nutritional aspects of management of hematological disorders in older adults - chapter 10
DESCRIPTION
Hematopoiesis Anemia Hematological deficiencies Iron deficiency anemia Vitamin B12 deficiency Anemia of Chronic DiseaseTRANSCRIPT
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