|Year : 2017 | Volume
| Issue : 3 | Page : 794-799
Anemia among the elderly attending a family health center, Menoufia University, Egypt
Enshad Badawy MSc , Hala M Shaeen, Nagwa N Hegazy, Enshad E Mohammed
Department of Family Medicine, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt
|Date of Submission||19-Sep-2016|
|Date of Acceptance||02-Jan-2017|
|Date of Web Publication||15-Nov-2017|
Shebin El-Kom, Menoufia, 32511
Source of Support: None, Conflict of Interest: None
The aim of the present study was to assess the prevalence of anemia and the associated cognitive and nutritional status among the elderly attending the Munshat Sultan Family Health Center.
Anemia is a common health problem with serious consequences among the elderly. Multiple studies demonstrate that anemia is an independent risk factor for increased morbidity and mortality among the elderly.
Patients and methods
This case-controlled, cross-sectional study was conducted on 200 elderly persons of both sexes recruited from Munshat Sultan Family Health Center, Menoufia district, Menoufia governorate, Egypt. Initially, the sample size was calculated to be 163, which was then increased to 200. All participants underwent a comprehensive medical history and clinical evaluation, and then complete blood count was measured, and anemia was defined according to the WHO criteria (hemoglobin level <13 g/dl in men and <12 g/dl in women).
The study revealed that the prevalence of anemia was 17.5% among the participants (19.3% among men and 16.7% among women), 16% had mild anemia, and 1.5% had moderate anemia, which significantly increased with age in the anemic group compared with the nonanemic group. Anemia increased significantly among participants with a history of blood loss and intake of NSAIDs (P = 0.01 and 0.003, respectively). The impact of anemia on functional status showed a significant difference between anemic and nonanemic groups as regards instrumental activity of daily living; moreover, there was a significant correlation between anemia and minimental state examination (P < 0.001), with worse performance among the anemic ones.
Anemia represented a significant health problem among the elderly with bad drawbacks on their functional level and cognitive function.
Keywords: anemia, cognition, elderly, functional status, nutrition
|How to cite this article:|
Badawy E, Shaeen HM, Hegazy NN, Mohammed EE. Anemia among the elderly attending a family health center, Menoufia University, Egypt. Menoufia Med J 2017;30:794-9
|How to cite this URL:|
Badawy E, Shaeen HM, Hegazy NN, Mohammed EE. Anemia among the elderly attending a family health center, Menoufia University, Egypt. Menoufia Med J [serial online] 2017 [cited 2019 Dec 10];30:794-9. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/794/218286
| Introduction|| |
Anemia is a common condition at all ages. More than two billion individuals have anemia worldwide, especially in underdeveloped and developing countries . This is especially true among the older population as the prevalence of anemia rises with advancing age . According to the results of some epidemiologic studies, the prevalence of anemia among adults increases sharply after the age of 60 years .
Prevalence figures of anemia in the elderly vary among different countries. Elderly anemia prevalence of 11 and 10.2% in free-living men and women aged 65 years and above in the USA has been reported . Another study carried out in Italy showed that 11.8% of the elderly were anemic . In south Brazil, a prevalence of 12.8% in a population of elderly persons was documented . In Egypt, a study in Meet Abbad-Nabaroh, Dakahlia, revealed that the prevalence of anemia among the elderly was about 15% .
Although it was previously believed that a decline in hemoglobin level might be a normal consequence of aging, evidence has accumulated that anemia reflects poor health and increased vulnerability to adverse outcome in older persons . The consequences of anemia in the elderly range from a general perspective regarding its negative impact on quality of life , to specifics such as diminished cognitive function  and decreased physical performance and muscle strength . Some studies demonstrated that anemia impaired both cognitive functions and daily living activities in the elderly ,. Therefore, anemia should be treated properly among the elderly . The prevalence and etiology of anemia in free-living elderly people of developing countries is not well established. In Egypt studies assessing the prevalence of anemia among community-dwelling elderly were lacking; therefore, the objectives of this study were to assess the prevalence of anemia and the associated cognitive and nutritional status among the elderly attending the Munshat Sultan Family Health Center.
| Patients and Methods|| |
This case-controlled, cross-sectional study was performed on 200 elderly persons aged 60 years and older of both sexes attending Munshat Sultan Family Health Center, in Menoufia district, Menoufia governorate, Egypt. Initially, the sample size was calculated to be 163, which was then increased to 200 to round off the figure. The sample size was calculated on the basis of the prevalence of anemia in the elderly using the Center for Surveillance, Epidemiology & Laboratory Services (CSELS), GA, USA calc program, version 12. The total population in the catchment area was 910. Considering the prevalence of anemia according to review of literature 15.05% and using 80% the power of the study . The study was approved by the Ethics Committee of Menoufia University.
