1. European Journal of Internal Medicine 19 (2008) 488 – 493
www.elsevier.com/locate/ejim
Review article
Update of nutrient-deficiency anemia in elderly patients ☆
Emmanuel Andrès a,⁎, Laure Federici a , Khalid Serraj a , Georges Kaltenbach b
a
Departments of Internal Medicine, Diabetes and Metabolic Disorders, University Hospital of Strasbourg, Strasbourg, France
b
Internal Medicine and Geriatrics, University Hospital of Strasbourg, Strasbourg, France
Received 25 May 2007; received in revised form 27 December 2007; accepted 20 January 2008
Available online 14 March 2008
Abstract
Anemia, defined as a hemoglobin level b 13g/dL in men and b 12g/dL in women, is an important healthcare concern among the elderly.
Nutrient-deficiency anemia represents one third of all anemias in elderly patients. About two thirds of nutrient-deficiency anemia is associated
with iron deficiency and most of those cases are the result of chronic blood loss from gastrointestinal lesions. The remaining cases of nutrient-
deficiency anemia are usually associated with vitamin B12, most frequently related to food-cobalamin malabsorption, and/or folate deficiency and
are easily treated (nutrient-deficiency replacement).
© 2008 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
Keywords: Anemia; Nutrient-deficiency anemia; Elderly; Iron deficiency; Vitamin B12 deficiency; Folate deficiency
1. Introduction In the present paper, we report and discuss the current lit-
erature of nutrient-deficiency anemia in elderly patients.
Anemia is a common condition in elderly patients and its
prevalence increases with age. It affects quality of life, cognitive 2. Bibliographic search strategy
and physical function and is a comorbid condition that affects
other diseases (e.g. heart disease, cerebrovascular insufficiency) A review of the medical literature was conducted to identify
and is even associated with a risk of death [1]. Thus, anemia original studies and review concerning anemia in elderly
should not be accepted as a consequence of aging. In elderly, patients. In March 2007, Pub Med was searched for English
many underlying conditions lead to anemia but the most often and French-language article. Textbooks of Hematology, Internal
one is nutrient deficiencies, especially iron deficiency, folate medicine and Geriatrics, and information gleaned from
(folic acid, vitamin B9) deficiency and vitamin B12 (cobalamin) international meetings were also used.
deficiency [2,3]. Recognition of these deficiencies is a
prerequisite of successful therapy. 3. Definition of anemia in the elderly
The World Health Organization (WHO) defines anemia as
hemoglobin (Hb) concentration b 12g/dL for non-pregnant
women and b 13g/dL for men [1,4]. In elderly, the values vary
☆
Supported by a grant from the Fondation de France: Prix Robert et between countries, regions and laboratories. Although low
Jacqueline Zittoun, 2004. hemoglobin levels are often seen with advancing age, anemia
⁎ Corresponding author. Service de Médecine Interne, Diabète et Maladies
should not be assumed to be a normal consequence of aging. A
Métaboliques, Clinique Médicale B, Hôpital Civil, Hôpitaux Universitaires de
Strasbourg, 1 porte de l'Hôpital, 67091 Strasbourg Cedex, France. Tel.: +33 3
Hb concentration b 12g/dL is commonly considered as an
33 88 11 50 66; fax: +33 3 33 88 11 62 62. “established” anemia [4]. Age may be associated with
E-mail address: emmanuel.andres@chru-strasbourg.fr (E. Andrès). compromised hematopoietic reserve and consequently with an
0953-6205/$ - see front matter © 2008 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejim.2008.01.016

2. E. Andrès et al. / European Journal of Internal Medicine 19 (2008) 488–493 489
Table 1 as anemia of chronic inflammation; and unexplained anemia
Etiology of anemia in 300 consecutive patients older than 65 years, hospitalized [1,8,10]. In the NHANES III study, 34% of all anemia in elderly
in the department of internal medicine in a tertiary reference center (personal
communication in the French Congress of Internal Medicine, Aix-en-Provence,
patients is caused by folate, vitamin B12, or iron deficiency,
June 2001) alone or in combination (nutrient-deficiency anemia), 12% was
Etiology Prevalence (%)
associated with renal insufficiency, 20% was due to chronic
diseases, and in 34% the cause remained unexplained [7]. About
Chronic inflammation (chronic disease) 23.0
60% of nutrient-deficiency anemias are associated with iron
Iron deficiency 18
Renal failure 9 deficiency and most of those cases are the result of chronic
Liver disease and endocrine disease (chronic disease) 7 blood loss from gastrointestinal lesions. The remaining cases of
Posthemorrhagic 7 nutrient-deficiency anemia are usually associated with vitamin
Folate deficiency 6 B12 and/or folate deficiency and are easily treated. In Table 1,
Myelodysplasia 5
we report our personal experience (retrospective study) of the
Vitamin B12 deficiency 4
Unexplained causes 21 etiology of anemia in 300 hospitalized patients ≥ 65years old
(personal communication in the French Congress of Internal
Medicine, Aix-en-Provence, June 2001).
