Anemia associated with higher risk of death in the elderly

October 24, 2005

CHICAGO - Elderly people with the lowest and highest hemoglobin concentrations (the component of red blood cells that carries oxygen) are at increased risk of death, according to a study in the October 24 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Increasing evidence indicates that anemia is common in the elderly population, but few studies have assessed the association of anemia with clinical outcomes, such as illness and death, according to background information in the article. Anemia is defined by the World Health Organization (WHO) as a hemoglobin concentration of less than 12 g/dL (grams per one tenth liter) for women and less than 13 g/dL for men.

Neil A. Zakai, M.D., of the University of Vermont College of Medicine, Burlington, compared the association of hemoglobin concentration and anemia status with subsequent death over the course of eleven years in elderly adults living in four U.S. communities. Hemoglobin concentrations were determined for participants recruited between 1989 and 1993. Participants were contacted biannually; telephone and clinic examinations were conducted alternately. Deaths were reviewed and classified as cardiovascular or noncardiovascular. Complete follow-up was available through June 2001 for this analysis.

Hemoglobin concentration was analyzed in two ways: by dividing the participants' baseline hemoglobin into five equal levels and by the WHO criteria for anemia. Based on the WHO criteria for anemia, 498 individuals were anemic on enrollment (8.5 percent of the 5,797 included in the analysis), the researchers report. The hemoglobin concentration for the 1,205 individuals in the lowest fifth was higher than the WHO criteria for anemia, and 41.3 percent of these 1,205 people did qualify as anemic by WHO standards.

"In this elderly cohort, the prevalence of anemia was 7.0 percent among white and 17.6 percent among black individuals," the authors write. "After 11.2 years of follow-up, lower hemoglobin concentrations were associated with increased mortality risk, independent of many potentially confounding factors. The magnitude of this association was similar whether the lowest quintile [fifth] of hemoglobin or the WHO criteria for anemia was used; however, the number of participants was much larger when considering the lowest quintile of hemoglobin concentration." Another finding of the study was that there was also elevated mortality among those in the highest hemoglobin quintile, even after extensive adjustment for other factors.

"In conclusion, a lower hemoglobin concentration was independently associated with mortality in this elderly cohort," the authors write. "The bottom hemoglobin quintile defined a larger group at risk than anemia status based on WHO criteria. Future areas of investigation should determine the optimal hemoglobin value that defines an abnormal concentration in elderly individuals, study the causes of low hemoglobin concentrations in elderly individuals and how these relate differentially to outcomes, evaluate the causes of increased mortality in individuals with low and high hemoglobin concentrations, and assess whether treatment of low hemoglobin in the general population reduces mortality."
(Arch Intern Med. 2005; 165: 2214-2220. Available pre-embargo to media at

Editor's Note: This research was supported by contracts from the National Heart, Lung, and Blood Institute, Bethesda, Md. Dr. Cushman has received research funding in the form of a subcontract with the University of Alabama funded by Amgen; the project is not related to this article.

Editorial: Anemia in the Elderly
Time for New Blood in Old Vessels?

In an accompanying editorial, Jerry L. Spivak, M.D., of The Johns Hopkins University School of Medicine, Baltimore, Md., writes, "The four articles in this issue of the Archives usefully highlight and advance our conceptions of the cause of anemia in the elderly and anemia's health-related impact. Anemia, of course, is always the consequence of another disorder, and correction of the underlying disorder is the most effective means of alleviating the anemia. However, anemia in the majority of the elderly is caused by conditions such as chronic renal insufficiency, chronic inflammation, cancer, or bone marrow failure, some of which are actually an aftermath of the aging process and most of which defy correction. It is now also well established that anemia frequently exacerbates the illness causing it, while having its own independent adverse effects."

"What remains to be determined is whether pharmacologic correction of anemia ... can slow disease progression, reduce morbidity [illness], improve quality of life, and prolong survival, and whether there is a favorable cost-benefit ratio to society for such improvements," Dr. Spivak continues. "Recent failed attempts to answer these questions in the setting of renal failure or cancer indicate that this will not be an easy task, but the prospect of a doubling in the number of elderly persons over the next 25 years indicates that it is a task that cannot be ignored or deferred."

(Arch Intern Med. 2005; 165: 2187-2189. Available pre-embargo to media at

For more information, contact JAMA/Archives Media Relations at 312-464-JAMA (5262) or email

Media Advisory: To contact corresponding author Mary Cushman, M.D., M.Sc., call Jennifer Nachbur at 802-656-7875. To contact editorial author Jerry L. Spivak, M.D., call John Lazarou at 410-502-8902.

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