After obtaining their oral consent, all participants were subjected to the following:
- A careful history taking including personal data, special habits, for example, smoking, socioeconomic history using El Gilany et al.  socioeconomic scoring, and detailed medical history
- Assessment of cognitive function using the minimental state examination (MMSE) 
- Assessment of function using activity of daily living  and instrumental activity of daily living (IADL) . Assessment of nutritional status by a validated mininutritional assessment short form 
- Physical examination that included measurement of weight, height, and BMI
- Complete blood picture, performed in the same health facility laboratory for the assessment of the type of anemia regarding red blood cells size and hemoglobin percentage on Advia 2120 (Siemens Poland, Wielkopolskie, Poland) .
Statistical and analyses were carried out by using the statistical package of the social science (SPSS, version 20; IBM Personal Computer, IBM (NY, USA)). Quantitative data were expressed as mean and SD, and analyzed by using Student's t-test. Qualitative data were expressed as number and percentage and analyzed by using the χ2-test. P value less than 0.05 was considered statistically significant
| Results|| |
The prevalence of anemia among the studied participants was found to be 17.5% [Figure 1]. About 16% of the participants had mild anemia (hemoglobin from 10 to 11.99 g%) and only 1.5% had moderate anemia (hemoglobin from 7.1 to 9.99 g%), whereas no participant had severe anemia (hemoglobin <7 g%).
|Figure 1: Frequency of anemia among the studied group and classification of anemia according to hemoglobin percentage.|
Click here to view
Based on mean corpuscular volume and mean corpuscular hemoglobin concentration, 6% of the participants had microcytic hypochromic anemia and 11.5% had normocytic normochromic anemia [Figure 2].
|Figure 2: Classification of the studied group as regards mean corpuscular volume and mean corpuscular hemoglobin concentration. MHA, microcytic hypochromic anemia; NNA, normocytic normochromic anemia.|
Click here to view
On comparing between anemic (n = 35) and nonanemic (n = 165) participants regarding demographic data, this study showed that the prevalence of anemia increased with increasing age (P = 0.005). It also showed that the prevalence of anemia was higher among men (19.3%) than among women participants (16.7%). This study also reported a highly significant relation between the prevalence of anemia and low sociodemographic score (P < 0.001) [Table 1].
|Table 1: Comparison between anemic and nonanemic groups as regards personal characteristics of the participants|
Click here to view
A comparison between these two groups regarding past medical history showed that the anemic group had a significant history of blood loss and use of NSAIDs (P = 0.01 and 0.003, respectively) [Table 2].
|Table 2: The comparison between anemic and non-anemic groups as regards possible risk factors|
Click here to view
There was a highly significant relation between anemia and malnutrition. About 34% of the anemic group had malnutrition and about 51% were at a risk for malnutrition (P < 0.001) [Table 3].
|Table 3: Comparison between anemic and non-anemic groups as regards total scores of the following questionnaires: mini nutritional assessment short form, activity of daily living, instrumental activity of daily living, and minimental state examination|
Click here to view
On comparing both groups (anemic vs. nonanemic) as regards functional status, a statistically significant difference was found between both groups as regards IADL where anemia affected the functional abilities of the studied anemic group (P = 0.02), but there was no statistically significant relation to activity of daily living. And on comparing both groups (anemic vs. nonanemic) as regards cognitive functions, there was a statistically highly significant difference between both groups as regards the MMSE. About 80% of the anemic group had cognitive impairment (P < 0.001), as shown in [Table 3].
| Discussion|| |
The reported prevalence of anemia among the elderly in the present study was in agreement with a study in Meet Abbad-Nabaroh, Dakahlia, conducted on 93 participants, that found the prevalence of anemia among the elderly to be about 15%; this finding was slightly lower than that of the present study . A cross-sectional study conducted by Kamel et al.  on 175 participants (60 years and older) selected from geriatric clubs in Cairo and Giza governorates in Egypt revealed that the prevalence of anemia in geriatric clubs was 24%, which was much higher than that in this study (17.5%); this difference may be attributed to different demographic characteristic of the participants of both studies, including that in the current study the participants had more homogenous criteria.
The findings of the current study were also in agreement with the international prevalence rates in Japan and Taiwan (17.9 and 18.8%, respectively) ,.
In contrast, the current prevalence was relatively high compared with other studies: the prevalence of anemia in other countries such as the USA, Italy, and Germany was reported to be 10.6, 11.8, and 4.3%, respectively ,,. This may be due to difference in sociodemographic characteristics of the participants.
