Introduction to a How I Treat series on geriatric hematology

It has been estimated that individuals >65 years old will comprise more than 20% of the population of the United States and more than 15% of the world’s population by 2050¹; chronologic age, however, should not be considered the sole determinant of frailty or susceptibility to disease. Aging is associated with a variety of biological processes that may lead to the development of disease or that represent the consequence of chronic illness. Somatic genetic alterations accrue as we age,² and age-related changes in the immune system contribute to the increased susceptibility of the older patient to infections, autoimmune disorders, anemia, inadequate responses to vaccination, and cancer.³ Acquired conditions, including nutritional deficiencies as well as adverse reactions to therapies for chronic illnesses, also contribute to the development and manifestation of hematologic disorders as we age.

This How I Treat series includes 4 articles that address hematologic disorders encountered in older adults by using illustrative patient examples:

• Jacqueline N. Poston and Rebecca Kruse-Jarres, “How I treat von Willebrand disorders in older adults”

• Charity I. Oyedeji, Andrew S. Artz, and Harvey Jay Cohen, “How I treat anemia in older adults”

• Patrick Foy, Kenneth D. Friedman, and Laura C. Michaelis, “How I diagnose and treat thrombocytopenia in geriatric patients”

• Thierry Facon, Xavier Leleu, and Salomon Manier, “How I treat multiple myeloma in geriatric patients”

von Willebrand disease (VWD) is the most common inherited bleeding disorder, but, as patients age, von Willebrand factor (VWF) levels may rise, which may lead to changes in the bleeding phenotype over time. Poston and Kruse-Jarres emphasize the importance of a current bleeding score assessment as well as clotting factor activity results when assessing bleeding risk in older patients with a history of type 1 VWD. In addition, certain therapies, for example, desmopressin (1-desamino-8-d-arginine vasopressin, or DDAVP), may have more side effects in an older patient population, which need to be taken into consideration when developing a treatment plan. The authors also present an older patient with an acquired deficiency of VWF. Acquired VWD may develop in association with a variety of clinical disorders encountered more frequently in older patients, including lymphoproliferative and myeloproliferative disorders, cardiac valvular disease, and left ventricular assist devices.

Anemia is a common hematologic problem in older adults, affecting 12% of persons >65 years of age living in the community, but the prevalence of anemia rises to 47% of persons living in nursing homes and 40% of patients on admission to the hospital.⁴ The most common anemias in the older people are anemia caused by nutritional deficiencies, anemia of chronic inflammation, and unexplained anemia of aging. In addition, anemia can often be multifactorial, which needs to be taken into consideration during diagnostic evaluation. Oyedeji and colleagues use several patient scenarios to describe their approach to older individuals with anemia, highlighting the importance of a systematic approach to their evaluation. This approach will facilitate making the correct diagnosis, minimize additional unnecessary testing, and avoid potentially incorrect treatments.

Thrombocytopenia is another hematologic disorder that is frequently encountered in older individuals, and although it is an isolated finding in some individuals, it can also be associated with a variety of other conditions. Foy and colleagues emphasize a systematic approach to the evaluation of older individuals presenting with thrombocytopenia similar to the evaluation of anemia in older people. The authors present several scenarios to describe the diagnostic approach and therapeutic management of patients with immune thrombocytopenia, myelodysplastic syndrome, and drug-induced thrombocytopenia. The authors also note that certain therapies, especially for immune thrombocytopenia, may be less effective, and/or have significant adverse effects, in an older population.

Myeloma is a malignant disorder that predominantly affects an older patient population. As noted by Facon and colleagues in their article, approximately a third of patients with myeloma are older than 75 years at diagnosis. The authors emphasize the value of performing frailty assessments on older patients with myeloma and describe several tools that have been developed to determine a frailty score. These scores provide valuable information that can impact prognosis prediction and can be used to help select the optimal therapeutic approach for an individual patient. The authors then review the therapeutic landscape for myeloma and provide important considerations for selections and modifications that can be applied for older patients who have a higher frailty score.

These How I Treat articles provide important insights and recommendations concerning the diagnosis and management of hematologic disorders in the expanding number of older individuals we will be seeing in our clinical practice.