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A F R E E D O M M A G A Z I N E S P U B L I C A T I O N

Supplement to

CLIN

ICAL STRATEGIESINLTC

Council for Anemia

An Accredited Program Sponsored by Medical Education Resources Inc., a nonprofit medical education company, through an unrestricted educational grant from Amgen, Inc.

22

Robert P. Geronemus, MDPresidentSouth Florida Nephrology

Associates Private PracticeFt. Lauderdale, Florida

Jeffrey Hoggard, MDMedical DirectorGreenville Dialysis CenterGreenville, North Carolina

Anne M. Murray, MD, MScAssistant Professor of MedicineUniversity of MinnesotaHennepin County Medical Center,

GeriatricsMinneapolis, Minnesota

Armon B. Neel, Jr., PharmD, CGP, FASCP

PresidentMedicationXpert, LLC Griffin, Georgia

Miriam B. Rodin, MD, PhD,CMD

Assistant Professor of ClinicalMedicine

The University of ChicagoChicago, Illinois

Laurence Z. Rubenstein, MD,MPH, FACP

Professor of Geriatric MedicineUCLA School of MedicineDirector, Sepulveda VA GRECCLos Angeles, California

Michael W. Schuster, MDProfessor of Clinical Medicine at

the Weill Medical College ofCornell University

Director of Bone MarrowTransplantationand Clinical ResearchHematology/Oncology Division

New York Presbyterian HospitalNew York, New York

Eric G. Tangalos, MD, CMDChair, Division of Community

Internal MedicineProfessor of MedicineMayo Medical SchoolRochester, Minnesota

Lynn Williams Shipp, RPh,FASCP

President ofSenior Care PharmacyBoulder, Colorado

Shing-shing Yeh, PhD, MDAssociate Professor in MedicineUniversity Hospital SUNY at

Stony BrookGeriatric Division Department

of MedicineVA Medical Center at NorthportNorthport, New York

Council Consensus Committee

Authors

Methods

Council ChairJohn E. Morley, MB, BCh

Dammert Professor of Gerontology Director, Division of Geriatric Medicine

St. Louis University Health Sciences CenterDirector, GRECC, St. Louis Medical Center

St. Louis, Missouri

Consensus CommitteePublication Chair

David R. Thomas, MD, CMD, FACP, AGSFProfessor of Medicine

Division of Geriatric MedicineSt. Louis University Health Sciences Center

St. Louis, Missouri

Diagnosis and Management of Anemia in Long-Term Care

This expert panel of interdisciplinary thought leaders representing academia and the medical community was assembled by Medical Education Resources (MER), a nonprofit medical educationcompany, to review the existing literature and author this publication on thediagnosis and management of anemia in long-term care. Where evidenceexisted, it served as the basis for specific recommendations. In the absenceof evidence, consensus was obtained. Programs in Medicine was selectedto facilitate a summit meeting and a closed Internet discussion forum toobtain consensus agreement by the members of the Council on the information presented within this publication.

August 2003

3


SPONSORSHIP AND ACCREDITATION INFORMATION

Target AudienceThis program is intended for long-term care

physicians, pharmacists, and nurses who diag-

nose and treat elderly patients with anemia.

Educational ObjectivesUpon completion of this program, participants

should be able to:

• Describe the epidemiology of anemia in

long-term care.

• Define the differential diagnosis of anemia

in long-term care.

• Discuss the management options for

anemia in long-term care.

Program Completion TimeBased upon trials, the estimated time to

complete this program is 1 hour.

Educational Grant This program is made possible by an unrestricted

educational grant from Amgen, Inc.

SponsorshipThis activity is sponsored by Medical Education

Resources Inc., a nonprofit medical education

company. Programs in Medicine was selected to

manage program logistics.

Physician AccreditationMedical Education Resources is accredited by the

Accreditation Council for Continuing Medical

Education (ACCME) to sponsor continuing med-

ical education for physicians.

Credit DesignationMedical Education Resources designates this

continuing medical education activity for up to

1 credit hour in category 1 of the Physician’s

Recognition Award of the American Medical

Association. Each physician should claim only

those hours of credit that he/she actually spent

in the activity.

This CME activity was planned and produced

in accordance with the ACCME Essentials.

Nursing AccreditationThis program qualifies for 1.25 contact hours.

Medical Education Resources is approved as a

provider of continuing education in nursing

(CNE) by the Colorado Nurses’ Association,

which is accredited as an approver of CNE by

the American Nurses Credentialing Center’s

Commission on Accreditation.

Provider approved by the California Board of

Registered Nursing, Provider CEP # 12299, 1.25

contact hours.

Each participant should claim only those hours of

credit that he/she actually spent in the educational

activity.

Pharmacy AccreditationMedical Education Resources (MER) is approved by

the American Council of

Pharmaceutical Education as a

provider of continuing pharmaceuti-

cal education. MER designates this

continuing education activity for 1.0 contact hour

(0.1 CEUs) in states that recognize ACPE. Universal

Program Number: 816-000-03-043-H04.

DisclaimerThe content and views presented in this educational

program are those of the faculty and do not neces-

sarily reflect those of Medical Education Resources,

Amgen, Inc., or MultiMedia HealthCare/Freedom,

LLC. The authors have disclosed if any unlabeled use

of products is mentioned in the material. Before

prescribing any medicine, primary references and

full prescribing information should be consulted.

August 2003

4


August 2003

4

Faculty Disclosure Policy It is the policy of Medical Education Resources

(MER) to ensure balance, independence, objec-

tivity, and scientific rigor in all its educational

activities. All faculty participating in our pro-

grams are expected to disclose any relationships

they may have with commercial companies

whose products or services may be mentioned

so that participants may evaluate the objectivi-

ty of the presentations.

Dr. Robert P. Geronemus reported that he

serves on the Speakers’ Bureau for Amgen, Inc.,

Ortho Biotech Products, and Watson

Laboratories.

Dr. Jeffrey Hoggard reported that he serves

on the Speakers’ Bureau for Amgen, Inc.

Dr. John Morley reported that he receives

Grant/Research support from Organon Inc.,

Merck & Co. Inc, Nestec Ltd, Bayer Corporation,

and B. Braun McGaw. He serves on the

Speakers’ Bureau for LXN, Organon Inc.,

GeriMed of America, UniMed Pharmaceuticals

Inc., Solvay Pharmaceuticals, Essentia, Alza

Pharmaceuticals, Pharmacia & Upjohn, Glaxo

Wellcome, B. Braun McGaw, Bristol-Myers

Squibb, Novartis, Pfizer Inc/Parke-Davis and

GlaxoSmithKline. He receives grant support

from Solvay Pharmaceuticals to undertake a

study on testosterone and renal failure. He is

also an 8% shareholder of CUM

Pharmaceuticals, which is developing an

inhalation form of testosterone.

