Iron Deficiency Anemia in Older Adults

Background Information on Iron Deficiency Anemia

Iron deficiency anemia is a widespread nutritional deficiency in the United States. It is a condition where the body has decreased iron content. When an individual has anemia, the body lacks adequate red blood cells in the bloodstream. Further, when one has iron deficiency anemia, the red blood cells have reduced capabilities of supplying the body tissues with oxygen. Thus, iron deficiency anemia arises when the iron deficit is severe to the extent that it weakens erythropoiesis hence leading to the development of anemia. Anemia often occurs due to lack of iron and vitamins such as the folic acid and B12. Iron is a vital element that is required in the production of hemoglobin. It can also occur due to the destruction of the structure and the shape of red blood cells. There are numerous types of anemia such as anemia caused by blood loss, anemia resulting from reduced blood cells, and that arising from the destruction of red blood cells. Nevertheless, anemia resulting from reduced blood cells (iron deficiency) is one of the commonest types of anemia in the world. When the human body does not have sufficient red blood cells, the capability of the affected individuals is often diminished. As such, the affected people cannot perform any physical job. It also affects the learning and growth of the young ones. Iron deficiency anemia has been common among the elderly people. This condition has been known to increase as their age increase. The predominance of iron deficiency anemia varies from 8%-44%. The highest rates of iron deficiency anemia occur among men who are 85 years and above. Due to this increased incidence iron deficiency anemia as a result of ageing, most people speculate that lower levels of hemoglobin are as a result of usual result of aging. However, it should be considered as an illness among the elderly because the older individuals maintain the red blood cell count. This essay will look at the background information of iron deficiency anemia pathophysiology, etiology, epidemiology identification of risk factors, symptoms of the disease, drug therapy, and monitoring. 

Pathophysiology

Iron is required by organisms since it is useful in metabolic processes like the transportation of oxygen to various parts of the body, transport of electrons, and in DNA synthesis.1 Among adults, men lose an approximate of 1 mg daily in skin cells and feces. On the other hand, women who have not yet reached menopause lose 1.5mg of iron. 1 An approximate concentration of iron for healthy individuals is 60ppm. This is usually regulated by the absorptive cells that occur in the small intestines. 1 These cells change the absorption of iron to match iron losses in the body. When errors occur during iron balance, the result is hemosiderosis or iron deficiency anemia. These two disorders affect the transportation of oxygen to various parts of the body. Too much iron loss or reduced absorbable nutritional iron causes iron deficiency in the body. Hemorrhage is known to be the cause of iron deficiency anemia. Cases of iron malabsorption are rare unless one has GI surgery or a bowel illness. 

Etiology 

Teenagers are at a high risk of getting iron deficiency anemia because their bodies require high levels of iron, which is due to their rapid growth. Similarly, among the older adults, males need large amounts of iron when they reach the peak of their pubertal development. 1 At this stage, they require high levels of iron because of muscle mass, increase in the volumes of blood in their bodies, and myoglobin. For the older females, iron is supposed to keep on being high after menarche due to high loss of menstrual blood. During their menstruation, they lose 20mg of iron on a monthly basis.1Some other women may lose 58mg of iron during their menstruation. When blood is lost, chances of getting iron deficiency anemia are high. Oral contraceptives tend to reduce blood losses whereas some intrauterine procedures may increase menstrual losses. 

Despite the high iron needs, many teens, especially females, may take 10-11mgs of iron in a day leading to an approximate of 1mg of the iron absorbed by the body 8. About three-quarter of women do not meet their iron nutritional requirements compared to seventeen percent of men. 

Epidemiology 

Iron deficiency anemia is prevalent among the women who are still in their bearing years in countries like Europe and North America. 2 Iron deficiency anemia that is as a result of diet is not very common in older adults in nations where meat is vital in the diet. There are numerous criterions used in the diagnosis of iron deficiency anemia. Regardless of the criteria used, an approximate of four to eight percent women who have not yet reached menopause have iron deficit.2 In premenopausal females and males, iron deficiency is regularly accompanied by bleeding. 

