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Anemia in
Long Term Care
New Directions: Management Of Anemia In Long-term Care
Eric G. Tangalos, MD, FACP,
AGSF, CMD
Professor of Medicine
Chair, Primary Care Internal
Medicine
Co-Director, Robert and Arlene
Kogod Program on Aging
Mayo Clinic College of Medicine
Barbara Zarowitz, Pharm. D.,
FCCP, CGP, BCPS
Chief Clinical Officer
Vice President of Professional
Services
Omnicare, Inc.
Debbie Gunter, RN,MN,FNP,
ACHPN
Director of Clinical Services
VistaCare Center at
Wesley Woods Center of Emory
University
William McClellan, M.D., M.P.H.
Clinical Professor of Medicine
Emory University School of Medicine
Acknowledgement
The production of this monograph
was supported by an unrestricted
educational grant from Amgen, Inc.
to the Emory University Center for
Health in Aging and the Division of
Geriatric Medicine and Gerontology
in the Department of Medicine at
Emory University School of
Medicine.
The contents of the monograph are
based on a review of relevant
literature and a meeting among the
authors held in September, 2005 to
discuss key points for long-term care
professionals.
Sherry Baker and Joseph Ouslander,
M.D. assisted with editing the
monograph.
The purpose of this monograph is to
provide a concise update on the
management of anemia for
multidisciplinary health professionals
who work in long-term care (LTC)
facilities. New information on the
pathophysiology of anemia, and the
availability of potentially effective
therapy for anemia associated with
chronic kidney disease (CKD), which
is prevalent in the LTC population,
have provided an impetus for
clinicians to consider evaluating and
treating this condition more actively
that has been the case in the past. The
monograph is intended to provide an
overview of these new directions in
the management of anemia in LTC.
Is anemia too often the missing
diagnosis in LTC residents? A
case example:
A 92 year-old cognitively intact female
nursing home resident with congestive
heart failure (CHF) and chronic renal
insufficiency experienced an increase
in edema in her legs, weight gain, and
shortness of breath on minimal
exertion. These exacerbations of her
symptoms, as well as several falls,
lead to increasingly frequent
hospitalizations. Her CHF
medications were maximized but she
continued to complain of weakness.
Her multiple health problems –
obviously serious in the setting of
advanced age – appeared to explain
her physical decline.
Neither the family nor the patient was
ready to “give up”. Additional steps
were taken to further evaluate the
patient.
Laboratory testing performed during
her most recent hospitalization
revealed a hemoglobin (Hgb) value of
9.0, well below the generally accepted
value for anemia (<12 g/dL). Her
hemoglobin values had declined over
the years, and no bleeding source had
ever been identified. Her creatinine
had gone from 1.3 to 1.6 over the last
4 years and at age 92 she “weighed
her age”. She was given an
erythropoiesis stimulating protein to
treat the condition and, over three
months her hemoglobin improved.
Her weakness improved and other
vague symptoms, including dizziness
and lack of appetite, also got better.
She was able to stay out of the
hospital for the next 8 months.
Anemia in LTC: What is the scope
of the condition?
Despite an estimated prevalence of
over 40 % within LTC facilities,
anemia may not always be “on the
radar screen”. There are a host of
explanations why the condition may
be overlooked. The symptoms and
signs of anemia in the elderly such as
fatigue, weakness, and dyspnea are
not specific and can be attributed to
old age, making it a condition
somewhat easy to overlook. Even skin
pallor, which can be a helpful
diagnostic clue in younger patients,
may be hard to recognize in an elderly
patient. Mild anemia in particular
may not result in a comprehensive
analysis of its cause – especially when
there are other serious co-morbidities
present.
