Anemia as We Age – Part 3

The following information on anemia is excerpted from “Anemia in the Older Adult: 10 Common Causes & What to Ask,” originally written and published by Leslie Kernisan, MD, on Better Health While Aging.net. I am reposting this with her permission and am sharing it to educate readers about anemia.

How doctors evaluate anemia

Once anemia is detected, it’s important for health professionals to do some additional evaluation and follow-up, to figure out what might be causing the anemia.

Understanding the timeline of the anemia — did it come on quickly or slowly? Is the red blood count stable or still trending down with time? — helps doctors figure out what’s going on, and how urgent the situation is.

Common follow-up tests include:

• Checking the stool for signs of microscopic blood loss
• Checking a ferritin level (which reflects iron stores in the body)
• Checking vitamin B12 and folate levels
• Checking kidney function, which is initially done by reviewing the estimated glomerular filtration rate (included in most basic blood work results)
• Checking the reticulocyte count, which reflects whether the bone marrow trying to produce extra red blood cells to compensate for anemia
• Checking levels of an “inflammation marker” in the blood, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
• Evaluation of the peripheral smear, which means the cells in the blood are examined via microscope
• Urine tests, to check for proteins associated with certain blood cell disorders

If the anemia is bad enough, or if the person is suffering significant symptoms, doctors might also consider a blood transfusion. However, although even mild anemia has been associated with worse health outcomes, research suggests that transfusing mild to moderate anemia generally isn’t beneficial. (This issue especially comes up when people are hospitalized or acutely ill.)

What to ask the doctor about anemia

If you are told that you or your older relative has anemia, be sure you understand how severe it seems to be, and what the doctors think might be causing it. This will help you understand the plan for follow-up and treatment.

Some specific questions that can be handy include:

• How bad is this anemia? Does it seem to be mild, moderate, or severe?
• What do you think is causing it? Could there be multiple causes or factors involved?
• How long do you think I’ve had this anemia? Does it seem to be stable or is it getting worse?
• Is this the cause of my symptoms or do you think something else is causing my symptoms?
• Could any of my medications be involved?
• What is our plan for further evaluation?
• What is our plan for treating this anemia?
• When do you recommend we check the CBC again? What is our plan for monitoring the anemia?

Be sure to request and keep copies of your lab results. It will help you and your doctors in the future to be able to review your past labs related to anemia and any related testing.

Avoiding common pitfalls related to anemia and iron

A very common diagnosis in older adults is iron-deficiency anemia. If you are diagnosed with this type of anemia, be sure the doctors have checked a ferritin level or otherwise confirmed you are low on iron.

I have actually reviewed medical charts in which a patient was prescribed iron for anemia, but no actual low iron level was documented. This suggests that the clinician may have presumed the anemia was due to low iron.

However, although iron deficiency is common, it’s important that clinicians and patients confirm this is the cause, before moving on to treatment with iron supplements. Doctors should also assess for other causes of anemia, since it’s very common for older adults to simultaneously experience multiple causes of anemia (e.g. iron deficiency and vitamin B12 deficiency).

If an iron deficiency is confirmed, be sure the doctors have tried to check for any causes of slow blood loss.

It is common for older adults to develop microscopic bleeds in their stomach or colon, especially if they take a daily aspirin or a non-steroidal anti-inflammatory drug (NSAIDs) such as ibuprofen. (For this reason — and others — NSAIDs are on the list of medications that older adults should use with caution.)

Bear in mind that iron supplements are often quite constipating for older adults. So you only want to take them if an iron-deficiency anemia has been confirmed, and you want to make sure any causes of ongoing blood loss (which causes iron loss) have been addressed.

The most important take home points on anemia in older adults

Here’s what I hope you’ll take away from this article:

#1. Anemia is a very common condition for older adults, and often has multiple underlying causes.

#2. Anemia is often mild-to-moderate and chronic; don’t let the follow-up fall through the cracks.

