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CNE Objectives and Evaluation Form appear on page 305.

Anemia in Older Adults

Ayhan Aytekin Lash Sharon M. Coyer Anemia in the older adult is associated with changes in quality of life, decreased cognition and functional ability, and an increased risk for falls, infections, morbidity, and mortality. The prevalence, etiology, pathophysiology, and diagnosis of anemia in older adults are reviewed. Collaborative interventions that assist the older adult, the family, and health care professionals in its management are identified.

Ayhan Aytekin Lash, PhD, RN, FAAN, is a Professor, Northern Illinois University, School of Nursing, DeKalb, IL, and a member of the MEDSURG Nursing Editorial Board. Sharon M. Coyer, PhD, CPNP, APN, is an Associate Professor, Northern Illinois University, School of Nursing, DeKalb, IL. Note: The authors and all MEDSURG Nursing Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article.

esearch shows that anemia in the older adult is a common problem as the prevalence of the disease increases with each decade of life once individuals reach age 70 (Beghe, Wilson, & Ershler, 2004; Bhat, Kirmani, & Raw, 2008; Guralnik, Ershler, Schrier, & Picozzi, 2005). From 2000 to 2004, anemia was the cause of death for about 10% of Americans age 65 and older, or over 3.6 million persons (National Center for Health Statistics [NCHS], 2007). With the size of the aging population expected to more than double, reaching 71.5 million by 2030 (MetLife Mature Market Institute, 2008), the prevalence of anemia is likely to increase substantially in the near future. Anemia in the older adult has been reported to have reached crisis levels as anemia is associated with changes in the quality of life, decreased cognition and functional ability, and an increased risk for falls, infections, morbidity, and mortality (Bhat et al., 2008; Guralnik et al., 2005). The prevalence, etiology, classification, and diagnosis of anemia in older adults are reviewed and collaborative interventions identified for its management.

Prevalence
Research investigating the prevalence of anemia in older adults has shown mixed results due to variations in study designs, sample size, population characteristics, and even criteria used to define anemia. The majority of studies (Beghe et al., 2004; Dharmarajan, Avula, & Norkus, 2006) use hemoglobin concentration to define anemia, with separate

threshold values for women and men as established by the World Health Organization (WHO) (<12.0 g/dL for women and <13.0 g/dL for men) (Beghe et al., 2004; Dharmarajan et al., 2006). Hematocrit values, alone or along with hemoglobin concentration, also were used to assess anemias prevalence (Beghe et al., 2004; Thomas, 2004). Study populations also vary, with some healthy and living at home and others living in institutionalized settings (Guralnik, Eisenstaedt, Ferrucci, Klein, & Woodman, 2004). In spite of these variations, however, consistent patterns have emerged. A systematic review of 71 studies investigating the prevalence of anemia in adults age 65 and older, found the prevalence of the disease to be 3.3%-41% among women and 2.9%-61% among men (Beghe et al., 2004). The wide range found in this study illustrates the difficulty with absolute assessment of prevalence of anemia among older adults. The most unswerving finding of this systematic review was the strong positive relationship of anemia with age: the higher the age, the higher the prevalence of the disease. The greatest prevalence occurred after age 85, when individuals have anemia 2-3 times more often than the younger cohorts. In addition, the highest rates for both men and women occurred among hospitalized older adult in acute-geriatric units, and those living in institutional settings such as nursing homes. By contrast, the lowest rates were among those living independently.

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The most comprehensive studies investigating the prevalence of anemia in older adults were reported by Guralnik and colleagues (2004, 2005). Both studies used data from the Third National Health and Nutrition Examination Survey (NHANES) (NCHS, 1996). The original NHANES III data (Guralnik et al., 2004) were obtained from 39,695 persons, 5,252 of whom were community-dwelling persons age 65 and older. Blood tests identified anemia using the hemoglobin results defined by WHO. Data on co-morbidities, race, gender, and ethnicity also were collected. This large study found the overall prevalence of anemia in the population age 65 or older to be 10.6%, with a prevalence of 11% for men and 10.2% for women. The slightly higher overall prevalence of anemia in men was attributed to the higher threshold set for them. More significant, however, was the pronounced increase in the prevalence of anemia by age; among those age 85 and older, 26% of men and 20% of women (see Figure 1) were anemic, a disparity that continues into advanced age brackets. Moreover, substantial differences existed in the prevalence of anemia by race and ethnicity: non-Hispanic Whites 9%, Mexican-Americans 10.4%, and non-Hispanic Blacks 27.8%, nearly a three-fold increase in this group (see Table 1). Other researchers corroborated these findings in ethic differences. In their sample of 1,744 men and women age 71 or older and living at home, Denny, Kuchibhatla, and Cohen (2006) found that anemia was three times more prevalent among African Americans than their Caucasian counterparts. Other similar results also had been reported (Salive et al., 1992). In summary, studies show that anemia is more prevalent among those over age 70, are male, are nonHispanic Blacks, and live in institutional settings.

