Nutritional Aspects of Management of Hematological Disorders in Older Adults - Chapter 10

Nutritional Aspects of Management of Hematological Disorders in Older

AdultsChapter 10

Introduction

• Hematopoiesis• Anemia• Hematological deficiencies

– Iron deficiency anemia– Vitamin B12 deficiency– Anemia of Chronic Disease

Physiology

• Blood Components

Physiology

• Red Blood Cell Production– Produced in the bone marrow– Committed progenitor cells– Adequate amounts of proteins, vitamins, and

minerals required

• B and T-Cells– Lymphoid stem cells

• Myeloid Stem Cells

Physiology

• Myeloid Stem Cells– Erythroid

• Yields red blood cells• Folic acid and Vitamin B12 are required

– Megakaryocytic– Phagocytic

The Aging Hematopoetic System

• Decline in reserve capacity• Numerous age related changes

– Determines effects of aging on organ function and lifespan

– Cell division and cell differentiation are balanced by apoptosis

The Aging Hematopoetic System

Anemias in Elderly Persons

• Prevalence increases with age– Normocytic anemia– Microcytic anemia– Megaloblastic anemia– Sideroblastic anemia

• Anemia of Chronic Disease• Iron Deficiency Anemia• Can occur with slow blood loss

Anemias in Elderly Persons

• Signs and Symptoms of Anemia– Fatigue is often the presenting symptom

• Physical decline and loss of independence• Untreated anemia

– Increased mortality and comorbidities

Anemias in the Elderly Persons

• The Comprehensive Assessment– History and Physical

• Physical indicators of anemia• Indication of protein and/or energy

malnutrition• Weight change• Review of medications• Diet history or food records

Anemias in Elderly Persons

• The Diagnosis– Complete Blood Count (CBC)– Other lab tests and assessments– Serum ferritin– Examples of CBC panels

• Total Iron Binding Capacity or Transferrin– Evaluates iron status– Can be used to monitor nutrition trends

Iron Deficiency Anemia

• Most common form of anemia worldwide• Iron stores increase with age

– Body not able to eliminate excessive iron

• Iron malabsorption• Advanced heart failure can cause IDA• Deficiency of Vitamin A may contribute to IDA

Iron Deficiency Anemia

• Inhibitors of Iron Absorption– Various foods

• Enhancers of Iron Absorption– Various foods– Host-mediated enhancers

Iron Deficiency Anemia

• Stages to disease progression

Insel P, Turner RE, Ross D. Nutrition. 3rd ed. Sudbury, MA: Jones & Bartlett; 2007, p. 506. Reproduced with permission.

Iron Deficiency Anemia

• Presentation of Iron Deficiency Anemia– Mild may be asymptomatic – More severe symptoms occur– Abnormalities– Confusion and mental disturbances

• Laboratory Iron Tests– Numerous lab tests– Serum transferrin receptor test

Iron Deficiency Anemia

• Management of Iron Deficiency Anemia– Determine and eliminate cause– Iron replacement therapy

• If anemia is due to nutrition problems• Use of medication to treat• Increase intake of high (heme) iron foods• Parenteral iron• Iron-sucrose complex for predialysis patients

Iron Deficiency Anemia

• Drug Interactions Associated with Treatment Success and Potential Complications– Medications that decrease acidity may decrease

the absorption of iron• Take 2-3 hours apart from iron

supplementation• Vitamin C may increase iron absorption

Iron Overload

• Hemosideran– How excess iron is stored in body tissues

• Hemosiderosis– Tissue damage caused by excess iron stores– Deposits of iron accumulate within the organ

• Lungs affected

• Primary Hematochromotosis

Iron Overload

• Primary Hematochromotosis– Hereditary disorder– Increased iron absorption from the GI tract and

deposition in tissue– Diagnosis based on serum iron status

• Management of Iron Overload– Serial phlebotomies– Nutrition education

Iron Overload

• Other Disorders– Alcoholic liver disease– Nonalcoholic steatohepatitis– Chronic hepatitis C infection

Anemia of Chronic Disease

• Most common anemia in the older population– As it progresses it becomes microcytic and

hypochromic– Iron stores are normal or increased– Labs show mild anemia– ACD developed from rheumatoid arthritis– Chronic renal failure

• EPO therapy– Nutrition counseling

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Megaloblastic anemia– Usually develops from vitamin B12 and folic acid

deficiency– Multiple causes– Potentially serious and can be deadly– Excessive folate may interfere with function of