Dr. Anne M. Murray reported that she is a

consultant for Amgen, Inc.

Dr. Miriam B. Rodin reported that she is a

consultant for Amgen, Inc.

Dr. Michael W. Schuster reported that he

receives Grant/Research support from Amgen,

Inc. He serves on the Speakers' Bureau for

Amgen, Inc. and Ortho Biotech Products.

Dr. Eric G. Tangalos reported that he is a con-

sultant for Omnicare, Eli Lilly and Company,

Janssen Pharmaceutica, and Abbott Laboratories.

Dr. David Thomas reported that he is a con-

sultant for Amgen, Inc.

Dr. Armon B. Neel, Dr. Lawrence Z.

Rubenstein, Dr. Lynn Williams Shipp, and

Dr. Shing-shing Yeh reported that they do

not have a financial arrangement or affiliation

with commercial companies whose products

may be mentioned in this program.

Obtaining Continuing Education CreditTo receive credit, participants must complete

the CME/CE Test Questionnaire that appears at

the end of this program and fax or mail it to:

Medical Education Resources1500 West Canal Court

Littleton, CO 80120Fax: 303-798-5731

A minimum score of 70% on the Continuing

Pharmaceutical Education Test is required for

credit. A certificate of completion will be

mailed within 4 weeks of receipt of the com-

pleted answer sheet.

Program Release Date: August 2003 Program Expiration Date: August 2005

FACULTY DISCLOSURE POLICY

August 2003

5

AAnemia is very common in nursing home resi-

dents and is associated with increased morbidity

and mortality. While some of this anemia is due

to deficiencies in iron, folate, or vitamin B12, the

most common cause is anemia of chronic dis-

ease. Much of the anemia of chronic disease is

associated with chronic kidney disease. Erythro-

poietin, or epoetin alfa, has been demonstrated

to restore hemoglobin concentrations approach-

ing normal in these persons. Darbepoetin alfa

has a longer half-life than that of epoetin alfa,

and can thus be administered every other week.

Studies are in progress on less frequent dosing.

The Council for Anemia Clinical Strategies in

Long-Term Care recommends that the causes of

anemia should be aggressively sought and that

appropriate treatment should be given to correct

underlying causes and restore hemoglobin con-

centrations to normal.

Anemia is not a normal finding in older per-

sons, and hemoglobin concentration should

not be adjusted downward in older persons.1,2

Hemoglobin and hematocrit values differ little

between the healthy elderly population and the

younger population. A hemoglobin concentra-

tion of less than 13 g/dL in men and less than

12 g/dL in women defines anemia, according

to World Health Organization standards.

While the World Health Organization cutoffs

for anemia may be reasonable, they should not

be considered optimal hemoglobin concentra-

tion. For example, women with a hemoglobin

concentration between 13-14 g/dL have better

mobility and lower mortality compared to

those with a hemoglobin concentration of less

than 12 g/dL.3

We know from the third National Health and

Nutrition Examination Survey (NHANES II)

that there is a significant increase in anemia with

each decade of life over the age of 70. The preva-

lence jumps from 10.6% in males aged 70-79

years to 22% in males aged 80-89 years. For

each decade of life over the age of 70 years, the

percentage of anemic patients is consistently

higher in men than in women, probably in part

due to falling androgen levels. Sex differences in

hemoglobin concentration result chiefly from

differences in testosterone concentration. Hypo-

gonadism in older males (andropause) is com-

monly associated with approximately a 1 g/dL

6


fall in hemoglobin concentration.4 Further-

more, men who have functional hypogonadism

from pituitary adenomas are anemic,5 and men

with prostate cancer who are undergoing thera-

py with total androgen blockade are anemic.6

Anemia is as abnormal in the elderly as it is

in the young. It should be investigated and

treated appropriately, irrespective of age.

A Brief History of Blood As long ago as 2500 BCE, Egyptians induced ane-

mia to cure disease by bleeding from the foot and

neck. In 350 BCE, Aristotle considered blood to

be the mirror of the soul. However, it was not

until 1628 that William Harvey demonstrated

that blood circulates throughout the body. Thirty

years later, Jan Swammerdam, a Dutch micro-

scopist, described red blood cell morphology.

The first recorded blood transfusion was car-

ried out in 1665 by Richard Lower, who used a

syringe made from a goose quill and bladder to

connect the jugular vein of one dog to another.

The anemic dog survived. Two years later, Jean-

Baptiste Denis transfused a teenage boy with

camel blood, and the boy lived. In 1795, Philip

Syng Physick performed the first human-to-

human blood transfusion, although it was not

until 1818 that another blood transfusion

between humans was published. In 1907, at

Mount Sinai Hospital in New York, the first

transfusion using crosstyping of blood was per-

formed. In 1917, the United States Army started

to use type O blood preserved with a citrate-glu-

cose solution to store blood for casualties during

August 2003

FIGURE I

7


the Battle of Cambrai. This led to the establish-

ment of blood banks in hospitals in the 1920s.

During World War II, the Red Cross widely

advertised for blood donations using a series of

posters to encourage Americans to give blood for

the soldiers (Figure 1). In 1963, Paul Beeson

reported jaundice in persons who had received a

blood transfusion. Thus, the understanding of

the nonbenign nature of transfusions was

enhanced with the first report of transfusion-

transmitted hepatitis.

Erythropoietin is a 30,400 dalton glycopro-

tein that is produced by the kidney and stimu-

lates erythropoiesis. Its existence was first hinted

at by Camot and Deflande in 1906, when they

demonstrated that serum from anemic rabbits

increased red cell mass in nonanemic rabbits.

They named this substance “hematopoietine,”

and it was renamed erythropoietin in 1948 by

Bonddorf and Jelaviste after it was shown to

have a specific effect on red blood cells. In 1957,

Jacobson and colleagues identified the kidney as

the source of erythropoietin. Erythropoietin was

purified in 1957, and the gene was cloned in

1985. One year later, it was clearly established to

reverse the anemia of chronic renal disease.

