Anemia is one of the most common clinical problems in the elderly.

As even mild to moderate anemia can lead to significant morbidity, correctly identifying the cause of anemia and coordinating appropriate pharmacotherapy is critical.

The most prevalent deficiency disease in elderly long-term care facility residents is anemia. The fact that types and treatments of anemia are complex and numerous only makes the condition more difficult to treat, Thomas C. Snader, PharmD, noted during a presentation at Geriatrics ’99, the 21st ASCP Midyear Conference in Palm Desert, California.

Snader, president of TCS Pharmacy Consultants, Sellersville, Pennsylvania, defined anemia as a decrease in total red blood cell mass. Anemia is usually treated when hemoglobin levels drop to 8%–10% or lower in women or to 14% in men. Once the condition is diagnosed, however, selecting and dispensing the correct treatment can be a conundrum.

Factors That Can Cause Increased Hemoglobin Levels Infection-related increase in white blood cells Heavy smoking Dehydration Diurnal variations (nighttime levels are higher) Pediatric patients Postural changes African Americans and women also have lower levels

“The issue of anemia in long-term care facilities is really confusing. You see a lot of iron therapy, folic acid therapy, shotgun therapy, weird combinations of products, but you often see no changes in hemoglobin and hematocrit once treatment is started, and you also see lots of side effects, such as constipation, that you’d like to eliminate,” Snader said.

“Consultant pharmacists are not diagnosticians,” he said. “But in this day and age, under the Medicare prospective payment system [PPS], they do need to be able to help sort out those conditions that really need to be treated and those that don’t.

“It’s not enough anymore for us to decide whether one proton pump inhibitor is cheaper than another; it’s a time to decide whether or not we even need a proton pump inhibitor. Even though you’re not a diagnostician, you still need to be able to buy into the therapy.”

Without stepping over the boundaries of diagnosis, consultant pharmacists need to have the ability to help determine, during chart review, whether or not a therapy for anemia is indicated or whether therapy already initiated should be discontinued, Snader said.

Types of Anemia

“Comorbidities, more than anything else, make an anemia more significant when you’re dealing with the elderly,” Snader noted. “Don’t ever forget that you can have a mixed disease state. For example, if you have a patient with joint pain, it may be degenerative joint disease and rheumatoid arthritis plus anemia. There can be multiple diseases going on there—even two different anemias or blood disorders.”

Treatment goals include stopping blood loss, replacing lost iron, and checking absorption of oral iron supplements to be sure the therapy is working correctly. To restock the body’s iron stores, the patient’s weight must be calculated, the dosage determined, and the date of therapy initiation considered. It takes at least six months to replace the body’s stores of iron.

Hemoglobin is the main indicator of anemia in laboratory tests, because it is much more sensitive to test than hematocrit. However, mean corpuscular volume (MCV) is probably the most accurate measure. Elevated MCV often indicates chronic alcoholism, while low MCV can be a sign of anemia of chronic disease and is common in skilled nursing facilities. However, elevated MCV does not respond to iron therapy, so it makes no sense to pour iron supplements into elderly residents who could be harmed by it, Snader warned. MCV is defined as abnormally large blood cells, and it is determined by dividing the patient’s hematocrit level by the red blood cell count. Complete blood cell (CBC) counts can have a high error rate if MCV and hemoglobin counts are based on red blood cell counts. CBCs based on hematocrit or hemoglobin levels carry a lower incidence of error.

Of all patients with macrocytic anemia (large red blood cells), 10%–30% are deficient in folic acid and vitamin B₁₂; this condition can also be caused by cytotoxic chemotherapy, heart failure, and chronic obstructive pulmonary disease. Mixed anemias are difficult to diagnose, as patients usually present with normal MCV and hemoglobin levels. However, treatment of macrocytic anemia can actually increase the body’s production of young—and therefore large—red blood cells, which translates into an increase in MCV. The elderly can have preleukemic changes in their blood cells, known as “myeloproliferative disease,” which also can cause increased MCV.

