- Anaemia, polypharmacy, advanced malignancies, disorders, cultural/religious sensitivities, nutritional deficiencies, thrombocytopenia and bleeding are common
In the context of an ageing population, anaemia (lower than normal number of red blood cells or the haemoglobin concentration within them, which results in fatigue, weakness, dizziness and shortness of breath, among others), polypharmacy, advanced malignancies, disorders, cultural and religious sensitivities, nutritional deficiencies, thrombocytopenia (abnormally low levels of platelets [for clotting] in the blood) and bleeding are commonly seen challenges among elderly patients.
These concerns were raised in an opinion article on ‘Haematology (branch of medicine involving the study and treatment of blood) Are we ready for an ageing population?’ which was authored by C.C. Kariyawasam (Consultant Haematologist at the Sri Jayewardenepura General Hospital's Haematology Department) and B.L.T. Balasooriya (Medical Laboratory Technologist at the same Department), and published in the Sri Lanka Journal of Haematology's 16th Volume, last month.
According to the World Health Organisation (WHO), an aged population is considered as those over 60 years. In 2020, the aged population of the world was one billion, and by 2030, it will increase to 1.4 billion and will double to 2.1 billion by 2050, with those above 80 years trebling between 2020 to 2050 to reach 426 million. According to the UN, the ageing population is those over 65 years, which constitutes 10.3% of the global population at present and which is expected to increase to 20.7% in 2074. With regard to population ageing, at present, low- and middle-income countries (LMICs) are experiencing the greatest change (WHO). By 2050, two-thirds of the world’s population over 60 years will live in LMICs. Within South Asia, Sri Lanka demonstrates the most rapid ageing process. By 2042, almost one out of every four persons is expected to be elderly.
At the biological level, ageing results from the impact of the accumulation of a wide variety of molecular and cellular damage over time. This leads to a gradual decrease in the physical and mental capacity, a growing risk of disease and ultimately death. In addition to these biological changes, ageing is also associated with other life changes such as retirement, relocation to more appropriate housing and the death of friends and partners.
Increased life expectancy and decreased fertility rates are the primary reasons identified for the aforementioned figures and this places a significant strain on healthcare systems, social security programmes and the workforce.
As the global population ages, haematology practices too must evolve to meet the unique challenges and needs of the older population. This demographic shift has led to an increase in age-associated haematological disorders, such as anaemia, myelodysplastic syndromes (MDSs) (a group of cancers in which blood cells in the bone marrow don’t mature and develop into healthy blood cells), clotting abnormalities, and haematological malignancies such as leukemia (a group of blood cancers that usually begins in the bone marrow and produces high numbers of abnormal blood cells), and the embracing of a multidisciplinary and patient-centred approach.
The complexities of managing haematological conditions in the elderly, emphasises the importance of individualised care, multidisciplinary collaboration, and resource-conscious approaches. Thus, certain key methods can be incorporated to adapt haematology practices for an ageing population.
Personalised and comprehensive assessment
The elderly are often present with multiple comorbidities, polymedication and limitations of functions that complicate haematological care. Comprehensive geriatric assessments, which include physical, cognitive, nutritional and social evaluations, must be included into the haematology practice. Using such a comprehensive approach will ensure that treatment plans align with the patients’ overall health status and quality-of-life.
Tailored diagnostic approaches
Diagnostic protocols should be designed for age-related physiological changes. For example, baseline hemoglobin levels tend to decline with age, requiring the careful interpretation of anaemia thresholds. In addition, bone marrow biopsies and other invasive procedures may require modification or the use of alternative techniques to minimise discomfort and risks.
Individualised treatment plans
Treatment protocols must be designed to balance efficacy with tolerability. Older patients may not tolerate aggressive therapies due to generalised weakness or comorbid conditions. Dose adjustments, supportive care (e.g. use of growth factors, transfusions), and less toxic alternatives like oral or targeted therapies should be considered. Engaging patients in the decision-making process regarding their treatment ensures that their preferences and values are respected.
Prevention and early detection
Preventative measures should be given priority, including regular screening for nutritional deficiencies (e.g. iron, vitamin B12, and folate), thrombotic (the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system) risks and the early detection of hematological malignancies by the close monitoring of symptoms and blood counts which can improve outcomes.
Management of age-specific risks
Older adults are more susceptible to thrombotic events and bleeding-related complications. Anticoagulation therapy must be carefully managed, weighing the risks of clotting against bleeding, especially as most elderly patients have some degree of renal impairment which may necessitate the reduction of the dose of commonly used oral anticoagulants. Therefore, collaboration with geriatricians and cardiologists can help optimise anticoagulation, particularly in patients with atrial fibrillation (abnormal heart rhythm with the rapid and irregular beating of the atrial chambers of the heart).
Palliative and supportive care
Palliative care should be commenced early for elderly patients with advanced haematological malignancies. While the management of symptoms like fatigue, pain, and dyspnea (difficult or laboured breathing) improves the quality of life, providing emotional and psychological support to patients and caregivers is of equal importance.