Figure 1. Percentage of Persons Considered Anemic According to Age and Gender

30 Male Percent Who Have Anemia 25 20
15.7% 20.1%

Female

26.1%

15 10
6.0% 8.7%

12.2% 10.3% 6.8% 4.4% 1.5% 8.5% 7.8%

5 0

1-16

17-49

50-64

65-74

75-84

85+

Age Group (Years) Source: NCHS, 1996.

Table 1. Percentage of Persons 65 and Older Anemic by Race/Ethnicity and Sex

Race/Ethnicity Non-Hispanic Black Mexican American Non-Hispanic White Other Total Male (%) 27.5 11.5 9.2 20.4 11.0 Female (%) 28.0 9.3 8.7 7.5 10.2 Total (%) 27.8 10.4 9.0 14.0 10.6

Sources: Guralnik et al., 2004; NCHS, 1996.

Etiology and Pathophysiology

Three broad etiologies of anemia in the older adult have been proposed (Guralnik et al., 2004; Joosten et al., 1992). These are anemias due to blood loss/nutritional deficiencies, anemias due to chronic illness/inflammation or chronic kidney disease (CKD), and those due to unexplained etiologies. Anemias due to blood loss/nutritional deficiencies. This type of anemia in older adults accounts for 34% of all the cases (Guralnik et al., 2005; Spivak, 2000) and is related to either insufficiency of raw material to produce erythro-

cytes or excessive loss of the erythrocytes. Nutritional deficiencies are related to iron, vitamin B12, and folate (Guralnik et al., 2005). These vitamins are essential both for normal hematopoiesis and maturation of many other types of cells. DNA synthesis is impaired in their absence, leading to the production of abnormally large erythrocytes called megaloblasts. Some 15%-30% of all anemias found in the older adult are due to iron deficiency (Guralnik et al., 2005; Joosten et al., 1992). Another 20% are due to B12 (cobalamin) deficiency (Andres et al., 2004;
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Guralnik et al., 2004). However, the older adult is B12 deficiency (Andres et al., 2004) is caused primarily by food-cobalamin malabsorption (60%-70%) and pernicious anemia (15%-20%), rather than poor intake. Diet deficiency alone is responsible (Guralnik et al., 2005) for less than 5% of the B12 deficiencies; in fact, only 1%-2% of anemias are due to B12 deficiency alone (Guralnik et al., 2005). If untreated, B12 deficiency anemia can lead to serious neurological complications, such as polyneuritis and optic neuritis (Andres et al., 2004). Similarly, folate deficiency is uncommon among older adults due to the established practice of taking vitamins and other nutritional supplements (Guralnik et al., 2005). If folate deficiency appears, as in megaloblastic anemia, the etiology may be due to alcohol abuse; alcohol impairs absorption of folic acid (Guralnik et al., 2005). Identification of nutritional deficiency anemias represents one of the most effective opportunities to treat anemia in the older adult. Both the folate and B12 deficiencies may be treated easily with supplements once the etiology of nutritional deficiency is established (Guralnik et al., 2005). Most adults with iron deficiency have excess blood loss from the gastrointestinal (GI) tract (Guralnik et al., 1994; Ioannou, Spector, Scott, & Rockey, 2002). Chronic blood loss can occur due to bleeding ulcers, hemorrhoids, cancer, intestinal lesions, and polyps. A prospective study considered hospitalized iron-deficient (serum ferritin less than 50 mg/L) patients, age 70 and older, with or without anemia (defined as hemoglobin <13 g/dL for men, <12 g/dL for women) (Joosten et al., 1999). Of 151 persons in the study, 97 (about 64%) had both anemia and iron deficiency. Of this group, about 50% (with or without anemia) had bleeding upper GI lesions. However, the majority
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(60%) of patients with the lesions had no GI symptoms masking the etiology of the anemia. Two other studies (Ioannou et al., 2002; Rockey & Cello, 1993) reported similar results as colon cancer and premalignant tumors were common among patients with iron deficiency anemia (IDA). The researchers recommended that among iron-deficient older adults, with or without low hemoglobin, endoscopic studies may be of diagnostic value to find the underlying etiology (Ioannou et al., 2002; Joosten et al., 1999). Anemia of chronic illness/inflammation or CKD. This etiology often encompasses any anemia in persons with a high burden of chronic disease without a clearly defined etiology (Guralnik et al., 2004). Hence, the anemia of chronic illness (ACI) may include patients with rheumatoid arthritis, systemic lupus erythematosus, acute or chronic hepatitis, chronic renal failure, congestive heart failure (CHF), and malignancies (Cavill et al., 2006; Luthi, Flanders, Burnier, Burnand, & McClellan, 2006). In terms of prevalence, the ACI is responsible for about 33% of all anemia cases. Anemias in this classification often are normocytic-normochromic (Mansen & McCance, 2006), with normal iron stores but with low circulating iron. One marker of a chronic condition is the production of hepcidin, a liverderived antimicrobial serum protein (Guralnik et al., 2004). Hepcidin, master regulator of iron metabolism, inhibits iron absorption when released from macrophages. Inflammation and interleukin 6 are strong stimuli for hepcidin production, pointing to the relationship among chronic illness, inflammation, infections, and anemia. Similarly, an estimated 40% of patients with cancer have hemoglobin concentration less than 12 g/dl (Guralnik et al., 1994; Knight, Wade, & Balducci, 2004).

