Anemia in the Elderly

Anemia in the Elderly offers a thoughtful overview of a common yet underdiagnosed medical condition affecting nearly 3 million older adults in the United States. Throughout this book, the editors build a strong case for the clinical significance of anemia by highlighting key geriatric aspects of illness. Specific concerns of anemia include an increased risk of congestive heart failure, kidney disease, and cognitive disorders, as well as functional dependence and hospitalization. Aside from the high prevalence, the authors suggest that approximately 70% of anemia in older individuals is potentially reversible.

The book starts with a rather technical review of stem cell aging. Unfortunately this detailed discourse on telomeres, genetics deletions, and stem cells offers little in the way of clinical relevance and is difficult to understand. Many readers would be well served to simply skip this chapter altogether and move on to “the good stuff.”

Chapter 2, aptly entitled “Anemia and Aging or Anemia of Aging?” contains an outstanding, concise review of geriatrics—a sort of “Geriatrics 101” for nongeriatricians. Here the authors examine the biology of aging and introduce readers to fundamental concepts such as comprehensive geriatric assessment, functional status, frailty, social support, and caregiving. The authors use this clearly written and informative section to provide the necessary clinical context for the rest of the book. This chapter also contains several tables and figures that illustrate the clinical implications of common geriatric syndromes, focusing not just on etiology but on consequences.

The bulk of the book addresses more general anemia issues such as iron and vitamin B₁₂ deficiency, myelodysplastic syndromes, and the still-elusive “anemia of chronic inflammation.” While the approach to these problems has not changed significantly, the authors review the current state of the art, including both basic science and clinical aspects. Laudably, the authors and editors manage to keep most of this book clinically focused, attempting to provide evidence-based answers to challenging questions regarding why older patients become anemic, the clinical consequences of anemia, and when a diagnostic work-up of anemia should be initiated.

Besides the more traditional anemia topics, this book contains several chapters specifically addressing issues pertinent to elderly individuals. One example is the “Anemia in Long-Term Care” chapter, in which the discussion includes not just pathophysiology but Centers for Medicare & Medicaid Services payer issues and logistical barriers that limit anemia work-ups in a nursing home population. Another exceedingly relevant chapter is that entitled “Erythropoietin Deficiency and Late-Life Anemia.” Here the concept of erythropoietin deficiency without overt renal failure is addressed thoroughly and thoughtfully. The authors provide a sensible paradigm for the management of erythropoietin deficiency—a common clinical conundrum without a clear answer—including recommendations on who should receive an erythropoietin-stimulating agent. The authors write that

To the extent that erythropoietin deficiency contributes to unexplained anemia, it is likely that treatment with recombinant erythropoietin or similar agents would raise hemoglobin effectively. However, it remains to be demonstrated whether such treatment would be associated with improved quality of life, physical or cognitive function, and whether administration could be accomplished safely in frail, elderly anemic patients.

Anemia in the Elderly is an excellent example of the critical need to incorporate issues of functional status into the approach to the medical care of older adults, especially those who are frail and elderly. In this sense, it is not the thorough review of anemia that is the book's most noteworthy contribution but rather the clear demonstration of the interplay between anemia and aging, with an emphasis on functional outcomes, that is most significant. In other words, the authors do not focus simply on mortality but also on whether an older adult becomes functionally dependent as a consequence of disease.

Although at times certain chapters get too focused on mouse models, cytokines, and genetic markers, this book carries tremendous clinical relevance for its intended audience—physicians and other clinicians who care for older adults. More importantly, this book goes beyond what a simple Google or UpToDate search will provide by offering the essential framework necessary for excellent medical care of elderly individuals.

In an era in which textbooks are no longer a primary source of information, I believe that Anemia in the Elderly fills an important gap. The major contribution of this text is the elegant integration of geriatrics throughout. By offering a thoughtful approach to anemia that takes functional status into account, this book is an important addition to the fields of geriatrics and hematology.