Education and training
Healthcare workers in haematology should be trained to understand the complexities of ageing, such as recognising geriatric syndromes, managing frailty and addressing ethical issues like end-of-life care. A multidisciplinary team effort ensures comprehensive patient management.
Research and innovation
The ageing population necessitates active research into geriatric haematology. Clinical trials should actively include older adults to generate age-specific data. Novel research into biomarkers for frailty, minimally invasive diagnostic tools, and therapies tailored to geriatric physiology are mandatory for aged care.
How can the haematology practice be adapted for an ageing population in the low-socioeconomic context?
With the prediction of two-thirds of the world population over 60 to be living in LMICs, certain measures can be adopted in addition to or in place of the aforementioned in respect of the ageing population in resource limited settings, in order to enhance the haematological management of the elderly.
Individualised and resource-conscious treatment plans
Resource limitations necessitate prioritising affordable and sustainable treatment options. Generic medications, simplified chemotherapy (the treatment of disease by the use of chemical substances, especially the treatment of cancer with cytotoxic [toxic to living cells] and other drugs) protocols, and oral formulations of drugs can improve accessibility. Collaboration with global health organisations and non-governmental organisations can help subsidise essential medicines, such as anticoagulants, iron supplements, or chemotherapy agents.
In such resource limited settings, task-sharing with trained nurses, community health workers, and pharmacists can extend the reach of the haematology services. Simple and clear protocols for managing common conditions like anaemia or thrombosis (the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system) can empower primary care providers to deliver effective care.
Strengthening prevention and early detection
Prevention is particularly important in resource-limited settings. Public health campaigns focused on addressing malnutrition, preventing infections like malaria (a common cause of anaemia) and promoting immunisation can reduce the burden of haematological diseases. Low-cost interventions, such as iron and folic acid supplementation programmes, can address common deficiencies in older adults.
Early detection efforts can be promoted through community-based screening programmes using simple tests like the full blood count (FBC) and peripheral smear analysis. Training primary care providers to recognise early signs of haematological conditions will ensure the timely referral to specialists.
Building resilient health systems
Strengthening health systems is the ultimate solution for sustainable care. This includes improving healthcare infrastructure, increasing the availability of trained haematologists, and ensuring a steady supply of essential medicines and diagnostic tools. Collaborations between governments, private sectors and international organisations are essential to achieve this goal.
Managing anaemia in elderly patients
A 70-year-old female patient presented with severe fatigue and pallor. Upon conducting a comprehensive assessment, it was discovered that she had iron deficiency anaemia due to chronic gastrointestinal bleeding due to a jejunal (the second part of the small intestine) tumour which was detected due to the examination of her stools for occult blood (traces of blood in the stool which can’t be seen from the naked eye) and upper and lower gastrointestinal endoscopy (a procedure used in medicine to look inside the body through the use of an endoscope to examine the interior of a hollow organ or cavity of the body). This case highlighted the importance of thorough history-taking, physical examination and early non-invasive tests such as FBC, the peripheral blood smear and stool tests, which allowed for the diagnosis without too much delay. Not only the haematological aspects but also the patient’s dietary habits and potential sources of blood loss were considered. The treatment involved iron supplementation and addressing the underlying cause, which required collaboration with a gastroenterologist and a surgeon.
Addressing polypharmacy
A 68-year-old male patient with multiple comorbidities, including hypertension, diabetes, chronic kidney disease (CKD) and atrial fibrillation, was on several medications, including anticoagulants. He presented with unexplained bruising and occasional nosebleeds.
This situation underscored the challenges of polypharmacy and the multiple comorbidities in the patient. His medication regimen was carefully reviewed, considering the drug interactions, the patient’s excretory functions because of the CKD and the cumulative effects of the anticoagulants. Collaboration with the primary care physician was done to adjust his medications including doses, ensuring that the need for anticoagulation with the risk of bleeding was balanced.
Palliative care for advanced haematological malignancies
An 80-year-old patient diagnosed with acute myeloid (bone marrow) leukaemia is not a candidate for aggressive treatment due to frailty and comorbidities.
This experience teaches the importance of palliative care and symptom management. The focus was on providing comfort measures, managing pain and addressing emotional and physical needs. Engaging in discussions about end-of-life care and respecting the patient’s wishes were a profound learning experience that emphasised the need for compassion in haematology.
Early detection of haematological disorders
During a medical check-up event, a 65-year-old woman who had no prior medical history and no clinical findings on examination, presented. Her FBC revealed thrombocytopenia which was finally diagnosed as early non-alcoholic chronic liver cell disease (CLCD).
This case reinforced the significance of frequent screening in the elderly population. The value of medical check-ups and education in identifying potential haematological issues before they escalate can be learned through this. Regular medical check-ups should be advocated for in the elderly population.
Collaboration with multidisciplinary teams
A case conference was held for a 67-year-old male patient with CLCD after a cardiac bypass graft, who had developed a proximal deep vein thrombosis on the third day post-operation and an acute kidney injury which required a comprehensive treatment plan involving haematology, nephrology (the study of the kidneys), medical and cardiac teams in managing the anticoagulation in the presence of renal (kidneys) and liver compromise.
