JAGS 51 (Suppl) S14–S17, 2003© 2003 by the American Geriatrics Society 0002-8614/03/$15.00

Cost of Anemia in the Elderly

Bruce Robinson, MD

As the aging population and the incidence of age-relatedhealth conditions increase, the cost of healthcare is alsoexpected to rise. Anemia commonly occurs in the elderly,and is associated with a number of health conditions suchas falls, weakness, and immobility. It can also lead tomore-serious complications such as cardiovascular andneurological impairments. Consequently, anemia can havea significant effect on healthcare requirements and health-care expenditure. Research is needed into the opportunityto reduce costs.

J Am Geriatr Soc 51:S14–S17, 2003.

Key words: aging; anemia; healthcare costs

may be low, because the shrinking cohort of adult care-givers relative to the increasing elderly population (Figure3)

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may be unable to provide the level of home care for de-pendent elderly individuals currently offered.

The goals of care for this expanding elderly popula-tion were articulated 20 years ago, in that further increasesin survival are likely to stall quickly at biologically deter-mined limits of life span.

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A rational theme of health carefor the 21st century will be to reduce the time spent in de-pendency by expanding the functional life expectancycurve toward the survival curve (Figure 4). Debate contin-ues on how much reduction in dependent (vs active) lifeexpectancy can be achieved, and it is suggested that thegreatest expectation is for substantial reductions in timespent with disability and dependency. Several researchershave indicated that the point at which dependency occursis more likely to be delayed, and, because of the overall in-crease in life expectancy, the amount of dependent time be-fore death may require more support and resources.

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Never-theless, it is clear that the goals of the health-conscious,politically active, and affluent “baby boomer” generationare consistent with maintaining an active and independentlife until death. Therefore, increasing consumer demandfor treatments that can deliver improved function overtime can be expected.

POTENTIAL ECONOMIC EFFECT OF ANEMIA

Anemia and its Associated Comorbidities

One potential model of the association between anemiaand morbidity is presented in Figure 5. This model showsthat anemia in the elderly can lead to a vicious cycle ofevents that not only affect tissue oxygen delivery, but alsohave the potential to affect physical and mental perfor-mance adversely in multiple systems. This is particularlytrue when limited functional reserves of various organs,due to aging or disease, lead to borderline capacity to meeteveryday demands for oxygenation. Minor functional lim-itations due to anemia may be amplified over time as dele-terious lifestyle changes driven by anemia-related func-tional limitations cause further losses in physical and mentalfunction.

Costs Associated With Anemia

Costs of anemia can be divided into direct, indirect, and in-tangible costs. Direct costs include the bills for treatments

From the Sarasota Memorial Hospital and the University of South Florida, Sarasota, Florida.

Address correspondence to Bruce Robinson, MD, Chief of Geriatrics, 1700 South Tamiani Trail, Sarasota, FL 34239. E-mail: Bruce-Robinson@smh.com

T

he high birth rates that occurred in the United Statesin the late 1940s and 1950s will result in an increase

in the population of the young old (65–74), the old old(75–84), and the oldest old (

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85) from 2015 on. It hasbeen reported that progress is being made in lowering

death rates (Figure 1): according to the Old Age andSurvivors and Disability Insurance report there will be anestimated continued decline in death rates for the popula-tion aged 65 and older of 0.65% per year for the next 75years.

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With the increasing proportion of elderly people and ahigher age at death, the costs of health care for the agingpopulation are expected to increase substantially. Currentprojections show a dramatic increase in Medicare costsover the next 40 years, from 1.3% to 2.9% of gross do-mestic product by 2030.

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Additionally, the number ofnursing home residents is projected to increase from 2 mil-lion to 5 million by 2040, at an overall cost of $700 billionannually.

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The costs of care for functional dependency innursing homes, largely borne by the federal Medicaid pro-gram and private payments, can also be expected to risedramatically (Figure 2).

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Even these increased projections,based on current usage rates of long-term care services,

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and services required for managing this condition and itscomplications. Indirect costs include travel expenditure todoctors’ appointments and lost workdays for the patientand their caregiver. Intangible costs, such as decreases indaily activities, lost time with family and friends, and a re-duction in family help provided by the elderly person (e.g.,baby sitting), should also be considered. The direct and in-direct costs can be substantial because of the various dis-eases and disabilities that anemia potentially affects.

Costs Associated With the Comorbidities of Anemia

Evidence regarding the effect of anemia on the overallhealth of the older population and the costs of care can beevaluated from several sources. Anemia is associated witha number of the key producers of functional decline. For

example, anemia has been linked to increases in the risk offall,

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dementia,

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and depression.

