Introduction
Both developed and developing countries are witnessing a rising trend in the number and proportion of older persons aged 60 years and above. Anemia is one of the most prominent health-related issues in this cohort. It has often been considered a normal consequence of aging. Importantly, it can coexist with other comorbidities of aging and can contribute significantly to increased morbidity and mortality, affecting the overall quality of life.[ 1 , 2 ] Health-related pathologies pertaining to this age group are also rising. This has resulted in the development of a new subspecialty of medicine called geriatric medicine.[ 3 , 4 ]
According to the third National Health and Nutrition Examination Survey (1988-1994), the prevalence of anemia was greater than 20% in people aged 85 and older, whereas 11.0% of men and 10.2% of women aged 65 and older were anemic overall.[ 5 , 6 , 7 ] The symptoms of anemia include easy fatigability, muscle wasting, reduced physical strength, frequent falls, and cardiovascular compromise, which are often ignored as sequelae of aging.[ 8 , 9 , 10 ] In younger people, mild anemia is commonly tolerated and frequently goes undetected, but in older people, it may have harmful effects.[ 11 , 12 ]
Primary care doctors, who treat a wide range of elderly health issues, initially have to detect various etiologies of anemia and then provide proper treatment and referrals. The main causes of anemia in elderly patients may differ from those in young patients. The aim of the present study is to determine the various causes of anemia in hospital-admitted geriatric patients and to categorize the types of anemia based on laboratory findings (microcytic, normocytic, and macrocytic).
Materials and Methods
The present study is a hospitalbased prospective observational study conducted between July 2019 and January 2022. A total of 102 anemic patients aged 60 years and above were admitted to the Geriatric or General Medicine wards of Sir Sunderlal (S.S.) Hospital, Banaras Hindu University, Varanasi were included in this study. The study was conducted after obtaining ethical approval from the Institute Ethics Committee (letter no. 2019/EC/1521). Written consent was taken from all the patients. Anemia was defined as a hemoglobin level of less than 12 g/dL for females and less than 13 g/dL for males to include patients in this study. Patients who had received blood transfusions in the last three months before admission to the hospital and patients undergoing aggressive radiation therapy or chemotherapy for cancer were excluded from the study. Age, sex, occupation, habits, past medical history, history of chemotherapy or radiation, and socioeconomic status of the patient were collected on a premade proforma. Clinical information was gathered, including presenting complaints and their thorough history. The patient underwent extensive general and systemic examinations, with special attention paid to any signs of anemia, the existence of any bleeding spots, organomegaly, and lymphadenopathy. Serum iron level, complete blood counts, peripheral blood smear examination, serum lactose dehydrogenase (LDH), and liver function tests were performed. The seven-part cell counter machine was used to perform a complete blood count. Peripheral blood smear and bone marrow cell morphology, assessed on Leishman-stained preparations, were used to detect the cause of geriatric anemia. As needed, bone marrow aspirate smears were stained with Perl’s stain to evaluate iron levels. In several instances, bone marrow biopsies were also performed. Reticulin stain and hematoxylin and eosin were used to stain the biopsy sections.
Statistical analysis
Statistical analysis was performed by Statistical Package for the Social Sciences version 23.0. Categorical variables were expressed as frequencies. Quantitative variables were expressed as mean and standard deviation.
Results
The present study was carried out on 102 elderly anemic patients in the age group of 60 years or above. These 102 patients were categorized into three groups according to the severity of anemia. Among the total 102 cases of geriatric anemia most of the patients were in the age group of 60-65 years, i.e. 45 (44.1%) followed by patient with age group of 66-70, i.e. 26 (25.5%). Out of 102 patients 71 were male, i.e. 69.60% and 31 were female, i.e. 30.39%. The ratio of male: female is 2.29:1. Hemoglobin concentration ranges from 2.9 to 11.0 gm/dl, with a mean 7.53 gm/dl. Mean corpuscular volume among all cases ranges from 64.6 to 131.6 fl, with a mean 94.20 fl. Mean corpuscular hemoglobin ranges from 19.0 to 40.1 pg with mean 29.96 pg. Mean corpuscular hemoglobin concentration ranges from 20.8 to 37.8 gm/dl, with a mean 31.76 gm/dl. The range of red blood cell (RBC) count was 0.83-4.5 million/mm 3 , with a mean of 2.60 million/mm 3 . Hematocrit ranges from 8.90 to 37.90% with a mean of 23.77%. Red cell distribution width-coefficient of variation ranges from 11.6 to 29.90 with a mean value of 17.80. LDH ranges from 173.3 to 1453.00 gm/dl with a mean of 358.28. Serum iron ranges from 12.50 to 318 mcg/dl, with a mean of 112.10 mcg/dl and Total iron binding capacity ranges from 117.60 to 396 mcg/dl with a mean of 226.42 mcg/dl. Anemia of chronic disease (ACD) formed the major cause of anemia (31.37%) among geriatric patient, followed by myelodysplastic syndrome (MDS) (7.8%), iron deficiency anemia (IDA) (7.8%), and megaloblastic anemia (6.8%). Anemia due to hematological malignancy formed the largest group among the causes of ACD. Multiple myeloma was found to be the commonest cause among ACD. The different etiologies of geriatric anemia and their frequency are shown in Table 1 . Most of the geriatric patients had a severe degree of anemia (56.9%) followed by a moderate degree of anemia (41.1%). Only 2% of cases had a mild degree of anemia.
