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Anemia, Blood Disorders, THE MERCK MANUAL OF HEALTH & AGING Page 1 of 3

Anemia
In anemia, the number of red blood cells (red blood cell count) is low. In some types of anemia, red blood cells are
also abnormal in size or shape.

Anemia, although common among older people, is never normal. Anemia can have serious causes and
consequences and should always be evaluated by a doctor.

Red blood cells contain a protein called hemoglobin, which contains a tiny amount of iron. Hemoglobin enables red
blood cells to carry oxygen from the lungs and deliver it to the body's tissues. Every cell in the body needs oxygen to
produce energy for the cell's activities. When energy is produced, carbon dioxide is given off as a waste product.
Red blood cells carry carbon dioxide away from the tissues and back to the lungs to be breathed out. In anemia,
there is not enough hemoglobin because there are not enough red blood cells or because less hemoglobin is
produced. In some anemias, hemoglobin is also abnormal. Thus in anemia, blood cannot carry enough oxygen to
the body's tissues or remove enough carbon dioxide.

A hormone called erythropoietin helps the body maintain a normal number of red blood cells. When tissues are not
getting enough oxygen, the kidneys produce erythropoietin. Erythropoietin stimulates the inner part of bones (bone
marrow) to produce more red blood cells.

To produce red blood cells, the body needs many nutrients. The most critical ones are iron, vitamin B12, and folic
acid. When the body does not get enough of these nutrients, the bone marrow does not produce enough red blood
cells, and the ones produced may be abnormal. If iron is lacking, red blood cells may be abnormally small. If vitamin
B12 or folic acid is lacking, red blood cells may be abnormally large.

Causes
Anemia may be caused by abnormal bleeding. Anemia develops when the bone marrow cannot produce enough red
blood cells to replace those lost through bleeding. Bleeding is not always obvious. Sometimes it is gradual and slow
and goes unnoticed. For example, a stomach ulcer, a polyp in the large intestine, or cancer of the kidneys, bladder,
or digestive tract can cause bleeding that may not be noticed. Iron—a critical nutrient for red blood cell production
and a component of hemoglobin—is also lost when bleeding occurs. Iron deficiency anemia, usually due to abnormal
bleeding, is the most common anemia among older people.

Another cause of anemia is reduced production of red blood cells. To produce red blood cells, the body needs
enough vitamin B12, folic acid, and iron. Consuming too little of one of these nutrients or being unable to absorb one
of them can result in anemia. For example, in pernicious anemia, the body is not able to absorb vitamin B12.
Consuming too little iron can result in iron deficiency anemia. However, in the United States, anemia rarely results
from consuming too little iron because supplemental iron is added to many foods.

Certain chronic disorders—such as infections, inflammation (as occurs in rheumatoid arthritis), cancer, and kidney
disorders—can reduce red blood cell production. The type of anemia that results is called anemia of chronic disease.
In some disorders, abnormal cells invade and replace much of the bone marrow, where red blood cells are
produced. These disorders include cancer that has spread to bone (metastatic cancer), leukemia, multiple myeloma,
and lymphoma. Other problems in the bone marrow, including aplastic anemia and myelodysplastic syndrome may
result in anemia. In some kidney and other chronic disorders, the kidneys do not produce enough erythropoietin,
which stimulates red blood cell production.
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Less commonly, the cause of anemia is destruction of more red blood cells than can be produced. This type of
anemia is called hemolytic anemia. In older people, the cause of hemolytic anemia is often unknown. However,
hemolytic anemia may result from many disorders and from use of certain drugs. Sometimes hemolytic anemia
results from an autoimmune reaction: The immune system mistakes red blood cells for foreign invaders and
produces antibodies to destroy them. Why this reaction occurs is unknown.

Anemia may result from hereditary disorders, which are usually detected early in life. Examples are sickle cell
anemia and thalassemias.

Symptoms
Typically, anemia causes fatigue and weakness. It also makes people look pale. Older people are less likely to look
pale, although the gums and other tissues in the mouth may be paler. Older people with anemia, even when mild
(when the red blood cell count decreases only slightly), are more likely to become confused, depressed, agitated, or
listless than younger people. They may also become unsteady and have difficulty walking. However, some older
people with mild anemia have no symptoms at all, particularly when anemia develops gradually, as it often does in
older people. Other people experience symptoms only when the body's tissues require more oxygen quickly, for
example, during physical activity.

As the red blood cell count decreases further, anemia may cause light-headedness, sweating, a rapid pulse, and
rapid breathing. These symptoms may occur even during rest. When tissues do not get enough oxygen, anemia may
cause painful lower leg cramps during exercise, shortness of breath, and chest pain (angina), especially in people
who have peripheral arterial disease or certain types of lung or heart disorders. Symptoms tend to be more severe
when anemia develops rapidly.