#3. If you are diagnosed with anemia or if you notice a lower than normal hemoglobin on your lab report, be sure to ask questions to understand your anemia. You’ll want to know:

• Is the anemia chronic or new?
• Is it mild, moderate, or severe?
• What is thought to be the cause? Have you been checked for common problems such as low iron or low vitamin B12?

#4. If you are diagnosed with low iron levels: could it be from a small internal bleed and could that be associated with aspirin, a non-steroidal, or another medication?

#5. Keep copies of your lab reports.

#6. Make sure you know what the plan is, for following your blood count and for evaluating the cause of your anemia.

Anemia as We Age – Part 2

The following information on anemia is excerpted from “Anemia in the Older Adult: 10 Common Causes & What to Ask,” originally written and published by Leslie Kernisan, MD, on Better Health While Aging.net. I am reposting this with her permission and am sharing it to educate readers about anemia.

The most common causes of anemia

Whenever anemia is detected, it’s essential to figure out what is causing the low red blood cell count.

Compared to most cells in the body, normal red blood cells have a short lifespan: about 100-120 days. So a healthy body must always be producing red blood cells. This is done in the bone marrow and takes about seven days, then the new red blood cells work in the blood for 3-4 months. Once the red blood cell dies, the body recovers the iron and reuses it to create new red blood cells.

Anemia happens when something goes wrong with these normal processes. In kids and younger adults, there is usually one cause for anemia. But in older adults, it’s quite common for there to be several co-existing causes of anemia.

A useful way to think about anemia is by considering two categories of causes:

• A problem producing the red blood cells, and/or
• A problem losing red blood cells

Here are the most common causes of anemia for each category:

Problems producing red blood cells. These include problems related to the bone marrow (where red blood cells are made) and deficiencies in vitamins and other substances used to make red blood cells. Common specific causes include:

• Chemotherapy or other medications affecting the bone marrow cells responsible for making red blood cells.
• Iron deficiency. This occasionally happens to vegetarians and others who don’t eat much meat. But it’s more commonly due to chronic blood loss, such as heavy periods in younger women, or a slowly bleeding ulcer in the stomach or small intestine, or even a chronic bleeding spot in the colon.
• Lack of vitamins needed for red blood cells. Vitamin B12 and folate are both essential to red blood cell formation.
• Low levels of erythropoietin. Erythropoietin is usually produced by the kidneys, and helps stimulate the bone marrow to make red blood cells. (This is the “epo” substance used in “blood doping” by unethical athletes.) People with kidney disease often have low levels of erythropoietin, which can cause a related anemia.
• Chronic inflammation. Many chronic illnesses are associated with a low or moderate level of chronic inflammation. Cancers and chronic infections can also cause inflammation. Inflammation seems to interfere with making red blood cells, a phenomenon known as “anemia of chronic disease.”
• Bone marrow disorders. Any disorder affecting the bone marrow or blood cells can interfere with red blood cell production and hence cause anemia.

Problems losing red blood cells. Blood loss causes anemia because red blood cells are leaving the blood stream. This can happen quickly and obviously, but also can happen slowly and subtly. Slow bleeds can worsen anemia by causing an iron-deficiency, as noted above. Some examples of how people lose blood include:

• Injury and trauma. This can cause visibly obvious bleeding, but also sometimes causes people to bleed into a space inside the body, which can be harder to detect.
• Chronic bleeding in the stomach, small intestine, or large bowel. This can be due to many reasons, some common ones include:
  • taking a daily aspirin or non-steroidal anti-inflammatory drug
  • peptic ulcer disease
  • cancer in the stomach or bowel
• Frequent blood draws. This is mainly a problem for people who are hospitalized and getting daily blood draws.
• Menstrual bleeding. This is usually an issue for younger women but occasionally affects older women.

There is also a third category of anemias, related to red blood cells being abnormally destroyed in the body before they live their usual lifespan. These are called hemolytic anemias and they are much less common.

