Iron deficiency in the elderly population, revisited in the hepcidin era

Abstract

Iron deficiency (ID) is relatively common among the elderly population, contributing substantially to the high prevalence of anemia observed in the last decades of life, which in turn has important implications both on quality of life and on survival. In elderly subjects, ID is often multifactorial, i.e., due to multiple concurring causes, including inadequate dietary intake or absorption, occult bleeding, medications. Moreover, because of the typical multimorbidity of aged people, other conditions leading to anemia frequently coexist and make diagnosis of ID particularly challenging. Treatment of ID is also problematic in elderly, since response to oral iron is often slow, with a substantial fraction of patients showing refractoriness and requiring cumbersome intravenous administration. In the last decade, the discovery of the iron regulatory hormone hepcidin has revolutionized our understanding of iron pathophysiology. In this review, we revisit ID among elderly people in the light of the impressive recent advances on knowledge of iron regulation, and discuss how hepcidin may help in diagnosis and treatment of this common clinical condition.

Keywords: anemia; elderly; ferritin; hepcidin; iron deficiency.

FIGURE 1

Gastrointestinal diseases representing the most frequent causes of ID and IDA in elderly patients. Of note, more than one of these conditions not infrequently coexist in a given individual. Bleeding is often favored by antithrombotic drugs for treatment of cardiovascular diseases that are highly prevalent in this age group. Suggested diagnostic tools are reported on the right side. AAG, autoimmune atrophic gastritis; CD, celiac disease; GI, gastrointestinal; HP, Helicobacter pylori; IBD, inflammatory bowel disease; PPI, proton pump inhibitors; VCE, video capsule endoscopy.

FIGURE 2

Serum hepcidin (A) and ferritin (B) levels stratified by decades in healthy subjects older than 50 years. Subjects were from the Val Borbera study, a large population survey including 1657 subjects. Adapted from Traglia et al. (2011).

FIGURE 3

Possible algorithm for the diagnosis and treatment of IDA in elderly in a near future scenario. The proposed algorithm is based on most recent pathophysiological and therapeutic advances in the field. Dotted lines for evaluation of hepcidin levels indicate that the available data suggesting this approach (Bregman et al., 2013) need confirmation by future studies. Similarly, before this approach enters the clinical practice, a better standardization of hepcidin assays is needed. AAG, autoimmune atrophic gastritis; AI, anemia of inflammation; CD, celiac disease; CKD, chronic kidney disease; GI, gastrointestinal; Hb, hemoglobin; HM, hematologic malignancies; HP, Helicobacter pylori; IDA, iron deficiency anemia; MDS, myelodysplastic syndrome; TS, transferrin saturation.