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ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 126-130

Analysis of hemogram profile of elderly diabetics in a tertiary care hospital


1 Department of Pharmacology, Kasturba Medical College, Manipal University, Mangalore, India
2 Department of Medicine, Kasturba Medical College, Manipal University, Mangalore, India

Date of Submission29-Mar-2012
Date of Acceptance04-May-2012
Date of Web Publication3-Jun-2013

Correspondence Address:
Nithyananda K Chowta
Department of Medicine, Kasturba Medical College, Manipal University, Light House Hill Road, Mangalore - 575 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-0738.112836

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   Abstract 

Background: Anemia is a common concern in geriatric health, but its exact incidence and prevalence are unclear. Several studies have addressed this issue with discrepant results. Recent findings have shown that anemia can lead to cardiovascular and neurological complications, such as congestive heart failure and impaired cognitive function. Objective: To evaluate the hemogram profile in elderly diabetic patients and compare the same with younger diabetic patients. Materials and Methods: A retrospective chart review of type 2 diabetic patients who participated in clinical trials on diabetes mellitus was carried out. The clinical trials have been approved by the institutional ethics committee. Patient population included both males and females. Patients who underwent baseline hemogram profile were included for the study. Laboratory parameters collected include hemoglobin, hematocrit value, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), glycosylated hemoglobin, serum creatinine, and urine albumin. Results: A total of 127 elderly patients with age >60 years and 122 patients with age below 60 years were included in the study. Mean hemoglobin concentration in elderly was 13.1 g/dL and in younger patients was 14.8 g/dL. The differences in the hemogram values among the two populations showed statistical significance only for hematocrit (P = 0.03) and RDW (P = 0.002). There was significant positive correlation between hemoglobin level and creatinine clearance (P = 0.019) and between hemoglobin and urine albumin concentration (P = 0.035) among elderly patients. Among the elderly patients 25 (19.7%) had anemia (hemoglobin below 12 g/dL), and 18 (14.8%) younger patients had anemia. Chi-square analysis did not show significance for distribution of anemia among the two populations. Conclusion: There was significant difference in the hemogram profile of elder and younger diabetics; levels were much less in elderly patients.

Keywords: Anemia, diabetes mellitus, elderly, hemogram


How to cite this article:
Chowta MN, Chowta NK, Adhikari P, Shenoy AK. Analysis of hemogram profile of elderly diabetics in a tertiary care hospital. Int J Nutr Pharmacol Neurol Dis 2013;3:126-30

How to cite this URL:
Chowta MN, Chowta NK, Adhikari P, Shenoy AK. Analysis of hemogram profile of elderly diabetics in a tertiary care hospital. Int J Nutr Pharmacol Neurol Dis [serial online] 2013 [cited 2020 Jan 18];3:126-30. Available from: http://www.ijnpnd.com/text.asp?2013/3/2/126/112836


   Introduction Top


Anemia is a common concern in geriatric health, but its exact incidence and prevalence are unclear. Several studies have addressed this issue with discrepant results. It is often incorrectly attributed to the ravages of normal aging. Hemoglobin levels should not vary due to age in elderly patients who are free of disease with bone marrow that is not stressed. Causes of anemia in the population over age 65 years are relatively few and include nutritional deficiency, renal insufficiency, and chronic diseases. The criteria set by the World Health Organization (WHO) for hemoglobin level is <120.0 g/L for women and <130.0 g/L for men. [1] Most existing reports indicate that elderly men have higher rates of anemia than do elderly women. Incidence of anemia rises with age; some studies report a particularly notable increase in prevalence of anemia in the oldest subjects, those ≥85 years of age. [2] Recent findings have shown that anemia can lead to cardiovascular and neurological complications, such as congestive heart failure and impaired cognitive function. In addition, anemia has been implicated in functional impairment, depression, and falls. Untreated geriatric anemia has been associated with increased mortality, increased prevalence of various comorbid conditions, and decreased function. [3],[4] Failure to evaluate anemia in the elderly could lead to delayed diagnosis of potentially treatable conditions. Mild grade anemia was found to be prospectively associated with clinically relevant outcomes such as increased risk of hospitalization and all-cause mortality. [5] Mild grade anemia was independently associated with worse selective attention performance and disease-specific QoL ratings. [6] Available data have shown that the successful management of this condition will not only improve patients' quality of life, but also reduces cardiovascular and neurological complications. [7] Few Indian studies were available regarding the prevalence of anemia in geriatric population.

Hence, the present study was undertaken with the objective of evaluation of hemogram profile in elderly diabetic patients and compare the same with younger diabetic patients.


