPI use Only 4/26 pts with iron def in Stanford study had MCV < 80 Leukopenia, thrombocytopenia, macrocytosis frequently seen with myelodysplasia

10. Iron deficiency in the elderly Importance of diagnosing iron deficiency in elderly (Gastroenetrol Clin Biol 2007:31:169) – 111 hospitalized pts > 74 yrs with Fe def anemia – 68% had bleeding source found on EGD/coloscopy – 28% had colon cancer – 5% had UGI malignancy Diagnosis – Ferritin may be falsely elevated due to malignancy, so some advocate using higher cut-off (50) – Some had advocated using sTfR/log ferritin ratio

11. Case Q2 Two days later his Hgb is 10.9. You ask the intern why she thinks the Hgb has fallen has fallen by 2.1 g/dL and she says it’s probably dilution due to the fluids he received. Q2 Do you agree?

12. Hospital acquired anemia

14. Causes of dilution anemia Acute blood loss with crystalloid replacement Pregnancy Plasma exchange/plt transfusion (mostly kids) “Sports anemia” (<1.0 g/dL) Venous sample drawn from vein with infusion

15. Anemia and CAP BMC Pulm Med 2010; 10:15

21. Case Q3 On day 3, he falls going to the toilet and fractures his hip. He undergoes surgical reapir. On the second post-operative day he is doing well. Hgb = 8.2. Your resident suggests transfusing the patient because he has CAD and is going to start ambulation. Q3 Do you agree?

22. Transfusion for anemia in the elderly 428 pts post post-CABG (1999) – 428 pts, transfuse Hgb <8 vs “usual care” – No diff in morbidity, mortality, fatigue TRICC (Transfusion Requirements in Critical Care) Trial (1999) – 838 pts – randomized to “restrictive” strategy (transfusion if Hgb < 7) vs “liberal” strategy (transfusion if Hgb < 10) – Mortality less in restrictive group if APACHE < 21 (6% vs 16%) & if younger than 55 yrs (6% vs 13%) – No diff if clinically significant heart dz (20% vs 23%)

23. FOCUS (Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) Trial Perioperative patients with cardiovascular disease and > 50 yrs Transfuse if Hgb < 10 vs < 8 NHLBI sponsored, multiple centers, 2016 pts

24. FOCUS Trial

28. Recommended consensus practice 1.Consider anemia in hospitalized elderly if Hgb < 13.2 in males and < 12.2 in females 2.Consider referral to GI, elderly patients with iron deficiency anemia 3.In the absence of significant ongoing blood loss, transfusion will be generally reserved for elderly with sxs of anemia or Hgb < 8 4.Change Adult Admit order set, so that the default lab draw is “once” rather than “daily for 4 days”