Emerging research over the past
decade has revealed a high prevalence
of anemia in the elderly population –
those with chronic disease and those
who otherwise appear healthy. Data
from the non-institutionalized U.S.
population assessed in the third
While many questions remain to be
answered, the implications of anemia
on the health and well-being of elderly
residents of LTC facilities can be
substantial. In a climate of everincreasing healthcare costs, it is also
important to note that although specific
data on the economic impact associated
with anemic elderly patients are
limited, a recent survey found adverse
health effects associated with the
condition increases costs.3
Anemia in elderly patients may be
implicated in a host of federal nursing
home quality indicators, including rates
of decline in mobility and being bedfast,
cognitive impairment, and decline in
activities of daily living such as eating
and bathing. Anemia may also be
associated with an increased risk of
falls in elders who live in the
community as well as LTC facilities.4
Anemia is known to impact several
outcomes. It can reduce exercise
tolerance and, by contributing to
frailty, lead to an increase in
hospitalizations and transitions in care.
In fact, an increased need for
hospitalization has been associated
with elderly people with anemia who
reside in nursing homes or the
community when compared with a
cohort without anemia.5 Also, anemia
has been shown to result in longer
hospital lengths of stay and an increase
in mortality after hip fractures when
compared to those without anemia.6
Recent studies have shown an
association between anemia and
increased severity of a number of
conditions in elders, including diabetes,
cardiovascular disease (CVD) and
chronic kidney disease (CKD).7
What is the pathophysiology of
anemia in the LTC population?
To understand the potential clinical
impact of anemia and to appreciate the
Figure 1
Prevalence of anemia in the elderly population
30.0
26.1%
Percent Who Have Anemia
National Health and Nutrition
Examination Survey (NHANES III)
showed anemia prevalence rates rose
rapidly after age 50 to > 20% at age
85 and older.1 In all, over 3 million
people in the U.S. aged 65 years and
older are anemic.2 (See Figure 1)
25.0
Male
Female
20.1%
20.0
15.7%
15.0
12.2%
10.3%
10.0
8.7%
6.8%
6.0%
7.8% 8.5%
4.4%
5.0
1.5%
0.0
1-16
17-49
50-64
65-74
75-84
85+
Age Group (years)
pharmacologic treatment of this
disorder, anemia must be thought of
first and foremost as increasing the
risk of tissue hypoxia. The heart
responds to tissue hypoxia by
increasing cardiac output, decreased
vascular resistance, and decreased
blood viscosity, allowing cardiac
output to rise without an increase in
blood pressure. Cardiac pump failure
follows along the Frank-Starling
curve.
A summary of potential symptoms
and signs of anemia illustrates that
many body systems may be adversely
affected by the hypoxic insult of
anemia, including the central nervous
system, gastrointestinal tract,
vascular system, and cardiorespiratory systems. (See Figure 2)
Erythropoiesis, the process of
producing red blood cells, occurs
almost exclusively in the bone
marrow. When low concentrations of
oxygen in the blood are detected, the
hormone erythropoietin (EPO) is
released by the kidneys, stimulating
the marrow to increase red blood cell
production. Erythropoiesis can be
affected by multiple factors, including
chronic disease, damage to erythroid
progenitor cells by pro-inflammatory
cytokines and free radicals, blood loss,
Figure 2
Signs and symptoms that may be
associated with anemia in the
LTC population
CARDIORESPIRATORY
• Dyspnea
• Tachycardia
• Hypotension or orthostatic
hypotension
• Wide pulse pressure
• Systolic ejection murmur
• Palpitations
• Cardiac enlargement or hypertrophy
• Cold intolerance
• Edema
GASTROINTESTINAL
• Anorexia
• Nausea
CENTRAL NERVOUS SYSTEM
(CNS)
• Fatigue
• Headache
• Dizziness
• Syncope
• Depression
• Impaired cognitive function
GENITAL TRACT
• Impotence
SKIN
• Pallor of skin, mucous membranes,
and conjunctivae
vitamin deficiencies, hypersplenism,
autoimmune hemolysis, renal
dysfunction, and other conditions.
What are the causes and risks of
anemia in the LTC population?
