Prevalence of anemia among elderly persons in selected village of Pyin Oo Lwin Township

Abstract

Background: Anemia is one of the most common public health problems of older populationespecially in developing countries. While decreased hemoglobin levels were previously largely considered a normal consequence of aging, now there is evidence that anemia is associated with an increased risk for morbidity and mortality.

Objective: To determine the prevalence of anemia and severity of anemia among elderly persons in Pyin Sa village in Pyin Oo Lwin Township.

Methods: Community and Laboratory-based, cross-sectional descriptive study was done at Pyin Sa Village Tract of Pyin Oo Lwin Township.Personal details of 100 elderly people over and the age of 60 years old were collected in eachcase, and taken 2ml of blood under aseptic condition. Blood haematological parameters were measured by haematological autoanalyzer. According to hemoglobin (Hb) cut-off levels defined by the World Health Organization (WHO) anemia is defined as Hb<12g/dl for females, <13g/dl for males. There are three grades of anemia severity were differentiated as severe (Hb<8 g/dL), moderate (Hb 8 to <9.5 g/dL), and mild (Hb≥ 9.5 g/dL) respectively.

Results: The overall prevalence of anemiaamong the older persons was 30%. The majority 28% showed mild anemia,and moderate anemia was recorded in 2%.Results show that prevalence of anemia 30% contains two types of anemia, hypochromic microcytic anemia 27% and macrocytic anemia 3% in this study.

Conclusion: The results showed awareness prevalence of anemia in the studied population. Therefore, geriatric persons should be routinely screened for anemia and early diagnosis, effective treatment and prevention of anemia are important in rural area of developing country.

Introduction

Anemia is one of the most common health problem of older population especially in developing countries.[3] Anemia is a condition characterized by reduction of the concentration of hemoglobin in blood below the normal level. Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body’s tissues and returns carbon dioxide from the tissues back to the lungs. The iron contained in hemoglobin is vital in transporting oxygen and carbon dioxide in our blood and also responsible for the red color of blood.[1]

According to hemoglobin (Hb) cut-off levels defined by the World Health Organization (WHO) anemia is defined as Hb<12g/dl for females, <13g/dl for males. [2] The normal ranges for hemoglobin depend on the age and, beginning in adolescence, the gender of the person. [1]There are three grades of anemia severity were differentiated as severe (Hb<8 g/dL), moderate (Hb 8 to <9.5 g/dL), and mild (Hb≥ 9.5 g/dL). [2]

In general, the levels of hemoglobin is found to be lower in older than young people. The exact causes unclear and can be a feature of normal ageing, pathological causes or nutritional deficiency. However, many physicians continue to neglect the significance of anemia as a serious clinical condition in the elderly. [4]

While decreased hemoglobin levels were previously largely considered a normal consequence of aging, and there is evidence now that anemia in the elderly is associated with an increased risk for morbidity and mortality, reducing not only functional capacity and but also quality of life. [5][6]

The pathophysiology of such an age-related decline in erythrocyte production is obscure, and efforts to understand anemia in elderly individuals have become a major target of research interest. [7]

WHO defines ages of 60 and 65 years as elderly and the Elderly Health Care Project of Myanmar accepts people ages 60 and above as elderly.Prevalence of anemia is increased sharply over the age of 60. [8]

On the basis of global scenario, in 2000 there were 600 million people aged 60 or over and it is estimated that this figure will double by 2025 and more than triple to 2 billion by 2050. [2] Thus, it is important to find out and understand the significance of common medical problems in older people including anemia. [6]

Early diagnosis, effective treatment and prevention of anemia are important for the elderly patients in developing countries in Asia. Myanmar is also facing the emerging issue of the growing number of older people. Since most of the people in Myanmar are rural people, “Rural ageing” has become an important issue.[10]

Most of the rural people are also nutritionally deficient due to the lack of nutritional knowledge. They also face shorter expected life span due to neglect of their health problems and lack of health education. The rural area of Pyin Oo Lwin Township, Pyin Sa village lies on the way from Mandalay and Pyin Oo Lwin. It is a developing village and the villagers’ lifestyle has changed due to the presence of many migrants. The Rural Geriatric Clinic for elderly health care is held every Wednesday. Both healthy and ill elderly persons participated in this study. After studying in this area firstly, the study of anemia among older people in the different zone of Myanmar including rural and urban is required to promote active, healthy ageing and to increase expected life span in Myanmar.