Prevalence of Anemia inOlder PersonsThere is a marked increase in the prevalence of

anemia with aging. In a population-based

study in Olmsted County, Minnesota, among

618 persons older than 65 years, the corrected

annual incidence of anemia was higher in men

(90.3 per 1000; 95% CI, 79.2-101.4) than

women (69.1 per 1000; 95% CI, 62.3-75.8),

and rose with age.7 Using the Established

Population data for 3946 adults aged 71 years

or older in three communities, hemoglobin

concentration level was inversely associated

with age. In men and women aged 71-74 years,

9% were anemic. The proportion of anemic

persons increased differentially with age, reach-

ing 41% for men and 21% for women, aged

90 years or older, respectively.8

In a study of 732 consecutively admitted

hospital patients to an acute geriatric ward,

26% had a hemoglobin concentration below

11.5%.9 Recent studies in long-term care insti-

tutions in Israel and Spain have shown a very

high prevalence of anemia in these settings. In

481 long-term care patients with an average

age of 81.4 years, the prevalence of anemia was

31.4%.10 In the Spanish study, the prevalence

of anemia was 40%.11

Anemia associated with chronic renal insuf-

ficiency is common. Approximately 13.5 mil-

lion adults have a creatinine clearance of 50

mL/min or less, and about 800,000 adults have

chronic renal insufficiency–associated anemia,

defined as a hemoglobin concentration of

<11 g/dL, according to a study of NHANES III

data. In that study, it was found that a statisti-

cally significant decrease in hemoglobin con-

centration was seen among men starting at a

creatinine clearance of 70 mL/min or less and

among women starting at 50 mL/min or less.

At any given level of creatinine clearance, men

had a larger decrease in hemoglobin concentra-

tion than women. For example, compared to

subjects with a creatinine clearance of greater

than 80 mL/min, the decrease in hemoglobin

concentration for subjects with a creatinine

clearance of 20-30 mL/min was 1.0 g/dL in

August 2003

8


women and 1.4 g/dL in men.7

A substantial number of subjects with

chronic renal insufficiency may not have suffi-

cient iron stores to support erythropoiesis, as

judged by the National Kidney Foundation

targets for transferrin saturation or serum fer-

ritin. In NHANES III, among those persons

with a creatinine clearance of 20-30 mL/min,

46% of women and 19% of men had a trans-

ferrin saturation of less than 20%, and 47% of

women and 44% of men had a serum ferritin

of less than 100 ng/mL.12

Effects of Anemia in OlderPersonsAnemia is associated with a number of symp-

toms and conditions including fatigue, weak-

ness, headache, tachycardia, shortness of

breath, cognitive impairment, depression, and

delirium (Figure 2).

Anemia is an independent risk factor for

increased mortality over 5 years.13 In addition,

anemia has been associated with frailty14 and

mobility impairment.3 Anemia is strongly

associated with an increase in myocardial

infarction and poor outcomes following an

infarct,15 and prolonged anemia results in left

ventricular hypertrophy.14,16 Anemia is a risk

factor for falls in older persons,17-19 and has

been shown to lead to functional impair-

ment.3,14 Quality of life is impaired in patients

with anemia,20 and persons with anemia have

August 2003

FIGURE 2

9


a high level of fatigue.21 Figure 3 summarizes

the major adverse effects of anemia on older

persons.

Causes of AnemiaIn one study of the prevalence of anemia in

hospitalized older persons, the most common

cause of anemia was anemia of chronic disease,

accounting for 35-40%. Iron deficiency ane-

mia accounted for between 8% and 15%,

blood loss accounted for 7%, myelodysplasia

for about 5%, Vitamin B12 deficiency for

another 5%, and chronic kidney disease was

responsible for 6-8%. As in most studies of

older persons, a large number of anemias had

no diagnosis.9 The causes and prevalence of

anemia vary between patient care settings,

depending on the population studied and the

author’s classification system.

Renal insufficiency accounts for the greatest

percentage of anemic individuals with the

diagnosis of anemia of chronic disease (27%).

Most of these patients have an erythropoietin

deficiency. However, other causes of anemia of

chronic disease account for 73% of cases.

These conditions include cancer (non-

chemotherapy patients), congestive heart fail-

ure, hepatitis C, inflammation, diabetes, and

rheumatoid arthritis. Of course, patients can

have more than one cause of anemia of chron-

ic disease (eg, iron deficiency, chronic kidney

disease, and rheumatoid arthritis).

August 2003

FIGURE 3

10


Similar findings on the etiology of anemia

in long-term care have been reported. In the

previously cited study in Israel, it was found

that 65.6% of nursing home residents who

were anemic had anemia of chronic disease,

13.2% had anemia attributed to chronic kid-

ney disease, and 4% had nutritional causes for

their anemia.

In summary, in the older population, ane-

mia of chronic disease and anemia associated

with chronic renal disease are the most com-

mon causes of anemia. However, nutritional

anemias including deficiency in iron, vitamin

B12, or folate, and anemia due to blood loss

and drug side effects should be excluded.

ErythropoiesisNormal hematopoiesis consists of the transfor-

mation of multipotential stem cells to commit-

ted progenitors and then into erythrocytes

(Figure 4). Once a progenitor is committed to

forming erythrocytes, it is stimulated by ery-

thropoietin and testosterone, and inhibited by

a variety of cytokines (eg, tumor necrosis factor

alpha, interferon gamma, and interleukin-6).

Dependent on the balance of the stimulus, the

cells either become mature erythrocytes or

undergo an apoptotic death.

Differential Diagnosis ofAnemiaAnemia can be due to failure of the bone mar-

row to manufacture adequate blood compo-

nents, gradual or rapid blood loss from hemor-

rhage, or rapid breakdown of blood compo-

nents from hemolysis. Causes of failure of the

August 2003

FIGURE 4

11


bone marrow to produce adequate blood com-

ponents include inadequate nutrients (vitamin

B12, folate, pyridoxine, or iron) necessary for

blood production, primary impairment of

hemoglobin synthesis (hemoglobinopathy), or

altered maturation of blood cells (myelodys-

plastic syndromes). This complex progression

of erythrocyte maturation lends itself to sever-

al strategies for the differential diagnosis of

anemia.

A corrected reticulocyte count is useful to

determine bone marrow function. Anemia

associated with an increased reticulocyte count

occurs when the bone marrow responds to red

cell destruction (hemolysis) or hemorrhage.