Diagnostic Indicators of Anemia High red cell distribution width (RDW): probably a replacement or deficiency disease Normal RDW, low MCV: chronic disease anemia Normal RDW, normal MCV: chronic anemia (90% of these people have deep bleeding or cirrhosis) Normal RDW, high MCV: aplastic anemia, myeloplastic syndromes High RDW, low MCV: iron-deficient anemia High RDW, normal MCV: early factor deficiency, sickle-cell anemia High RDW, high MCV: B12 deficiency, folic acid deficiency, autoimmune disorders

Reticulocytosis, or an increase in new, immature red blood cells, can be caused by hemolytic anemia, acute bleeding, or treatment of a deficiency anemia (vitamin B₁₂-, folic acid-, or iron-deficient anemia).

Every reticulocyte count must be adjusted to know whether or not the patient has a true need for iron supplements.

According to Snader, some anemias that present as iron-deficient anemia are really pyridoxine-deficient anemias. If the patient does not respond to iron therapy, long-term care providers should try initiating treatment with a pyridoxine supplement.

Morphological response is important: oval macrocytes suggest vitamin B₁₂ or folic acid deficiency or myelodysplasia, while round macrocytes indicate alcoholism, cirrhosis, hypothyroidism, and aplastic anemia.

In the big picture, it is also important not to subject nursing facility residents to excessive blood draws. Common sense, a thorough history, and careful observation can help prevent unnecessary testing, which can be dangerous.

“Too many blood tests can cause anemia,” Snader warned. “We have frail elderly patients. We ask for these lab tests, but it’s not merciful to give an elderly, frail person unnecessary lab tests.”

Even treatment can pose risks for older patients. For example, in the process of correcting a vitamin B₁₂ or folic acid deficiency, it is possible to cause an iron deficiency. In elderly patients who have marginal iron levels, the administration of vitamin B₁₂ or folic acid speeds up the rate of cell production, and, as a result, the body’s iron stores are quickly depleted.

However, vitamin B₁₂ deficiencies are slow to develop: one to two years is standard. Both methylmalonic acid (MMA) and homocysteine levels are elevated in vitamin B₁₂ deficiency, while homocysteine is elevated in folic acid deficiency only. Neither of these levels is elevated in patients with myelodysplastic disease.

Proper detection and treatment of anemia is sorely needed in the long-term care environment, Snader said. He recommended further study of the interpretation of laboratory tests, treatment of anemia, and dosage calculations (Clinical Laboratory Medicine by Ravell and The Washington Manual of Medical Therapeutics, in particular)

While treatment of anemia is highly complicated, it is certainly an area in which consultant pharmacists can excel and fill in the gaps in patient care and cost management.

“There is a real void in long-term care facilities. Under PPS, we have a lot of concerns about the appropriate use of medications, and we certainly have to be careful about where we spend our money.”

For example, in residents with altered mental status, physicians usually look for hypothyroidism “because it is a cause of dementia that may be correctable,” Snader said. “They pick up on the hypothyroidism and start to treat it. But how many times do the physicians check the CBCs to see if there’s an anemia? Probably never. This is something that you, the consultant pharmacist, can bring to the table.”

Newer, powerful anemia drugs, such as Procrit [epoetin alfa] or Epogen [epoetin alfa recombinant], are expensive and complex to administer. However, Snader said, there is definitely a place in anemia treatment for these agents.

“The hematocrit levels must be carefully monitored with these drugs. There is a critical issue here of overshooting the mark. But physicians don’t understand anemias and Epogen. Often it’s not indicated, or they don’t add iron, or they don’t use the correct dose. We are obligated to be on top of that.

“There’s a lot you can do to improve the treatment of anemias in your facilities.”

Copyright © 2000, American Society of Consultant Pharmacists, Inc. All rights reserved.