Materials and Methods

This Community and Laboratory-based, cross-sectional descriptive study was done at theDepartment of Medical Research (POLB) and Pyin Sa Village Tract of Pyin Oo Lwin Township.During the study period September to October 2015, the sample was be recruited from Pyin SaVillage Tract according to Rural health profile 2014, Pyin Sa Village. From the village, the participants was be selected randomly to obtain the required sample size 100 (minimum required sample size n=98). The sampling frame was be prepared using the list of household numbers available at ῝ Yat Kwat Yone῎.

Their relevant history regarding age, sex and general health information was taken. After getting informed consents from the participants and explaining the purpose, risks and benefits of the research, two ml of venous blood was be collected by trained laboratory personnel who processed blood using aseptic techniques, universal precautions, and disposable supplies. All the samples were collected by using the sterile and disposable materials.

Haematological parameters were assessed by using Humacount 60 Haematology Auto Analyzer for all cases and blood films examination were done under microscope by pathologist.

Relevant clinical data collection, data entry and analysis of the subjects werebe done with SPSS software(20.0 version). Prevalence of anemia was be shown with frequency (percentage).The prevalence rates were calculated with 95% Confidence Interval (95% CI). The proposal was be approved by the Ethics Committee of the Department of Medical Research before the study was conducted.

Results

The basic geographic characteristics of enrolled participants were shown in Table (1).

Table (1) Geographic Characteristics of 100 elderly persons >= 60 yr

Discussion and Conclusion

Anemia, defined as a low blood haemoglobin concentration, has been shown to be a public health problem that affects low, middle and high income countries and has significant adverse health consequences and impacts on social and economic development. Although the most reliable indicator of anemia at the population level is blood haemoglobin concentration, measurements of this concentration alone do not determine the cause of anemia. [13]

The world is going through a demographic transition. The percentage of elderly is increasing at a tremendous rate. Anemia continues to be a major public health problem at all ages worldwide. It is common in older adults and is an independent predictor for increased morbidity and mortality in several disease states. [4]

In this study, the prevalence rates of the anemia were 30 of 100 elderly (30%). Mean level of haemoglobin (mean+/- SD) were 13.4± 1.7 mg/dl and 12.7±1.0 mg/dl in men and women. In one study in Korea, mean level of haemoglobin were 14.5± 1.4 mg/dl and 13.7±1.1 mg/dl in men and women. [14]The result of this study is compatible with the Korea study.

In a hospital based cross sectionalobservational study in India, the trend of anemia from 2008 to 2011 was an increasing trend, 9%, 15%, 22%, and 27% respectively and in 2012 constant around 26%. Anemia was more common in females than males, 18% males and 82% females were reported. Anemia was highest among 11-25 years of age 42% followed by 26-40 years 23% and lowest among 0-10 years of age 8.69%. Anemia among elderly was quite higher at 15.5%. Most of the males had mild anemia (16%) followed by moderate (6.61%) and severe (0.77%) . In contrast, most of the females had moderate anemia(42%) followed by mild (31.35%) and severe (3%). The anemia trend in female patients increased from 2008-2009, with a slight decrease in 2010 and further decrease in 2011 followed by an increase in 2012.[15]

In this rural community study of elderly persons, the prevalence of anemia was 30% which was higher than the study done in India rural Hospital base study in 2008 to 2012. Among the elderly persons, 28%were mildly anemic, 2 % showed moderate anemia and there was no severe anemia in both gender. Although typically mild, it has been associated with substantial morbidity and mortality.The prevalence rate of anemia were36.58 % (15 of 41) in men and 25.4% (15 of 59) in women respectively; men had higher anemia rates than women.