increased susceptibility to anemia in the presence of hemato- Rare unknown causes of nutrient-deficiency anemia also
poietic stress induced by an underlying disorder [3,5]. In include several other vitamin deficiencies, zinc or copper
practice, a Hb level b 10g/dL is considered as a trigger for the deficiencies.
investigation and treatment of the cause of anemia [6].
6. Iron deficiency anemia in the elderly
4. Prevalence of anemia in the elderly
Iron deficiency anemia, the second most common cause of
The prevalence of anemia increases with advancing age, anemia in the elderly [7], usually results from chronic
especially after age 60–65years, and rises sharply after the age gastrointestinal (GI) blood loss mainly caused by: esophagitis,
of 80years [1,5]. Results from the third National Health and gastritis, ulcer, related or not related to nonsteroidal anti-
Nutrition Examination Survey (NHANES III) carried out in the inflammatory drug intake and/or chronic Helicobacter pylori
United States indicate that the prevalence of anemia was 11% in infections, varices (portal hypertension), colorectal cancer or
community-dwelling men and 10.2% among women ≥ 65years pre-malignant polyps, or angiodysplasia [2,12]. GI blood loss is
of age [7]. Survey findings indicate further that most anemia often occult and is not ruled out by negative fecal blood tests. GI
among the elderly is mild; only 2.8% of women and 1.6% of tract abnormalities can be identified in the majority of patients
men had a Hb b 11g/dL [8]. Results from the Framingham with iron deficiency anemia [13]. In 40 to 60% of patients, the
cohort indicates a slightly lower prevalence of anemia among source is in the upper GI tract [2,14]. The blood loss is in the
older people living in the United States. In this group of 1016 colon in 15 to 30% of cases. The source is not found in the
subjects 67–96years of age, the prevalences of anemia in men remaining 10 to 40% of elderly patients with gastrointestinal
and women are 6.1% and 10.5%, respectively [9]. In the elderly, blood loss. Fortunately these patients do well with iron
much of the variability in the reported prevalence of anemia replacement and repeat investigation is not often needed [15].
reflects the heterogeneity of this population. Variables such as H. pylori infection and chronic gastritis, especially atrophic
race, living circumstances, and health status may all influence gastritis, are significantly associated with unexplained iron
the prevalence of anemia [1]. deficiency anemia [16]. Table 2 presents our experience of the
5. Etiology of anemia in the elderly
Table 2
Results of the evaluation of the gastrointestinal tract in 90 consecutive elderly
Because elderly patients often have several associated co- patients (≥65 years) with chronic blood loss, hospitalized in the department of
morbid conditions and are commonly taking a variety of medi- internal medicine in a tertiary reference center (personal communication in the
cations, some of which may contribute to anemia, the etiology French Congress of Internal Medicine, Aix-en-Provence, June 2001)
of anemia is frequently difficult to determine even after ex- Etiology Prevalence (%)
tensive investigations, including bone marrow examination
Esophagitis and Mallory Weiss syndrome 4.4
[10]. Examination of the etiology of anemia indicates that, in Gastritis, atrophic gastritis and ulcer related or 30
most cases (approximately 80%), the etiology of anemia in the not related to NSAID use and/or Helicobacter
elderly can be identified [3,11]. A significant proportion of pylori infection
elderly anemic patients (30–50%) are presumed to have mul- Varices related to portal hypertension 9
Angiodysplasia 2.25
tiple causes for their anemia [2,10]. In the cases for which the
Colon diverticula 4.5
cause of anemia has not been established, patients may have Colorectal benign and pre-malignant polyps 5.5
received an inadequate diagnostic work-up. Colorectal cancer 5.5
In elderly, causes of anemia are divided into three broad Inflammatory bowel disease 2.25
groups: nutrient-deficiency anemia, most often iron deficiency Unexplained causes 36.6
anemia; and/or anemia of chronic disease, perhaps better termed NSAID: Nonsteroidal anti-inflammatory drug.

