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RBC indices and morphological pattern of anemia in geriatric population: A cross-sectional study in Eastern India


1 Department of Pathology, Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Biochemistry, Medical College and Hospital, Kolkata, West Bengal, India

Date of Submission02-Feb-2022
Date of Decision15-Mar-2022
Date of Acceptance24-Mar-2022

Correspondence Address:
Aparajita Samaddar,
4/3K/297 Ho-Chi-Minh Sarani. Sakuntala Park. Kolkata- 700 061, West Bengal
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_101_22

  Abstract 


Background: Geriatric anemia is one of the neglected and undiagnosed health problems throughout the world leading to increased morbidity and mortality among this vulnerable age group. Anemia in elderly is often an indicator of an underlying co-morbid condition. Morphological pattern of anemia may reflect the underlying etiology and thus directs the appropriate way to management of the condition. Aims: To evaluate the severity and morphological pattern of anemia in geriatric age groups. Materials and Methods: Elderly individuals aged 60 years or older of either sex with Hb level <12 gm/dl in women and <13 gm/dl in males were included in this study as geriatric anemic population. Blood samples were analyzed for Hb, hematocrit (Hct), Mean corpuscular volume (MCV), Mean corpuscular haemoglobin (MCH), Mean corpuscular haemoglobin concentration (MCHC) and Red cell distribution width (RDW-CV). Anemia was graded as mild, moderate and severe according to WHO criteria. Morphological classification was done based on RBC indices and peripheral blood smear examination. Statistical analysis was done using SPSS software. Results: Total 277 geriatric anemic subjects were included in this study. Female to male ratio was 1.9:1. Most of the participants (60.29%) were in the age group of 60-69 years. Majority had mild anemia (48.02%). Normocytic-normochromic was the most predominant morphological subtype (74.73%). Mean Hb, MCH and MCHC were found to be significantly lower in geriatric females compared to males (P < 0.05).Conclusion: Normocytic-normochromic anemia of mild degree was the most common type of anemia among geriatric population. Evaluation of morphological pattern of anemia may help in appropriate management of underlying condition.

Keywords: Aged, anemia, erythrocyte indices



How to cite this URL:
Talukdar M, Samaddar A, Lahiri S. RBC indices and morphological pattern of anemia in geriatric population: A cross-sectional study in Eastern India. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=344577




  Introduction Top


Anemia is defined as a reduction in red blood cell count (RBC) and/or hemoglobin (Hb) level below the normal for the respective age, sex and environment leading to reduced oxygen carrying capacity of blood. According to WHO, anemia is defined as Hb concentration <13 g/dl for men and <12 g/dl for women.[1] It is a major health concern throughout the world. Globally, 1.62 billion people constituting 24.8% of the world population is affected by anemia.[2] WHO mentioned people over 60 years of age as geriatric population or 'elderly' person.[3] Anemia in geriatric population seeks special attention because the common presenting symptoms of anemia like fatigue, breathlessness and generalized weakness often mimic features of physiological aging process and hence overlooked. This makes the early diagnosis of anemia in geriatric population difficult leading to increased mortality and morbidity in this age group from complications associated with delayed diagnosis of anemia.[4] According to WHO, the number of people aged 60 years and older was 1 billion in the year 2019 and this will increase to 1.4 billion by 2030 and 2.1 billion by 2050.[5] The census report of 2011 stated that elderly population comprises 8.1% of the total population of India which is expected to grow to 19% by the year 2050.[6] The prevalence of anemia in people over 60 years of age varies between 8% and 44% in different parts of the world.[7] Again, prevalence of anemia increases with advancing age with the highest prevalence noted among men aged 85 years or more.[3],[8] Anemia in this age group is not only attributed to underlying nutritional deficiency, inflammatory conditions or poor quality of life, but it is often associated with underlying life-threatening co-morbid conditions like diabetes, dementia, depression, hypertension, chronic renal diseases and malignancies.[9] Again, persistent anemia can worsen the other health problems also like cardiovascular complications leading to increased mortality. A previous study noted higher death rate among elderly individuals with anemia compared to those without (38% vs 28%).[10] Hence, an early diagnosis of anemia is of critical importance in geriatric age group as this can help in detection of underlying potentially treatable conditions, thus improving the expectancy and quality of life. However, there is paucity of literature on geriatric anemia which necessitates elaborated studies to raise the awareness about the morphological pattern of anemia in elderly individuals that can reflect the underlying disease conditions and may direct towards appropriate management. With the background of above knowledge, the present study was conducted to evaluate the severity and morphological pattern of anemia in this vulnerable age group.