Although anemia is common in the
elderly population and its prevalence
increases with age, it is not an
inevitable consequence of aging. In
approximately 80 percent of elderly
patients diagnosed with anemia, an
underlying cause for hemoglobin
values of less than 12 g/dL is
identified - most commonly iron
deficiency and chronic disease (CKD,
infections, malignancies, and chronic
inflammatory disorders).
Other causes are gastrointestinal
bleeding, myelodysplastic syndromes,
vitamin B12 deficiency, and folate
deficiency. Blood loss from surgery,
injuries, and gastrointestinal and
genitourinary bleeding increases risk
but is more common in hospitalized
patients. Multiple factors often
contribute to the problem in the LTC
population, among whom multiple comorbidities are common. However, in
about 20% of elderly population who
are anemic, no cause is found.
There are multiple definitions for
anemia (see Figure 3). Although
these definitions are useful for
diagnostic purposes and clinical
studies, they should not be thought of
as a “magic” number that reveals an
absolute high and low risk of adverse
outcomes in elderly anemic patients.
Figure 3
Definitions
nitions of Anemia
De
World Health Organization
(WHO)
Women: Hgb < 12 g/dL
Men: Hgb < 13 g/dL
National Kidney Foundation
Recommends further evaluation of
CKD patients if Hgb is < 12 g/dL
The Women’s Health and Aging
Study, a cohort study of communitydwelling women 65 years of age and
older, revealed that hemoglobin values
below 13 g/dL are an independent risk
factor for mortality and disability.8
Moreover, two recent studies
concluded that higher hemoglobin
measurements, up to approximately
14 g/dL, are associated with improved
overall health measures, and
concentrations only slightly below the
WHO threshold level may be
correlated with worse outcomes in the
elderly.9,10
How is anemia diagnosed in the
LTC population?
A careful history and physical
examination coupled with a laboratory
evaluation (complete blood count with
reticulocyte count, tests of hepatic and
renal function, serum ferritin, vitamin
B12 level, stools for occult blood)
frequently provide enough information
to determine the cause of anemia in
an elderly patient. Microcytosis and
reduced serum ferritin values – both
signs of iron deficiency – are
somewhat less likely to be present in
older people; anemia due to iron
deficiency can be masked by elevations
due to the presence of other comorbidities. Pernicious anemia (which
affects approximately 2% of the
population older than 60 years) can be
missed because of the absence of
macrocytosis or clinical signs.
Measurement of vitamin B12 levels is
therefore important in anemic LTC
patients. The evaluation of anemia in
patients with CKD is discussed
further below.
What is the relationship between
anemia and CKD in older people?
Chronic kidney disease (CKD) is
defined by the National Institutes of
Health’s National Kidney Disease
Education Program (NKDEP) as a
persistent and usually progressive
reduction in glomerular filtration rate
(GFR less than 60 mL/min/1.73 m2),
and/or albuminuria (more than 30 mg
of urinary albumin per gram of
urinary creatinine). This definition is
consistent with the National Kidney
Foundation’s definition of CKD.
According to the NKDEP, in adults
the best equation for estimating GFR
from serum creatinine is the
Modification of Diet in Renal Disease
(MDRD) equation. However, it is
important to note inaccuracies due to
the non-steady state of serum
creatinine. In addition, older patients
often have co-morbidities causing
malnutrition, and may be prescribed
medications that can interfere with
the measurement of serum creatinine.
A calculator for GFR based on both
the MDRD and Cockcroft-Gault
equations is available on the internet
at www.nephron.com.