Table 1
Distribution of etiological causes of geriatric anemia
SLE: Systemic lupus erythematosis
| Diagnosis | Number | Percentage | |
| Anemia of Chronic Disease (ACD) (32 cases) (31.37%) | Hematological malignancy • Multiple myeloma (MM) | 13 | 12.7 |
| • Chronic lymphocytic leukemia (CLL) | 4 | 3.9 | |
| • Acute leukemia | 1 | 0.9 | |
| Other neoplasm | 1 | 0.9 | |
| Infections | |||
| • Tuberculosis | 3 | 2.9 | |
| • Worm Infestation | 1 | 0.9 | |
| • Kala-azar | 1 | 0.9 | |
| Inflammation | 0.9 | ||
| SLE | 1 | ||
| Others (Anemia of chronic disease) | 7 | 6.8 | |
| Myelodysplastic syndrome (MDS) | 8 | 7.8 | |
| Iron deficiency anemia (IDA) | 8 | 7.8 | |
| Megaloblastic anemia | 7 | 6.8 | |
| Dimorphic anemia | 2 | 1.9 | |
| Hemolytic anemia | 1 | 0.9 | |
| Diabetes mellitus | 1 | 0.9 | |
| Aplastic anemia | 5 | 4.9 | |
| Gelatinous transformation of bone | 1 | 0.9 | |
| Hypersplenism | 4 | 3.9 | |
| Chronic kidney disease (CKD) | 7 | 6.8 | |
| Pure red cell aplasia | 1 | 0.9 | |
| Myelofibrosis | 3 | 2.9 | |
| Hemophagocytic lymphohistiocytosis (HLH) | 1 | 0.9 | |
| Waldenstrom’s macroglobinemia | 2 | 1.9 | |
| Osteosclerosis | 1 | 0.9 | |
| Immune thrombocytopenia (ITP) | 2 | 1.9 | |
| Acute infection | 3 | 2.9 | |
| Unexplained | 13 | 12.7 | |
| Total | 102 | 100 |
Among 102 patients, 43 (42.2%) showed normocytic normochromic (NCNC) anemia in peripheral blood smear examination. Twenty-nine (28.4%) patients showed dimorphic anemia. Microcystic hyochromic anemia was present in 16 (15.7%) patients, and eight patients (7.8%) showed macrocytic blood picture. In patients of ACD, a moderate degree of anemia was present in 53.12% of cases, followed by a severe degree of anemia present in 43.75% of cases.
Among hematological malignancies responsible for ACD, the most common hematological malignancy was multiple myeloma (72.22%). After multiple myeloma, chronic lymphocytic leukemia was the second most common hematological malignancy (22.22%). Acute leukemia (5.56%) was the third common cause of ACD due to hematological malignancy. The hemoglobin range was 8 to 10.9 gm/dl in most patient cases of hematological malignancy.
Of 13 cases of multiple myeloma, 12 cases were male and 1 case was female. Nine (69.23%) cases of multiple myeloma had a moderate degree of anemia. Of eight cases of IDA, seven cases were male and one case was female. Five cases of IDA had a moderate degree of anemia. Most common etiological factor for IDA was dietary deficiency (50%). In Total, 62.5% cases of IDA showed moderate degree of anemia. MDS was more common in males (62.5%) compared to females (37.5%) in the present study. Most of the cases of MDS showed a moderate degree of anemia. Out of the total seven cases of megaloblastic anemia, four were male and three were female. Five cases (71.43%) showed a severe degree of anemia. Out of two cases of dimorphic anemia, one case had a moderate degree of anemia and one had a severe degree of anemia. Both the cases of dimorphic anemia were male. Out of five cases of aplastic anemia, three cases were male and two cases were female. Microscopic findings of Myelodysplastic syndrome (MDS) in bone marrow aspiration and biopsy are shown in Figure 1a and b . Trephine biopsy sections demonstrating bone marrow fibrosis in myelofibrosis are shown in Figure 1c . Megaloblasts characteristic of megaloblastic anemia are illustrated in Figure 1d and e .