   Materials and Methods Top


A retrospective chart review of type 2 diabetic patients who participated in clinical trials on diabetes mellitus was carried out. The clinical trials have been approved by the institutional ethics committee. Patient population included both males and females. Patients who underwent baseline hemogram profile were included for the study. Demographic characteristics collected include age, gender, body weight, height, and duration of diabetes. Information regarding antidiabetic medication was also recorded. Laboratory parameters collected include hemoglobin, hematocrit value, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), glycosylated hemoglobin, serum creatinine, and urine albumin.

Statistical analysis

Continuous data were analyzed by independent student 't' test whereas categorical data were analyzed by chi square test. Pearson correlation coefficient was used to correlate the quantitative data. A P value less than 0.05 was considered significant.


   Results Top


A total of 127 elderly patients with age >60 years and 122 patients with age <60 years were included in the study. Among the elderly patients, 67 were males (50.4%) and 66 were females (49.6%). Among the patients in age group below 60 years, 65 (50.4%) were males and 64 were females (49.6%). Mean hemoglobin concentration in elderly was 13.1 g/dL and in younger patients was 14.8 g/dL. The values of hematocrit in elderly was 0.40 v/v and in younger patients was 0.41 v/v. Mean MCV in elderly was 88.3 fl and in younger patients was 89.0 fl. Mean MCH in elderly was 29.0 pg and in younger patients was 29.6 pg. Mean MCHC in elderly was 32.8 g/dL and in younger patients 33.1 g/dL. The value of mean RDW was more in elderly (15.79% vs. 14.93%). The differences in the hemogram values among the two populations shown statistical significance only for hematocrit (P = 0.03) and RDW (P = 0.002) [Table 1]. There was significant positive correlation between hemoglobin level and creatinine clearance (P = 0.019) and between hemoglobin and urine albumin concentration (P = 0.035) among elderly patients. Among the elderly patients, 40 (31.5%) had anemia and 23 (18.9%) younger patients had anemia. Chi-square analysis for distribution of anemia among the two populations showed statistical significance (P = 0.03, [Table 2]). There was significant difference in the hemogram profile of males and females in the general population; as expected, values were less in females. But when analysis was done group wise, prevalence of anemia was more in elderly males compared with younger males (P = 0.004, [Table 2]). Prevalence of anemia was significantly higher in younger females compared with younger males (P = 0.007, [Table 2]). There was no statistically significant difference in the distribution of anemia among elderly males versus elderly females as well as among elderly females versus younger females.
Table 1: Comparison of hemogram profile of geriatric and younger diabetic patients

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Table 2: Group wise analysis of distribution of anemia

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   Discussion Top


The present study has shown significant difference in the hemogram profile among elderly and younger diabetics. Prevalence of anemia was more in geriatric population. Anemia was more common in elderly males compared with younger males. Significant difference was not observed for the female gender in the two different age groups.

Although the prevalence of anemia does increase with age, successful aging is not usually associated with anemia. Anemia should not be accepted as an inevitable consequence of aging, because a cause is identified in about 80% of elderly patients. [8] In ambulatory elderly patients, the most common causes of anemia are chronic disease [9] (kidney disease, infections, malignancies, and chronic inflammatory disorders), iron deficiency, and nutritional and metabolic disorders. Blood loss as a causal factor (from surgery, injuries, and gastrointestinal and genitourinary bleeding) is more common in hospitalized patients. [10],[11] Frequently, multiple factors contribute to the problem in the individual patient. Proposed mechanisms include the presence of inflammatory cytokines and abnormal cytokine modulation of erythropoiesis, due both to abnormal production of stimulatory cytokines and decreased responsiveness of the erythroid precursors. [12] An increased amount of fatty marrow tissue, possibly related to atherosclerotic changes in the bone marrow feeding arteries, may also play a role. [13]

Our study has shown significant difference for hematocrit and red cell redistribution width among elderly and younger population. Analysis of hemogram values in elderly patients with anemia showed that values of MCV, MCH, and MCHC were within normal limits, but the RDW value was high (18.31%). The possible causes of normal MCV and high RDW include: Early iron or folate (or both) deficiency, hemoglobin SS, hemoglobin SC, myelofibrosis, and sideroblastic anemia. Since MCH and MCHC were near normal, nutritional deficiency of folate or vitamin B12 deficiency in the elderly patients may be one of the causes of anemia in our patients.