On the other hand, this study showed a lower prevalence of anemia than did other studies. In Turkey, a study reported a prevalence of anemia of 32.5% among 501 older outpatients . Another study found 32% of 430 community-dwelling elderly living in the northeast of Turkey to be anemic, according to WHO anemia criteria . In India, a study revealed that anemia was a significant public health challenge among the elderly, with a prevalence rate of 29.86% .
Differences in anemia definition criteria, in study populations, and in age limits for inclusion in studies are possible reasons for variability in the reported results.
Based on mean corpuscular volume and mean corpuscular hemoglobin concentration, this study showed that 6% of participants had microcytic hypochromic anemia and 11.5% of participants had normocytic normochromic anemia. This was in agreement with the findings of studies conducted in the USA, Italy, and Germany ,,.
In the current study, 16% of the participants had mild anemia and 1.5% had moderate anemia, whereas no participant had severe anemia. These results were in agreement with the results from a study conducted in Meet Abbad-Nabaroh, Dakahlia, that showed that 93.5% of the anemic participants had mild anemia and only 6.5% had moderate anemia, whereas no participant had severe anemia .
The current study showed that the prevalence of anemia significantly increased with increasing age, which was in agreement with the results of the studies conducted in Italy, Egypt, and India ,,.
As regards sex differences, the prevalence among men participants was higher than that among women in the current study. This was in agreement with the findings of a study in Meet Abbad-Nabaroh, Dakahlia, in which 14.5% of the women and 16.1% of the men were found to be anemic . Another study conducted on the elderly recruited from geriatric clubs in Cairo and Giza governorates found a significant statistical relation between anemia and sex – men had a higher prevalence of anemia than did women . In addition, Tettamanti et al.  found that 14.1% of elderly men and 12.6% of elderly women were anemic; another study found that 11.0% of men and 10.2% of women aged 65 and older and living in the USA were anemic according to the WHO criteria .
On the other hand, there were other studies that found that the prevalence of anemia was higher in women than in men, as in a study conducted on 1716 community residents aged 60 years or older, 14.1% women and 10.2% men had anemia ; moreover, another study conducted 1016 community-dwelling elderly found that 28% of women and 17% of men were anemic , and a study on 1016 participants, 67–96 years of age, found 10.5% of women and 6.1% of men were anemic .
The differences between the findings of the studies regarding sex prevalence of anemia need to be further assessed and explained on physiological basis, as there is some explanation for this difference: women show a lower prevalence of anemia than do men in most studies simply because the WHO definition is 13 g/dl in men and 12 g/dl in women . It is useful to question whether 15 years and more after menopause it is reasonable that women should continue to have lower hemoglobin levels than men.
The current study showed a statistically significant difference in the frequency of anemia among participants as regards history of blood loss and NSAIDs intake. This was in agreement with the results of the study performed in Dakahlia, as there was a significant correlation between history of blood loss and frequency of anemia (P = 0.001); furthermore, there was a highly significant correlation between intake of NSAIDs and anemia (P > 0.001) . Multiple studies have demonstrated a significant relation between history of blood loss and anemia .
This study also showed that the prevalence of anemia was higher among participants with low sociodemographic score, which was in agreement with the finding that iron deficiency is most common among groups of low socioeconomic status .
As regards nutritional assessment of the studied group, this study showed a highly significant relation between anemia and malnutrition. This was partially in agreement with the findings of other studies ,.
In the current study, the comparison between anemic and nonanemic participants as regards functional assessment tools found a significant difference in IADL, where anemia affected the functional abilities of the studied groups, making the anemic group more dependent than the non-anemic one. This was in agreement with the findings of other epidemiologic studies that reported an association between anemia, even mildly low hemoglobin level, and a worse outcome of IADL . Furthermore, it was in agreement with Andro et al.  and Kamel et al.  who found more impairment in functional status in the anemic than in the non-anemic group.
On comparing the anemic and nonanemic groups regarding the assessment of cognitive function using MMSE, this study showed a highly statistically significant difference – that is to say, even mild anemia can cause diminished cognitive function.
This was in agreement with a study that concluded a significant positive association between anemia and global cognitive decline . Another study conducted by Terekeci et al.  and a study in Egypt by Kamel et al.  found more impairment in cognition (MMSE) in the anemic than in the nonanemic group.
| Conclusion|| |
According to the WHO definition of anemia, the prevalence of anemia among the studied groups was reported to be 17.5%, with a significant increase with age. It exerted negative impact on both cognition and physical activity of the participants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abdel-Rasoul GM, El Bahnasy RE, El Shazly HM, Gabr HM, Abdel-Aaty NB. Epidemiology of iron-deficiency anemia among primary school children (6-11 years), Menoufia governorate, Egypt. Menouf Med J 2015; 28
Mindell J, Moody A, Ali A, Hirani V. Using longitudinal data from the Health Survey for England to resolve discrepancies in thresholds for hemoglobin in older adults. Br J Haematol 2013; 160
Patel KV. Epidemiology of anemia in older adults. Semin Hematol 2008; 45
Guralnik JM, Eisenstaedt RS, Ferrucci L, Klein HG, Woodman RC. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood 2004; 104
Tettamanti M, Lucca U, Gandini F, Recchia A, Mosconi P, Apolone G, et al.