Discussion
Because it emphasizes the complex nature and prevalence of anemia in older persons, which frequently goes untreated, the study on anemia in senior patients is extremely pertinent to primary care providers. Primary care doctors are frequently the initial point of contact and are essential in the early detection, evaluation, and treatment of anemia. Primary care physicians can provide prompt treatments, such as blood testing, therapy for underlying problems, and appropriate referrals, by having a thorough understanding of its causes, which can range from chronic diseases to dietary deficiencies. Elderly patients’ quality of life can be improved, problems can be decreased, and patient outcomes can be improved with early diagnosis. Because anemia in older persons typically manifests in subtle ways and many people modify their activities as their bodies react physiologically to the illness, it is frequently disregarded. Anemia’s common symptoms, which include weakness, fatigue, and dyspnea, are not unique to older persons and are typically ascribed to aging.[ 13 , 14 , 15 ] In a large majority of individuals, the cause of anemia is still unknown despite extensive workup. Anemia is found to be highly prevalent in older people who are hospitalized or institutionalized. Impaired renal functions, endocrine insufficiency, and MDS can be considered as other unique contributors to anemia in the elderly.[ 4 , 16 , 17 ] Other propositions include activation of inflammatory pathways, and presence of hypoproliferative and hyporesponsive hematopoietic stem cell reserves in old age. Inflammation is an important component in the pathogenesis of ACD. It can occur secondary to various infections and age-related chronic inflammatory diseases. Although inflammation was not considered a significant factor in the pathogenesis of some of these chronic diseases like congestive heart failure, coronary artery disease, and chronic kidney disease, recent studies have highlighted an associated inflammatory component to these diseases. Hence, ACD could be an associated finding with chronic inflammatory diseases.[ 11 , 18 , 19 , 20 ] The mean age of presentation of anemic geriatric patients in our study is 68.33 years.
In the present study, male patients are commonly affected by anemia as compared to females. A similar gender distribution of anemia is seen in studies done by Guralnik et al .[ 19 ] and Vanasse et al .[ 20 ] Pallor is present in 82.35% of cases ( n = 84). The mean hemoglobin concentration was 7.53 gm/dl in our study. Out of all cases, mild anemia accounts for only 2% of cases. One possible explanation for this could be that, as a tertiary care facility, we receive referrals from main and secondary care facilities. Second, it is possible that the majority of older patients with moderate anemia are either receiving care in primary and secondary care centers or are not showing up to seek an opinion. NCNC RBC morphology is the most common peripheral blood examination finding in our study. Similar findings have been noted in few previous studies, as shown in Table 2 .
Table 2
RBC morphology findings of geriatric anemia patients in various studies
RBC: red blood cells
| Study | RBC morphology | |||
| Normocytic normochromic | Dimorphic | Microcytic hypochromic | Macrocytic | |
| Shrivastava SR, et al.[ 21 ] | 78.05% | 4.24% | 11.6% | 6.02% |
| Gangadharan V, et al.,[ 22 ] | 73% | 8% | 16% | 3% |
| Soni PN, et al.,[ 23 ] | 70.73% | 4.07% | 11.11% | 5.96% |
| Present study | 42.2% | 28.4% | 15.7% | 7.8% |
In the present study, the most common cause of anemia was anemia due to chronic disease 31.3% ( n = 32). IDA and megaloblastic anemia are other common causes of anemia in geriatric patients. ACD and IDA are the most frequent causes of anemia in previous studies. The frequency of etiological causes of anemia in previous studies is shown in Table 3 . The distribution of different hematological malignancies causing anemia of chronic disease is shown in Graph 1 .
Table 3
Frequency of different etiologies of anemia in earlier studies
| Etiologies | Study | |||
| Tay MRJ, et al.[ 24 ] (Total cases 424) | Tettamanti M et al.[ 25 ] Total cases 493) | Mann S et al.[ 26 ] (Total cases 60) | Present study (Total cases 102) | |
| Anemia of chronic disease | 14.2% | 17.4% | 41.67% | 31.3% |
| Iron deficiency anemia | 13.0% | 16.0% | 35.0% | 7.8% |
| Megaloblastic anemia | 8.3% | 10.1% | 3.34% | 7.8% |
| Dual deficiency anemia | 3.8% | 6.5% | - | 1.9% |
| Myelodysplastic syndrome | - | - | 5.0% | 7.8% |
| Aplastic anemia | - | - | 1.67% | 4.9% |
The majority of moderate anemia cases in the current study had a significant underlying hematological malignancy. In my study, hematological malignancies constitute 17.64% case of anemia. The study by Bhasin A et al .[ 11 ] also has a similar percentage (18%) of cases.