Problems losing red blood cells. Blood loss causes anemia because red blood cells are leaving the blood stream. This can happen quickly and obviously, but also can happen slowly and subtly. Slow bleeds can worsen anemia by causing an iron-deficiency, as noted above. Some examples of how people lose blood include:

• Injury and trauma. This can cause visibly obvious bleeding, but also sometimes causes people to bleed into a space inside the body, which can be harder to detect.
• Chronic bleeding in the stomach, small intestine, or large bowel. This can be due to many reasons, some common ones include:
  • taking a daily aspirin or non-steroidal anti-inflammatory drug
  • peptic ulcer disease
  • cancer in the stomach or bowel
• Frequent blood draws. This is mainly a problem for people who are hospitalized and getting daily blood draws.
• Menstrual bleeding. This is usually an issue for younger women but occasionally affects older women.

There is also a third category of anemias, related to red blood cells being abnormally destroyed in the body before they live their usual lifespan. These are called hemolytic anemias and they are much less common.

A major study of causes of anemia in non-institutionalized older Americans found the following:

• One-third of the anemias were due to deficiency of iron, vitamin B12, and/or folate.
• One-third were due to chronic kidney disease or anemia of chronic disease.
• One-third of the anemias were “unexplained.”

Anemia as We Age – Part 1

As we age, anemia can become a fact of life. Many people fail to realize that some types of food plans can promote anemia at any age.

Anemia is often more serious than even many doctors are willing to admit. Three friends of mine had anemia and when taken to the emergency room were treated as having something contagious and were admitted under quarantine while several of us repeatedly asked for them to be checked for anemia.

We were politely ushered out of the hospital after being thoroughly checked and rechecked for the same symptoms the other three had. Yet no one would believe us about anemia until three days later when none of the other symptoms of the disease they were expecting developed. Then they were tested and retested for anemia and severe anemia was determined.

My final thoughts: If you have diabetes, be extra cautious and make sure your doctor does all the tests to determine the correct cause of any anemia diagnosed. Also read my blog about anemia. Another of my blogs on vitamin deficiency anemia can be read here.

The following information on anemia is excerpted from “Anemia in the Older Adult: 10 Common Causes & What to Ask,” originally written and published by Leslie Kernisan, MD, on Better Health While Aging.net. I am reposting this with her permission and am sharing it to educate readers about anemia.

Defining and detecting anemia

Anemia means having a lower-than-normal count of red blood cells circulating in the blood.

Red blood cells are always counted as part of a “Complete Blood Count” (CBC) test, which is a very commonly ordered blood test. To determine your general health status; to screen for, diagnose, or monitor any one of a variety of diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorder, or cancer

A CBC test usually includes the following results:

• White blood cell count (WBCs): the number of white blood cells per microliter of blood
• Red blood cell count (RBCs): the number of red blood cells per microliter of blood
• Hemoglobin (Hgb): how many grams of this oxygen-carrying protein per deciliter of blood
• Hematocrit (Hct): the fraction of blood that is made up of red blood cells
• Mean corpuscular volume (MCV): the average size of red blood cells
• Platelet count (Plts): how many platelets (a smaller cell involved in clotting blood) per microliter of blood

(For more information on the CBC test, see this Medline page.)

By convention, to detect anemia clinicians rely on the hemoglobin level and the hematocrit, rather than on the red blood cell count.

A “normal” level of hemoglobin is usually in the range of 14-17gm/dl for men, and 12-15gm/dl for women. However, different laboratories may define the normal range slightly differently.

A hemoglobin level below normal can be used to detect anemia. Clinicians often confirm the lower hemoglobin level by repeating the CBC test.

If clinicians detect anemia, they usually will review the mean corpuscular volume measurement (included in the CBC) to see if the red cells are smaller or bigger than normal. This is because the size of the red blood cells can help point doctors towards the underlying cause of anemia.

Hence anemia is often described as:

• Microcytic: red cells smaller than normal
• Normocytic: red cells of a normal size
• Macrocytic: red cells larger than normal

Symptoms of anemia

The red blood cells in your blood use hemoglobin to carry oxygen from your lungs to every cell in your body. So when a person doesn’t have enough properly functioning red blood cells, the body begins to experience symptoms related to not having enough oxygen.