3. 490 E. Andrès et al. / European Journal of Internal Medicine 19 (2008) 488–493
jejunum. Folate deficiency usually develops as a result of
inadequate dietary intake [2,7]. The body stores very little folate,
only enough to last 4 to 6months. Patients usually have a history
of weight loss, poor weight gain and weakness. In addition
several drugs (methotrexate, cotrimoxazole, sulfasalazine,
anticonvulsants…) and alcohol may cause deficiency of folate.
8. Vitamin B12 deficiency anemia in the elderly
Both vitamin B12 and folate deficiency are common among
the elderly, each occurring in at least 5% of the patients [2]. The
Fig. 1. Etiologies of cobalamin deficiency in 172 elderly patients hospitalized in Framingham study demonstrated a prevalence of 12% among
the University Hospital of Strasbourg, France.
elderly people living in the community [18]. In elderly patients,
the etiologies of cobalamin deficiency are represented primarily
evaluation of the GI tract in 90 elderly patients with chronic by food-cobalamin malabsorption (FCM) and pernicious anemia
blood loss (personal communication in the French Congress of and, more rarely, by intake deficiency and malabsorption [19]. In
Internal Medicine, Aix-en-Provence, June 2001). Chronic blood our work in which we followed more than 200 elderly patients
loss from genitourinary tract and chronic hemoptysis may result with a proven deficiency, FCM accounted for about 60% to 70%
in iron deficiency but are much less common causes [2]. of the etiologies of cobalamin deficiency, and pernicious anemia
Bleeding disorders and particularly anticoagulants (vitamin K 15% to 25%. Fig. 1 presents the principal causes of cobalamin
antagonists) may favor iron deficiency in elderly (around 20% deficiency in 172 elderly patients (median age: 70years)
in our experience). hospitalized in the University Hospital of Strasbourg, France [20].
Older persons may also become iron deficient because of Initially described by Carmel in the 1990s, the FCM is
inadequate dietary intake or inadequate absorption or bioavail- characterized by the inability to release cobalamin from food
ability of iron (with anti acids) [2]. Heme iron from animal and/or intestinal transport proteins, particularly in the case of
sources is better absorbed than non-heme iron from plant hypochlorhydria, where the absorption of “unbound” cobalamin
sources. Vitamin C in food enhances iron absorption from non- is normal [21]. As we have recently indicated, this syndrome is
heme sources. The tannins and polyphenols in tea and coffee defined by cobalamin deficiency despite sufficient food-
can inhibit iron absorption. Any elderly subject whose dietary cobalamin intake and a normal Schilling test, where the latter
intake is poor, has recent unexplained weight loss is a candidate rules out malabsorption or pernicious anemia [20]. FCM is
for increasing attention. Nevertheless, iron deficiency anemia is caused primarily by atrophic gastritis. Over 40% of patients
rarely the result of dietary deficiency in industrialized countries older than 80years of age have gastric atrophy that might or
[17]. Without blood loss, anemia takes several years to develop. might not be related to H. pylori infection [19]. Other factors
that commonly contribute to FCM in elderly people include
7. Folate deficiency anemia in the elderly chronic carriage of H. pylori and intestinal microbial prolifera-
tion (in which case cobalamin deficiency can be corrected by
A regular diet contains 500 to 700µg of folate. On average, 50 antibiotic treatment); long-term ingestion of antacids, including
to 60% of dietary folate is absorbed in the duodenum and H2-receptor antagonists and proton-pump inhibitors, and
Table 3
Manifestations related to vitamin B12 deficiency (with the exception of hematological manifestations)
Neuro-psychiatric manifestations Digestive manifestations Other manifestations
– Frequent: polyneurites (especially sensitive ones), – Classic: Hunter's glossitis, jaundice, – Under study: atrophy of the vaginal
ataxia, Babinski's phenomenon LDH and bilirubin elevation (“intramedullary mucosa and chronic vaginal and urinary
destruction”) infections(especially mycosis), venous
thromboembolic disease, angina
(hyperhomocysteinemia)
– Classic: combined sclerosis of the spinal cord – Debatable: abdominal pain, dyspepsia, nausea,
vomiting, diarrhea, disturbances in intestinal
functioning
– Rare: cerebellar syndromes affecting the cranial – Rare: resistant and recurring mucocutaneous
nerves including optic neuritis, optic atrophy, urinary ulcers cobalamin deficiency
and/or fecal incontinence
– Under study: changes in the higher functions, even
dementia, stroke and atherosclerosis
(hyperhomocysteinemia), parkinsonian syndromes,
depression, multiple sclerosis

4. E. Andrès et al. / European Journal of Internal Medicine 19 (2008) 488–493 491
Table 4 10. Clinical presentation in the elderly
Hematological manifestations of vitamin B12 deficiency in 201 patients with
documented cobalamin deficiency, followed in the department of internal
medicine in a tertiary reference center [23]
Fatigue, dispend, and other typical symptoms often occur
less severe anemia in elderly patients than would be expected
Parameters Values
with younger adults. The onset of symptoms is usually
Hemoglobin level (g/dL) 10.3 ± 0.4 (4.9–15.1) insidious, and many elderly patients adjust their activities. In
Mean erythrocyte cell volume (fL) 98.9 ± 25.6 (76–142)
elderly, these symptoms of anemia are likely to be overlooked.