The relationship between CKD and anemia in older adults has been established in numerous studies (Coresh et al., 2004; Hsu, McCulloch, & Curhan, 2002; Luthi et al., 2006; National Kidney Foundation [NKF], 2006). Epidemiologic studies show that CKD impacts millions of people worldwide, including 20 million Americans (NKF, 2002). Hemoglobin levels are associated with the changes in glomerular filtration rate (GFR). NHANES III data (Hsu et al., 2002) have shown a decrease in the hemoglobin level among adults with even a modest decrease in renal function. More specifically, patients with moderate CKD (defined as GFR <30-59 mL/mi) had significant anemia (Nurko, 2006). Hence, the NKF Clinical Practice Guidelines (2002) recommend an evaluation of anemia when hemoglobin is less than 12 g/dl among adult men and postmenopausal women with renal insufficiency. The association between anemia and CKD is due to the kidneys role as the source of 90% of erythropoietin (EPO), a glycoprotein hormone that regulates the day-today production of erythrocytes. Chronic kidney disease is associated with hypoproliferative anemia from failure to produce adequate amounts of the hormone to stimulate erythrocyte production in the bone marrow. This type of anemia generally is normochromic microcytic (Smith, 2000). EPO deficiency in CKD is thought to be a functional response to decreased GFR (Nurko, 2006). With adequate nutrition, EPO is effective (Dharmarajan, Pais, & Norkus, 2005; Nurko, 2006; Thomas, 2004) as the treatment can increase the production of erythrocytes four to five fold within 7-14 days (Adamson & Longo, 2005). Anemia and chronic kidney disease are associated with poor outcomes, particularly among older adults with heart failure (Luthi et al., 2006). Despite its high prevalence, how-

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ever, CKD among older adults is not identified readily; hence anemia related to this chronic illness remains undertreated. Anemia can be both the cause and the result of CHF. In the absence of underlying heart disease, severe anemia can lead to left ventricular failure (LVF) then ultimately to CHF (Lipschitz, 2003). When heart disease is already present, anemia can worsen the heart function, leading to angina pectoris, fatigue, neurologic symptoms, decline in physical function, and ultimately, increased risk for morbidity and mortality (Lipschitz, 2003; Luthi et al., 2006). Anemia of unknown etiology. Anemia of unknown etiology presents a special challenge to health care professionals. An early study (Nilsson-Ehle, Jagenburg, Landahl, Svanborg, & Westin, 1988) found no identifiable causes for anemia among 33% of anemic persons age 70, 23% of persons age 75, and 36% of persons age 81. A later study (Guralnik et al., 2004) also reported that this category is a common etiology among the communitydwelling population age 65 and older. Anemia of unknown etiology also was common among nursing home residents (Beghe et al., 2004). To diagnose the presence of anemia expediently, Ioannou and colleagues (2002) recommended an evaluation of ferritin levels in all patients with anemia of unknown etiology who demonstrate a mean corpuscle volume (MCV) less than 95 fL (MCV 95 fL). In their research with over 7,000 patients, they indicated that ferritin levels detected IDA accurately in most cases, especially among those with GI lesions. Smith (2000) also identified evaluation of serum ferritin levels as most useful in differentiating anemia of CKD from IDA in 70% of patients.

