Anemia is defined as a low hemoglobin level and blood count. By the World Health Organization definition, it is a measurement of hemoglobin less than 13g/dl in men and less than 12g/dl in women. Anemia is a common condition in aging and is present in more than 10 percent of all people older than age 65 and up to 50 percent of those elderly in nursing homes. While lower levels are somewhat expected as we age and our metabolic demand isn’t as high, evidence is increasing that there is a definite increase in both mortality and morbidity in untreated anemia.
Much of the cause of anemia in younger ages is acute blood loss. Trauma with blood loss is well recognized, as is gastro-intestinal bleeding from such sources as ulcer disease and diverticulitis. Female blood loss from prolonged and heavy menstrual cycles also is a cause of anemia. On the far more serious end of the spectrum, cancer is always looked for by physicians when they see sudden anemia for the first time. Often acute symptoms lead the younger individual to the doctor and the diagnosis is made quickly.
Anemia has a more insidious onset in older people. Blood counts may drop slowly and the decrease in oxygenation will cause symptoms that are often attributed simply to the process of aging. A decrease in stamina, fitness, or energy, and even dizziness or falls is often ascribed just to getting older and not to the underlying process of lowered hemoglobin levels and blood oxygenation that is behind it. Shortness of breath, fatigue and even confusion can ensue with chronic and persistent anemia, which may be overlooked by the clinician and those sub-specialists providing ancillary care.
Nutritional and chronic diseases are often implicated in anemia in the older population, short of acute blood loss or undetected cancer. Iron deficiency, folate deficiency, and low stores of B12 account for at least a third of cases. Diagnosis is difficult unless levels of each of these are drawn in blood testing. These can be readily reversed with replacement or a change in nutrition, but require a reasonable index of suspicion by the treating physician to recognize and diagnose.
Microcytic anemia is usually caused by iron deficiency. While older aged individuals usually do not intake the same diet rich in iron because of their inability to chew, process or digest iron-rich substances, gastrointestinal bleeding and malignancy are the most dangerous conditions that must be ruled out. Malignancy work-ups are generally undertaken when the blood loss is rapid and the iron stores are exceedingly low.
Macrocytic anemia has many causes, such as being secondary to drug therapy, liver disease, thyroid disease or alcoholism. The nutritional anemias referenced above are most often macrocytic in nature. Alcoholism is a very real problem in the elderly who find that alcohol relieves stress and brings short term pleasure, and who are not worried about long term health consequences. It is a significant cause of unrecognized morbidity and mortality and an underlying cause not often uncovered by a doctor during a medical visit without persistent questioning. There are some adults who realize their faults and bad habits and try to follow along with the principles of AA as well as attend support meetings and such but not everyone does, and that’s when the outcome of the situation isn’t so pleasant and could perhaps result in long term body damage or even death.
One of the biggest problems with anemia in the elderly is the inability of the body to compensate for a lowered blood count or cell oxygenation from the lowered hemoglobin concentration circulating in the bloodstream. Older individuals cannot increase their heart rate and cardiac output as easily as younger persons, and shortness of breath, fatigue and confusion become more common as the anemia worsens. This leads to instability, falls, fractures, and causes of morbidity only peripherally related to the underlying condition. Surgery in anemic individuals carries a much higher risk of mortality and may not always be able to be postponed in an acute situation.
In underwriting, mild, stable anemia with a known cause doesn’t usually result in an adverse action. A rapid onset or significant anemia found recently or as part of the underwriting process often results in a postponement until the underlying cause is identified and treated. Sometimes that cause may render an individual uninsurable, depending on its severity. There is increasing evidence that both low hemoglobin levels and anemia are significant markers of physiologic decline-a situation that has to be reviewed carefully, particularly for older clients.