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In addition, severe ane-mia can lead to congestive heart failure.

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Anemia is alsoassociated with general functional disability, which drivesdemand for long-term care services.

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Falls in older adults (

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65) are a major cause of deathand a significant source of morbidity and, for the latterreason, can considerably increase healthcare costs.

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Onestudy reported that one or more injurious falls in an el-derly person (

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72) resulted in an annual increase in nurs-ing home costs of $5,300 and total healthcare costs of$19,000.

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Further data have shown that fall-related inju-ries, such as hip fractures, which frequently occur inpeople aged 70 and older, can cost in excess of $10 bil-

Figure 1. Projected death rate for the population aged 65 andolder.

Figure 2. Lifetime nursing home expenditures by age at death.3

Figure 3. Number of elderly individuals (per 100 persons) from2000 to 2040.

Figure 4. Goals of health care for the aging population(Adapted from Fries JF4). The dark line represents the cumula-tive survival of a population cohort over time, with the palerline indicating the proportion remaining functionally indepen-dent. The vertical dashed lines illustrate the size of the group re-maining alive (below the dark line) and remaining independentat a specific age. The goal of care is to push the paler line closerto the darker one.

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lion.

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A hospital stay for elderly patients who have expe-rienced a fall can be twice as long as for those who are ad-mitted for another reason.

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Alzheimer’s disease is strongly associated with age,and its prevalence is predicted to increase dramaticallywith the growing elderly population. One report describedthe potential economic effect of effective Alzheimer’s pre-vention and indicated that, if onset could be delayed onaverage by 1 year, there would be approximately 210,000and 770,000 fewer persons afflicted with Alzheimer’s dis-ease than projected 10 and 50 years after initiation of theintervention, respectively.

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An average 1-year delay indisease onset would result in annual savings of nearly$10 billion at 10 years after initiation of the intervention.Even a modest 6-month delay would correspond to annualsavings of approximately $4.7 billion at 10 years after ini-tiation of the intervention and nearly $18 billion annuallyafter 50 years. Additionally, it has been suggested that de-pression is associated with anemia, and the economic bur-den of depression has been estimated at approximately$44 billion per year.

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Anemia is often a comorbidity in patients with con-gestive heart failure and may be caused by a number offactors, such as cardiac input and output failure, rightheart failure, use of angiotensin-converting enzyme inhibi-tors, and increased production of proinflammatory cyto-kines.

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Congestive heart failure is associated with sig-nificant health costs, estimated at approximately $38billion per year.

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MANAGEMENT OF ANEMIA

The causal link between anemia and the costs of the dis-eases listed above remains to be established. However, themore relevant question for management is the ability ofanemia correction using erythropoietin to reduce the mor-bidity, mortality, and costs of conditions associated withanemia in the elderly population.

The benefits of anemia correction using erythropoietin

for some conditions have been established through con-trolled trials. In renal failure, benefits include measurableimprovements in multiple areas of health, such as cognition,energy level, work capacity, aerobic capacity, immune func-tion, and health-related quality of life.

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In congestiveheart failure, erythropoietin therapy also appears effectivein improving functional class, renal function, and hospital-ization rate.

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CONCLUSIONS

A number of expensive health conditions in the elderlyhave been linked epidemiologically to anemia, and currentresearch in patients with renal failure and congestive heartfailure has shown that treating the anemia can be benefi-cial. These studies have demonstrated that safe and effec-tive correction of low hemoglobin levels in many elderlypeople with anemia is possible with erythropoietin agents.Presently, no generally equivalent therapy in terms of safety,patient acceptance, and effectiveness is available for manyelderly patients with erythropoietin responsive anemia.

The current research agenda is to determine, throughcontrolled trials, the ability of the higher hemoglobin lev-els made possible by erythropoietin therapy to alter therates or complications of the epidemiologically or theoreti-cally linked conditions discussed in this article. Once theseeffects are established, it will be possible to estimate the ef-fect of the benefits observed on the overall costs. In con-clusion, erythropoietin therapy could be a useful tool inthe dominant goal of care for the elderly over the decadesto come, namely, to add life to years.

REFERENCES

1. The 2001 Annual Report of the Board of Trustees of the Federal Old-Ageand Survivors Insurance and Disability Insurance Trust Funds. Washington,DC: Office of the Chief Actuary, Social Security Administration, 2001.

2. Besdine RW, Rubenstein LZ, Cassel C. Nursing home residents need physi-cians’ services. Ann Intern Med 1994;120:616–618.