Outcomes of Anemia
Despite its prevalence, very few studies specifically examined the outcomes of anemia in the older adult. A systematic review of

74 articles (Beghe et al., 2004) found only three studies specifically focused on the outcomes of anemia in the older adult. Available studies generally show, however, that anemia in the older adult is associated with increased hospitalization and morbidity (Denny et al., 2006; Salive et al., 1992), increased mortality (Kikuchi, Inagaki, & Shinagawa, 2001), decreased cognitive function (Beard, Kokmen, OBrien, Ania, & Melton, 1997), decreased mobility (Chaves, Ashar, Guralnik, & Fried, 2002), and progressive decline in physical performance (Penninx et al., 2003). An 8-year study of 1,744 community dwelling persons age 71 or older found an overall increase in mortality of 40% among those with anemia (Denny et al., 2006). Moreover, researchers found a positive association between anemia and decline in physical and cognitive status. This was true particularly for older adult women, suggesting a sensitivity of women to the effect of anemia. A 4-year prospective cohort study evaluated whether or not anemia would affect physical decline among community-dwelling persons age 65 and older (Penninx et al., 2003). The adjusted mean decline in physical performance was significantly greater among those who had anemia compared to those who did not. The decline persisted even after adjusting for serum cholesterol, iron, and albumin, showing that anemia in old age was a risk factor for decline in physical performance. As presented in the discussion of prevalence and etiology, one of the most common outcomes of chronic anemia is left ventricular failure due to the increased heart rate to compensate for the reduction in the hemoglobin concentration even in individuals without heart disease (Goodnough & Nissenson, 2004). When it persists, LVF contributes to ventricular hypertrophy, CHF, and ultimately, increased risk for morbidity and mortality (Luthi et al., 2006).

Evidence suggests that anemia in the older adult contributes to falls, decreased quality of life, and alterations in functional status (Dharmarajan et al., 2006; Guralnik et al., 2004; Thomas, 2004). Among ambulatory hospitalized older adults, those who fell had a significantly lower hemoglobin and hematocrit than the control group (Dharmarajan et al., 2006). A logistic regression model showed 22% decreased risk for falls for every 1.0 g/dL increase in hemoglobin above 6.8 g/dL. An important finding of this study was that the age, gender, and place of residence were unrelated to risk of falls, indicating anemia as an independent factor.