The presence of elevated concentrations of

unconjugated bilirubin and lactic dehydroge-

nase usually accompany hemolysis. If these

concentrations are normal, a source of blood

loss should be sought, including gastrointesti-

nal bleeding, intracranial bleeds, epistasis,

hemoptysis, trauma (consider liver, spleen, or

hip), vaginal bleeding, and severe ecchymoses.

Since gastrointestinal bleeding is the most

common cause of occult blood loss, a stool

occult blood test should be obtained.

Absence of elevated lactate dehydrogenase

(LDH) and indirect bilirubin only tell us that

there is no hemolysis. Many conditions—not

just blood loss—may be present. For example,

myelodysplastic syndrome, which is on the rise

in the elderly in the U.S., is associated with a

August 2003

FIGURE 5

12


normal LDH, normal bilirubin, and low retic-

ulocyte count. A low or normal corrected retic-

ulocyte count in the presence of anemia indi-

cates an inadequate bone marrow response

(Figure 5). In the presence of a low corrected

reticulocyte count, determination of red cell

morphology indices is useful. An elevated

mean corpuscular volume (macrocytosis) sug-

gests vitamin B12 or folate deficiency, hepatic

disease, myelodysplasia, hypothyroidism, and

alcoholism. Drugs may cause either hemolysis

or macrocytosis—notably, phenytoin, metho-

trexate, and azathioprine.

Measurement of vitamin B12 and folate

concentrations will determine anemia due to

these causes in the majority of cases.

Confirmation of nutritional deficiency in

those patients who have values in the lower

normal range should be obtained. Diagnosis

of vitamin B12 deficiency is typically based on

measurement of serum vitamin B12 levels;

however, about 50% of patients with subclin-

ical disease have normal B12 levels. A more

sensitive method of screening for vitamin B12

deficiency is measurement of serum methyl-

malonic acid and homocysteine levels, which

August 2003

Diagnosis and Management of Myelodysplasia

DIAGNOSIS TEST FINDINGHemoglobin Decreased (100%)Neutrophils Decreased (50%)Thrombocytes Decreased (25%)Peripheral smear Hyposegmented white cell nuclei

Unusual white cell granular content

Megakaryocytes Erythropoietin May be very highBone marrow Hypercellularity

Ringed sideroblasts Increased blasts

Karyotype analysis Deletion chromosome 5qMonosomy chromosome 5 or 7

Vitamin B12 NormalFolate Normal

MANAGEMENTErythropoietinGranulocyte-colony stimulating factorTransfusion when symptomatic

TABLE I

13


are increased early in vitamin B12 deficiency. A

homocysteine level will be elevated in both

vitamin B12 and folate deficiencies, but a

methylmalonic acid level will be elevated only

in vitamin B12 deficiency. Renal failure is the

only other confounding cause of an elevated

methylmalonic acid concentration. Use of the

Schilling test for detection of pernicious ane-

mia has been supplanted for the most part by

serologic testing for parietal cell and intrinsic

factor antibodies.

Myelodysplastic syndrome is a bone marrow

failure state associated with varying degrees of

pancytopenia. About half of these patients will

also have neutropenia. An elevated mean cor-

puscular volume with abnormalities in red cell

corpuscular shape suggests myelodysplastic

(MDS) anemia when nutritional deficiency,

drugs, and chemotherapy have been excluded.

A peripheral blood smear in patients with

MDS may show hyposegmented nuclei in the

neutrophils (pseudo Pelger-Huët phenome-

non) or abnormal granular content in the

white cells. Approximately one-quarter of the

patients have thrombocytopenia with

megakaryocytes in the peripheral smear. Bone

marrow examination confirms the diagnosis

with increased cellularity, maturational abnor-

malities, ringed sideroblasts, and an increase in

blasts as well as karyotype abnormalities (eg,

loss of the long arm of chromosome S). The

bone marrow examination may reveal different

abnormalities that are useful in classifying the

subtype of MDS. Measurements of erythropoi-

etin should be undertaken because those with

concentration below 200 μm/mL often have

an excellent response to treatment with ery-

thropoietin and granulocyte-colony stimulat-

ing factor. The diagnosis and treatment of

myelodysplasia are summarized in Table I.

In persons with a low or normal mean cor-

puscular volume, the likely diagnoses include

anemia of chronic disease, anemia of renal dis-

ease, iron deficiency anemia, or thalassemia

minor. The differential diagnosis of iron defi-

ciency anemia from anemia of chronic disease

is given in Table II. Persons with microcytosis,

a low serum iron, and low ferritin concentra-

August 2003

Comparison of Iron Deficiency Anemia and Anemia of Chronic Disease

IRON DEFICIENCY ANEMIA OF ANEMIA CHRONIC DISEASE

Mean corpuscular volume Normal or Decreased Decreased or Normal Serum iron Decreased DecreasedTotal iron-binding capacity Increased Normal to DecreasedSerum ferritin Decreased IncreasedSoluble transferrin receptor Increased Normal to Decreased

TABLE II

14


tions have iron deficiency anemia. If the iron is

low and the ferritin is high, this is suggestive of

anemia of chronic disease. Unfortunately, these

and other causes of anemia commonly coexist

in older persons. In these cases, soluble trans-

ferrin receptor may be useful in determining

the diagnosis.

Circulating soluble transferrin receptors are

a relatively new tool in the diagnosis of anemia.

They are elevated in iron deficiency anemia

even in the presence of chronic disease, but

normal or only slightly raised in anemia of

chronic disease. Since ferritin concentrations

are elevated in inflammation, liver disease,

renal disease, cancer, and in some elderly

women, soluble transferrin receptors, can be of

use in making the diagnosis of iron deficiency.

Soluble transferrin receptors divided by the log

of ferritin (< 2.55) is the best method of differ-

entiating anemia of chronic disease from ane-

mia of chronic disease associated with iron

deficiency anemia.22 However, there does not

appear to be much advantage of these newer,

more expensive methods over measuring total

iron-binding capacity.23

Anemia of chronic kidney disease is diag-

August 2003

FIGURE 6

15


nosed by recognizing renal disease in associa-

tion with a low erythropoietin level. If the

serum creatinine is greater than 2 mg/dL, it is

unnecessary to measure erythropoietin.