3. Spillman BC, Lubitz J. The effect of longevity on spending for acute andlong-term care. N Engl J Med 2000;342:1409–1415.

4. Fries JF. Aging, natural death, and the compression of morbidity. N Engl JMed 1980;303:130–136.

5. Branch LG, Guralnik JM, Foley DJ et al. Active life expectancy for 10,000Caucasian men and women in three communities. J Gerontol 1991;46:M145–M150.

6. Herndon JG, Helmick CG, Sattin RW et al. Chronic medical conditions andrisk of fall injury events at home in older adults. J Am Geriatr Soc 1997;45:739–743.

7. Beard MC, Kokmen E, O’Brain P et al. Risk of Alzheimer’s disease among el-derly patients with anemia: Population based investigations in OlmsteadCounty. Olmstead County, Minnesota. Ann Epidermiol 1997;7:219–224.

8. Katz IR, Beaston-Wimmer P, Parmelee P et al. Failure to thrive in the elderly.Exploration of the concept and delineation of psychiatric components. JGeriatr Psychiatry Neurol 1993;6:161–169.

9. Anand IS, Chandrashekhar Y, Ferrari R et al. Pathogenesis of oedema inchronic severe anaemia: Studies of body water and sodium, renal function,haemodynamic variables, and plasma hormones. Br Heart J 1993;70:357–362.

10. Kamenetz Y, Beloosesky Y, Zeltzer C et al. Relationship between routine he-matological parameters, serum IL-3, IL-6 and erythropoietin and mild ane-mia and degree of function in the elderly. Aging Clin Exp Res 1998;10:32–38.

11. Hauer K, Rost B, Rutschle K et al. Exercise training for rehabilitation andsecondary prevention of falls in geriatric patients with a history of injuriousfalls. J Am Geriatr Soc 2001;49:10–20.

12. Rizzo JA, Friedkin R, Williams CS et al. Health care utilization and costs in amedicare population by fall status. Med Care 1998;36:1174–1188.

13. Fuller GF. Falls in the elderly. Am Fam Physician 2000;61:2159–2168.14. Brookmeyer R, Gray S, Kawas C. Projections of Alzheimer’s disease in the

United States and the public health impact of delaying disease onset. Am JPublic Health 1998;88:1337–1342.

Figure 5. The association of anemia with morbidity. In thismodel, anemia causes reduced exercise tolerance, leading inturn to relative immobility, muscle wasting (sarcopenia), falls,and diminished cardiovascular fitness that further reduces exer-cise tolerance. This downward spiral produces the conse-quences listed on the right: frailty, dependency, depression, andthe need for expensive services to support the person with theseconditions.

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15. Greenberg PE, Stiglin LE, Finkelstein SN et al. The economic burden of de-pression in 1990. J Clin Psychiatry 1993;54:405–418.

16. Silverberg DS, Wexler D, Blum M et al. The use of subcutaneous erythropoi-etin and intravenous iron for the treatment of the anemia of severe, resistantcongestive heart failure improves cardiac and renal function and functionalcardiac class, and markedly reduces hospitalizations. J Am Coll Cardiol2000;35:1737–1744.

17. Chatterjee B, Nydegger UE, Mohacsi P. Serum erythropoietin in heart failurepatients treated with ACE-inhibitors or AT antagonists. Eur J Heart Fail2000;2:393–398.

18. Biasucci LM, Vitelli A, Liuzzo G et al. Elevated levels of interleukin-6 in un-stable angina. Circulation 1996;94:874–877.

19. Fonarow GC, Stevenson LW, Walden JA et al. Impact of a comprehensiveheart failure management program on hospital readmission and functional

status of patients with advanced heart failure. J Am Coll Cardiol 1997;30:725–732.

20. Eschbach J, Egrie J, Downing M et al. Correction of anemia of end-stage re-nal disease with recombinant human erythropoietin. N Engl J Med 1987;316:73–78.

21. Levin N. Maximizing patient benefits with epoetin alfa therapy: National co-operative rHu erythropoietin study in patients with chronic renal failure—aninterim report. Am J Kidney Dis 1993;22:3–12.

22. Marsh J, Brown W, Wolcott D et al. rHuEPO treatment improves brainand cognitive function in anemic dialysis patients. Kidney Int 1991;39:155–163.

23. Revicki D, Brown R, Feeny D et al. Health-related quality of life associatedwith recombinant human erythropoietin therapy for predialysis chronic renaldisease patients. Am J Kidney Dis 1995;25:548–554.