CKD is prevalent in the U.S.,
affecting close to 19 million people,
with the greatest prevalence in those
over age 65 and those with diabetes or
hypertension.11 Clinically significant
declines in kidney function have been
reported in LTC populations. For
example, a recent Canadian study
found almost 40 percent of residents
in LTC facilities had a GFR < 60
mL/min/1. 73m2. 11
Anemia increases in prevalence and
severity as renal function
deteriorates, adding to the morbidity
and mortality of CKD. Anemia can
develop relatively early in the course
of CKD. A health maintenance
organization study of 1,658 CKD
patients found 73 % had serum
creatinine values of less that 1.0
mg/dL, but higher gender-specific
norms – and in 28% of these mild
CKD cases, anemia was noted.
As kidney function declines, the
likelihood of anemia associated with a
poor endogenous EPO response
increases. Awareness of the adverse
consequences of untreated anemia of
CKD has increased and national
guidelines have been developed by the
National Kidney Foundation (see
Figure 4) to disseminate diagnosis,
workup and treatment standards for
anemia associated with CKD.13
Early detection and treatment of
anemia associated with CKD may
significantly improve the quality of
life of elderly patients, and may also
slow the progress of cardiovascular
disease and decrease hospitalizations
and mortality in this population.14
Figure 4
Evaluation of Anemia in Patients with CKD
Serum
creatinine
≥ 2 mg/dl?
© 2001 National Kidney Foundation, Inc.
web version created by cyberNephrology
and The Nephron Information Center
(Used with permission)
TM
Yes
Check
Hgb
No
work-up
No
≤ 12.5( ,
Post-menopausal )
≤ 11.0 ( /prepubertal)?
Yes
Work-up
Normal?
CBC, Indices, Retics;
Iron; TIBC, Fe, Tsat
Ferritin; Stool Guaiac
No
Fe
deficiency?*
Yes
No
Refer for
hematology
work-up
How do we optimally treat anemia
in the LTC population, based on
what we know now?
Therapeutic strategies for anemia
include:
Yes
Treat with
Epoetin if
indicated
Treat with
iron
Anemia
not
corrected
The impact of even mild anemia in
patients with CHF can be significant.
In a retrospective study of 142 CHF
patients with anemia, 40 % of the
patients were also diagnosed with
CKD. Epoetin and intravenous iron
were administered once weekly to
achieve target hemoglobin values of
12.5 g/dL. The final mean hematocrit
reached in this group was 35.9 %.
Over a period of about 7.2 months, the
left ventricular ejection fraction
(LVEF) increased significantly (from
27.7 % to 35.4 %). Of particular
interest to the LTC community was a
significantly decreased rate of
hospitalization – the number of
hospitalizations per patients was
reduced more than 10 fold.19 In
addition, the RENALL trial
demonstrated that a hemoglobin value
of approximately 11 g/dL was
associated with a four times greater
risk of End Stage Renal Disease
(ESRD) than normal hemoglobin
defined as >13.6g/dl.20
Anemia
corrected:
periodic
follow up
• Identifying and treating any
underlying disorder (e.g. vitamin
B12 deficiency, acute or chronic
blood loss)
• Iron
•Erythropoietic agents
What is the impact of anemia,
CKD, and cardiovascular disease
in the LTC population?
Cardiovascular disease, also common
in the LTC population, as well as
CKD, may be complicated individually
by anemia. This triad of disorders may
be the best reason to treat anemia of
CKD in the elderly. Such compounding
of multiple co-morbidities is in fact
common in the LTC population.
A case in point: recent research has
shown that anemia associated with
CKD is a risk factor for increased
morbidity and mortality due to
cardiovascular events in a diverse
adult population.15 16 In addition,
anemia and abnormal renal function
have been associated with an
increased risk of death in patients
who undergo percutaneous coronary
interventions.17 Another recent study
of 436 high-functioning communitydwelling women between the ages of
70 and 80 participating in the
Women’s Health and Aging Studies I
and II found that mildly low and even
low-normal hemoglobin
concentrations were associated
independently with increased frailty.
This risk was synergistically modified
and increased in women with CVD.18
It remains unproven whether this
association is causal.
