Fatigability as a Predictor of Subclinical and Clinical Anemia in Well-Functioning Older Adults

J Am Geriatr Soc. 2020 Oct;68(10):2297-2302. doi: 10.1111/jgs.16657. Epub 2020 Jul 3.


Background/objectives: Anemia is a common condition in older adults for which fatigue, the primary symptom, often goes unrecognized as individuals typically equilibrate their activity to avoid fatigue. Whether assessing fatigability (i.e., susceptibility to fatigue) facilitates identification of anemia is unknown. This study examines the association between fatigability and prevalent, incident, and persistent subclinical and clinical anemia in well-functioning older adults.

Design, setting, participants: Longitudinal analysis of 905 well-functioning men and women aged 60 to 89 years and followed for 1 to 5 years from the Baltimore Longitudinal Study of Aging conducted at the National Institute on Aging, Clinical Research Unit, Baltimore, MD.

Measurements: Perceived fatigability was assessed as a rating of perceived exertion (RPE) from 6 to 20 following a 5-minute treadmill walk at 1.5 mph (.67 m/s); fatigue was assessed as reported unusual tiredness in the past month. Clinical anemia was defined using World Health Organization hemoglobin cutpoints of below 13 g/dL and below 12 g/dL for men and women, respectively, and subclinical anemia was defined as 13.0 to 13.9 g/dL and 12.0 to 12.9 g/dL, respectively.

Results: Overall, 14% of participants had clinical and 30% had subclinical anemia at baseline. Each increment (1 RPE) of fatigability was associated after covariate adjustment with 14% (95% confidence interval [CI] = 5-25%, P = .005) and 8% (CI = 1-17%; P = .031), respectively, greater likelihood of prevalent clinical and subclinical anemia. An average of 2.2 years later, each 1 RPE increment in baseline fatigability predicted an 11% (CI = 2-20%; P = .016) higher likelihood of incident and/or persistent subclinical and clinical anemia. Reports of unusual tiredness were associated with prevalent subclinical anemia only.

Conclusion: This study provides evidence that perceived fatigability may help identify well-functioning older adults with borderline to clinical anemia who are on a trajectory of persistently suboptimal or worsening hemoglobin status. Assessing fatigability may facilitate earlier diagnosis of health conditions that underlie persistent suboptimal hemoglobin status. J Am Geriatr Soc 68:2297-2302, 2020.

Keywords: anemia; fatigability; hemoglobin; older adults.

Publication types

  • Research Support, N.I.H., Intramural

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anemia / complications
  • Anemia / diagnosis*
  • Anemia / epidemiology*
  • Disease Susceptibility
  • Exercise Test
  • Fatigue / diagnosis*
  • Fatigue / etiology
  • Fatigue / physiopathology*
  • Female
  • Geriatric Assessment
  • Health Status
  • Hemoglobins
  • Humans
  • Longitudinal Studies
  • Male
  • Maryland / epidemiology
  • Middle Aged
  • Perception
  • Physical Exertion
  • Physical Functional Performance*
  • Prevalence


  • Hemoglobins