  Materials and Methods Top


The present study was conducted after obtaining Institutional Ethical clearance and informed consents from all the participants. Patient's identity was kept confidential. It was a hospital-based cross-sectional study done over a period of 3 months. Elderly individuals aged 60 years or older of either sex with Hb level <12 gm/dl in women and <13 gm/dl in males were included in this study as geriatric anemic population.[1],[3] Patients suffering from bleeding or inherited coagulation disorder, hematological malignancy or receiving chemotherapeutic drug, and having history of blood transfusion in past 3 months were excluded from this study. Convenient sampling was done from elderly individuals attending Central Laboratory of the hospital referred from various out patient departments (OPD) of the hospital by the concerned physicians for complete hemogram. Venous blood samples were collected in EDTA anticoagulant vial and at OPD blood collection center of Central Laboratory by single prick technique. Blood collected were analyzed by 6 part automated cell counter at Pathology division of Central Laboratory. Hb and RBC indices including hematocrit (Hct), Mean corpuscular volume (MCV), Mean corpuscular haemoglobin (MCH), Mean corpuscular haemoglobin concentration (MCHC) and Red cell distribution width (RDW-CV) were recorded. Anemia was graded as mild, moderate and severe according to WHO criteria.[3] Mild anemia was defined as Hb 11-12.9 g/dl in males and 11-11.9 g/dl in females, moderate anemia as Hb 8-10.9 g/dl and severe anemia as <8 g/dl. Mean corpuscular volume (MCV) was used to classify anemia as microcytic (MCV <80 fl), normocytic (MCV 80-100 fl) and macrocytic (MCV >100 fl).[9] RBC morphology was further evaluated for correlation by examining the blood films stained by Leishman's stain under a binocular light microscope (Olympus CH20i).

Statistical analysis was done using Statistical package for social sciences (SPSS software, version 16). The study participants were categorized into four age groups as follows: 60-69 years, 70-79 years, 80-89 years and ≥90 years. Study subjects were also categorized into three groups based on severity and morphological types of anemia, namely, microcytic, normocytic and macrocytic anemia separately. Difference in types of anemia by age groups and gender were analyzed by unpaired t test. P value <0.05 was considered as statistically significant.


  Results Top


Out of total 277 anemic cases of geriatric age group included, 126 were male and rest 151 participants were female with female: male ratio of 1.19:1. Most of the participants (60.29%) were in the age group of 60-69 years Overall, most of the cases have mild degree of anemia (48.02%) followed by moderate (46.93%), whereas only 5.05% cases have severe anemia [Table 1]. However, if we compare in different gender groups, female participants have mostly moderate degree of anemia (58.27%), but in male group, most have mild degree of anemia (61.12%). [Table 2] illustrates the distribution of Hb level and RBC indices in male and female patients according to different age group. Pearson correlation test shows that Hb level has a small but significant negative correlation with an increase in age in female participants (r = −0.207; P = 0.01), whereas in case of male participants, this test indicates a non-significant very small negative relationship between age and Hb level (r = −0.05; P = 0.57) [Figure 1] and [Figure 2].
Figure 1: Graphical representation of Pearson correlation test between age and Hb level in female

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Figure 2: Graphical representation of Pearson correlation test between age and Hb level in male

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Table 1: Grading of anemia in male and female participants

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Table 2: Distribution and comparison of Hb level and RBC indices in different age groups of male and female participants

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Regarding the morphological pattern, most of the cases are normocytic normochromic in both male (97 cases; 76.99%) and female groups (110 cases; 72.84%). In the male group, 15.87% cases and in the female group 21.19% cases were microcytic hypochromic. Rest cases were macrocytic (7.14% and 5.97% in male and female, respectively).

