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Monday 14th November, 2005
Elderly people with the lowest hemoglobin
concentrations were found to be at an increased risk of death.
CHICAGO ? Elderly people with the lowest and highest
hemoglobin concentrations (the component of red blood cells that
carries oxygen) are at increased risk of death, according to a
study in the October 24 issue of Archives of Internal Medicine,
one of the JAMA/Archives journals.
Increasing evidence indicates that anemia is common in the
elderly population, but few studies have assessed the
association of anemia with clinical outcomes, such as illness
and death, according to background information in the article.
Anemia is defined by the World Health Organization (WHO) as a
hemoglobin concentration of less than 12 g/dL (grams per one
tenth liter) for women and less than 13 g/dL for men.
Neil A. Zakai, M.D., of the University of Vermont College of
Medicine, Burlington, compared the association of hemoglobin
concentration and anemia status with subsequent death over the
course of eleven years in elderly adults living in four U.S.
communities. Hemoglobin concentrations were determined for
participants recruited between 1989 and 1993. Participants were
contacted biannually; telephone and clinic examinations were
conducted alternately. Deaths were reviewed and classified as
cardiovascular or noncardiovascular. Complete follow-up was
available through June 2001 for this analysis.
Hemoglobin concentration was analyzed in two ways: by
dividing the participants' baseline hemoglobin into five equal
levels and by the WHO criteria for anemia. Based on the WHO
criteria for anemia, 498 individuals were anemic on enrollment
(8.5 percent of the 5,797 included in the analysis), the
researchers report. The hemoglobin concentration for the 1,205
individuals in the lowest fifth was higher than the WHO criteria
for anemia, and 41.3 percent of these 1,205 people did qualify
as anemic by WHO standards.
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"In this elderly cohort, the prevalence of anemia was 7.0
percent among white and 17.6 percent among black individuals,"
the authors write. "After 11.2 years of follow-up, lower
hemoglobin concentrations were associated with increased
mortality risk, independent of many potentially confounding
factors. The magnitude of this association was similar whether
the lowest quintile [fifth] of hemoglobin or the WHO criteria
for anemia was used; however, the number of participants was
much larger when considering the lowest quintile of hemoglobin
concentration." Another finding of the study was that there was
also elevated mortality among those in the highest hemoglobin
quintile, even after extensive adjustment for other factors.
"In conclusion, a lower hemoglobin concentration was
independently associated with mortality in this elderly cohort,"
the authors write. "The bottom hemoglobin quintile defined a
larger group at risk than anemia status based on WHO criteria.
Future areas of investigation should determine the optimal
hemoglobin value that defines an abnormal concentration in
elderly individuals, study the causes of low hemoglobin
concentrations in elderly individuals and how these relate
differentially to outcomes, evaluate the causes of increased
mortality in individuals with low and high hemoglobin
concentrations, and assess whether treatment of low hemoglobin
in the general population reduces mortality."
(Arch Intern Med. 2005; 165: 2214-2220).
Editor's Note: This research was supported by contracts from
the National Heart, Lung, and Blood Institute, Bethesda, Md. Dr.
Cushman has received research funding in the form of a
subcontract with the University of Alabama funded by Amgen; the
project is not related to this article.
Editorial: Anemia in the Elderly
Time for New Blood in Old Vessels?
In an accompanying editorial, Jerry L. Spivak, M.D., of The
Johns Hopkins University School of Medicine, Baltimore, Md.,
writes, "The four articles in this issue of the Archives
usefully highlight and advance our conceptions of the cause of
anemia in the elderly and anemia's health-related impact.
Anemia, of course, is always the consequence of another
disorder, and correction of the underlying disorder is the most
effective means of alleviating the anemia. However, anemia in
the majority of the elderly is caused by conditions such as
chronic renal insufficiency, chronic inflammation, cancer, or
bone marrow failure, some of which are actually an aftermath of
the aging process and most of which defy correction. It is now
also well established that anemia frequently exacerbates the
illness causing it, while having its own independent adverse
"What remains to be determined is whether pharmacologic
correction of anemia ? can slow disease progression, reduce
morbidity [illness], improve quality of life, and prolong
survival, and whether there is a favorable cost-benefit ratio to
society for such improvements," Dr. Spivak continues. "Recent
failed attempts to answer these questions in the setting of
renal failure or cancer indicate that this will not be an easy
task, but the prospect of a doubling in the number of elderly
persons over the next 25 years indicates that it is a task that
cannot be ignored or deferred."
(Arch Intern Med. 2005; 165: 2187-2189).