Anemia Underappreciated in Elderly Psychiatric Inpatients

March 14, 2011 (Vienna, Austria) — Anemia commonly occurs in elderly psychiatric inpatients. However, new research presented here at EPA 2011: 19th European Congress of Psychiatry suggests that although the disorder is usually detected on admission, albeit incidentally, its causes are rarely sought and treatment is infrequent.

"The findings from this pilot study suggest that we are not satisfactorily meeting the UK government’s objective to improve the physical health of patients with psychiatric disorders," Julian Beezhold, FRCPsych, consultant in emergency psychiatry at Hellesdon Hospital in Norwich, England, told Medscape Medical News.

The findings from this pilot study suggest that we are not satisfactorily meeting the UK government’s objective to improve the physical health of patients with psychiatric disorders.

"Anemia in the elderly is typically an incidental finding that is routinely viewed as benign. However, the disorder is associated with significant morbidity and mortality in this population, and we strongly recommend that anemia detection and management be included as a routine component of the overall health care in our elderly psychiatric inpatients," he added.

Dr. Beezhold and colleagues reviewed the records of 20 patients 65 years or older who were admitted to the Julian Hospital in Norwich during a recent 6-month period. The Julian Hospital is a specialist facility for people older than 65 years with a broad range of mental health disorders.

Adverse Outcomes

Below-normal hemoglobin levels commonly occur in older patients, which has led to the misconception that anemia is a natural consequence of aging. However, recent research has challenged this view, with several studies showing a direct link between anemia and adverse outcomes in older patients. Outcomes may include deterioration in cognition and mood, overall physical function, and quality of life and also an increased risk for death.

In the present series, 9 patients had dementia, 3 had bipolar disorder, 5 had unipolar recurrent depression, 2 had acute delusional disorder, and 1 patient had delirium superimposed on schizotypal personality disorder. Half of patients were taking psychotropic medications. Most patients had at least 1 comorbidity.

The analysis showed the following:

Six patients, or 30%, had anemia at the time of admission using the World Health Organization definition as a hemoglobin concentration of less than 12 g/dL in women and less than 13 g/dL in men.
All 20 patients had a complete blood cell count on admission; however, specific blood tests to detect the cause(s) of anemia were infrequent. For example, only 8 patients (40%) had ferritin levels checked. Ferritin is measured to help distinguish anemia of chronic disease from iron deficiency anemia. Also, blood tests were rarely repeated after admission even when there were mild changes from the normal range.
Four of 6 patients required treatment for their anemia; however, only 1 of the 4 patients in whom treatment was clinically indicated was actually undergoing treatment.
Two patients (33%) had anemia related to chronic diseases, 1 patient (16%) had anemia due to chronic kidney disease, 1 patient (16%) had iron deficiency anemia, and 2 patients (33%) had anemia of undetermined origin.

Dr. Beezhold emphasized that although the sample size was small the results nonetheless document suboptimal management of anemia in elderly psychiatric inpatients.

Notably, the lack of a consistent approach at his institution may reflect the absence of guidelines on the management of anemia in this population.

"Even at admission, adequate attention is not always paid to the patient’s physical history," he said.

He also pointed out that the management of anemia in elderly psychiatric inpatients is a complex problem and may require input from other specialists, including, for example, geriatricians, hematologists, and gastroenterologists. However, access to these specialists is often not readily available for psychiatric inpatients.

Importantly, mental health staff are often unclear about their role in relation to the physical health of their patients, he added.

"While this study focused only on anemia, it nonetheless raises the question as whether other signs and symptoms of physical illness may also be overlooked," Dr. Beezhold said.

Provocative Study

This is a provocative study which reinforces the sad observation that just as physically ill patients in primary care do not receive adequate mental health care, mentally ill patients in psychiatry settings do not receive adequate primary care...

"This is a provocative study which reinforces the sad observation that just as physically ill patients in primary care do not receive adequate mental health care, mentally ill patients in psychiatry settings do not receive adequate primary care, which is referred to as generalist care in the UK," Gary Kennedy, director of geriatric psychiatry at Montefiore Medical Center in Bronx, New York, told Medscape Medical News.

"The study might be more provocative had the authors indicated the severity of the anemia they discovered. Nonetheless, even 1 person in 20 hospitalized for mental illness is one too many not to receive treatment for potentially debilitating anemia."

Neither Dr. Beezhold nor Dr. Kennedy has disclosed any relevant financial relationships.

EPA 2011: 19th European Congress of Psychiatry: P02-266. Presented March 14, 2011.