The frequency of hematological malignancies as cause of anemia in few previous studies is shown in Table 4 .
Table 4
Frequency of hematological malignancies as cause of anemia in different studies
| Study | Place | Hematological malignancies % |
| Bhasin A et al.,[ 11 ] | Bangalore | 14.3% (6) |
| Mann S et al.,[ 26 ] | Dehradun | 40% (10) |
| Present study | Varanasi | 17.64% (18) |
MDS constituted about 7.8% cases of anemia in the elderly. The cause was unexplained in 13 (12.7%) cases; this was because the majority did not come for follow-up.
Limitations
Since this is a single center hospital-based study with a limited sample size, the demographic data of the study cannot be generalized.
Conclusion
Our study reveals that most geriatric patients present with moderate degree of anemia. Multiple myeloma, IDA, and megaloblastic anemia are the most common etiologies associated with anemia in elderly patients. The detection of this potentially curable condition may be delayed if elderly anemia is not evaluated. In the elderly population, nonspecific symptoms like weakness and exhaustion should not be disregarded as they may be significant indicators that anemia is present in these individuals. Before starting a particular treatment, an attempt should always be made to determine the etiology of anemia. Complete blood count and meticulous peripheral blood smear study, along with bone marrow examination, are necessary to find out the etiological causes of anemia in the elderly.
Key messages
Hematological malignancy like multiple myeloma is a common cause of anemia in hospital-admitted geriatric patients. IDA and megaloblastic anemia are the other frequent nonneoplastic causes of anemia in the elderly.
NCNC anemia is the most prevalent peripheral blood examination findings.
In the present study, anemia is more prevalent in elderly males as compared to elderly females in hospitalized patients.
Ethical policy and Institutional Review board statement
Ethical approval letter from the Institute Ethics Committee (letter no Dean/2019/EC/1521) is attached below.
Patient declaration of consent statement
Written consent from all the patients were taken, and those were included in this study.
List of abbreviations
List of abbreviations
| Abbreviation | Definition |
| ACD | Anemia of chronic disease |
| AIPC | Anisopoikilocytosis |
| MDS | Myelodysplastic syndrome |
| PAS | Periodic acid-schiff |
| BMB | Bone marrow biopsy |
| SBB | Sudan Black B |
| IHC | Immunohistochemistry |
| TIBC | Total iron-binding capacity |
| MCV | Mean corpuscular volume |
| MCH | Mean corpuscular hemoglobin |
| IDA | Iron deficiency anemia |
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
Authors would like to thanks Pawan Pandey and Rahul Upadhyay to help in staining of bone marrow aspirate smears.
Funding Statement
Nil.
References
1. Cannon EJ, Misialek JR, Buckley LF, Aboelsaad IAF, Ballantyne CM, Leister J, et al. Anemia, iron deficiency, and cause-specific mortality: The atherosclerosis risk in communities study. Gerontology. 2024;70:1023–32. doi: 10.1159/000539973.
2. Singh S, Bajorek B. Defining ‘elderly’ in clinical practice guidelines for pharmacotherapy. Pharm Pract (Granada) 2014;12:489. doi: 10.4321/s1886-36552014000400007.
3. Sharma D, Suri V, Pannu AK, Attri SV, Varma N, Kochhar R, et al. Patterns of geriatric anemia: A hospital-based observational study in North India. J Family Med Prim Care. 2019;8:976–80. doi: 10.4103/jfmpc.jfmpc_450_18.
4. Agravat AH, Pujara K, Kothari RK, Dhruva GA. A clinico-pathological study of geriatric anemias. Aging Med (Milton) 2025;4:128–34. doi: 10.1002/agm2.12150.
5. Krishnamurthy S, Kumar B, Thangavelu S. Clinical and hematological evaluation of geriatric anemia. J Family Med Prim Care. 2022;11:3028–33. doi: 10.4103/jfmpc.jfmpc_2239_21.
6. Ambrosy AP, Gurwitz JH, Tabada GH, Artz A, Schrier S, Rao SV, et al. Incident anaemia in older adults with heart failure: Rate, aetiology, and association with outcomes. Eur Heart J Qual Care Clin Outcomes. 2019;5:361–9. doi: 10.1093/ehjqcco/qcz010.