Reticulocyte count (%) 15.2 (1–32)
White cell count (/mm3) 6200 ± 4100 (500–20,000) In this situation, pallor can be helpful but hard to detect [2]. The
Platelet count (103/mm3) 146 ± 42 (27–580) symptoms of other diseases may be exacerbating if anemia is
Anemia with Hb level b12 g/dL 37% also present. Therefore anemia should be considered when
Anemia with Hb level b6 g/dL 2.5% patients present worsening of heart or lung disease. Anemia can
Anemia and macrocytosis (MECV N 100 fL) 33.8%
also contribute to problems, such as decreased mobility,
Isolated macrocytosis (VGM N 100 fL) 17%
Microcytosis (VGM b 80 fL) 5% dizziness, cognitive impairment, and even depression [1].
White cell count b4000/mm3 14% Moreover, symptoms related to nutrient deficiency (iron,
Neutrophile count b1000/mm3 3% vitamin B12 and folate) may be present, outside the hematological
Thrombopenia (b150 × 103/mm3) 10% sphere. Table 3 presents features related to vitamin B12 deficiency
Neutrophile hypersegmentation 32%
in elderly patients [19]. It should be noted that vitamin B12
Megaloblastosis 60%
Life threatening manifestations 9% deficiency may be present even in the absence of anemia. The
symptoms of folate deficiency are nearly indistinguishable from
those of cobalamin deficiency. Iron deficiency is responsible for
changes in hair, nails, mucosa and tongue as pruritus, chronically
biguanides (metformin); chronic alcoholism; surgery or gastric sustained inflammation, dermatitis herpetiformis, photodermati-
reconstruction (e.g. bypass surgery for obesity); partial and tis, and Plummer's syndrome [22].
pancreatic exocrine failure [20]. Nutrient-deficiency anemia in elderly is generally hypor-
egenerative and represents the consequence of the older he-
9. Rare causes of nutrient-deficiency anemia in the elderly matopoietic system to replace the peripheral blood loss [2,3].
Elderly patients with nutrient-deficiency anemia often have
In elderly patient, often malnourished, rare unknown causes mild to moderate anemia with Hb levels between 8 and 10g/dL.