In this study, the mean age was 71±8 yr and the largest group was 60-69yr. In the 60-69yr group, 28.2% (13 of 33) had mild anemia but in the 70-79 yr group, 30.5% (11 of 36) had anemia (10 were mild anemia and 1 was moderate anemia) and in the>80yr age group,33.3% (6 of 18) were anemic (5 were mild anemia and 1 was moderate anemia).The prevalence of anemia in Thai community dwelling older adults >= 60yr data from the multistage cross-sectional National Health Examination Survey (NHES) IV conducted in 2009 was 40.3% over all, 34.5%, 48.4%, 60.7% in the group of 60-69, 70-79, >80yr old respectively.[16] There were different data of prevalence in the Thai study and the present study with different ethnicity and sample size.

Anemia is the most common disorder of the blood that affects about a quarter of people globally.[17] Iron-deficiency anemiaaffects nearly 1 billion. In 2013 anemia due to iron deficiency resulted in about 183,000 deaths, down from 213,000 deaths in 1990. [18] It is more common in females than males in childhood, during pregnancy and in the elderly.[19]

Anemia in the elderly can generally be categorized into four major types: anemia related to nutrient deficiencies (iron, cobalamin, and folic acid), anemia related to chronic inflammation, anemia due to renal insufficiency, and unexplained anemia. [21]

In this study, the most common type of anemia was Hypochromic Microcytic Anemia (HMA). Microcytic anemia is primarily a result of hemoglobin synthesis failure/insufficiency, which could be caused by several etiologies: iron deficiency anemia, chronic diseases, thalassemia, sideroblastic anemia etc. Iron deficiency anemia is the most common type of anemia overall and it has many causes.

In the United States, the most common cause of iron deficiency is bleeding or blood loss, usually from the gastrointestinal tract. Worldwide, the most common cause of iron deficiency anemia is parasitic infestation (hookworms, amebiasis, schistosomiasis and whipworms).[20]

There was a 2% rate of macrocytic anemia in present study. Megaloblastic anemia, the most common cause of macrocytic anemia, is due to a deficiency of either vitamin B12, folic acid, or both.[20]

The prevalence of anemia in Myanmar women and children is very high. Despite iron tablets supplementation for pregnant women, school going girl and children aged 6 to 36 months, the prevalence rates have not improved or have even increased. Iron deficiency anemia among pregnant women was 58 percent in 1994 according to a survey by the Department of Medical Research, and 71 percent in 2003. Prevalence of anemia among preschool children was 30 percent in 1994 (DMR) and 75 percent in 2004 (NNC). Anemia was more common in coastal and delta regions.[22]

A study done in Pyinmana Township, Myanmar, 2010, reported the prevalence of anemia and iron deficiency anemia among pregnant women 60.1% and 40.6% respectively.[23]

The one study done in 2014-2015 showed a high prevalence of anemia (64.2%) in which 86.5% (77 of 89 cases) was mild anemia and 13.5% (12 of 89 cases) was moderate anemia on screening haemoglobinopathy among pregnant women attending to antenatal clinic of Pyin Oo Lwin General Hospital.[24]

Nowadays, Myanmar gives attention to elderly health care to promote active and healthy ageing. The Ministry of Health implemented the health care project in Myanmar since 1992-93. Being an integral part for the primary health care for elderly became one of the sub programs under the umbrella of community program since National Health Plan (1993-96). This programme is based on five health care; promotive, preventive, curative and rehabilitative cares.[10]

Therefore, prevalence of anemia in elderly person in rural area of Pyin Oo Lwin Township (30%) is reliable data for Elderly Health Care program in Myanmar. The results of present study are useful for screening programs and clinical management of elderly anemia in this area.A nationwide study should be conducted to collect or update information on the prevalence and severity of anemia in the age group of over 60 years as well as urban and rural areas of the country.

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Nandar Ko
M.B., B. S, M.Med.Sc (Pathology)
Research Officer, Department of Medical Research (POLB)

Khin Moe Aung, Deputy Director, Department of Medical Research (POLB)
Tin Moe Khaing, Research Officer, Department of Medical Research (POLB)
Win Aung, Deputy Director General (Retired), Department of Medical Research (POLB)