7. Röhrig G. Anemia in the aged. Z Gerontol Geriatr. 2018;51:935–46. doi: 10.1007/s00391-018-01479-y.
8. Alwar V, Reethi K, Rameshkumar K. Geriatric anemia: An Indian perspective. Indian J Hematol Blood Transfus. 2013;29:126–7. doi: 10.1007/s12288-012-0146-y.
9. Girelli D, Marchi G, Camaschella C. Anemia in the elderly. Hemasphere. 2018;2:e40. doi: 10.1097/HS9.0000000000000040.
10. Groarke EM, Young NS. Aging and hematopoiesis. Clin Geriatr Med. 2019;35:285–93. doi: 10.1016/j.cger.2019.03.001.
11. Bhasin A, Rao MY. Characteristics of anemia in elderly: A hospital based study in South India. Indian J Hematol Blood Transfus. 2011;27:26–32. doi: 10.1007/s12288-011-0056-4.
12. Kaur D, Rasane P, Singh J, Kaur S, Kumar V, Mahato DK, et al. Nutritional interventions for elderly and considerations for the development of geriatric foods. Curr Aging Sci. 2019;12:15–27. doi: 10.2174/1874609812666190521110548.
13. Strollo F, Gentile S, Strollo G, Mambro A, Vernikos J. Recent progress in space physiology and aging. Front Physiol. 2018;9:1551. doi: 10.3389/fphys.2018.01551.
14. Simonsick EM, Patel KV, Schrack JA, Ferrucci L. Fatigability as a predictor of subclinical and clinical anemia in well-functioning older adults. J Am Geriatr Soc. 2020;68:2297–302. doi: 10.1111/jgs.16657.
15. Michalak SS, Rupa-Matysek J, Hus I, Gil L. Unexplained anemia in the elderly-A real life analysis of 981 patients. Arch Med Sci. 2019;16:834–41. doi: 10.5114/aoms.2019.82723.
16. Deal JA, Carlson MC, Xue QL, Fried LP, Chaves PH. Anemia and 9-year domain-specific cognitive decline in community-dwelling older women: The women's health and aging study II. J Am Geriatr Soc. 2009;57:1604–11. doi: 10.1111/j.1532-5415.2009.02400.x.
17. Mikhail A, Brown C, Williams JA, Mathrani V, Shrivastava R, Evans J, et al. Renal association clinical practice guideline on Anaemia of Chronic Kidney Disease. BMC Nephrol. 2017;18:345. doi: 10.1186/s12882-017-0688-1.
18. Fougère B, Puisieux F, Chevalet P, Annweiler C, Michel E, Joly L, et al. Prevalence of iron deficiency in patients admitted to a geriatric unit: A multicenter cross-sectional study. BMC Geriatr. 2024;24:112. doi: 10.1186/s12877-024-04719-6.
19. Guralnik JM, Ershler WB, Schrier SL, Picozzi VJ. Anemia in the elderly: A public health crisis in hematology. Hematology Am Soc Hematol Educ Program. 2005;1:528–32. doi: 10.1182/asheducation-2005.1.528.
20. Vanasse GJ, Berliner N. Anemia in elderly patients: An emerging problem for the 21st century. Hematology Am Soc Hematol Educ Program. 2010;2010:271–5. doi: 10.1182/asheducation-2010.1.271.
21. Shrivastava SR, Hippargi SB, Ambali AP, Yeikar BR. Pattern of anemia in geriatric age group. J Krishna Inst Med Sci Univ. 2013;2:77–81.
22. Gangadharan V, Lakshmi SS, Mohan KVM. Morphological pattern of geriatric Anemia- A study. J Dent Med Sci. 2016;15:24–6.
23. Soni PN, Jawale RB, Soni SP. Study of anemia in geriatric population: A hospital based study in Marathwada region, Maharashtra, India. Int J Adv Med. 2016;3:197–99.
24. Tay MRJ, Ong YY. Prevalence of anemia and risk factor of anemia in older hospitalized patients. Proc Singapore Healthcare. 2011;20:71–9.
25. Tettamanti M, Lucca U, Gandini F, Recchia A, Mosconi P, Apolone G, et al. Prevalence, incidence and types of mild anemia in the elderly: The “Health and Anemia” population-based study. Haematologica. 2010;95:1849–56. doi: 10.3324/haematol.2010.023101.
26. Mann S, Kumar A, Singh SK, Katyal S, Chopra G, Varma SK. Clinical evaluation of anemia in geriatric patients-A cross sectional study conducted at tertiary care hospital. Nat J Community Med. 2014;5:316–20.