The present study has shown prevalence of anemia as 31.5%. In contrast to this finding, earlier outpatient studies of more heterogeneous geriatric populations report prevalence of anemia between 5.2% and 13.6%. [14] Systematic review of 45 studies by Gaskell et al. showed mean prevalence of anemia as 17% (3-50%) overall, 12% (3-25%) in studies based in the community, 47% (31-50%) in nursing homes, and 40% (40-72%) in hospital admissions. Anemia prevalence increased with age, was slightly higher in men than women, and was higher in black people than white. Most individuals classified as anemic using WHO criteria were only mildly anemic. [15] Tettamanti et al. reported prevalence of anemia in elderly population as 11.1%. [16] Higher prevalence in our study may be due to the fact that study population consists of only diabetic patients. Diabetic related renal insufficiency along with nutritional deficiency would have played a role for higher prevalence of anemia in the present study. Since hemoglobin level correlated positively with creatinine clearance, anemia could be related to reduced glomerular filtration rate in the elderly. A recent review of studies of anemia in elderly patients found a wide variation in prevalence, ranging from 2.9% to 61% in men and 3.3% to 41% in women. A retrospective chart review of 151 elderly hospitalized patients by Sahadevan and colleagues found that slightly more than a third of the patients were anemic. The prevalence of anemia was significantly higher in those > 75 years old, 42.9%, compared with those 65 to 74 years old (25%). [17] Similarly, a retrospective chart review of 183 hospitalized patients by Smieja and associates found that 36% were anemic. [18]

Our study has shown that there was significant difference in the prevalence of anemia in elderly diabetic males when compared with younger males. Significant difference was not seen in the prevalence of anemia between elderly and younger female population. Age-related decline in testosterone level and hence the decreased erythropoietin production may be responsible for the increased prevalence of anemia in elderly male group. The present study did not show difference in the distribution of anemia between elderly males and females, which is in contrast to the earlier literature that claims higher prevalence in elderly men than elderly women. Prevalence of anemia was significantly higher in younger females compared younger males. Female patients are more likely to be anemic than male diabetics in the younger age group. As age advances, increased number of males may develop anemia due to decrease in testosterone production, thereby eliminating the gender difference in the prevalence of anemia in elderly population, as seen in our study.

An accurate history and focused physical examination, together with a limited, noninvasive laboratory evaluation, which includes complete blood count with reticulocyte count, tests of hepatic and renal function, serum ferritin, vitamin B12 level, and stools for occult blood, are frequently sufficient to determine the cause of geriatric anemia and to direct management. The differentiation between anemia of chronic disease and iron deficiency may be more challenging in older individuals because the hallmarks of iron deficiency, microcytosis, and reduced serum ferritin level, are somewhat less likely to be present. [19] Microcytosis may be masked by coexistent conditions usually associated with macrocytosis like folate and vitamin B12 deficiency and hypothyroidism. Serum ferritin, in addition to being a marker for iron stores, is an acute phase reactant. Therefore, low levels due to iron deficiency could be masked by elevations due to the presence of other comorbidities. The clinical context helps in the interpretation of equivocal laboratory results. [20] or the C-reactive protein concentration may contribute to the differential diagnosis. [21] The prevalence of anemia due to vitamin B12 deficiency may be much higher than that of pernicious anemia. With aging, the most common cause of vitamin B12 deficiency is achylia, which prevents proper digestion of food. [22]

Limitations of our study also should be considered. Nutritional assessment such as ferritin levels and B12 and folic acid level were not estimated in the present study. Sample size may be inadequate to draw valid a conclusion. Future directions for research on anemia should include a more detailed examination of the importance of aging or age-related diseases on the pathogenesis of anemia, an assessment of the importance of anemia on outcomes such as physical function and cognitive function, and an analysis of whether impairments associated with anemia are amenable to correction by improving hemoglobin concentration. Anemia may significantly impair the exercise capacity and also has a negative effect on quality of life. Further studies are needed with a larger sample size to confirm the findings of this study.


   Conclusion Top


There was significant difference in the hemogram profile and prevalence of anemia in elder and younger diabetics; levels were much less in elderly patients. Nutritional deficiency of folic acid/vitamin B 12 along with renal insufficiency may be the possible causes of anemia in the elderly diabetic population. Anemia is a common problem in the elderly, accounting for significant morbidity and mortality.

