The story of ASH’s involvement in the study and treatment of anemia in the elderly (which even when mild can have a profound deleterious impact on quality of life and cognition) is an example of how being prepared lets you take advantage of opportunities. Up until 2003, ASH officers and staff made single, yearly visits to the NIH Institutes involved in hematologic issues: NCI, NIDDK, and NHLBI. In 2002, I participated as vice president in the fairly formal courtesy visits, where we emphasized ASH’s very substantial strengths and mutually bemoaned the lack of sufficient research money. As an outcome of ASH’s strategic planning program, there was an increase in ASH’s government affairs efforts such that staff and officers now make more frequent visits to these Institutes.
At one of our regular meetings, late in 2003, we were exploring options for further research. The National Institute on Aging (NIA) team led by Jack Guralnik, MD, PhD, had just completed and drafted their National Health And Nutrition Examination Survey (NHANES) 3 study on anemia in the elderly based on more than 5,000 community-dwelling elderly. The paper was subsequently published in Blood. The authors, using WHO criteria, discovered that about 10 percent of men and women over age 65 were anemic. Some of the findings had been, in part, previously noted by groups in Italy and elsewhere. The anemia noted in NHANES 3 was very mild in most cases, and, as a practicing hematologist, I tended to pay little attention to these patients. However, the NIA study not only tried to dissect the multiple and complex causes of the anemia, but showed in fairly dramatic fashion that even the very mild anemia led to losses in exercise capability and increased morbidity and mortality after hospitalization and after a heart attack. Anemia may even lead to loss of a cognitive skill called executive function. The clinical impact of even mild anemia meant that it was critical to understand the many underlying causes of the anemia and to aim for its correction. It was most likely at this moment that the idea of ASH sponsoring an agenda-setting conference gelled. I had read the NIA report and knew that ASH members had the requisite skills and experience to tackle and solve problems of anemia.
Accordingly, in 2004, ASH and the NIA co-sponsored a conference on anemia in the elderly that was designed to explore the multiple causes of the anemia, possible means of correction, and the causation of the associated morbidity. We also decided to propose suggestions for clinical work-up of affected patients. The conference was funded by ASH. This agenda-setting conference convened in February of 2004, and the participants consisted of about 10 gerontologists/ hematologists from the NIA and 10 ASH experts in disorders of red cells and anemia. The structure of the meeting was unusual in that the opening presentation by the NIA group of the NHANES data was the only PowerPoint presentation allowed. During the conference, we identified 10 key areas for analysis, distributed relevant papers, and assigned experts to take responsibility for the discussion. Deprived of the PowerPoint crutch, these experts really interacted. The participants identified key areas for research, which became the basis for a Request for Applications (RFA) subsequently sent out by the NIA. There were about 25 proposals; five R01s were awarded and are now beginning year three. We reviewed the progress of these grants in Bethesda, MD, this past fall.
The participants at the agenda-setting conference noted that hematologists, as well as primary-care physicians, tended to ignore the usually mild anemia in the elderly, and they recommended that educational programs were needed to correct this flaw. Accordingly, the ASH Committee on Practice presented a special education program on this subject at the 2005 annual meeting. It was well received and needed three overflow rooms to accommodate the attendees.
About two years ago, NIA convened an ad-hoc advisory group to consider whether NIA should establish a consortium of centers that could test treatment strategies for anemia in the elderly. Many ASH members participated, and we supported the idea, provided that the consortium would also be able to do basic research to test hypotheses regarding the causes of the complex anemia. Currently, several proposals are under review.
The collaboration has now led to a research endeavor that not only explores new areas of biology but, hopefully, will lead to improved patient care.
