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Indian Journal for the Practising Doctor

Anemia in the Elderly Residing in a South Indian Rural Community

Author(s): Ramachandra SS, Kasthuri A

Vol. 5, No. 4 (2008-09 - 2008-10)

Ramachandra SS, Kasthuri A

Dr Srikrishna S Ramachandra, MD, MPH; Fellow, Future Faculty Program, Public Health Foundation of India (PHFI), Delhi, Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, USA; and
Dr Arvind Kasthuri, MD, Professor, Department of Community Health, St. John’s Medical College, Bangalore 560034, Karnataka, India

Correspondence: Srikrishna S Ramachandra, 1440, Canal Street, Suite 2200, New Orleans, LA 70112, USA
Email: srikrishnasr (at) gmail.com;
Phone: 001-504-261-7932

Abstract:

Background: Anemia is common in the elderly; the reported prevalence ranging from 8% to 44%. The prevalence increases with age, the highest prevalence seen in men aged 85 and older. However, the process is not entirely physiological. Many authors believe that the finding of anemia generally suggests an etiology apart from the process of aging, even though there is a decrease in hematopoetic function in old age.
Objective: Documentation of the health and social profile of the elderly in the area, with a view to initiate service intervention based in the community.
Methods: A house to house survey was conducted in seven villages in a rural area near Bangalore, and 402 persons aged 60 years and above were identified. A structured interview was conducted at the residence of the elderly person, which included a 24-hour semi-quantitative dietary recall to estimate daily caloric and protein intake. Estimation of hemoglobin was done using the microhematocrit technique. Data analysis was done using EPI INFO version 6.0 for windows.
Results: 8.09% (402) of the population (4965 persons) in the study villages were 60 years of age or older. Using the World Health Organization criteria for the diagnosis of anemia (hemoglobin less than 12 gm/dl in females and less than 13 gm/dl in males), the prevalence of anemia was estimated to be 17.7 percent. The prevalence of anemia increased with age in our study (p<0.01). Daily calorie intake, daily protein intake and Body Mass Index were found to be inversely related to anemia (p<0.05).
Conclusion: Anemia is present in almost one fifth of the rural elderly population. The presence of anemia in the elderly suggests the co-existence of malnutrition. Programmes aimed at the promotion and preservation of the health of the elderly must focus on their nutritional needs.

Key Words: Rural Elderly, Anemia, Calorie intake, Protein intake, BMI

Introduction

Anemia is defined as a reduction in the body’s red cell mass1, reflected in a reduced oxygen carrying capacity of the blood. The World Health Organisation criterion for the diagnosis of anemia is a level of hemoglobin below 13gm/ dl in males and 12 gm/dl in females2. A 10-year prospective study in Europe has shown an increased risk of mortality among a group of elderly community residents when hemoglobin levels were lower than the standards prescribed by the WHO, thereby validating the WHO cut-off levels.3

The prevalence of anemia among the elderly, as reported in the Indian cross -sectional studies, varies between 6 and 30% among males and between 10 and 20% among females4. Population-based studies in Great Britain have reported prevalence figures ranging from 5% to 25%5, while other Western studies report a range between 8% and 44%, with the highest prevalence in men aged 85 and older. Studies indicate that the prevalence of anemia increases with advancing age6.

The present study was aimed at documenting the health and social profile of the elderly residing in rural South India with a view to initiate an appropriate targeted interventional programme in the community.

Materials and Methods

The study was conducted in a rural area (7 villages of Anekal taluk) situated about 35 kilometres from Bangalore City in the Karnataka State of South India, covered by a government run subcentre. An interview schedule was constructed based upon a review of standard interview schedules used in the study of the health of the Elderly7,8,9. It was pre-tested, modified, and then using a house to house survey method, was administered to all persons above the age of 60 years after obtaining their consent. The interview included a semi-quantitative dietary assessment based on 24-hour recall and a clinical examination by a medical doctor. A sample of blood was collected by a finger prick for estimation of hemoglobin using the microhematocrit method. Data analysis was done using EPI INFO version 6.0 for Windows.

Results and Discussion

Baseline characteristics of the study group

402 persons [217 (54%) were males, and 185 (46%) females] above the age of 60 years were identified among a population of 4965 persons in 7 villages, which forms 8.09% of the population.