This experience highlighted the importance of a multidisciplinary approach in managing complex cases. Diverse perspectives and the expertise that each team member brought to the table, ultimately leading to a more holistic and effective treatment plan for the patient, should be appreciated.
Cultural/religious sensitivity in treatment decisions
A 72-year-old woman diagnosed with aplastic anaemia (the body fails to make blood cells in sufficient numbers) who was hesitant to accept blood transfusions due to religious beliefs was cared for.
This situation taught the importance of personal, cultural and religious sensitivity and effective communication in haematology. The doctors engaged in open discussions to understand the patient’s beliefs and worked together in exploring alternative treatment options that aligned with her values while still addressing her medical needs.
Addressing nutritional deficiencies
An 80-year-old male who lived alone, presented to the Out-Patient Department due to severe fatigue and weakness. Upon questioning, it was found that he had difficulty accessing nutritious food due to mobility issues. He was admitted and comprehensive laboratory tests revealed vitamin B12 deficiency anaemia.
This case highlighted the association of nutrition and haematology in the elderly. Coordination was done with a dietitian to develop a nutritional plan that included vitamin B12 supplementation and dietary modifications that can be obtained easily. This experience reinforced the importance of addressing social determinants of health and the importance of community-based management in haematology.
Individualised treatment, comprehensive assessments, and the need for collaboration among healthcare professionals are important.
Discussion
Age-related hematologic changes are accentuated by a decline in marrow cellularity, increased risk of myeloproliferative disorders (a group of blood cancers in which excess red blood cells, white blood cells or platelets are produced in the bone marrow) and anaemia, and a decline in adaptive immunity.
In 2020, about 600,000 people who were 65 years and above were diagnosed with haematological malignancy worldwide. This number is expected to increase to almost one million by 2040, with the largest growth taking place in regions with less developed economies. Globally, healthcare systems are not prepared to face this foreseen increase in the burden of haematological malignancies among the elderly and geriatric oncology (the study, treatment, diagnosis, and prevention of cancer) and haematology are not properly developed in most LMICs.
Anaemia is one of the commonest haematological problems affecting 12% of the elderly above 65 years, living in the community, with the percentage increasing to 40% and 47% in the hospitalised and the elderly living in nursing homes, respectively. The most common anaemias in the older people are anaemia caused by nutritional deficiencies, anaemia of chronic inflammation, and the unexplained anaemia of ageing. In addition, anaemia can be due to other bone marrow disorders and various non-haematological disorders, necessitating a systematic approach to the evaluation of the cause for anaemia.
Thrombocytopenia can be identified as another common haematological disorder seen in the elderly. Mild thrombocytopenia is a frequent presentation due to an idiosyncratic side effect of the cocktails of drugs that is a common feature in most elderly patients. In addition, disorders affecting the bone marrow such as MDSs, myelofibrosis occurring in the older patients (a bone marrow blood cancer), infiltration by haematological malignancies and thrombocytopenia can occur in isolation or together with other cytopenias (low levels of red or white blood cells or platelets). Immune aetiology for thrombocytopenia is now becoming a common presentation too. Such thrombocytopenia can occur with or without bleeding. The importance of proper evaluation in determining the aetiology is thus stressed.
Bleeding is another common presentation in the older population which again can be due to the frequent use of painkillers, anticoagulants and blood thinners for ischemic heart disease (the reduction of the blood flow to the cardiac muscle due to a build-up of atheromatous [fatty material] plaque in the arteries of the heart), arrhythmias and thrombotic events which are common in these patients and also the development of acquired bleeding disorders and other rare factor deficiencies such as paraneoplastic syndromes (consequence of a tumour) or those associated with clonal (a single blood stem cell acquires a mutation, causing it to divide and create a clone of abnormal cells)/malignant haematological disorders. Therefore, the careful, focused evaluation of elderly patients presenting with bleeding is imperative to prevent delay and unnecessary investigations in their diagnosis and management.
As most haematological clonal/malignant disorders are common in the older population, it is imperative that all elderly patients presenting with a bi-cytopenia (affecting two types of blood cells) or pancytopenia (affecting all three types of blood cells) are considered as potential candidates for an underlying bone marrow pathology and thereby evaluate the patient with minimally invasive investigations initially, which would direct the clinician to proceed with further specific investigations in arriving at a diagnosis without undue delay and expense.
The education of health workers, especially in haematology, acting with a high degree of suspicion and a multidisciplinary approach are paramount in the management of elderly patients with haematological disorders.
Conclusion
Adapting haematology for an ageing population, according to Kariyawasam et al., requires a paradigm shift toward individualised, multidisciplinary, and patient-centred care. By addressing the unique challenges of older adults, haematologists and healthcare workers can enhance outcomes, improve the quality of life, and ensure equitable care for this growing population. In respect of low-socioeconomic countries, focusing on cost-effective solutions, capacity building, prevention, and community involvement and most importantly, empathy towards the elderly, point to the way forward. Ensuring equitable access to haematology services is not just a medical challenge but a moral obligation to address the disparities in global health.