The prevalence of iron deficiency anemia is very high among the nations having little meat in the diet. The frequency is six to eight times more than in countries like Europe and North America. Anemia is worsened by intestinal parasites such as hookworm because a lot of blood is lost from the GI tract. 3 In such geographical regions, iron deficiency anemia is common among premenopausal females and children. 

Males gain and loss 1mg of iron daily for a diet that contains 10-20mg of iron. During the years of childbearing, women lose an approximate of 2mg of iron on a daily basis. To maintain the iron balance, they must absorb 2mg of iron. 1, 2 As a matter of fact, women eat less as compared to men, they should absorb dietary iron twice than a man does to maintain the balance and evade anemia caused by iron deficiency. 

Males lose iron from body secretions, and blood loss from GI tract. This can be equated to 1mg of iron. Men who undergo blood transfusion can lose 4mg of iron through such routes. Women lose approximately 500mg of iron during pregnancy. During menstruation, they may lose 4mg to 100mgs of iron monthly. 1, 2 as a result, the blood losses increase their needs of absorbing iron as compared to men. During pregnancy, efforts should be made to detect and treat iron deficit. The same effort should be made to identify it during early childhood stages since it affects learning, development, and growth of children. 

Identification of Risk Factors 

Approximately, ten percent of the older adults who are aged sixty-five years have iron-deficiency anemia. Iron deficiency anemia in older adults has been attributed to medications, poor absorption, blood loss, cancer therapies, and dietary deficiencies. The older adults who take diets that are limited in variety are at a high risk of having nutritional deficiencies that cause anemia. The adults who use aspirin and other anti-inflammatory substances tend to have digestive tract bleeding that can cause iron deficiency anemia. When the older adults take aspirin more than one time in a day, an individual can lose 100-125 mg of iron. The people who use aspirin-related substances can lose up to 50-60 mg of iron in a month. Blood losses among the older adults may be due to an internal lesion, ulcers, colon cancer, diverticular bleeding, and esophageal varices. 

In the absence of blood loss, iron deficiency anemia takes many decades to develop. Inadequate absorption or intake of iron is likely to occur among older adults who take poor diets and who have abnormal acids in their stomachs. Stomach acid is usually the Hydrochloric Acid that is important in iron absorption. When older adults have low levels of Hydrochloric acid or absence of it, they may end up developing iron deficiency anemia. 

Signs/Symptoms/Diagnosis

The primary onset of the signs and symptoms is insidious, and numerous patients alter their day to day activities since their bodies can adapt to this condition. 4 Regardless of the type of anemia, the common symptoms include headache, chest pain, skin paleness, uneven heartbeat, and lack of energy, loss of appetite, sore tongue, brittle nails, unusual cravings, and shortness of breath. 4 For the individuals having mild anemia, these symptoms may not show up. However, some symptoms such as fatigue and dyspnea are not common among the since they are attributed to their advancing age

DRUG THERAPY 

Pharmacologic Treatment Options

When a blood test is carried out, and the patient is found to have iron deficiency disease, both pharmacological and non-pharmacological treatment options can be used to help the patient improve their lives and symptoms. 

For pharmacologic options, iron deficiency anemia patients take iron drugs such as iron sulfate for the duration of about six months. After taking drugs within the required period, the iron level is balanced. However, to make sure the pills work effectively, the individuals continue taking the pills for many months. This treatment option replenishes iron stored in the bone marrow. In people’s bodies, thirty percent of the iron is stored in the bone marrow. Thus, it is vital to replenish bone marrows regularly.5After this treatment option, iron deficiency anemia should be corrected. Nevertheless, individuals who are in the high-risk categories should go for further and regular checkups. Older adults should be monitored regularly or get special treatment when their iron deficiency is as a result of other things such as cancer. 