• Blood transfusions
A brief note about blood transfusions:
the decision to transfuse elderly
anemic patients, especially those
undergoing surgery, is not always
clearly defined and the issue has seen
sparked debate and controversy. In
the ABC (anemia and blood
transfusions in the critically ill) study
involving 3,534 patients in 146
western European ICUs, 54% of
patients were transfused because of
an inadequate hemoglobin
concentration, and transfusions
increased with age. The results of the
study suggest a deleterious effect of
blood transfusion on surgical
outcomes.20 Each patient should be
assessed individually with the clinical
decision to transfuse based on the
individual’s condition, age, and
oxygenation parameters with indexes
of tissue hypoxia, as well as
traditional measurements of
hemoglobin and hematocrit.
Drug treatments for anemia are
outlined in Figure 5.
Supplementation with iron is used for
the treatment of iron deficiency
anemia. The usual recommended dose
is 50 to 100 mg of elemental iron three
times a day. If side effects such as
constipation and/or compliance are
problematic, a lower dose of elemental
iron, such as a single 325-mg tablet of
iron sulfate can be tried, although it is
often inadequate to replace iron
stores, especially during initial
management. Patients with iron
deficiency who fail to respond to these
strategies can be given intravenous
(IV) iron replacement. IV iron sucrose
(Venofer ®) can be administered safely
in pre-dialytic patients with anemia
without the risk of adverse reactions
associated with iron dextran products.
Vitamin B12 deficiency is treated by
administration of parenteral or oral
vitamin B12 supplementation. The
intramuscular dose is 1,000 µg,
usually given daily for one week, then
weekly for one month and then
monthly. Daily oral therapy (1,000 to
2,000 µg of vitamin B12) has been
shown to be as effective as
intramuscular injections.
Human recombinant erythropoietin
(epoetin alfa), introduced in 1989, has
significantly impacted the treatment
of anemia associated with CKD.
Today, two erythropoiesis-stimulating
proteins (ESPs) are available for
anemia associated with CKD - epoetin
alfa and darbepoetin alfa. Standard
dosing for these drugs are based on
weight (but units differ for each ESP).
All patients on ESP treatment should
receive concomitant iron therapy in
order to replenish iron stores that are
used in the process of erythropoiesis.
Are ESPs safe and efficacious in
the elderly LTC population?
Figure 5 Drug Treatment for Anemia and Anemia associated with CKD
Drug
Darbepoetin alfa (ARANESP®)
Epoetin alfa
(EPOGEN®, PROCRIT®)
Ferrous gluconate
Ferrous sulfate
Ferrous sulfate elixir
(FEOSOL®)
Ferrous sulfate tablets
(FEOSOL®)
Iron sucrose
(VENOFER®)
Iron dextran
(INFED®,DEXFERRUM®)
Sodium ferric gluconate
(FERRLECIT®)
Dose
Initial
0.45 mcg/kg once weekly subcutaneously
Maintenance
Individualized to target hemoglobin 11 - 12 g/dL
Initial
50 - 100 units/kg 3 times weekly subcutaneously
Maintenance
Individualized to target hemoglobin 11 - 12 g/dL
300 mg PO TID
300 mg PO TID
220 mg/5 mL elixir PO TID
220 mg/5 mL elixir PO TID
100 mg IV over 2-5 min x 10 sequential dialysis
sessions; no more than 3 doses per week
Pre-dialysis 200 mg IV over 2 - 5 min 3 x weekly to
a total of 1,000 mg
100 mg/day IV is individualized based on weight
and Hgb to a maximum of 1,000 mg in 250-1,000
mL infused over 1-6 hrs
125 mg IV over 10 min or in 100 mL NS over 1 hour
x 8 sequential dialysis sessions
Several studies have addressed this
question and concluded there were no
significant differences in safety and
efficacy for older patients when
compared to younger cohorts.20
An important aspect of ESP therapy is
monitoring the hemoglobin response,
initially once per week to make sure
hemoglobin is not increasing too
quickly. Dosage should be reduced by
25 % if the hemoglobin rises by more
than 1 g/dL over a course of 2 weeks.