[Table 2] also shows the comparison of Hb level and RBC indices between male and female patients. Unpaired t test shows that female participants have significantly low levels of Hb, MCH and MCHC in comparison to male participants; however, MCV and RDW-CV had no statistically significant variation.


  Discussion Top


Anemia in an elderly age group is a common clinical condition, especially in hospitalized geriatric patients leading to a marked increase in their morbidity and mortality.[11] Common symptoms of anemia are non-specific and often mimic the features of normal aging process and hence remain undiagnosed. In elderly individuals, anemia is often manifestation of underlying co-morbid conditions which may deteriorate the quality of life. Pattern of anemia can reflect the underlying disease etiology. Hence, an early diagnosis of anemia including morphological pattern is of critical importance in geriatric population. The most common cause of elderly anemia is anemia of chronic disease (ACD) (30-45%) associated with chronic infections and inflammatory conditions like tuberculosis, infective endocarditis, chronic urinary tract infections, osteoarthritis and rheumatoid arthritis. About two-thirds of these cases present with normocytic-normochromic anemia, whereas one-third of them present with microcytic anemia. ACD is followed by anemia of nutritional deficiency like iron, vitamin B-12 and folic acid deficiency. Ten percent of anemia in geriatric population is associated with haematological malignancies like chronic lymphocytic leukaemia/lymphoma and myelodysplastic syndrome (MDS). Instead of thorough investigation, no cause can be identified in 15-25% of cases of elderly anemia.[12] Iron deficiency anemia (IDA) can be confirmed by estimation of serum ferritin, total iron binding capacity (TIBC) and serum iron in adjunct with microcytic picture in peripheral blood smear. In geriatric population, IDA is often associated with gastric or colon carcinoma. Vitamin B12 and folic acid deficiency and MDS often presented with macrocytic anemia. Presence of immature white cells, nucleated red blood cells and pancytopenia may indicate underlying MDS and necessitates bone marrow study. Anemia of chronic kidney disease (CKD) is another important cause geriatric anemia which may be suspected in patients with normocytic-normochromic anemia with glomerular filtration rate (GFR) <60 ml/min.[13] The present study was conducted to evaluate the pattern of anemia in geriatric age groups, which may help in early diagnosis of anemia and detection of potentially treatable underlying co-morbid conditions at an earlier stage. In the current study, most of the participants (60.29%) were in the age group of 60-69 years. This finding was in concordance with the study done by Choukimath SM et al.,[2] Bhasin et al.,[7] and Jain V et al.[9] A slight female preponderance was noted among geriatric anemic subjects with a ratio of 1.9:1 in this study. Similar observation was noted by Jadhav M et al.[14] and Singhal S et al.[15] who also found a female preponderance among anemic geriatric population. However, this finding was contradicted by Guralnik et al.[16] who found male preponderance in their study. Petrosyan I et al.[17] also found male preponderance among anemic subjects in the age group of 60-69 years with a male to female ratio of 1.14:1. Similar observation was recorded by Price EA et al.[18], Tay MRJ et al.,[19] Bang SM et al.[20] Contreras MM et al.[21] and Sherawat et al.[22] also recorded male to female ratio of 1.3:1 in their study. This variation in gender distribution among anemic elderly population may be due to the fact that male patients often approach to the hospital for their health-related problems more frequently than females in different geographic locations of the world and also in different regions of the same country. Most of the participants (48.02%) were found to have mild anemia in this study followed by moderate (46.93%) and severe (5.05%) anemia [Table 1]. Singh R et al.[3] also found mild anemia of Hb <10 g/dl in 67.3% of geriatric anemic population. Previous studies by Petrosyan I et al.,[17] Hafiz F et al.,[23] Cherian M et al.,[24] and Melku M et al.[25] also found majority of the elderly participants as having mild anemia. However, other studies by Singhal et al.[15] and Sherawat et al.