Majority of them were in the low and lower middle socio economic class and were illiterate; 58.2% were living with their spouses. (Table 1)

The Prevalence of Anemia

Hb estimation of 396 samples, using the microhematocrit method, showed that 70 persons (17.7%) were anemic based on the hemoglobin cutoffs prescribed by the WHO. The respective figures for the males and females were 17.4%:18%; thus the prevalence did not show any gender association. (Table 2)

The prevalence of anemia showed a rise with advancing age; from 7.6% among persons aged 60-64 to as high as 43.4% in those aged 80 years and over. (Figure 2)

The increasing prevalence of anemia with advancing age is consistent with that reported in other studies. There has been a debate as to whether anemia in the elderly is due purely to a decline in marrow function occurring as a result of the process of aging, or has, in addition, a specific underlying cause as in other age groups10. One view is that while the marrow does show hematopoietic changes due to aging like a decrease in the number of committed stem cells and an increase in fat, the presence of anemia is more a result of a blunted response to hematopoietic stress, such as the presence of iron deficiency, chronic disease states and malnutrition10.

Our study attempted to identify associations between the presence of anemia and nutritional status in the elderly. Nutritional status was assessed from the Body Mass Index (BMI), and estimation of the routine dietary pattern, in terms of the total daily calorie and protein intake. The latter was derived from a 24-hour dietary recall using a semi-quantitative approach. The resulted showed a statistically significant inverse association between, both, daily total calorie intake and daily total protein intake and the presence of anemia. The low intake probably contributed to a low BMI, and the association between higher prevalence of anemia and a low Body Mass Index was also found to be statistically significant. (Figures 3, 4 and 5)

The mean daily intake of calories and protein among males and females in the study group is shown in table 3. From the studies conducted in 1996, the National Nutrition Monitoring Bureau (NNMB) has found comparable figures of mean calorie and protein intake among persons above 60 years of age, which are reproduced alongside. The mean daily intake of energy (calories) and protein found in NNMB studies are less than the recommended daily intake by 35% and 29% respectively.11

The role of nutritional deficiency in the etiology of anemia among the elderly involves several possible mechanisms. Nutritional Iron deficiency is not as common in the elderly as in the young, mainly because of the iron stores which have been cumulatively built up in the tissues. Protein acts as an adjuvant in the transport of iron across the intestinal mucosa, while the transfer of iron in the blood is also mediated by protein moieties.12

Chatta and Lipschitz13 propose that anemia in the elderly could have a nutritional basis. They found that serum albumin, transferrin and pre-albumin which reflect a person’s nutritional status appeared to be good predictors of anemia. They also observe that there is a marked similarity between the alteration in hematopoietic function which occurs with aging and that which occurs with protein energy malnutrition. Also, it has been reported that a low BMI is associated with an increased risk of mortality.14

In our study, anemia was found to be more prevalent among the illiterate and those with low socio economic status, and among those not living with their spouses. These associations, however, were not statistically significant. Other similar insignificant associations were found with reported financial independence (less anemia), toilet facility at home (less anemia) and usage of alcohol and tobacco (more anemia).

Conclusion

The prevalence of anemia in our study group of 396 rural community residents is 17.7%. This is similar to the levels reported by other studies conducted on non-institutionalised populations. Though the present study does not document the further investigation of the persons with anemia to determine the type of anemia and therefore the probable underlying cause, the associations with nutritional status are important. The study underlines the importance of maintaining an adequate nutritional intake among the elderly, and the need to focus upon this sub group of the population in the design and implementation of population-based nutritional programmes. Further study on the group could yield information on the exact cause, precipitating or contributing factors, and help in determining if anemia in the elderly could be used as a marker for hidden chronic disease and in identifying those at ‘high risk’ in population-based programmes directed at the preservation of the health of the elderly.