However, older persons can have a declining

glomerular filtration rate in face of a relatively

normal serum creatinine. This is because of the

loss of lean mass (sarcopenia) associated with

aging. This can be even more marked in the

nursing home resident with cachexia. For

example, an 85-year-old female nursing home

resident with a hemoglobin concentration of

10 g/dL who weighs 55 kg and has a serum

creatinine of 1.3 mg/dL (normal range) will

have a creatinine clearance calculated by the

Cockcroft-Gault equation (Figure 6) of 27.5

mL/min.24 For this reason creatinine clearance

should be calculated in all nursing home resi-

dents with anemia to determine their renal sta-

tus. The Cockcroft-Gault equation will

demonstrate that the majority of older female

nursing home residents with a creatinine of 1.2

mg/dL or greater have severe renal impair-

ment.

The Cockcroft-Gault equation is not perfect

but has been shown to be strongly correlated

with more accurate measures of GFR measured

creatinine clearance.25,26 A schematic diagram

for evaluation of anemia in long-term care is

given in Figure 7.

August 2003

FIGURE 7

16


Management of Anemia in Long-Term Care

Nutritional Anemia

Anemia due to folate or vitamin B12 defi-

ciency is treated by replacement of the vitamin.

Vitamin B12 can be replaced either by injec-

tions (1000 μg weekly for 1 month, then

monthly thereafter), orally (1000 μg daily,

which should not be given with food), or

intranasally. Folate 1 mg should be used to

treat folate deficiency and should be used dur-

ing the first few weeks of vitamin B12 defi-

ciency.

In persons with iron deficiency, the recom-

mended treatment is iron sulfate 325 mg three

times a day, providing 195 mg of elemental

iron per day.27-29 The sulfate moiety can cause

gastrointestinal distress, and if this occurs, iron

in the form of gluconate or fumerate may be

helpful. Some experts suggest that iron sulfate

once a day may have a similar effect to three-

times-a-day dosing if absorption is normal.

The duration of iron therapy may be longer

when once-a-day dosing is used. Whatever the

chosen dose, a reticulocyte count should be

obtained one week after starting iron. If there

is not a robust reticulocyte response, intra-

venous iron should be considered. An

approach to the management of anemia in

long-term care residents is given in Table III.

Transfusions are regularly given to older

persons who become symptomatic, have their

hemoglobin concentration drop below 8 g/dL,

or who have an acute bleed. However, it is

important to realize that despite adequate care-

ful cross-matching of blood, complications are

all too common. Transfusion reactions can lead

to hemolysis and fever. Transfusions are often

associated with circulatory overload. Since the

original description of blood-born hepatitis A,

numerous infections including AIDS have

been transmitted to patients during blood

transfusions. For these reasons, attempting to

August 2003

Approach to the Management of Anemia in Long-Term Care Residents

DIAGNOSIS TREATMENTIron deficiency Ferrous sulfate 325 mg 1-3 times dailyVitamin B12 deficiency Vitamin B12 1000 μg orally or

intramuscularlyAnemia of chronic kidney disease Epoetin alfa 10,000 U weekly or

darbepoetin alfa 60 mcg every two weeksAnemia of chronic disease Treat underlying condition; consider epoetin

alfa weekly or darbepoetin alfa every two weeks

TABLE III

17


maintain hemoglobin concentration by other

approaches is very important in the long-term

care resident. Human recombinant erythropoi-

etin administration can reduce blood transfu-

sion requirements.30

ErythropoietinSince the introduction of human recombinant

erythropoietin (epoetin alfa) in 1989 to treat

anemia in chronic kidney disease patients

(patients on dialysis and patients not yet on

dialysis), the treatment of anemia has been rev-

olutionized. In patients with chronic kidney

disease, the workup for anemia should begin in

an adult female with a hemoglobin concentra-

tion of 11 g/dL or less, and in an adult male

with a hemoglobin concentration of 12 g/dL

or less. Anemia can develop relatively early in

the course of chronic renal failure, and has

been associated with a serum creatinine as low

as 2.0 mg/dL.31 A linear relationship between

glomerular filtration rate and anemia has been

demonstrated. Significant anemia was noted

when the calculated glomerular filtration rate

was less than 20-35 mL/min.32,33 In patients

with impaired renal function and a nor-

mochromic, normocytic anemia, it is rare for

the serum erythropoietin level to be elevated.

Therefore, measurement of erythropoietin lev-

els in such patients is not likely to guide clini-

cal decision-making or therapy.

While the majority of persons on dialysis

receive erythropoietin, there are many persons

who have chronic kidney disease who do not

receive erythropoietin. This is particularly true

in the long-term care setting.

Erythropoietin has been shown to increase

hemoglobin concentration in patients with

anemia associated with surgical blood loss, can-

cer chemotherapy, anemia associated with drug

therapy for AIDS or hepatitis C virus,

myelodysplastic disease, and the anemia of

chronic disease, especially when associated

with rheumatoid arthritis (See Table IV for

Food & Drug Administration-approved indi-

cations for use of erythropoietin). Many condi-

tions involve additional causes for an inade-

quate response to erythropoietin therapy and

should be corrected when possible in order to

reverse the anemia (Table V34).

August 2003

Food & Drug Administration-Approved Indications for Use of Erythropoietin

• Anemia of chronic renal disease (chronic renal insufficiency and end-stage renal disease)

• Chemotherapy-induced anemia in patients with non-myeloid malignancies• Zidovudine-related anemia in HIV-infected patients• Reduction of allogeneic blood transfusion in surgery patients

TABLE IV

18


Erythropoietin therapy increases hemoglo-

bin concentration, improves quality of life, and

may improve long-term health outcome and

even survival.20,21 Erythropoietin causes a

decrease in the left ventricular hypertrophy

associated with anemia.16 As may be expected

with increased blood volume, erythropoietin

therapy increases blood pressure, necessitating

close monitoring in patients with known car-

diovascular disease.

Recently, a novel erythropoietin, or erythro-

poiesis-stimulating protein, darbepoetin alfa,

has become available. Darbepoetin alfa is indi-

cated for the treatment of anemia associated

with chronic renal failure, including patients

on dialysis and those not yet on dialysis, and

for chemotherapy-induced anemia in patients

with non-myeloid malignancies. Darbepoetin

alfa is compared to epoetin alfa in Table

VI.35,36 Because of its longer half-life, darbe-

poetin alfa appears to

have great potential in the

long-term care setting.

The approximate

threefold longer half-life

with darbepoetin alfa

compared to epoetin alfa

has allowed for less fre-

quent administration.