Common symptoms of anemia are:

• fatigue
• weakness
• shortness of breath
• high heart rate
• headaches
• becoming paler, which is often first seen by checking inside the lower eye lids
• lower blood pressure (especially if the anemia is caused by bleeding)

However, it’s very common for people to have mild anemia — meaning a hemoglobin level that’s not way below normal — and in this case, symptoms may be barely noticeable or non-existent.

That’s because how bad the symptoms depends on two crucial factors:

• How far below normal is the hemoglobin level?
• How quickly did the hemoglobin drop to this level?

This second factor is very important to keep in mind. The human body does somewhat adapt to lower hemoglobin levels, but only if it’s given enough time to do so.

So this means that if someone’s hemoglobin drops from 12.5gm/dL to 10gm/dL (which we’d generally consider a moderate level of anemia), they are likely to feel pretty crummy if this drop happened over a two days, but much less so if it developed slowly over two months.

Anemia Can Be a Problem with Diabetes

I have been fortunate to have never had anemia since developing type 2 diabetes, but I know several of our support group that have. If you have diabetes, you will need to have your blood checked regularly for anemia. It is common for people with diabetes to also end up with this blood condition. It happens when your body’s red blood cells cannot deliver as much oxygen as your body needs. If you spot anemia early on, you can better manage the issues causing it.

Usually, anemia happens because you don’t have enough red blood cells. That can make you more likely to get certain diabetes complications, like eye and nerve damage. In addition, it can worsen kidney, heart, and artery disease, which are more common in people with diabetes.

Diabetes often leads to kidney damage, and failing kidneys can cause anemia. Healthy kidneys know when your body needs new red blood cells. They release a hormone called erythropoietin (EPO), which signals your bone marrow to make more. Damaged kidneys don’t send out enough EPO to keep up with your needs.

Often, people don’t realize they have kidney disease until it’s very far along. But, if you test positive for anemia, it can be an early sign of a problem with your kidneys.

People with diabetes are more likely to have inflamed blood vessels. This can keep bone marrow from getting the signal they need to make more red blood cells.

And some medications used to treat diabetes can drop your levels of the protein hemoglobin, which you need to carry oxygen through your blood. These drugs include ACE inhibitors, fibrates, metformin, and thiazolidinediones. If you take one of these, please talk to your doctor about your risk for anemia.

If you have kidney dialysis, you may have blood loss, and that can also cause anemia.

When your brain and other organs don’t get enough oxygen, you feel tired and weak. Other signs you may have anemia include:

• Shortness of breath
• Dizziness
• Headache
• Pale skin
• Chest pain
• Cold hands and feet
• Low body temperature
• Rapid heartbeat

A complete blood count gives your doctor a good picture of what’s going on in your blood. It counts your red and white blood cells and platelets, and it checks whether the red blood cells are a normal size.

It also checks the levels of hemoglobin in your blood and your blood volume. If your hemoglobin levels are low, you may be anemic. The normal ranges are 14 to 17.5 for men and 12.3 to 15.3 for women. If you have a lower percentage of red blood cells in your blood, you may be anemic.

If you are, the next step is to find out why. Your doctor may test you for:

• Iron deficiency
• Kidney failure
• Vitamin deficiency
• Internal bleeding
• Bone marrow health

If you’re anemic because your iron levels are low, it may help to eat iron-rich foods and take supplements. For people on kidney dialysis, it's best to get iron injected directly into a vein.

If your kidneys don’t make enough EPO -- the hormone that boosts the level of red blood cells you make -- your treatment may be a synthetic version of the hormone. You’ll get an injection every week or two, or you’ll have it during dialysis. It raises hemoglobin for most people, but it may also increase your chances of a heart attack or stroke. Your doctor needs to watch you closely while you’re on it

If your anemia is severe, you may need a blood transfusion.

You can lower your risk. Make sure you get enough iron from the food you eat. Most adult women need about 18 milligrams every day. Men need about 8.

Good sources of iron include:

• Iron-fortified breads and cereals
• Beans and lentils
• Oysters
• Liver
• Green leafy vegetables, especially spinach
• Tofu
• Red meat
• Fish
• Dried fruit, like prunes, raisins and apricots

Your body absorbs iron better if you have it along with food that contains vitamin C, like fruits and vegetables. Coffee, tea, and calcium can make you absorb less of it.