References

  1. Schnell, Berliner, Duffy, Benz. in Hematology Basic Principles and Practice of, 3rd edition, 2000, Churchill Livingstone, pp 367-
  2. World Health Organisation. Nutritional Anemias – Report of a WHO Scientific Group, Geneva, Switzerland, WHO, 1968,
  3. Izaks, Westendorp, Knook., The definition of anemia in older persons; Journal of American Medical Association, 1999; 281(18): pp 1714-
  4. Agarwal A and Advani SH. Anemia, in Geriatric Care in India Geriatrics and Geronotology, A Textbook; OP Sharma, Ed, pgs 421-426
  5. Hyams DE. The Blood, in Textbook of Geriatric Medicine and Gerontology, JC Brocklehurst, 2nd edition, 1978, pgs 571-598
  6. Smith, Douglas. Anemia in the elderly, American Family Physician, October 1, 2000
  7. The Duke University Centre for the study of Aging and Human development Durham, NC. The OARS questionnaire – Older Americans Resources and Services program
  8. Rural Unit for Health and Social Affairs, Christian Medical College Vellore, 2000. Report on the in-depth study of the Problems and Needs of the elderly residing in KV Kuppam block, Tamil Nadu,
  9. Dey AB ed. 2000, Health care of the elderly- a manual for physicians in primary and secondary health care facilities, Dept of Medicine AIIMS, New Delhi
  10. Stander., Anemia in the Elderly; Symptoms, Causes and Therapies, Postgraduate Medicine, 1989; 85: 85-
  11. Vijayaraghavan K, N Balkrishna, Grace Maria Anthony. Report on food and nutrient intakes of individuals; 2000, National Nutrition Monitoring Bureau, National Institute of Nutrition, Hyderabad.
  12. Turnbull A. Iron in Biochemistry and Medicine; Academic Press, 1974, pp 369-
  13. Chatta,Gurkamal S and Lipschitz,David. 1999, Anemia; in Principles of Geriatric Medicine and Gerontology, Hazzard, Blass, Ettinger, Halter, Ouslander Ed; 4th edition, McGraw Hill; pgs 899-906
  14. Thomas AJ. Nutrition; in Brocklehursts Textbook of Geriatric Medicine and Gerontology;5th edition, 1998; Churchill Livingstone; pp899-

Tables

Table 1. Baseline characteristics of the study population

Characteristic Females Males Persons
Total number 185 217 402
Median Age (inter-quartile range) 67 yrs (62-73) 67 yrs (63-72) 67 yrs (63-73)
Low socio economic statusa 127 (68.6%) 128 (59%) 255 (63.4%)
Illiterate 162 (87.6%) 126 (58.1%) 288 (71.6%)
Not living with spouseb 127 (69%) 40 (18.4%) 168 (41.6%)
Median Haemoglobin (Inter-quartile range) 12.0 (12.0-12.8) 13.1 (13.0-13.8) 13.0 (12.0-13.4)

a – Includes low and lower middle class as defined by Kulshreshta and Parekh
b – Includes never married, separated and widowed

Table 2. Prevalence of Anemiaa

Characteristic Females Males Persons
Anemia present 33 (18%) 37 (17.4%) 70 (17.7%)
Normal 150 (82%) 176 (82.6%) 326 (82.3%)
TOTAL 183 213 396

a – Anemia defined as a Haemoglobin value <13.0g/dl in males and <12.0 g/dl in females

Table 3. Mean daily intake of calories and protein in study population compared with NNMB data

Mean daily intake Females – Study Females – NNMB Males – Study Males- NNMB
Calories (kcals) 1864 1764 2068 2167
Protein (gms) 45.4 46.0 50.0 56.0

Figures

Figure 1

study population distributed by age and sex

Figure 1. The study population distributed by age and sex

Figure 2

age-specific prevalence rate of anemia

Figure 2. The age-specific prevalence rate of anemia in the study population (p<0.01, n= 402 persons)

Figure 3

prevalence of anemia among the study population

Figure 3. The prevalence of anemia among the study population distributed according to daily calorie intake in kcals (p<0.05, n=396)

Figure 4

prevalence of anemia among the study population

Figure 4. The prevalence of anemia among the study population distributed according to daily protein intake intake in gms (p<0.05, n=396)

Figure 5:

prevalence of anemia among the study population

Figure 5. The prevalence of anemia among the study population distributed according to Body Mass Index (p<0.05, n=391- weight was not obtained in 5 persons). Cut-off values for Body Mass Index (BMI) are based on the values for Chronic energy deficiency (CED) which is said to exist when the BMI is below 18.5. 11

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