If anemia is due to vitamin B12 deficiency, symptoms may develop because the nerves malfunction. People may feel
tingling in the feet and hands and lose sensation in the legs, feet, and hands. The feet and legs are affected earlier
and more often than the hands and arms. People may lose the ability to sense vibration and to know where their
arms and legs are (position sense). Weakness in muscles may be slight or moderate, and reflexes may be lost.
Walking becomes difficult. Some people become irritable and depressed. Mental function may be impaired in a way
that resembles dementia. Some of these symptoms may occur before the anemia develops. They may be
permanent, even if the deficiency is treated and the anemia resolves.

If anemia is due to slow bleeding in the urinary tract, blood may appear in the urine. If bleeding occurs in the
digestive tract, blood may appear in the stool.

If anemia is due to sudden, excessive bleeding, two problems can result: Blood pressure falls because the amount of
fluid left in the blood vessels is insufficient, and the body's oxygen supply is drastically reduced because the number
of oxygen-carrying red blood cells has decreased so quickly. Either problem may lead to a heart attack, a stroke,
kidney failure, or death.

Diagnosis
Sometimes anemia is detected before a person notices symptoms, when routine blood tests are done. If the amount
of hemoglobin and the percentage of red blood cells in the blood (hematocrit) is low, anemia is diagnosed. Also,
blood tests can usually help doctors determine the type and cause of the anemia. Doctors look at the size and
appearance of red blood cells. They measure the levels of newly formed red blood cells, iron, ferritin (the protein that
carries iron when it is outside of red blood cells), vitamin B12, folic acid, and substances produced when red blood
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cells are destroyed. Other tests to determine the cause are also done.

Even if abnormal bleeding is not obvious, it is usually assumed to be the cause of iron deficiency anemia. In either
case, the stool and urine are tested for blood to try to identify the source of the bleeding. If the digestive tract is the
likely source, endoscopy is usually done first. A flexible tube is used to directly view the stomach (in a test called
esophagogastroduodenoscopy) and colon (in a test called colonoscopy).

Occasionally, when doctors are uncertain of the cause of anemia and think it could be serious, a sample of bone
marrow is removed and examined under a microscope. This procedure is called a bone marrow biopsy. The purpose
is to evaluate the stem cells that develop into red blood cells and to determine the amount of iron in the bone
marrow, where the body stores much of its iron.

See the figure Taking a Sample of Bone Marrow.

Imaging tests (such as computed tomography or a barium study) are sometimes needed. For a
barium study, x-rays of the digestive tract are taken after barium has been swallowed or given as
an enema. Barium, which appears white on x-rays, outlines the digestive tract and collects in abnormal areas.
Because barium can cause significant constipation, a laxative may be given after x-rays are taken.

Treatment
Treatment depends on the severity and cause of the anemia. If the anemia is mild, no treatment may be necessary.
If the anemia is severe, red blood cells must be replaced by giving blood transfusions. Otherwise, treatment focuses
on the cause of the anemia.

If the cause is abnormal bleeding, treatment involves locating the source of the bleeding and correcting the problem.
Typically, iron supplements, usually tablets, are taken for several months to replace iron that is lost when blood is
lost.

Anemia due to a deficiency of iron, vitamin B12, or folic acid is treated by taking supplements of the deficient nutrient.
Iron supplements are usually taken by mouth for about 6 months. Sometimes iron supplements are given by
injection. Vitamin B12 supplements are often given by injection. Injections are given daily or weekly for several
weeks, then once a month. Vitamin B12 supplements can also be taken as tablets. Almost everyone who has anemia
due to vitamin B12 deficiency must take these supplements for life. Folic acid supplements are usually taken as one
tablet daily.

If anemia is caused by a chronic disorder, treatment involves treating the disorder. Taking iron or vitamin
supplements does not help. Drugs that may be causing or contributing to the anemia are discontinued if possible.
Sometimes injections of erythropoietin (a synthetic version of the hormone produced by the body) or darbepoietin
help, particularly if the disorder cannot be cured. These drugs stimulate the production of red blood cells.

Sometimes blood transfusions are given for a short time. For example, they are given when blood loss is rapid or
massive or when other treatments cannot quickly and effectively relieve serious symptoms, such as very low blood
pressure or angina. Transfusions may be given when the red blood cell count is so low that a heart attack, a stroke,
or kidney failure is likely to occur. Blood transfusions may be needed indefinitely when anemia persists and no other
treatment is effective.

People who have anemia due to kidney failure or some other chronic disorder may benefit from injections of
erythropoietin.

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