Prevalence, incidence and types of mild anemia in the elderly: the health and anemia population based study. Haematologica 2010; 95
Sgnaolin V, Engroff P, Ely LS, Schneider RH, Schwanke CH, Gomes I, et al.
Hematological parameters and prevalence of anemia among free-living elderly in south Brazil. Rev Bras Hematol Hemoter 2013; 35
Kamel MA, Ebeid SM, Elakkad RM, Shafeek NE. Prevalence of anemia among community dwelling elderly in Dakahlia as a representative of rural areas in Egypt and its impact on their functional status. Adv Aging Res 2015; 4
Price EA, Mehra R, Holmes TH, Schrier SL. Anemia in older persons: etiology and evaluation. Blood Cells Mol Dis 2011; 46
Ross SD, Fahrbach K, Frame D et al.
The effect of anemia treatment on selected health-related quality-of-life domains: a systematic review. Clin Ther 2003; 25
Chaves PH, Carlson MC, Ferrucci L, Guralnik JM, Semba R, Fried LP. Association between mild anemia and executive function impairment in community-dwelling older women: the women's health and aging study II. J Am Geriatr Soc 2006; 54
Penninx BW, Guralnik JM, Onder G, Ferrucci L, Wallace RB, Pahor M. Anemia and decline in physical performance among older persons. Am J Med 2004; 115
Andro M, Le Squere P, Estivin S, Gentric A. Anemia and cognitive performances in the elderly: a systematic review. Eur J Neurol 2013; 20
Terekeci HM1, Kucukardali Y, Onem Y, Erikci AA, Kucukardali B, Sahan B, et al.
Relationship between anemia and cognitive functions in elderly people. Eur J Intern Med 2010; 21
Kim HS, Lee BK. Cross-sectional study on the prevalence of anemia among rural elderly in Asan. Nutr Res Pract 2008; 2
El Gilany A, El Wehady A, El Wasefy M. Updating and validation of the socioeconomic status scale for health research in Egypt. East Mediterr Health J 2012; 18
Hartigan, I. A comparative review of the Katz ADL and the Barthel index in assessing the activities of daily living of older people. Int J Older People Nurs 2007; 2
Graf C. The Lawton instrumental activities of daily living scale. Am J Nurs 2008; 108
Kaiser MJ, Bauer JM, Ramsch C. Validation of the mini nutritional assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13
Pervoic E. Overview of some clinically relevant parameters of hematological analyzer ADVIA 2120. Biochemia Medica 2009; 19
Hayashi F, Yoshiike N, Yoshita K, Kawahara K. Trends in the prevalence of anemia in Japanese adult women, 1989-2003. Public Health Nutr 2008; 11
Wang JL, Shaw NS. Iron status of the Taiwanese elderly: the prevalence of iron deficiency and elevated iron stores. Asia Pac J Clin Nutr 2005; 14
Eisele L, Dürig J, Broecker-Preuss M, Dührsen U, Bokhof B, Erbel R, et al.
Prevalence and incidence of anemia in the German Heinz Nixdorf recall study. Ann Hematol 2013; 92
Erkan, E, Muslu M, Sandikci S. The prevalence and clinical characteristics of anemia in elderly patients. Akad Geriatri 2011; 3
Yıldızhan E, Aydın Y, Coskun H, Kudas O. The prevalence and characteristics of anemia in geriatrics in the west black sea region, Turkey. Turk J Geriatr 2014; 17
Malhotra V, Krishna H, Bharti D. An epidemiological study on prevalence of anemia among elderly population residing in rural Nalgonda, Telangana, India. Sch J App Med Sci 2012; 3
Choi CW, Lee J, Park KH, Choi IK, Kim SJ, Seo JH, et al.
Prevalence and characteristics of anemia in the elderly: community-based study. Blood 2001; 98
Fleming DJ, Jacques PF, Dallal GE, Tucker KL, Wilson PW, Wood RJ. Iron status of the free-living, elderly Framingham heart study cohort: an iron-replete population with a high prevalence of elevated iron stores. Am J Clin Nutr 2001; 73
Niv E, Elis A, Zissin R, Naftali T, Novis B, Lishner M. Iron deficiency anemia in patients without gastrointestinal symptoms—a prospective study. Fam Pract 2005; 22
Smith DL. Anemia in elderly. Am Fam Physician 2000; 62
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]