Diagnosis and Management of Anemia

Diagnosis and management of anemia in the older adult do not differ significantly from other populations (Agarwal, 2006; Nurko, 2006; Smith, 2000). The overall aim of anemia management is to restore the patients functional status and quality of life, and minimize morbidity and mortality by restoring erythrocyte production or preventing erythrocyte loss. Nursing responsibilities include health assessment, education, and counseling of patients and family. In assessment of anemia, nurses collaborate with other health care providers, nutritional experts, and social workers to maximize data collection. Collaboration is particularly important for individuals living in assisted settings, especially if there is no close family. Smith (2000) asserted this etiology can be found in 80% of older adults with anemia with careful evaluation. Diagnosis. Diagnosis of anemia in the older adult begins with identifying its etiology through assessment of the patients health history, living conditions, dietary habits, inventory of drugs (e.g., antacids decrease iron absorption), and comorbidities (Agarwal, 2006; Nurko, 2006; Smith, 2000). Unhurried assessment is paramount as patients and families may be totally
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unaware of subtle functional changes or may attribute these to the aging process. Changes in lifestyle, such as reduced physical activity, decreased appetite, and changes in food preferences, also must be investigated. Oral health (gums and dental conditions) must be assessed because poor oral health may dictate food preferences. For example, periodontal disease may lead to elimination of foods difficult to chew, such as those high in fiber and animal products rich in iron. Atrophy of mucosa in the digestive tract is common in the aging process and reduces digestive secretions, causing decreased absorption of nutrients. Peptic ulcer due to thinning of the gastric mucosa, for example, is common in the older adult. Similarly, studies suggest that vitamin B12 deficiency anemia is more prevalent in the older adult than documented (Andres et al., 2004; Spivak, 2000). However, its classical symptoms of neurological changes, which could lead to diagnosis, usually precede the appearance of the low hemoglobin leading to underdiagnoses (Smith, 2000). The hemoglobin concentration criteria established by the WHO (Beghe et al., 2004; Dharmarajan et al., 2006) with separate threshold values for women and men are used to diagnose anemia. For differential diagnosis, corrected reticulocyte (immature red blood cells) count also is recommended to assess the bone marrow function; reticulocyte production initially increases in response to blood loss or hemolysis (Smith, 2000; Thomas, 2004). Similarly, stool occult blood (to rule out gastrointestinal bleeding), bilirubin (to rule out hemoglobin breakdown or hemolysis), lactic dehydrogenase (an intracellular enzyme that increases in serum after tissue damage, ischemia, or hemolysis) (Thomas, 2004), and ferritin analyses should be considered. Ferritin, the best predictor of IDA (Nurko, 2006), is an iron-storing protein; its
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elevation shows impaired release of stored iron. In addition, the MCV (calculating the average volume of erythrocytes) should be assessed because low MCV suggests anemia of chronic diseases (ACD), anemia of renal disease, or iron deficiency anemia (Thomas, 2004). As reviewed previously, IDA and ACD often coexist in the older adult. In addition, soluble transferring levels have diagnostic value; serum transferrin is elevated in IDA even in the presence of chronic disease, in contrast to chronic disease alone. Erythropoietin levels also should be obtained to evaluate the contribution of kidney to anemia (Nurko, 2006; Thomas, 2004). Although not age specific, anemia algorithms may be useful in the diagnosis of anemia in older adults (Smith, 2000). The list of diagnostic tests for anemia may appear cost-prohibitive. It has been pointed out, however, that screening for anemia is rather affordable. Considering the economic and emotional cost of the outcomes of the disease, such as falls, CHF, loss of independence, and increased hospitalization, screening may be the least expensive route to the diagnosis and ultimate treatment of the disease. Management of anemias in the older adult. Because anemia of chronic disease is the most common form of anemia in the older adult (Cavill et al., 2006; Goodnough & Nissenson, 2004; Guralnik et al., 2005), it is essential to treat the underlying disorders before initiating therapy for anemia. In ACD, the erythrocytes usually are normochromic and normocytic due to iron deficiency as the underlying etiology. However, iron replacement provides little benefit in the management of the ACD. A common treatment for ACD is erythropoietin. Since the introduction of human recombinant erythropoietin in 1989, the treatment of ACD has been improved immensely. Clinical trials have repeatedly shown EPO treatment as superior

to transfusions (Cavill et al., 2006; Thomas, 2004). EPO administration increases hemoglobin concentration in individuals with anemia from CKD, blood loss, cancer, chemotherapy, hepatitis C virus, and rheumatoid arthritis (Thomas, 2004). Improvements can be observed almost immediately after starting the treatment. Two forms of available EPO are epoietin alpha (Epogen, Procrit) and long-acting darbeopoetin alpha (Aranesp) (Nurko, 2006; Thomas, 2004). When correctly used, EPO can improve patient outcomes by improving quality of life, decreasing LVF, and decreasing anemia-related morbidity and mortality (Cavill et al., 2006). Management of iron (IDA), B12, and folate deficiency anemia. The underlying conditions of these two types of anemia must be identified before initiating treatment. In about 20%-40% patients (Guralnik et al., 2005; Spivak, 2000), the underlying condition lies in GI lesions (Ioannou et al., 2002). As indicated previously, serum ferritin is the best predictor of IDA (Nurko, 2006). In addition to the treatment of the underlying condition, iron-rich foods and iron supplements may be used to treat IDA (Mansen & McCance, 2006). Every effort must be made to find the least irritating and most easily absorbable form of the supplement. Oral iron sulfate (325 mg a day, providing 95 mg of elemental iron) (Smith, 2000) may be effective. Iron supplements should be continued for 3 months after correction has been achieved to allow time to replenish iron stores (Conrad, 2003). After the treatment is completed, red cell indices (reticulocytosis starts within weeks) should be monitored initially every 3 months for the first year (Conrad, 2003; Smith, 2000). Nursing care requires understanding that oral iron replacement may have side effects, such as heartburn, nausea, vomiting, constipation, and diarrhea. The tablet