[22] noted moderate anemia as the most common degree of anemia. It should be noted that even mild degree of anemia in geriatric age groups may adversely affect the life expectancy and quality of life in this age group, and hence, it should not be neglected as normal physiological aging process.[26] In the present study, mean Hb, MCH and MCHC were found to be significantly lower in geriatric female subjects compared to males (P < 0.05). However, no statistically significant difference in mean MCV and RDW-CV was noted among male and female participants [Table 2]. Again, Pearson correlation test showed that Hb level has a small but significant negative correlation with an increase in age in female participants (r = −0.207; P = 0.01), whereas in case of male participants, this test indicates a non-significant very small negative relationship between age and Hb level (r = −0.05; P = 0.57). In the current study, the majority of participants (74.73%) showed normocytic and normochromic anemia in both male and female subjects followed by microcytic and hypochromic type, encompassing that 18.77% of the participants and rest 6.5% of the participants showed macrocytic type of anemia [Figure 3]. Hence, it was concluded that normocytic and normochromic types are the most common morphological pattern of anemia in elderly individuals. Similar observation was recorded by Singh R et al.[3] who also found normocytic normochromic anemia in majority of elderly of both the sexes constituting 37.68% of total anemic patients followed by microcytic hypochromic (31.88%) and macrocytic (4.35%) type. Saurabh R Shrivastava et al.[27] also found normocytic normchromic anemia in majority of geriatric patients (69.8%) followed by microcytic hypochromic type (11.6%). Jain V et al.[9] noted normocytic-normochromic, microcytic-hypochromic and macrocytic anemia in 64%, 30.66% and 5.33% of geriatric anemic subjects, respectively. Again the distribution of normocytic normochromic anemia among male and female patients was found to be 76.99% and 72.84%, respectively, in this study, whereas those of microcytic-hypochromic were recorded to be 15.87% and 21.19% of male and female population, respectively. This observation was comparable to previous studies done by Ania et al.[28] and S. Amarneel et al.[29] Ania et al. observed normocytic-normochromic anemia in 83% of male and 80% of female when microcytic-hypochromic pattern was recorded in 14% of males and 16% of females. S. Amarneel et al. noted that 41.6% of male compared to 33.33% of female geriatric patients had normocytic normochromic anemia and 16.66% of male compared to 20% of female participants had microcytic hypochromic anemia. In contrast, Sherawat et al.,[22] Patel S et al.[30] and Mukaya et al.[31] recorded microcytic hypochromic anemia as the predominant morphological type among geriatric age groups constituting 42%, 72% and 54% of cases, respectively.
Figure 3: Proportion of different morphologic types of anemia among study participants (n = 277)

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To summarize, the present study has highlighted the distribution of severity and morphological pattern of anemia in both male and female elderly individuals with mild degree of normocytic normochromic anemia being the most common type. The evaluation of morphological pattern may indicate the underlying cause of anemia and direct the appropriate way to further investigation and management subsequently.

Limitations of the study: It was a hospital-based cross-sectional study; hence, it may not truly represent the problem at community level, and etiology of geriatric anemia including necessary further work-up required subsequently based on the morphological pattern of anemia to arrive at a final diagnosis could not be evaluated in this study.


  Conclusion Top


Despite increasing awareness and advances in health care system, the geriatric anemia is often one of the most neglected health problems and remains inadequately investigated. Normocytic-normochromic anemia of mild degree was found to be the most common type of anemia among geriatric population. Determining morphological pattern of anemia may help in evaluating the underlying etiology which may ensure adequate management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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