On the other hand, if hemoglobin has
not risen by more than 1 g/dL after 4
weeks, the dose should be increased by
25 % in order to reach a target
hemoglobin value in the range of 11 to
12 g/dL.
Emerging issues regarding pure
red blood cell aplasia in patients
receiving ESP therapy: in late
November 2005 both companies that
market ESPs, Amgen and Ortho
Biotech, sent letters to health
professionals warning of pure red
blood cell aplasia, associated with
darbepoetin alfa (Aranesp®), epoetin
alfa (Epogen® Procrit ®). Pure red blood
cell aplasia is an anti-erythropoietinantibody-mediated severe anemia and
red blood cell aplasia. The prevalence
of anti-erythropoietin-antibodies has
been reported at 3% in cancer
patients and 4% in patients with CKD
(with a product manufactured in
Europe (Eprex). Anti-erythropoietin
antibodies neutralize the
hematopoietic factor rendering it
ineffective and producing a severe
anemia.
What has yet to be reported is the
true risk of developing pure red cell
aplasia in elderly patients and
whether or not the potential is time or
dose dependent. In patients
developing antibody, there appears to
be a greater chance of this occurring
with subcutaneous injection rather
than IV infusion.
As a result of this information, new
recommendations are emerging.
Suggested monitoring
recommendations are listed in
Figure 6.
Figure 6
Recommendations for
Monitoring Erythropoietin
Stimulating Protein ESP)
Therapy
• Monitor hemoglobin weekly
upon initiation of therapy with
an erythropoietic stimulating
protein and then monthly once
stabilized at the desirable
hemoglobin concentration.
• Monitor for a sudden loss of
response (i.e. hemoglobin
declines that can no longer be
maintained at the target
concentration).
• If a sudden loss of response
occurs, an anemia assessment
including a reticulocyte count
should be recommended with a
comprehensive assessment of
causative factors.
• If anti-erythropoeitic antibody
pure red blood cell aplasia is
suspected:
• discontinue the erythropoeitic
stimulating protein contact
the manufacturer (Amgen: 1800-772-6436 and Ortho
Biotech: 1-800-325-7504,
prompt #2) to arrange for
assays for binding and
neutralizing the antibodies
and to confirm the diagnosis.
Once antibody-mediated anemia has
been confirmed, erythropoeitic factors
must be discontinued permanently.
Due to the potential for crossreactivity, the patient should not
receive alternative erythropoeitic
factors (i.e. if the anemia was caused
by Procrit® the patient cannot receive
Aranesp® or Epogen®.)
The manufacturers have reported that
no clinical sequelae have resulted from
antibody-mediated anemia.
Alternative therapy is not available for
patients that develop antibodymediated anemia to erythropoeitic
stimulating proteins. Iron therapy and
intermittent blood transfusions may
be needed, as dictated by the severity
of the underlying anemia of chronic
kidney disease or chemotherapy
induced anemia.
In conclusion: what do we know
and what should we be doing?
• We know anemia is common in the
LTC setting.
• From the data we have now, we
know that anemia is associated with
a number of adverse consequences
such as falls and frailty, but we
cannot say that anemia causes falls
and frailty.
• The impact of the increasing elderly
population coupled with the rise in
anemia and CKD in this population
heralds the need for diligence in
evaluating renal function in the
elderly.
• We need to recognize that anemia
can occur early in the course of CKD
and to think CKD when anemia is
diagnosed.
• We must also recognize diagnosis
can be a challenge.
• Treatment can be effective if
targeted at the underlying cause of
the anemia, however, we do not
know if treating asymptomatic
anemic elders results in benefits.