High blood pressure and high blood sugar cause the kidney damage that brings on anemia. If your doctor has prescribed you medication for either high blood pressure or high blood sugar, it’s important that you take it. A good diet and regular exercise also help.

Metformin Does Cause B12 Deficiency

Allen called me shortly after he read this. I say shortly because he knows I sleep late and he does respect my sleep time. He was surprised that it has taken this long to publish something we have known for a long time. He knew that I would be busy for most of the afternoon and again the following day, but felt this was important enough to remind me of it and ask that I blog about it. Then he asked if I could meet with Ben, Barry, and him on Saturday. I agreed and was happy to do this.

When I arrived, they were waiting for me. Allen had printed a copy for me and asked if I had read it. I told him that I had and would be blogging about it after March 18. Barry said you already have posts that far out and I said yes. Plus, I have three other blogs ready to post and about 18 more topics I want to write in the weeks ahead. Ben said yes, there have been many topics of interest lately. I said I wish I had time to write about all the topics that interest me.

People taking metformin, one of the safest type 2 diabetes medications, for several years may be at heightened risk of vitamin B12 deficiency and anemia, according to a new analysis of long-term data. Allen knows this from first hand experience and others of us know this because our vitamin B12 levels were low and we cannot absorb what we need from the foods rich in B12.

Metformin helps to control the amount of sugar, or glucose, in the blood by reducing how much glucose is absorbed from food and produced by the liver, and by increasing the body’s response to the hormone insulin, according to the National Institutes of Health.

The study used blood samples and the researchers found that at year five, average B12 levels were lower in the metformin group than the placebo group, and B12 deficiency was more common, affecting 4 percent of those on metformin compared to 2 percent of those not taking the drug.

Borderline low B12 levels affected almost 20 percent of those on metformin and 10 percent of those taking placebo.

Average vitamin B12 levels were higher by year 13 than in year five, but B12 deficiency was also more common in both the metformin and placebo groups, as reported in the Journal of Clinical Endocrinology and Metabolism. The down side of being vitamin B12 deficient can mean nerve damage that is severe and may be irreversible. Severe and prolonged B12 deficiency has also been linked to impaired cognition and dementia. It can also cause anemia (low red blood cell count), but fortunately, this condition is reversible with treatment. Another finding of the study was more people in the metformin group were also anemic at year five than in the placebo group.

Humans do not make vitamin B12 and need to consume it from animal sources or supplements. Vegetarians may get enough from eating eggs and dairy products, but vegans need to rely on supplements or fortified grains.

Doctors who prescribe metformin to patients long-term for type 2 diabetes, gestational diabetes, polycystic ovarian syndrome or other indications should consider routine measurement of vitamin B12 levels, the authors conclude.

People who are taking metformin should ask their doctor about measuring their B12 level. Restoring healthy B12 levels is easy to accomplish with pills or monthly injections.

Finally, the study authors say, “The risk of B12 deficiency should not be considered a reason to avoid taking metformin.”

Vitamin Deficiency Anemia

Since Allen ended up on the deficient side for Vitamin B12, we have been doing a lot of research about the signs, symptoms, and causes. We have found quite a bit of information. First, from the Mayo Clinic is their article on vitamin deficiency anemia, which covers the tests Allen was fortunate that the doctor did do. He was at the low point on folate, very low on vitamin B-12, and low normal range for vitamin C.

The doctor did tell him to add a daily men’s supplement to his regimen and make sure that he added a vitamin C to his regimen. The doctor told him that the prescription levels of vitamin D and vitamin B12 would be for a month only and then he should purchase the supplements in any store and set the lower limit at the level he ordered until the completion of the next tests. Allen commented that this was good to know and that he was surprised that the doctor was concerned about his supplements. Both Tim and I said that was a good thing and that he would probably continue to test for these until his body maintained them in the recommended range.