B12– Deficiencies occur as a result of inadequate

vitamin B12 or folic acid

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Clinical presentations of two types of anemia– Vitamin B12 deficiency

• Inadequate level of B12

– Pernicious Anemia• Rare blood disorder• Inability of body to properly use B12

– Signs are subtle– Eventually leads to ineffective hematopoiesis– Hyperhomocysteinemia

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Pernicious Anemia– Inability to properly use B12– Develops slowly over 20-30 years– Result is ineffective erythropoiesis– Three types of PA

• Congenital• Juvenile• Adult-onset

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Pernicious Anemia– Cause: chronic atrophic gastritis and poor Vitamin

B12 absorption– Often associated with other autoimmune

disorders– Occurs primarily in adults older than 60– Treated with Vitamin B12

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Pathology of Pernicious Anemia– Ineffective erythropoiesis in bone marrow– Macrocytes in blood circulation– Cell is normochromic– Premature cell death– Increase in LDH– Increase in indirect bilirubin

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Diagnosis of Vitamin B12 deficiency and Pernicious Anemia– Megaloblasts

• Larger than normal RBCs and have small nuclei

• Diminished levels of B12 accompanied– Increased homocysteine– Increased MMA

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Management of Vitamin B12 Deficiency and Pernicious Anemia– Lifelong administration of Vitamin B12

• Injections• Nasal

• Folic Acid Deficiency– Results from inadequate intake– Body stores from 4-6 months of folic acid

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

Insel P, Turner RE, Ross D. Nutrition. 3rd ed. Sudbury, MA: Jones & Bartlett; 2007, p. 442. Reproduced with permission.

Megaloblastic Anemia-Vitamin B12 and Folic Acid Deficiency

• Folic Acid Deficiency– Clinical Presentation

• Results in neurological problems– Diagnosis

• Confirmed by macrocytic RBCs and hypersegmented neutrophils

– Management• medication

Myelodysplastic Syndromes: Sidroblasts and other Anemias

• Group of stem cell disorders causing anemia• Most common hematologic cancers in older

adults• Sideroblastic Anemia

– Presenting signs of myelodysplastic syndromes• Dominated by peripheral neuropathy and

dermatitis– Diagnosis

• Development is slow, asymptomatic• Anemia attributed to aging

Myelodysplastic Syndromes: Sidroblasts and other Anemias

• Management– Prognosis is variable– Severe cases

• Induce partial or complete remission• Minimize number of transfusions• Blood transfusions• Nutrition support as needed

Myelodysplastic Syndromes: Sidroblasts and other Anemias

• Refractory Anemia– Disorder of the RBC lineage of cells

• Thalassemia Minor– Most common in African, American Indian, and

Asian populations– Causes microcytosis with or without anemia– No treatment is required– May benefit from a diet high in quality protein– Avoid multivitamin/minerals– Maintain adequate fluid intake

Vitamin and Mineral Considerations in Hematologic Problems

• Hyperhomocysteinemia– Abnormally large levels of homocysteine in the

blood– Inherited as a defect in methionine metabolism or

Acquired by Vitamin B6, B12, or folate deficiency

• Vitamin C– Anemia will occur if vitamin C and iron intake are

low

Vitamin and Mineral Considerations in Hematologic Problems

• Vitamin B1 and B2– Thiamine can create a shortage of other B vitamins if

taken in excess– Riboflavin helps in the production of RBCs

• Vitamin K– Necessary for the regulation of coagulation– Management is parenteral Vitamin K

• Calcium– Absorption decreases with age– Calcium citrate effectively absorbed

Vitamin and Mineral Considerations in Hematologic Problems

• Copper– The “twin” to iron– Aids in the formation of Hb– Promotes absorption of iron from GI tract– A deficiency can prevent the release of iron from

storage– Supplement copper to correct deficiency

Vitamin and Mineral Considerations in Hematologic Problems

• Zinc– Assists in linking oxygen to Hb– Vital to immune response– An important role in taste– Large amounts of phytate and fiber can depress

zinc absorption

Protein Calorie Malnutrition

• Common syndrome in older adults• Clinical manifestation relates to the duration

of malnutrition• Stress-related malnutrition (kwashiorkor)• Compensated malnutrition (marasmus)• Nutrition objectives

– Correct weight loss, provide adequate nutrients, correct dehydration, avoid refeeding

Conclusion

• Assessment and treatment of anemia is complicated

• Each type of anemia has its own impact on metabolic process