Working as a multi-disciplinary team
can help overcome obstacles in the
early identification and treatment of
the anemia in the LTC patient
population. Nursing staff can be
instrumental in identifying sometimes
subtle signs and symptoms. The
consultant pharmacist also plays a
critical role in the management of
anemia associated with CKD in the
LTC setting, monitoring not only
pertinent laboratory values and ESP
therapy, but the use of multiple
therapeutic agents for anemia, other
serious illness such as CKD and CVD,
as well as medications for concomitant
disorders often seen in the elderly
population. They can also help with
issues of reimbursement and timing
for treatment and appropriate site for
administration. Primary care
clinicians must be involved in the
diagnostic evaluation and targeting of
treatment for anemia in LTC
residents, and medical directors
should be involved in developing
policies and procedures that assure
adequate identification and
management of these common
conditions.
Well-designed, prospective studies that
address clinically meaningful outcomes
in LTC residents with anemia and
anemia associated with CKD will help
all of us make better decisions. Such
studies should address the optimal
therapeutic regimen for patients with
anemia associated with CKD and other
conditions. Documentation of
improvements in function, quality of
life, and other outcomes with optimal
diagnosis and treatment of the various
forms of anemia will result in a
welcome addition to out therapeutic
armamentarium in the LTC
population.
References
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Ferrucci L, Klein HG, Woodman RC.
Prevalence of anemia in persons 65
years and older in the United States:
evidence for a high rate of unexplained
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2. Guralnik JM, Ershler WB, Schrier
SL, VJ P. Anemia in the Elderly: A
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Hematology 2005;Jan. 2005:528-532.
3. Artz AS. Outcomes of Anemia in the
Elderly: What We Know. In: What
More Should We Be Doing (Interactive
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March 18, 2005.
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Zuckerman JD, Koval KJ. The
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comment]. Journal of the American
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Fried LP. Looking at the relationship
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American Geriatrics Society
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Eknoyan G, Levey AS. Prevalence of
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kidney function in the adult US
population: Third National Health and
Nutrition Examination Survey.
American Journal of Kidney Diseases
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Campbell G, Clarke JA, Ray JG.
Estimating the prevalence of renal
insufficiency in seniors requiring longterm care.[see comment]. Kidney
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Nissenson AR, Pereira BJG.
Prevalence and management of
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Center for Health in Aging
Division of Geriatric Medicine and Gerontology
1841 Clifton Road, NE
Atlanta, GA 30329
Nonprofit
Organization
U.S. Postage
Paid
Permit No. 3604
New Directions: Management Of Anemia In Long-term Care
“Not all anemias need interventions- the
main question or thought should always be
‘what is the overall plan of care for this
patient? Would giving them a weekly
injection or daily injection cause so much
distress that the benefit is outweighed by the
distress?’” – Debbie Gunter, G.N.P.
Quotes from the
Participants
“All we can ask of our clinicians at this
time is to first be aware of the
hemoglobin values in each of their patients.
Anemia should be on the radar screen, not
just background noise. If anemia is
discovered the question should be ‘what
should I do about it’. One next step in the
differential should be to estimate renal
function and if reduced to look at the patients
cardiovascular risk, especially
hospitalizations. The rest of the decision
making based on clinically relevant data will
drive therapy.” – Eric G. Tangalos, MD,
FACP, AGSF, CMD
“Important to the correction of anemia in
older persons with chronic kidney disease
and other causes of anemia is adequate
replacement of iron stores in addition to
supplementation with erythropoietic therapy.
In the elderly, iron stores are difficult to
replete due to the side effects of iron therapy,
but nonetheless critical to the therapeutic
success of the anemia regimen.” –
Barbara Zarowitz, Pharm. D.
“From a societal perspective, the growth
in the older population in LTC settings
who have anemia associated with CKD as
well as cardiovascular disease and other
comorbidities will pose enormous challenges.
Further research is critically needed to
determine the impact of diagnosing and
treating anemia in the LTC population on
function, quality of life, other health
outcomes, and the costs of care.”
William McClellan, M.D., M.P.H.