Among the non-pharmacological treatment options, the elderly patient can be informed on how to take diets that are rich in iron. This can be attained by educating them on specific types of foods that are rich in iron such as cereals, red meat, greens, liver, and oysters. 6 Besides, they can be encouraged to eat foods that are rich in vitamin C since they increase iron absorption. These patients should also be encouraged to reduce foods rich in calcium since they inhibit the absorption of iron.7Besides, they should be educated on how to limit their activities since they may inhibit iron absorption. Lastly, the patients should also be encouraged to focus on regular consultation since it controls iron deficiency anemia trough frequent monitoring.7 

Mechanism of Action

When iron is absorbed into the body, oxygen usually combines with iron and later transported to the plasma. During this process, it is bound with transferrin. Both transferrin and iron are used to produce hemoglobin (a molecule that is that transports oxygen into the blood stream) and myoglobin (a molecule that helps muscle cells to store oxygen). 

Adverse Effects

When treatment is done using oral iron, the most common adverse effects include constipation, diarrhea, or discomfort in the abdomen. 8 When the drug is taken after meals, it can result in increased interaction with other substances. These adverse effects are dependent on the dose. The dose may be adjusted when a patient has severe effects. When under medication, the stool may change in color and become black. 9 In such cases, the doctor should explain to the patient that the change of color is healthy, and they should not worry about it. When liquid iron supplements are taken, teeth may change their color. 10 However, to avoid this effect, the patients are advised to use a straw when taking the drug. When it is administered through injection, brown stain is noticed

Dosing/Administration

When an individual has been diagnosed with iron deficiency anemia, the next step is to restore the iron supply in the body. 11 Iron supplements are the commonest forms of drugs. They are defined as nutritional supplements that contain iron.

Oral routes may be used to administer iron supplements. Numerous pharmacological forms such iron (II) sulfate are used. There are cases where some iron supplements like ferrous fumarate are not absorbed. When that happens, Heme iron polypeptide (HIP) is used because it increases levels of iron as opposed to ferrous fumarate. Another drug that may be used when iron supplements are not absorbed is Ferro glycine sulfate.

Since oral iron has recurrent intolerance and slow improvement, parenteral iron (which is administered when oral iron therapy fails), is recommended 12. Oral absorption occurs when an individual cannot swallow a drug or when compromised by a certain disease. Oral therapy exhibits slow improvement especially when a person has had a prior surgery. 

A patient suffering from iron deficiency anemia should use iron supplements that are only prescribed by the doctor. Using them in larger quantities or longer than recommended by the physician may bring adverse effects to the body. 

When an iron supplement such as ferrous gluconate is recommended, one should take one to two hours before eating. When one is under such medication, antibiotics or antacids should be avoided before taking the iron supplement. A glass of water often accompanies this drug. All iron supplements should be measured appropriately. If the iron supplements require a special diet, the patient should follow it to the latter. 12 Just like many drugs, all iron supplements should be stored at room temperature away from heat and moisture.

Drug-Drug Interactions

Iron interferes with absorption of various drugs. This is the main reason why patients are advised to take iron supplements in one to two hours before or after taking other pills. When a patient is on other medications apart from iron supplements, he or she should talk to a medical doctor to avoid possible drug-drug interactions.13Some drugs are not supposed to be used with iron supplements. For example, Allopurinol is a drug that treats gout and increases the quantities of iron in the liver. When iron supplements are used with penicillamine, they reduce iron absorption. Other nonsteroidal anti-inflammatory drugs increase the likelihood of stomach bleeding. Thus, they should not be used with iron. Birth control pills decrease the absorption of iron. 