of nutrient-deficiency anemia also include: 1) several vitamin In practice, because of the multifactorial etiologies of anemia in
deficiencies: vitamin A, vitamin E, vitamin B2 (riboflavin), elderly, the erythrocytes are frequently normocytic: mean
vitamin B3 (in pellagra), vitamin B6 (pyridoxine) and vitamin C erythrocyte cell volume (MECV) between 80 and 100fL. In
(in scurvy); and 2) several mineral deficiency as zinc or copper anemia of exclusive iron deficiency, the erythrocytes are usually
deficiencies. microcytic (MECV b 80fL). In anemia of exclusive folate and/
Table 5
Personal experience on oral cobalamin therapy: results on hematological manifestations [27]
Study characteristics (number of patients) Therapeutic modalities Results
Open prospective study of well-documented Oral crystalline cyanocobalamin: 650 µg – Normalization of serum vitamin B12 levels
vitamin B12 deficiency related to food- per day, during at least 3 months in 80% of the patients
cobalamin malabsorption (n = 10) – Significant increase of Hb levels (mean of
1.9 g/dL) and decrease of MECV (mean of 7.8 fL)
Open prospective study of low vitamin B12 Oral crystalline cyanocobalamin: 1000 µg – Normalization of serum vitamin B12 levels in
levels not related to pernicious anemia (n = 20) per day during at least 1 week 85% of the patients
Open prospective study of well-documented Oral crystalline cyanocobalamin: between – Normalization of serum vitamin B12 levels in 87%
vitamin B12 deficiency related to food- 1000 and 250 µg per day, during 1 month of the patients
cobalamin malabsorption (n = 30) – Significant increase of Hb levels (mean of 0.6 g/dL)
and decrease of MECV (mean of 3 fL); normalization
of Hb levels and ECV in 54% and 100% of the patients,
respectively
– Dose effect — effectiveness dose of vitamin
B12 ≥500 µg per day
Open prospective study of low vitamin B12 Oral crystalline cyanocobalamin: between 1000 – Normalization of serum vitamin B12 levels in all
levels not related to pernicious anemia (n = 30) and 125 µg per day during at least 1 week patients with at least a dose of vitamin ≥250 µg per day
– Dose effect — effectiveness dose of vitamin
B12 ≥500 µg per day
Open prospective study of low vitamin B12 Oral crystalline cyanocobalamin: 1000 µg – Significant increase of serum vitamin B12 levels in
levels related to pernicious anemia (n = 10) per day, during at least 3 months 90% of the patients (mean of 117.4 pg/mL)
– Significant increase of Hb levels (mean of 2.45 g/dL)
and decrease of MECV (mean of 10.4 fL)
Hb: hemoglobin. MECV: mean erythrocyte cell volume.

5. 492 E. Andrès et al. / European Journal of Internal Medicine 19 (2008) 488–493
or vitamin B12 deficiency, the erythrocytes are usually macro- 13. Conclusion
cytic (MECV N 120fL). Other hematological manifestations
may be associated as presented in Table 4, with the example In conclusion, nutrient-deficiency anemia represents around
of cobalamin deficiency [23]. A low serum iron level, an in- one third of all anemias in elderly patients. About two thirds of
creased total iron-binding capacity, and a low serum ferritin nutrient-deficiency anemias are associated with iron deficiency
level (b 15ng/mL) accompany iron deficiency anemia [2,15]. and most of those cases are the result of chronic blood loss
In cobalamin deficiency, serum vitamin B12 level is low from gastrointestinal lesions. The remaining cases of nutrient-
(b 200pg/mL), serum methylmalonic acid and homocysteine deficiency anemia are usually associated with vitamin B12,
levels are increased [19]. In folate deficiency, the red cell most frequently related to food-cobalamin malabsorption, and/
folate concentration is more reliable than the serum level and or folate deficiency. All these nutrient-anemias are easily treated
should be considered. with nutrient-deficiency replacement.
11. Complications of anemia in the elderly 14. Learning points
Anemia in older individuals is associated with a very wide • Nutrient-deficiency anemia represents one third of all ane-
range of complications, including increased risk for mortality, mias in elderly patients.
cardiovascular disease — anemia has been reported to worsen • About two thirds of nutrient-deficiency anemias are as-
angina and congestive heart failure, cognitive dysfunction related sociated with iron deficiency and most of those cases are the
to cerebrovascular insufficient, longer hospitalization for elective result of chronic blood loss from gastrointestinal lesions.
procedures and comorbid conditions, reduced bone density, and • The remaining cases of nutrient-deficiency anemia are
falls and fractures [1,5,24]. Not surprisingly, anemia also has a usually associated with vitamin B12, most frequently related
significant effect on quality of life (QOL) in the elderly. Notably, to food-cobalamin malabsorption, and/or folate deficiency.
these detrimental effects are observed not only in elderly • Treatment of nutrient-deficiency anemia is easy with
individuals with severe reductions in Hb, but also in those with nutrient-deficiency replacement but requires particular
mild anemia or low–normal Hb levels [1]. Nutrient deficiency attention to discerning the cause.
usually may be associated with several manifestations that also
may have an impact on health and QOL in elderly patients. References
12. Treatment of nutrient-deficiency anemia
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