Epoetin alfa is given 1-3

times a week or once

weekly. A study has evalu-

ated the efficacy of darbe-

poetin alfa dosed every 2

weeks in anemic patients

with chronic renal insuffi-

ciency. Darbepoetin alfa

has been demonstrated to

maintain hemoglobin

concentrations between

the study target hemoglo-

bin of 11-13 g/dL while

being administered every 2 weeks. When

administered every 2 weeks, darbepoetin alfa

produces a hemoglobin response at a median

time of 5-6 weeks with a range of 1-25 weeks.

The median darbepoetin alfa dose at the time

of hemoglobin response was 60 mcg every 2

weeks. Ninety-five percent of those completing

the study reached the target hemoglobin con-

centration. Side effects seen with darbepoetin

alfa were similar to those seen with epoetin

August 2003

Potential Causes for Inadequate Response to Erythropoietin Therapy

• Iron/B12/folate deficiency• Infection/inflammation (eg, access infections,

surgical inflammation, AIDS, systemic lupus erythematosus)

• Chronic blood loss• Osteitis fibrosa• Hemoglobinopathies (eg, alpha and beta

thalassemias, sickle cell anemia)• Multiple myeloma• Malnutrition• Hemolysis• Aluminum toxicity• Malignancy• Hyperparathyroidism• Hypogonadism• Other: angiotensin-converting enzyme inhibitors

(reported, but not verified)

TABLE V34

19


alfa.37 Further studies are evaluating extending

the dosing interval to once a month. Initial

dosing of epoetin alfa and darbepoetin alfa

should follow package insert guidelines.

Thereafter, dose adjustments should be made

as needed based on an individual’s hemoglobin

response.

Recommendations of theCouncil for Anemia ClinicalStrategies in Long-TermCareThe Council for Anemia Clinical Strategies in

Long-Term Care developed recommendations

for the treatment of anemia in long-term care.

The Council recommends that a hemoglobin

concentration of less than 12 g/dL should be

evaluated and treated when appropriate.

The Council recognized that there were lim-

ited data on erythropoietin use in long-term

care. Nevertheless, there are positive clinical

outcomes for treating anemia of chronic kid-

ney disease such as improved quality of life and

decreased hospitalization and mortality.

Chronic kidney disease and its associated ane-

mia are often underdiagnosed in the elderly.

The Council recommends increasing aware-

ness of chronic kidney disease in the elderly by

using conventional formulas to calculate the

creatinine clearance. Furthermore, the Council

recommends consideration of treating the ane-

mia of chronic kidney disease in the long-term

care setting. Pending future clinical studies of

treating other types of anemia of chronic dis-

ease in the elderly, current clinical research on

treating anemia of chronic kidney disease

should focus on measuring important out-

comes in the long-term care patient, such as

improved quality of life (physical and mental)

and decreased hospitalization (secondary to

decreased falls and fractures), and cardiovascu-

lar morbidity.

Erythropoietin should clearly be considered

in all anemic residents with chronic kidney dis-

ease whose serum creatinine is greater than 2

mg/dL. A calculated creatinine clearance

should be done to identify residents with

chronic renal failure whose creatinine is less

than 2 mg/dL. In patients with impaired renal

function and a normochromic, normocytic

August 2003

Comparison of Epoetin Alfa and Darbepoetin Alfa

EPOETIN ALFA DARBEPOETIN ALFA

Sialic acid35 ~14 ~22Half-life (hours), intravenously35 ~8.5 ~26.3Biological activity36 Less GreaterDosing36 Frequent Less often

TABLE VI

20


anemia, measurement of erythropoietin levels

is not likely to guide clinical decision-making

or therapy.

The Council suggests that the long half-life

of darbepoetin alfa may make it very useful in

long-term care where a once- or twice-a-month

dosing regimen could be utilized. When used,

the dosing regimen of erythropoietin should

lead to an increase of hemoglobin concentra-

tion by no more than 1 g/dL in a 2-week peri-

od, and target hemoglobin concentration

should not exceed 12 g/dL. Transferrin satura-

tion and ferritin concentration should be mon-

itored and iron replaced, either orally or intra-

venously, if iron deficiency develops. In addi-

tion, the Council strongly supports the devel-

opment of increased research in this area.

References1. Tran KH, Udden MM, Taffer GE, et al.

Erythropoietin regulation of hematopoiesis is preserved in healthy elderly people. Clin Res1993;41:116A.

2. Zauber NP, Zauber AG. Hematologic data ofhealthy very old people. JAMA 1987;257:2181-2184.

3. Chaves PH, Ashar B, Guralnik JM, Fried LP. Lookingat the relationship between hemoglobin concentra-tion and prevalent mobility difficulty in olderwomen. Should the criteria used to define anemiain older people be reevaluated? J Am Geriatr Soc2002;50:1257-1264.

4. Weber JP, Walsh PC, Peters CA, Spivak JL. Effect ofreversible androgen deprivation on hemogblobinand serum immunoreactive erythropoietin in men.Am J Hematol 1991;36:190-194.

5. Ellegala DB, Alden TD, Couture DE, et al. Anemia,testosterone, and pituitary adenoma in men. JNeurosurg 2003;98:974-977.

6. Bogdanos J, Karamanolakis D, Milathianakis C, etal. Combined androgen blockade-induced anemiain prostate cancer patients without bone involve-ment. Anticancer Res 2003;23:1757-1762.

7. Ania BJ, Suman VJ, Fairbanks VF, et al. Incidenceof anemia in older people: An epidemiologic studyin a well defined population. J Am Geriatr Soc1997;45:825-831.

8. Salive ME, Cornoni-Huntley J, Guralnik JM, et al.Anemia and hemoglobin levels in older persons:Relationship with age, gender, and health status. JAm Geriatr Soc 1992;40:489-496.

9. Joosten E, Pelemans W, Hiele M, et al. Prevalenceand causes of anaemia in a geriatric hospitalizedpopulation. Gerontology 1992;38:111-117.

10. Chernetsky A, Sofer O, Rafael C, Ben-Israel J.Prevalence and etiology of anemia in an institution-alized geriatric population [Hebrew]. Harefuah2002;1412:591-594.

11. Ania Lafuente BJ, Fernandez-Burriel Tercero M,Suarez Almenara JL, et al. Anemia and functionalincapacity at admission to a geriatric home[Spanish]. An Med Interna 2001;18:9-12.

12. Hsu CY, McCulloch CE, Curhan GC. Epidemiologyof anemia associated with chronic renal insufficien-cy among adults in the United States: Results fromthe Third National Health and NutritionExamination Survey. J Am Soc Nephrol2002;13:504-510.