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may be taken with meals to minimize the side effects. For patients having difficulty with tablets, liquid iron mixtures may be offered. However, liquid iron mixtures stain teeth and dentures; hence straws should be used both to make the medicine more acceptable and to protect teeth (Gould, 2006). Further, iron tablets may interact with other oral drugs patients take. Antacids and food, for example, decrease iron absorption while iron decreases absorption of several antibiotics. If oral iron replacement continues to be a problem, intravenous (IV) iron replacement can be recommended as a safe and effective route. However, IV treatment is more costly and adherence may be poor if travel is required. Other health care professionals, social workers, nutritional experts, pharmacists, and medical specialists may be consulted to assist with management issues such as these. Iron replacement therapy is monitored by starting to measure the reticulocyte count a week after initiating therapy. A consistent increase in the reticulocytes is expected. If reticulocytes increase without an improvement in anemia, blood loss or poor iron absorption must be suspected (Conrad, 2003). Similarly, anemia due to B12 or folate deficiency is corrected with replacement of these vitamins. Vitamin B12 deficiency anemia is nearly always the result of an inadequate absorption of the nutrients from the lack of intrinsic factor secreted by gastric mucosa (Smith, 2000). In addition, individuals with poor nutrition (Andres et al., 2004; Guralnik et al., 2005) and alcoholism (Guralnik et al., 2005) are at risk for these two deficiencies. The recommended treatment is to increase tissue stores of the vitamin with intramuscular (IM) injection of 1,000 g per day for 1 week, followed by 1,000 g weekly for a month, and then monthly injections for the rest of individuals life (Andres et al., 2004). Vitamin B12
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given orally (1,000-2,000 g/day) is as effective as the IM injections (Smith, 2000). High-dose oral vitamin B12 can correct the disease regardless of its etiology. Response to treatment can be assessed by the increase in the reticulocyte count that can begin within 1 week (Smith, 2000). Unlike B12 deficiency anemia, folate deficiency is a result of poor dietary intake (Smith, 2000). Folate, however, is essential for erythrocyte production and maturation, and necessary for the structural elements of DNA and RNA (Mansen & McCance, 2006). Hence, early diagnosis and replacement of folate deficiency are essential to improve the overall health of the older adult. As with B12 deficiency anemia, folate deficiency can be difficult to diagnose. If the underlying conditions are untreated, the deficiency will recur after the therapy is completed. Most anemic older adults with folate deficiency have normocytic anemia, with symptoms of this deficiency indistinguishable from B12 deficiency anemia (Smith, 2000). Chronic alcohol abuse also is among the main causes of this deficiency (Gutierrez & Peterson, 2007). Folate deficiency can be corrected with oral folate therapy (1 mg daily) for 2 weeks, which is expected to correct the deficiency (Smith, 2000). Long-term treatment is unnecessary if the appropriate nutritional adjustments are made by increasing vegetable intake (Mansen & McCance, 2006).

Conclusion
Anemia is recognized as the new epidemic among older adults. Because of the projected increase in the population age 65 and older, the prevalence of anemia will increase in the near future. Persons over age 70, particularly males, non-Hispanic Blacks, and those living in institutional settings, are at a high risk for anemia. In spite of its prevalence, however, anemia in older adults is recognized less

commonly than other diseases. The recognition of the disease as a public health concern prompted government and professional associations to establish age-specific criteria for the early diagnosis of the disease in the older adult. In addition, the current WHO criteria regarding hemoglobin should be considered along with an individuals living conditions, changes in dietary habits, general strength or frailty, cognition, level of independence, and quality of life. Working in a variety of settings in varying capacities, nurses are in an optimum position to recognize the disease and implement collaborative interventions to treat it. The growing specialty of geriatric nursing is a positive influence on expedient recognition and treatment of anemia among older adults. Research has shown that anemia increases the risks for falls among adults living at home, in long-term facilities, or hospitals (Dharmarajan et al., 2006). More importantly, the review showed an association between anemia and physical decline among older adults with no other co-morbidities. Hence, anemia should be evaluated explicitly among older adults manifesting frequent falls and a general decline in physical well-being. The review also showed that about one-third of the cases of anemia are due to nutritional deficiencies, one-third due to chronic diseases, primarily kidney diseases, and the remainder due to unknown factors. Fortunately, anemia is diagnosed easily with routine laboratory tests, hemoglobin. Improving the care of the older adult with anemia is possible once the cause is identified.
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