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ALNU 4050 Care of the Older Adult

Anemia and Blood Malignancies

Categorizing Anemias in your Text

Hypoproliferative-resulting from defective red blood cells
Iron Deficiency Vitamin B-12 Folate Deficiency
Chronic Disease causes

Erythropoietin deficiency-renal Cancer/inflammation

Blood loss
GI bleed, menorrhagia, trauma

Hemolytic-RBC being destroyed

Is not normal as you age Can be caused by a chronic illness or a malignancy Symptoms determined by severity Remember oxygen carrying capacity is affected Classified by cause or cell size, shape or substance Categorized microcytic, macrocytic, and normocytic

Microcytic Anemia: (hypoproliferative) Iron Deficiency Anemia

MCV is less than 80, Small, pale RBC Depleted iron stores, have to have for HGB to function Need to find out what is the cause Acute blood loss, chronic blood loss, inadequate nutritional intake Consider GI first (occult blood, GI workup) Tests
MCV Iron studies

Serum Ferritin reflects body stores of iron in bone marrow Transferrin saturation Total iron binding capacity

Bone marrow aspiration (if suspect leukemia)

Symptoms of Iron Deficiency Anemia

Onset gradual Usually Hgb drops to 7-8g/dl and then seek medical attention Non-specific early symptoms so difficult to diagnose Fatigue, weakness, shortness of breath, pale earlobes, palms, and conjunctiva More severe symptoms such as fingernails brittle and concave, soreness and redness of tongue, corner of mouth dry and cracked As it progresses, Gastritis, Neuromuscular changes, Irritability, Headache, Numbness and tingling of feet and hands, Vasomotor disturbances Elderly-mental confusion, memory loss, and disorientation

Don t treat anemia without knowing the cause Then treat the underlying cause
Can be reversed with 1-2 weeks of treatment

Ferrous Sulfate 325mg for 6-12 months after bleeding stops Daily until menopausal if Gynecological cause Patient education about Ferrous sulfate

Normocytic Anemia:
Anemia of chronic disease(hypoproliferative), Hemolytic anemia Aplastic anemia

Normal size cells Decreased production and survival of RBC, premature or rapid destruction

Anemia of Chronic Disease: Hypoproliferative

Malnutrition-missing folic acid and Vitamin C = decreased RBC Chronic infection/inflammation-decreased EPO production, decreased RBC survival, impaired transport to bone marrow Cancer-chemo side effects decreasing nutrition and suppression of bone marrow Renal insufficiency-decreased erythropoiesis and decreased RBC survival Chronic liver disease-alcohol toxic to bone marrow results in decreased iron stores and iron binding capacity

Hemolytic Anemia
Occurs at any age, More common with aging Hemolysis or premature destruction of RBC May be associated with autoimmune antibodies, Hodgkin's disease and non-Hodgkin's lymphoma, trauma, heart valves, burns, exposure to toxic chemicals, drugs, sickle cell anemia Ibuprofen, l-dopa, penicillin, cephalosporin's, tetracycline's, acetaminophen, ASA, PCE, hydralazine, HCTZ, insulin
Hemolysis stops when drug withdrawn

Folic Acid (need increased amount to increase RBC production)

Aplastic Anemia-Rare
More in young Overall mortality > 50% Bone marrow suppressed, decreased RBC, Low reticulocyte count Cause unknown or radiation or chemical substance Bone marrow transplant in patients over 65 usually not effective

Macrocytic Anemias (hypoproliferative) Pernicious and folate deficiency

MCV greater than 100 Most common cause of macrocytic anemia in older person B12 or folate deficiency Unusually large size RBC Defective DNA synthesis causes abnormally large and thickened cells.

Macrocytic Anemia: B-12 Deficiency

B-12 deficiency (pernicious anemia)
Lack of intrinsic factor
Gastrectomy, small bowel disease, H-pylori infection, prolonged antacids, strict vegetarian diet Heavy alcohol ingestion Cigarette smoking Autoimmune disorders-particularly those effecting endocrine

B-12 injections Neurologic deficits do not usually reverse, halts Lifetime treatment d/t incurable

Signs and symptoms of Pernicious Anemia

Develops slowly over 20-30 years By the time seek medical attention, very severe Early signs
Infections Mood swings GI/Cardiac/Kidney ailments Hgb 7-8g/dl develop classic signs of anemia
Weakness, fatigue, paraesthsia of feet and fingers, weight loss, sore mouth, beefy red tongue, difficulty walking, abdominal pain

Macrocytic anemia: Folate Deficiency

Folate deficiency
Malabsorption syndromes, poor nutrition, alcoholism, malignancies Folate essential for RBC/DNA synthesis in the erythrocyte Humans are totally dependent on nutritional intake Occurs more than B-12 deficiency particularly in alcoholics Malnourished especially fad diets or diets that limits vegetables