13. Izaks GJ, Westendorp RGJ, Knook DL. The defini-tion of anemia in older persons. JAMA1999;281:1714-1717.

14. Kamenetz Y, Beloosesky Y, Zelter C, et al.Relationship between routine hematological para-meters, serum IL-3, IL-6 and erythropoietin and mildanemia and degree of function in the elderly. AgingClin Exp Res 1998;10:32-38.

15. Wu WC, Rathore SS, Wang Y, et al. Blood transfu-sion in elderly patients with acute myocardialinfarction. N Engl J Med 2001;345:1230-1236.

16. Levin A, Singer J, Thompson CR, et al. Prevalent leftventricular hypertrophy in the predialysis popula-tion: Identifying opportunities for intervention. Am JKidney Dis 1996;27:347-354.

17. The prevention of falls in later life: A report of theKellogg International Work Group on the Preventionof Falls by the Elderly. Dan Med Bull1987;34(suppl 4):1-24.

18. Baker SP, Harvey AH. Fall injuries in the elderly.Clin Geriatr Med 1985;1:501-512.

19. Herndon JG, Helmick CG, Sattin RW, et al. Chronicmedical conditions and risk of fall injury events athome in older adults. J Am Geriatr Soc1997;45(6):739-743.

20. Valderrabano F. Quality of life benefits of early ane-mia treatment. Nephrology Dialysis Transplantation2000:15(suppl):23-28.

21. Cella D. Factors influencing quality of life in cancerpatients: Anemia and fatigue. Semin Oncol1998;25(3 suppl 7):43-46.

22. Malope BI, MacPhail AP, Alberts M, Hiss DC. Theratio of serum transferrin receptor and serum ferritinin the diagnosis of iron status. Br J Haematol2001;115(1):84-89.

August 2003

21


23. Wians FH Jr, Urban JE, Keffer JH, Kroft SH.Discriminating between iron deficiency anemia andanemia of chronic disease using traditional indices ofiron status vs transferrin receptor concentration. Am JClin Pathol 2001;115(1):112-118.

24. Cockcroft DW, Gault MN. Prediction of creatinineclearance from serum creatinine. Nephroj1976;349:163:31-41.

25. Robertshaw M, Lai KN, Swaminathan R. Prediction ofcreatinine clearance from plasma creatinine:Comparison of five formulae. Br J Clin Pharmacol1989;28:275-80.

26. Waller DG, Fleming JS, Ramsey B, Gray J. The accu-racy of creatinine clearance with and without urinecollection as a measure of glomerular filtration rate.Postgrad Med J 1991;67:42-46.

27. Provan D. Mechanisms and management of iron defi-ciency anaemia. Br J Haematol 1999;105(suppl1):19-26.

28. Goddard AF, McIntyre AS, Scott BB. Guidelines forthe management of iron deficiency anaemia. BritishSociety of Gastroenterology. Gut 2000;46(suppl 3-4):IV1-IV5.

29. Frewin R, Henson A, Provan D. ABC of clinicalhaematology. Iron deficiency anaemia. BMJ1997;314(7077):360-363.

30. Corwin HL, Gettinger A, Pearl RG, et al. Efficacy ofrecombinant human erythropoietin in critically illpatients: A randomized controlled trial. JAMA2002;288(22);2827-2835.

31. Hakim RM, Lazarus JM. Biochemical parameters inchronic renal failure. Am J Kidney Dis 1988;11:238-247.

32. Jacobs A, Worwood M. Ferritin in serum. Clinicaland biochemical implications. N Engl J Med1975;292:951-956.

33. McGonigle RJS, Boineau FG, Beckman B, et al.Erythropoietin and inhibitors of in vitro erythropoiesisin the development of anemia in children with renaldisease. J Lab Clin Med 1985;105:449-458.

34. Steinberg EP, Eknoyan G, Levin NW, et al. Methodsused to evaluate the quality of evidence underlyingthe National Kidney Foundation-Dialysis OutcomesQuality Initiative Clinical Practice Guidelines:Description, findings, and implications. Am J KidneyDis 2000;36:1-11.

35. Egrie JC, Browne JK. Development and characteriza-tion of novel erythropoiesis stimulating protein(NESP). Br J Cancer 2001;84(suppl 1):3-10.

36. Macdougall IC, Gray SJ, Elston O, et al.Pharmacokinetics of novel erythropoiesis stimulatingprotein compared with epoetin alfa in dialysispatients. J Am Soc Nephrol 1999;10(11):2392-2395.

37. Suranyi MG, Lindberg JS, Navarro J, et al. Treatmentof anemia with darbepoetin alfa administered denovo once every other week in chronic kidney dis-ease. Am J Nephrol 2003;23:106-111.

August 2003

August 2003

22


CME/CE TEST QUESTIONNAIRE

Please provide the following information (please print) in order toreceive your CME/CE certificate:Name ______________________________________________________Degree __________________________

Institution or Affiliation __________________________________________________________________________

Address ______________________________________________________________________________________

City, State, Zip ________________________________________________________________________________

Telephone __________________________________________Fax ____________________________________

To receive credit, participants must complete the form above and fax or mail it to: Medical Education Resources

1500 West Canal CourtLittleton, CO 80120Fax: 303-798-5731

1. A hemoglobin concentration of less than13 g/dL in men and less than 12 g/dL inwomen defines anemia, according toWorld Health Organization standards.

❏ True

❏ False

2. Anemia of chronic disease is the most com-mon cause of anemia in older persons.

❏ True

❏ False

3. Chronic kidney disease accounts for the great-est percentage of anemic individuals with thediagnosis of anemia of chronic disease.

❏ True

❏ False

4. Anemia can be due to a) failure of the bone marrow to manu-

facture adequate blood components b) rapid loss of formed blood from

hemorrhagec) rapid breakdown of blood components

from hemolysis d) all of the above.

5. Amemia in the elderly is not associatedwith increased mortality or quality of life.

❏ True

❏ False

Using a scale from 1 to 5, with 5=excellent, 4=very good, 3=adequate, 2=fair, 1=poor,please circle the number corresponding to your rating of the following:

Excellent Poor

1. Overall quality of the material 5 4 3 2 1

2. Clinical applicability or relevance of thematerial to participant’s practice 5 4 3 2 1

3. Extent to which the material met stated objectives 5 4 3 2 1

4. Extent to which participant will modify his/her practice as a result of participation in the program 5 4 3 2 1

5. Fair balance and objectivity of the material 5 4 3 2 1

6. Completion time 5 4 3 2 1

Please answer the following questions:

23


August 2003

This special report was sponsored by Medical Education Resources, Inc,

and produced by MultiMedia HealthCare/Freedom, LLC, under an

unrestricted educational grant from Amgen, Inc.

