Unexplained Anemia of Aging

Etiology, Health Consequences, and Diagnostic Criteria

Jack Guralnik MD, PhD; William Ershler MD; Andrew Artz MD; Alejandro Lazo-Langner MD; Jeremy Walston MD; Marco Pahor MD; Luigi Ferrucci MD, PhD; William J. Evans PhD


J Am Geriatr Soc. 2022;70(3):891-899. 

In This Article

Pharmacoeconomics: Anemia Leads to High Healthcare Costs in Older People

Use of healthcare resources and overall medical costs are significantly higher among patients with anemia. Anemia accounts for 2.8 million physician office visits and 890,000 emergency department visits per year in the United States.[33] One-quarter of patients admitted to the hospital for anemia are readmitted to the emergency department within 30 days,[34] with the likelihood of unplanned readmission increasing with the severity of anemia at first discharge.[35] Following admission, anemia is associated with elevated in-hospital mortality and longer stays.[36,37]

These trends are exacerbated in the older people, in whom anemia is associated with up to fourfold greater risk of overall mortality and twofold greater risk of hospitalization.[20,38] Hospital stays are longer among older patients with anemia:[37,39] average length of stay increases 4–5 days in patients with moderate anemia and 7–10 days in the most severe cases.[40] As a consequence of the combined increases in hospitalization, readmission, length of stay, morbidity, and mortality, patients with anemia experience medical costs more than twice as high as those of patients without anemia of comparable age, sex, comorbidities, and insurance status.[41] This holds true for patients overall, as well as for populations with specific comorbidities: greater costs have been reported for patients with anemia and chronic kidney disease,[42] chronic obstructive pulmonary disease[43] or colorectal disease requiring surgery.[44] Anemia is also strongly associated with frailty in older men and women:[45] an increase in one point of hemoglobin concentration is associated with a 14% risk reduction of being frail (OR = 0.86, 95%IC = 0.79–0.94).

Anemia drives up healthcare costs in the older people by increasing the risk of falls. Individuals with anemia over the age of 65 years are twice as likely to experience recurrent falling[46] and are 3-fold more likely to have a history of falls when controlling for age, gender, arthritis, and residence type.[40] Anemia is associated with a 66% increase in the incidence of injurious falls among people 65 years and older[47] (10% of all injurious falls in this age group). Risk rises as Hb level decreases, but importantly, even individuals with the mildest anemia (Hb 12–12.9 g/dl) are significantly more likely to experience falls.[40,47]

Fall injuries are the fifth largest category of personal health care spending in the United States. People over 65 sustain more than 3.2 million injurious falls per year[48] and the ensuing care is responsible for up to $48–49 billion in costs.[49,50] A retrospective analysis of claims for injurious falls from more than 30 health plans (mean patient age, 76 years) performed in 2005 found that anemia increased costs by $1855 per patient per month, and $2811 for falls causing hip fracture.[51] Between 1996 and 2013, spending on falls increased 25%–50%, depending on the category of care,[49] and expenditures are predicted to continue rising.[50] Among older nursing home residents with a hip fracture, anemia is associated with an increased mortality risk (HR = 1.6, 95% CI 1.1–2.5).[52] Anemia is 4-fold more prevalent among nursing home residents in the US than in community-dwelling older people (56% overall; 64% for males and 53% for females) and was associated with a 2-fold increase in risk of falling.[53]