Macrocytic anemia: Folic Acid

Scales and fissures in mouth Stomatitis Painful ulceration of the buccal mucosa and tongue Dysphagia Flatulence Water diarrhea

Malignancies of the Blood

Hematologic Malignancies
Immature lymphoid and myeloid cells are over-produced with associated bone marrow failure Classified by 1. Cell of origin 2. Degree of differentiation

Types of Leukemia
Acute Lymphocytic Leukemia-ALL Chronic Lymphocytic Leukemia- CLL Acute Myelogenous Leukemia-AML Chronic Myelogenous Leukemia-CML

Acute Myeloid Leukemia-AML

Unknown cause Rarely occurs before age 40, peaks 67 Characterized by immature myeloblasts in the bone marrow WBC may be low, normal or high Prognosis depends on patient
Develops as a secondary cancer, <1 yr 5 yr <65 = 35%, >65 survival 4%

Symptoms of AML
What are the symptoms of AML? Result from insufficient Blood cells
Fever and infection (neutropenia) Fatigue and weakness (anemia) Bleeding tendencies (thrombocytopenia)
Petechiae, bruising, massive blood loss

Painful enlarged liver or spleen (engorgement) Hyperplasia of gums Bone pain (expansion of marrow)

Diagnosis and Treatment

Decreased erythrocytes and plates Leukocytes may be normal, high or low

Bone marrow aspiration-excessive immature blast cells sitting in marrow Classification (7 subgroups we will not cover) Treatment-try to induce remission
Aggressive-cytarabine Elderly patients who cannot tolerate can take hydroxyurea (lower cure rate/increased quality of life) BMT use increasing (infused with donor cells to rescue marrow)

Complications of Treatment
Tumor lysis syndrome (pg. 390 table)
Lysis of cells leads to intracellular contents flooding the body.
Electrolyte imbalances Renal calculi Renal failure Prevention: pre-hydration, imbalances

Eradicating the bone marrow Complications of chemo listed in overview powerpoint

Nurses Role
Monitor for
Bleeding Infection Pain End of Life issues

Acute Lymphocytic Leukemia (lymphoblastic)

Most common type 80% age 2-4 Will not cover in this class

Chronic Leukemia
Progresses more slowly Longer Life expectancy (depending on stage) Cells better differentiated 25-40% of all leukemia's Cause unknown Link between Epstein Barr virus Predisposition in families

Chronic Leukemia
Chronic Lymphocytic Leukemia Chronic Myelogenous Leukemia

Chronic Lymphocytic Leukemia

Chronic Lymphoid Leukemia (CLL) disease of the older person (>72 usually) Characterized by malignant transformation of B cells Proliferation of small abnormal lymphocytes in bone marrow, peripheral blood, and body tissues Cells fail to develop into antibody producing cells

Chronic Lymphocytic Leukemia

B symptoms
Fevers, night sweats, unintentional weight loss and infections

Weak, fatigue and painful lymphadenopathy Anemia Thrombocytopenia (depending on stage) Enlarged spleen Elevated WBC 20-100, 000

Diagnosis and Treatment of Chronic Lymphocytic Leukemia

Bone marrow Treatment not started until symptoms appear/severe Treatment: Not curable only induce periods of remission
combination therapy (prolonged suppression) Radiation to thymus, spleen or entire body Older person have a heightened risk of second malignancy with radiation

5 remission in 70% of patients As progresses need nutritional support, pain control, skin care and emotional support

Chronic Myelogenous Leukemia

Philadelphia chromosome a good diagnostic marker is in 95% of patients* Overproduction of abnormal myeloid/blast
Uncontrolled proliferation of granulocytes Causes bone marrow and organs to enlarge (pain)

Risk dramatically increases with age If in chronic stage Life expectancy > 5 yrs. No known cause except for ionizing radiation

Symptoms of CML
May be asymptomatic and see leukocytosis Classic chronic symptoms
Fatigue, weakness, anorexia, weight loss, and splenomegaly (more prominent and painful)

Shortness of breath/confusion with very high leukocyte counts Lymphadenopathy generally not present Liver enlarged but function not effected Fever and adenopathy in blast stage WBC 15,000-500,000 (blast phase)*
50% to 60% will progress

Symptom Phases of CML

Symptom Stable Accelerated/t Blast Crisis ransformatio n

Presence of symptoms Splenomegaly WBC Differential

None to minimal Mild Slight elevation <1% blasts

Moderate Increased Erratic Increase in immature cells

Pronounced Marked Very High >25% blasts

CML moving through stages

How do we know?
May not Bone pain, fevers (no signs of infection), weight loss

Goal is to control the proliferation of WBC/induce remission Chemotherapy to suppress-in early stages
Hydroxyurea Busulfan Imatinib(gleevac) Blast Phase-aggressive Prognosis 2-4 months
Anthracyclines Cytosine Arabinoside Interferon-alpha