The views expressed in this publication are not necessarily

those of Amgen, Inc. or the publishers.

This publication may not be reproduced in whole or in part

without the express written permission of

MultiMedia HealthCare/Freedom, LLC.

Copyright © 2003 MultiMedia HealthCare/Freedom, LLC.

All rights reserved. Office Center at Princeton Meadows, Building 400,

Plainsboro, NJ 08536. Telephone: (609) 275-3800.

Printed in USA.

AMG-03543

If you would like to be added to the mail list to receive future Council publications and materials, please complete the following information:

Full Name Degree(s)Title/PositionPractice Name Full AddressCity State ZipPhone Fax E-mail

Thank you for your responses. They are very important to us.

1. Please indicate your area of specialty:❏ Medical Director❏ Attending Physician❏ Consultant Pharmacist❏ Director of Nursing❏ Other; please specify___________________

2. Overall, how many patients are youresponsible for in each of the followingsettings? If none, please put “0.”Skilled nursing facility Assisted living Home health care Private practice

We’d now like to focus on your skilled nursing patients only.3. How many skilled nursing facilities do

you serve?❏ 1-2 ❏ 3-5 ❏ > 5

4. Is your facility(ies) a member of a chain?❏ Yes ❏ NoIf yes, please specify name of chain:____________________________________

5. What is the average number of skilledcare beds in your facilities?❏ < 100 ❏ 100 – 150 ❏ 151 – 200 ❏ > 200

6. On average, how frequently do you seeeach of your skilled care patients?❏ Daily❏ Once a week❏ At least once a month❏ Once every 2-3 months

7. On average, what percentage of yourskilled care patients are anemic (Hgb <12 g/dL)? __________%

8. What are the top three diseases or con-ditions associated with anemia in yourskilled care patients? Please rank inorder 1 to 3, with 1 being the mostcommon of the 3.____ End-Stage Renal Disease (ESRD)____ Repeated Blood Draws____ Chronic Kidney Disease (CKD)____ Poor Diet/Nutrition____ Cancer (CIA/AOC)____ Iron Deficiency____ Acute Illness____ Myelodysplasia____ GI Bleeding____ Vitamin B12 Deficiency____ Surgery____ Blood Loss (from dialysis procedure

and/or vascular access site)____ Other; please specify:_____________________________________

9. Which of the following assessments doyou use to detect anemia in your skilledcare patients?❏ Circulating Soluble Transferrin

Receptor❏ Creatinine Clearance❏ Erythropoietin Level❏ Folate

❏ Hematocrit❏ Hemoglobin Concentration❏ Serum Methylmalonic Acid Level❏ Serum Vitamin B12 Level❏ Iron (T-Sat Ferritin Level)❏ Other; please specify_______________

10. How frequently is an anemia assessmenttypically performed on your skilled carepatients?❏ Once every 2 weeks❏ Once a month❏ Once every 3 to 6 months❏ If less frequent, please specify_____________________________________

11. Who typically first becomes aware thatyour skilled care patients have anemia?❏ Attending Physician❏ Consultant Pharmacist❏ Director of Nursing❏ Consultant Dietitian❏ Other; please specify_______________

12. At what point are your skilled carepatients first treated for anemia? ❏ At a hemoglobin concentration

of <12 g/dL❏ At a hemoglobin concentration

of <10 g/dL ❏ Only when the patient is

symptomatic❏ Other; please specify________________

13. In your anemic skilled care patients witha hemoglobin of less than 12 g/dL butgreater than 10 g/dL, what is your first-line treatment?❏ Drug Therapy❏ Ferrous Sulfate❏ Vitamin B12❏ Other; please specify__________________

14. In your anemic skilled care patients witha hemoglobin of less than 10 g/dL, whatis your first-line treatment?❏ Drug Therapy❏ Ferrous Sulfate❏ Vitamin B12❏ Other; please specify__________________

15. In your anemic patients with a hemoglo-bin of less than 12 g/dL, what percent-age is treated at any point with drug therapy? __________%

16. Of the following drugs, please checkthose with which you are familiar:❏ darbepoetin alfa (Aranesp)❏ erythropoietin alfa (Epogen, Procrit)❏ Other; please specify_________________

17. In your skilled care anemic patients thatare currently being treated with drugtherapy, please indicate the percentagethat are being treated with the follow-ing therapies. Total must equal 100%.❏ darbepoetin alfa (Aranesp)______%

❏ erythropoietin alfa

(Epogen, Procrit) _______%

❏ Other, please specify _______%

18. Considering the most common diseaseor condition associated with anemiathat you ranked as #1 in Question 8,please indicate your most frequent dosing regimen for each of the following therapies:

❏ darbepoetin alfa (Aranesp)______ mcg ______ interval ❏ N/A; don’t prescribe

erythropoietin alfa (Epogen,Procrit)______ units ______ interval ❏ N/A; don’t prescribe

❏ Other, please specify________ interval_________________________

19. Please rank in order of importance theimpact of the following factors in yourdrug selection using a scale of 1 to 7,where “1” means most important and“7” means least important:____ Product efficacy____ Product cost____ Ease of use and patient compliance____ Dosing frequency____ Prior experience with product____ Patient/family request____ Product is on formulary or part of

formal protocol____ Other; please specify_____________

20. Please rate the degree of influence thateach of the following parties has on yoursupportive care prescribing decisionsusing a scale of 1 to 5, where “1” meansnot at all influential and “5” meansextremely influential (circle rating).

Not at all ExtremelyInfluential Influential

Skilled nursing home formulary1 2 3 4 5

Skilled care director of nursing1 2 3 4 5

Consultant pharmacist1 2 3 4 5

Consultant dietitian 1 2 3 4 5

Patient/family1 2 3 4 5

Other; please specify _________________1 2 3 4 5

21. What type of educational programsfocusing on anemia would you like tosee?____________________________________________________________________

FAX-BACK SURVEYPlease Fax to 1-888-427-4997 (toll free)

The Council for Anemia is working to sponsor educational programming that meets the unique needs of elder care clinicians.In order to provide you with the most valuable and relevant educational programming, we would like to learn more about

your elderly patient population and your practice. Please take a few minutes to answer the following questions:

August 2003

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