Drug-food interactions

A doctor may recommend iron supplements to individuals who have reduced levels of iron to raise it to reasonable amounts. 13 When iron supplements are taken alongside with food, iron absorption may be reduced by about fifty percent. Food may reduce the acid in the stomach that aids in iron absorption. 7, 13 some components that are available in some foods may affect the absorption of iron in the bloodstream. Foods containing calcium inhibit the absorption of iron because calcium usually competes with iron. Such foods include dairy products, grains, rice, legumes, among others. It is recommended to avoid such foods when an individual is on iron deficiency medications. Iron absorption is increased by taking ferric iron supplements, taking foods rich in vitamin C, and consuming plant and animal-based products that are rich in iron. As discussed earlier, these supplements should be taken either one or two hours before meals. All diets should be rich in vitamin A because it makes iron available for the body. 

Drug-Disease Interactions

Medical problems affect nutritional supplements. Some diseases interact with iron drugs, and this may impair the health of an individual. Examples of these conditions include asthma, liver disease, kidney infections, arthritis, heart diseases, colitis, and stomach ulcers. When a person with medical problems takes iron drugs without doctor’s prescription, these conditions are worsened 7, 13. Therefore, when a person has any of these conditions, he or she should alert the doctor before taking iron drugs since they raise iron to toxic levels. 

Place in Therapy/Guidelines

Then main reason for treating iron deficiency anemia is to ensure that the iron stores are replenished. 14 Many drugs that have been used in the treatment of iron-deficiency anemia have been useful. Nevertheless, the drugs work effectively when the patients follow doctor’s prescriptions. 

MONITORING/CONCLUSION

Appropriate Parameters for Monitoring of Therapeutic Effects

It is the role of the physicians to monitor patients diagnosed with iron deficiency anemia. Monitoring has components such as proactive, observation, analysis, and course of action. For monitoring to achieve best results, all these mechanisms have to be followed to the latter. Monitoring is done to ensure satisfactory response to iron treatment and that the treatment is done until the body maintains iron equilibrium 

One of the appropriate parameters for measuring adverse effects of iron deficiency anemia is through testing the blood count occasionally. This helps the doctors to monitor patients with iron deficiency effectively. 

Monitoring should frequently be done until zero-levels of iron-deficiency anemia are achieved. Hemoglobin levels for the patients taking oral are supposed to be checked after every two weeks prior to medication. Iron deficiency anemia is corrected within two to four months if the patients are given proper iron dosages. After hemoglobin normalizes, older adults continue with the iron therapy for duration of four to six months. This is done to refill iron stores. The frequency of succeeding monitoring depends on the severity of iron deficiency anemia, the causal factors, and the medical effect upon the patient.14Doctors should carry a follow-up among the patients who have iron-deficiency anemia. Follow-up ensures that the original cause of iron-deficiency is treated. Sometimes, a therapeutic endpoint is usually hard to identify. Therefore, when the endpoint cannot be defined, monitoring the drug levels may assist in the therapy of iron deficiency anemia. 

Role Played by Pharmacists in Management of the Disease State

The pharmacists have played an important role in the management of iron deficiency anemia. First, they have collaborated with the physicians to manage the disease among the patients diagnosed with cancer. They have achieved this through the introduction of pharmacist anemia programs, which focus on raising awareness among the anemic patients.15 Secondly, they have helped in the screening of the patients diagnosed with anemia and aided in the formulation of guidelines regarding proper use of Erythropoiesis-Stimulating Agents. Thirdly, they have provided direct education to the patients who are affected by iron-deficiency anemia. They guide them on dosage and appropriate use of the drugs, which help the patients avoid further complications. Fourthly, they monitor the patients who have the disease to ensure maintenance of iron levels. 15 Fifthly, they have assisted in developing guidelines that have been used in anemia therapies. Lastly, they have helped patients in therapy management, especially in nutritional recommendations, administration of iron, and giving them drugs that can help them combat the disease. The pharmacists should always be aware of symptoms of iron deficiency anemia to assess the effectiveness of treatment and assist the individuals who seek medical help. Pharmacists can use their pharmacological skills and knowledge to increase positive results among the anemic patients.

References

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