We did discuss this and three of our members said they were going to ask their doctor to run the same tests. We also pulled up several listings of what foods were high in the vitamins and some minerals. Allen now has his license back and feeling much more active. He did decide to use insulin after we presented him with several articles and did a lot of discussion. He did ask if he might be able to drop back to oral medications and we all agreed that could be a goal if he wanted it, but that may not be what he needs for the long term.

After we covered many of the myths about insulin, even Ben admitted that his blood glucose management was so much better; he doubted he would consider going back to oral medications. Ben also has decided to change doctors so that he could be tested for vitamin shortages. We all have been reading about vitamin B12 and several things we could do. Vitamin B12 deficiency is a risk for neuropathy, and several other health problems.

Since the Mayo Clinic article lists the signs and symptoms of vitamin deficiency anemia, we decided to study the article with care. They list the following signs and symptoms:

• Fatigue
• Shortness of breath
• Dizziness
• Pale or yellowish skin
• Swollen tongue that may appear dark red
• Weight loss
• Diarrhea
• Numbness or tingling in your hands and feet
• Muscle weakness
• Irritability
• Unsteady movements
• Mental confusion or forgetfulness

All of us could recognize something in the list that fits us and so the discussion would continue. Everyone agreed that if their doctor would not test them for the same tests that Allen had, they would be changing doctors. Ben is back with the VA and he and Allen both have had their appointments scheduled. Allen is happy since this will help get his insulin much cheaper and they have moved his appointment up to the middle of May. Even Barry is now set up for an appointment locally after his move and his records are now here.

We discussed vitamin B12 foods that would help prevent the deficiency. Most were not aware that much of the vitamin B12 needed could be obtained from eggs, milk, cheese, yogurt, red and white meats, shellfish, and some fortified foods. This was a discussion that opened some eyes and at the same time led to a discussion of low cholesterol and low fat. Tim took over in this discussion about the importance of lower levels of carbohydrates, medium protein and fat since there was much resistance to higher cholesterol and fat.

Brenda did surprise us when she spoke up and said Tim was right and that she had been following this food regimen for several years and her tests showed that the food ratio of carbohydrates, protein, and fat of 20 percent: 30 percent, 50 percent had not caused her test results to increase and that she was actually having better test results and had lost a few pounds. She said she would provide the test information to anyone needing confirm this. She continued by saying that her sister, a nutritionist, had worked with her for the last five years and could also discuss this with anyone needing guidance.

This took a lot of the argument out of the discussion and we moved on to other causes of vitamin B12 deficiency. We pulled up the article by the Mayo Clinic and since no one has had gastric bypass surgery, Crohn's disease or celiac disease, or other problems that interfere with absorption of the vitamin B12, we moved to discussion of the intrinsic factor as vitamin B-12 deficiency is most often due to a lack of this substance.

Intrinsic factor is a protein secreted by the stomach that joins vitamin B-12 in the stomach and escorts it through the small intestine to be absorbed by your bloodstream. Without intrinsic factor, vitamin B-12 cannot be absorbed and leaves your body as waste. Lack of intrinsic factor may be due to an autoimmune reaction, in which your immune system mistakenly attacks the stomach cells that produce it. Vitamin B-12 deficiency anemia caused by a lack of intrinsic factor is called pernicious anemia.

Vitamin B12 is important not only for the production of red blood cells, but also for a healthy nervous system. Vitamin B12 deficiency can lead to neurological problems in neuropathy, mental confusion and forgetfulness. This tells us how important vitamin B12 is for healthy brain function.

Allen joked that he did not want to be the cause of all this learning, but felt that our insistence of his being tested had helped all of us and he had learned a great lesson about nutrition.

We agreed that we may have found a good article to use as our center of discussion, but that we all had learned and needed to learn more. I thanked Tim and Brenda for leading much of the discussion. Brenda said that was why she wanted to be part of this discussion as this was what she had gone through several years ago and realized we were serious about discussing it. She knew some things had changed and she wanted to learn more if possible and she had.

We also gave this article to everyone for reading. It is from WebMD and is very specific to vitamin B12 deficiency.