 
   References Top

1.World Health Organization. Nutritional anemias: Report of a WHO scientific group. Technical Report Series No. 405. Geneva: World Health Organization; 1968.  Back to cited text no. 1
    
2.Carmel R. Anemia and aging: An overview of clinical, diagnostic and biological issues. Blood Rev 2001;15:9-18.  Back to cited text no. 2
    
3.Argyriadou S, Vlachonikolis I, Melisopoulou H, Katachanakis K, Lionis C. In what extent anemia coexists with cognitive impairment in elderly: A cross-sectional study in Greece. BMC Fam Pract 2001;2:5.  Back to cited text no. 3
    
4.Milward EA, Grayson DA, Creasey H, Janu MR, Brooks WS, Broe GA. Evidence for association of anaemia with vascular dementia. Neuroreport 1999;10:2377-81.  Back to cited text no. 4
    
5.Riva E, Tettamanti M, Mosconi P, Apolone G, Gandini F, Nobili A, et al. Association of mild anemia with hospitalization and mortality in the elderly: The Health and Anemia population-based study. Haematologica 2009;94:22-8.  Back to cited text no. 5
    
6.Lucca U, Tettamanti M, Mosconi P, Apolone G, Gandini F, Nobili A, et al. Association of mild anemia with cognitive, functional, mood and quality of life out-comes in the elderly: The "Health and Anemia" study. PloS ONE 2008;3:e1920.  Back to cited text no. 6
    
7.Moreno F, Aracil FJ, Pérez R, Valderrábano F. Controlled study on the improvement of quality of life in elderly hemodialysis patients after correcting end-stage renal disease-related anemia with erythropoietin. Am J Kidney Dis 1996;27:548-56. erythropoietin.  Back to cited text no. 7
    
8.Smith DL. Anemia in the elderly. Am Fam Physician 2000;62:1565-1572.  Back to cited text no. 8
    
9.Lippi G, Franchini M, Salvagno GL, Montagnana M, Targher G, Guidi GC. Determinants of anaemia in the very elderly: A major contribution from impaired renal function? Blood Transfus 2010;8:44-8.  Back to cited text no. 9
    
10.Anía BJ, Suman VJ, Fairbanks VF, Rademacher DM, Melton LJ III. Incidence of anemia in older people: An epidemiologic study in a well defined population. J Am Geriatr Soc 1997;45:825-31.  Back to cited text no. 10
    
11.Kirkeby OJ, Fossum S, Risoe C. Anaemia in elderly patients: Incidence and causes of low haemoglobin concentration in a city general practice. Scand J Prim Health Care 1991;9:167-71.  Back to cited text no. 11
    
12.Joosten E, Pelemans W, Hiele M, Noyen J, Verhaeghe R, Boogaerts MA. Prevalence and causes of anaemia in a geriatric hospitalized population. Gerontology 1992;38:111-7.  Back to cited text no. 12
    
13.Takasaki M, Tsurumi N, Harada M, Rokugo N, Ebihara Y, Wakasugi K. Changes of bone marrow arteries with aging. Nippon Ronen Igakkai Zasshi 1999;36:638-43.  Back to cited text no. 13
    
14.Inelmen EM, D'Alessio M, Gatto MR, Baggio MB, Jimenez G, Bizzotto MG, et al. Descriptive analysis of the prevalence of anemia in a randomly selected sample of elderly people living at home: Some results of an Italian multicentric study. Aging (Milano) 1994;6:81-9.  Back to cited text no. 14
    
15.Gaskell H, Derry S, Moore RA, McQuay HJ. Prevalence of anaemia in older persons: Systematic review. BMC Geriatr 2008;8:1.  Back to cited text no. 15
    
16.Tettamanti M, Lucca U, Gandini F, Recchia A, Mosconi P, Apolone G. Prevalence, incidence and types of mild anemia in the elderly: The "Health and Anemia" population-based study. Haematologica 2010;95:1849-56.  Back to cited text no. 16
    
17.Sahadevan S, Choo PW, Jayaratnam FJ. Anaemia in the hospitalised elderly. Singapore Med J 1995;36:375-8.  Back to cited text no. 17
    
18.Smieja MJ, Cook DJ, Hunt DL, Ali MA, Guyatt GH. Recognizing and investigating iron-deficiency anemia in hospitalized elderly people. CMAJ 1996;155:691-6.  Back to cited text no. 18
    
19.McKay PJ, Stott DJ, Holyoake T, Hendry A, MacDonald JB, Lucie NP. Use of the erythrogram in the diagnosis of iron deficiency in elderly patients. Acta Haematol 1993;89:169-73.  Back to cited text no. 19
    
20.Wians FH Jr, Urban JE, Keffer JH, Kroft SH. Discriminating between iron deficiency anemia and anemia of chronic disease using traditional indices of iron status vs transferrin receptor concentration. Am J Clin Pathol 2001;115:112-8.  Back to cited text no. 20
    
21.Mitrache C, Passweg JR, Libura J, Petrikkos L, Seiler WO, Gratwohl A, et al. Anemia: An indicator for malnutrition in the elderly. Ann Hematol 2001;80:295-8.  Back to cited text no. 21
    
22.Herbert V. The elderly need oral vitamin B-12. Am J Clin Nutr 1998;67:739-40.  Back to cited text no. 22
    



 
 
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