CML treatment continued

Bone marrow transplants-sibling donor
successful if early is disease, under 50, and in good health Can potentially be cured with BMT Decreasing leukocytes in blast phase Leukophoresis: for Leukocytes > 300,000 can be life threatening. (temporary) Anthracycline chemotherapy when non-emergent

Nursing Care of Patients with Leukemia

Know potential effects of leukemia and of treatments and assess Manage mucositis (chapter 16) Control pain and discomfort Risk of dehydration Weakness and fatigue Rest between activities Assist with self-care Anxiety/Grief

Neoplastic tumor affecting lymphoid tissue
Hodgkin s Non-Hodgkin s

Hodgkin s Lymphoma
Peaks 20s and over the age of 50 More common in immunosuppressed patients Agent Orange Possible link to EBV 5 subgroups we will not cover each Characterized by:
Progression from one group of lymph nodes to another* Development of systemic symptoms Presence of the Reed-Stenberg cell(malignant lymph cell)*

Symptoms of Hodgkin s lymphoma

First sign often enlarged cervical node
The lymphadenopathy moves to axillary, inguinal, retroperitoneal

Presents with one or more enlarged, painless lymph nodes

Symptoms from pressure of lymph nodes

Asymptomatic, painless mediastinal mass on chest x-ray Organ symptoms from compression by tumor B symptoms: fever (without chills), Night sweats, weight loss Fatigue Pruiritus Early mild Anemia, then worsen and if accompanied by weight loss, poor prognosis Increased sedimentation rate, leukocytosis, eosinophilia, leukopenia (advanced), platelet count normal Impaired cellular immunity so decreased response to skin testing

Diagnosis of Hodgkin s lymphoma

Because painless can go many years without diagnosis Lymph node biopsy PET* CT CXR Classification

Treatment of Hodgkin s lymphoma

`Depends on staging `Stage I
Radiotherapy Cure Rate of 80%

`Stage II

`Stage III-IV
Combination Chemotherapy Radiotherapy 80% can be put in remission High rate of toxicity

Non-Hodgkin s Lymphoma
` Rate has doubled since 1970 possibly d/t immune deficiencies (5th most common type of cancer) ` Median age 67 ` Begin with one node and spread throughout body, to bone, CNS, and GI tract ` Lymphoid tissue replaced with disease cells resulting in infection and immune deficiency ` Prognosis for older adult poorer than with Hodgkin s lymphoma ` Success of Treatment depends on stage, with aggressive treatment can achieve remission ` Cause links to Impaired immune system (immunosuppression) Phenytoin use Prior treatment for cancer EBV/HIV Chemical exposure

Non-Hodgkin s Lymphoma
Diagnosed through lymph node biopsy PET scans* Staged based on nodular or diffuse cytology Stage does not necessarily predict prognosis
See text for prognosis classification

Non-Hodgkin s Lymphoma-symptoms
B complex symptoms Non-tender peripheral lymphadenopathy May have moderately enlarged liver and spleen

Non-Hodgkin s Lymphoma
Treatment (can be cured) Incidence of secondary cancer high Depends on staging

Treat when symptoms appear BMT can be used in those under the age of 60.

Multiple Myeloma
5 year survival for newly diagnosed patients 33%

Presentation of Multiple Myeloma

Infiltrates bone marrow and aggregates into tumor masses in skeletal system Most common presentation is bone pain Bone lesions
Caused by destruction of bone tissue Increased calcium from re-absorption of bone by osteoclasts

Renal failure secondary to hypercalcemia Anemia d/t inhibited erythropoiesis

Symptoms of Multiple Myeloma

Pathological fractures Back pain/ribs* usually presenting symptom Vertebrae Skull Pelvis Femur Clavicle scapula 10% have spinal cord compression Repeated infection from suppressed humoral response (pneumonia/pyelonephritis) Fever Weight loss Night sweats Breakdown of bone can lead to renal failure

Diagnosis of Multiple Myeloma

Diagnosis by blood test
Sudden spike in protein (blood/urine) End organ damage C: elevated calcium R: renal insufficiency A: anemia B: Bone lesion Bone marrow aspiration x-ray Nuclear bone scan

Treatment of Multiple Myeloma

Prognosis is poor (no cure) Treatment
Chemo used to treat intermediate and high grade Radiation Plasmapheresis-when blood viscosity high

Treatment of Multiple Myeloma

Difficult with older adult with comorbidities 6-8 months of aggressive treatment
May need help with
Pain control ADL Nutrition Symptom control