Page 87 Complete Your CE Test Online - Click Here The main function of the hematologic system is use of circulating blood to transport oxygen and nutrients to the body’s internal organs and peripheral tissues, and to remove carbon dioxide and waste products [9,53]. There are a number of age-related changes that occur in the hematologic system including [9,13,14]: ● ● As the body ages, the bone marrow’s ability to manufacture red blood cells (RBCs) swiftly (e.g. in the event of blood loss or disease) decreases. Hemoglobin and hematocrit values slightly decrease due to decreases in erythropoiesis and the incorporation of iron into RBCs, but should remain within normal ranges. ● ● There is a reduction in the number of stem cells in the bone marrow. ● ● There is decreased iron absorption. ● ● There may be an increase in platelet adhesiveness which may lead to a hypercoagulable state. ● ● There is a decreased production of intrinsic factor, which can trigger pernicious anemia. ● ● Cellular immunity decreases. ● ● The functional ability of the lymphocytes decreases. The most common hematologic disorder is anemia. Anemia, although common in older adults, is not a normal age-related change, contrary to what some healthcare professionals may believe. Anemia is a sign of disease, and, if it occurs, it cannot be successfully treated until the underlying cause is addressed [9,13]. Therefore, a thorough history must be obtained to identify underlying causes. Anemia exists when there is an inadequate amount of hemoglobin to meet the body’s needs. It is defined as a reduction in the number of circulating RBCs. This reduction can be due to loss of blood, an abnormally high rate of RBC destruction, or an inadequate or impaired production of RBCs [9]. There are several types of anemia. Some of those most commonly found in older adults are as follows. Anemia of chronic disease Anemia of chronic disease is the most common form of anemia in older adults. This anemia is due to an impaired ability to use the iron stored in the reticuloendothelial system. These iron stores are either normal or increased in anemia of chronic disease. Iron deficiency anemia is the main hematologic disorder to consider in the differential diagnosis of anemia of chronic disease. Iron deficiency anemia and anemia of chronic disease are accompanied by a low serum iron level. In classic iron deficiency anemia, the TIBC is higher than 400μg per dL. In anemia of chronic disease, the TIBC is usually below normal. When assessing for this condition, conjunctival pallor can be a reliable sign but few other signs are reliable. Serum ferritin level has been found to be the most useful laboratory test which differentiates anemia of chronic disease from iron deficiency anemia. Pernicious anemia Pernicious anemia is characterized by a decreased gastric production of hydrochloric acid and a deficiency of intrinsic factor. This disease is found most often in people of northern European ancestry and onset is usually after the age of 35. Pernicious anemia affects about two percent of people over the age of 60 [24]. Factors that contribute to this problem are small bowel disease, infection, excessive use of antacids, overgrowth of intestinal bacteria, and strict vegetarian diet [9]. The incidence of pernicious anemia increases with age. As people age, the body’s ability to absorb vitamin B12 diminishes. This vitamin is necessary for RBC growth [13]. Nursing consideration: Vitamin B12 absorption may decrease with age. This may lead to reduced erythrocyte mass and decreased hemoglobin and hematocrit levels [13]. Signs and symptoms of pernicious anemia include [24]: ● ● Cardinal signs are weakness, sore tongue, and numbness and tingling of the extremities. ● ● Lips, gums, and tongue seem to be bloodless. ● ● Patients are quite vulnerable to infections. ● ● The sclera and skin may be jaundiced. ● ● GI symptoms may include nausea, vomiting, weight loss, diarrhea, flatulence, and constipation. The tongue may become inflamed and the gums may bleed. ● ● Neurologic symptoms include weakness, poor coordination, ataxia, dizziness, and loss of bowel and bladder control. ● ● Cardiovascular symptoms include reduced hemoglobin levels, decreased cardiac output, rapid heart rate, and arrhythmias. ● ● Musculoskeletal symptoms include a scissors gait that may develop as a late sign if pernicious anemia goes untreated. Pernicious anemia is treated with a high dose of parenteral vitamin B12 replacement therapy. This triggers rapid regeneration of RBCs. After hemoglobin levels return to normal and the patient’s condition stabilizes, vitamin B12 can be administered monthly at maintenance level doses. Since the patient must continue to receive vitamin B12 injections for the rest of his or her life, s/he, a family member, or caregiver should learn to administer the injections [13]. Folic acid deficiency anemia Folic acid deficiency anemia is a common, slowly progressive anemia seen older adults and in infants, adolescents, pregnant and lactating women, alcoholics, and people with cancer or intestinal diseases. It is rather easy to develop a deficiency of folic acid since folic acid is a water-soluble vitamin that is quickly excreted from the body. Folic acid deficiency may be due to poor diet, impaired absorption, and prolonged use of certain medications such as anticonvulsants and estrogens [13]. EBP alert! Studies show that poor nutrition is often seen in people who abuse alcohol. Inadequate diet may quickly lead to folic acid deficiency anemia [13]. Thus, nurses must always include questions about alcohol intake when obtaining patient histories and performing physical and mental assessments. Typical symptoms of folic acid deficiency anemia include fatigue, shortness of breath, fainting, irritability, nausea, anorexia, and headache. Treatment consists of the administration of folic acid supplements and correction of underlying causes. Supplements may be given orally or parenterally [9,13]. Nursing consideration: Educate older adults about foods that are high in folic acid to help prevent folic acid deficiency anemia. Such foods include liver, orange juice, whole grains, beans, nuts, and dark green leafy vegetables [9]. Hemolytic anemia Hemolytic anemia is due to the premature destruction of RBCs (hemolysis). The body attempts to compensate for this destruction by increasing production of immature RBCs in the bone marrow. Hemolytic anemia becomes more common with aging. Infections, malignancies, trauma, burns, and exposure to toxic substances can cause this type of anemia. Drugs associated with its development include ibuprofen, aspirin, acetaminophen, insulin, some antibiotics, and sulfonamides [9,13,14]. The treatment involves folic acid supplements, since folic acid is depleted with increased bone marrow production of RBCs. Correction of underlying causes must also be accomplished. In addition to supplement administration, the patient’s diet should be rich in foods high in folic acid such as beans, nuts, whole grains, and green leafy vegetables [9]. Malignancies of the hematologic system Malignancies of the hematologic system are associated with overproduction of lymphoid and myeloid cells linked with bone marrow failure. They are characterized by the accrual of large numbers of white blood cells (WBC) in the bone marrow, liver, spleen, lymph nodes, and central nervous system [9,13,53]. Acute leukemia Charlotte is 82 years old. She has always enjoyed good health and an active lifestyle, often being mistaken for someone ten years younger. Over the past few months, however, she has become increasingly tired and pale and is confused at times. Her daughter attributes these signs to the aging process, but her husband is alarmed and insists that Charlotte see their physician. After conducting a physical examination and analyzing blood work results Charlotte is diagnosed with acute leukemia. Acute leukemia is a proliferation of the precursors of WBCs in bone marrow or lymph tissue. They accumulate in bone marrow, body tissues, and peripheral blood. The most common forms of acute leukemia are