Psychiatry and Clinical Neurosciences 2012; 66: 367369

doi:10.1111/j.1440-1819.2012.02347.x

Short Communication

Association of lower hemoglobin levels with depression,

though not with cognitive performance, in healthy
elderly men
pcn_2347

367..369

MD,1 Heng-Liang Yeh, MD3 and Shih-Jen Tsai, MD1,2*

1
Department of Psychiatry, Taipei Veterans General Hospital, 2Division of Psychiatry, School of Medicine, National
Yang-Ming University, Taipei and 3Taipei Veterans Home, New Taipei City, Taiwan

Hsi-Han Chen,

Lower hemoglobin (Hb) levels are a common feature

in the elderly. The present study recruited 180 healthy
elderly men. Participants were assessed using the
Geriatric Depression Scale, the Cognitive Abilities
Screening Instrument Chinese version, and the
Wechsler Digit Span Task test. The mean age
of the participants was 85.8 years (SD = 10.5).
Pearsons correlation tests demonstrated that Hb

concentrations negatively correlated with Geriatric

Depression Scale (r = -0.245, P = 0.001), but did not
correlate with Cognitive Abilities Screening Instrument, Forward or Backward Digit Span tests. Lower
Hb levels, therefore, were associated with depression
in the elderly men.

LDERLY PERSONS COMMONLY have hemoglobin (Hb) concentrations slightly below the lower
normal limit. A previous study reported that anemia
is associated with changes in quality of life, increased
risk of falls, infections, morbidity, and mortality in
the elderly.1 However, few studies have investigated
the influence of anemia on mental function in these
individuals. The association between anemia and
depression or cognitive function in the elderly
remains controversial. A Japanese analysis indicated
that lower Hb levels were significantly associated
with depressive moods in elderly women at high risk
of requiring care, though not in elderly men.2 A prospective population-based study in Italy showed that
depressive symptoms were associated with anemia in
a general population of older persons living in the
community,3 while a cross-sectional study found that
mild-grade anemia was independently associated
with worse selective attention.4 Another sectional
study in Turkey observed greater impairment to

global cognition (as assessed by Mini-Mental Status

Examination [MMSE]) in anemic than non-anemic
groups in elderly nursing home patients.5
The above studies analyzed populations with
medical problems or without excluding physical/
mental problems. The physical/mental problems in
these studied subjects may, therefore, have confounded the association between Hb and depression/
cognition. To avoid these confounding factors, the
current study analyzed the association of Hb levels
with depression and cognitive performance in elderly
Chinese men in relatively good health.

*Correspondence: Shih-Jen Tsai, MD, Department of Psychiatry,

Taipei Veterans General Hospital, No. 201, Shih-Pai Road, Sec. 2,
Taipei 11217, Taiwan. Email: tsai610913@gmail.com
Received 24 August 2011; revised 17 October 2011; accepted 27
December 2011.

Key words: aged, depression, hemoglobin.

METHODS
This study comprised 180 participants recruited from
a veterans home in Northern Taiwan. For each case,
the clinical research assistant performed an extensive
examination, including a diagnostic structured interview with the Mini-International Neuropsychiatric
Interview (MINI),6 the Geriatric Depression Scale
(GDS-15), the Clinical Dementia Rating Scale (CDR),
and cognitive tests, including the Cognitive Abilities
Screening Instrument Chinese version (CASI C-2.0)
test,7 and the Wechsler Digit Span Task test (Forward
and Backward). The CASI test is a 100-point cognitive

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Psychiatry and Clinical Neurosciences 2012 Japanese Society of Psychiatry and Neurology

367

test designed for cross-cultural studies and adapted in

Chinese for individuals with little or no formal education.8 Exclusion criteria included the following:
(i) presence of diagnoses on Axis I of the DSM-IV or
alcohol abuse/dependence; (ii) severe medical conditions, including advanced-stage cancer, renal, liver,
hematological disease and heart failure; (iii) neurobiological disorders (stroke or Parkinsons disease);
and (iv) CDR > 0.5 or CASI C-2.0 50 to exclude
possible dementia. All participants had sufficient
visual and auditory acuity for cognitive testing. A
standard procedure was used to collect blood
samples for Hb measurement. This study was
approved by the local institutional review board.
Informed consent was obtained from all subjects
prior to commencement.
Pearsons correlations were conducted to identify correlations between Hb concentration and
cognitive/depressive ratings. Data are presented as
mean (SD), with the criterion for significance set at
P < 0.05 for all tests.

Psychiatry and Clinical Neurosciences 2012; 66: 367369

12

10

GDS-15

368 H-H. Chen et al.

0
7.5

10.0

12.5

15.0

17.5

Hemoglobin (g/dl)

Figure 1. Correlation between hemoglobin concentrations

and Geriatric Depression Scale (GDS-15) rating in 180 elderly
men (r = -0.245, P = 0.001).

RESULTS
The subjects were 180 men aged between 65 and
98 years (mean = 85.8; SD = 10.5), with an average
of 5.1 years of education (SD = 4.6; ranged from 0 to
16 years of schooling). Cognitive function tests
showed that the mean total CASI score was 85.3
6.6 (range = 6898). Hb concentrations ranged from
6.1 to 17.3 g/dL, with an average of 13.5 g/dL (SD =
1.8 g/dL). Mean scores for GDS-15, Digit Span
Forward test, Digit Span Backward test and CDR were
2.9 (SD = 2.7), 11.4 (SD = 3.0), 3.4 (SD = 2.1) and
0.1 (SD = 0.2), respectively.
Pearsons correlation tests demonstrated that Hb
concentrations negatively correlated with GDS-15
(r = -0.245, P = 0.001) (Fig. 1). Among the 180 subjects, 56 were current smokers. After controlling for
age, education years and smoking status, the correlation was still significant (r = -0.261, P < 0.001). Hb
concentrations did not correlate with cognitive tests,
including CASI (P = 0.879), Forward Digit Span
(P = 0.286) and Backward Digit Span (P = 0.172).
After controlling for age, education years and
smoking status, the correlation was still insignificant
(data not shown). A linear-regression analysis performed with age, education years, and Hb concentrations as the predictor variables identified education
years as the only significant predictor of CASI score
(P < 0.001).

DISCUSSION
The results of this study indicate that Hb concentrations negatively correlated with depression, as evaluated using GDS-15, and did not correlate with
cognitive function. Our findings are consistent with
those of a previous study on English communitydwelling older adults (3816 men and women; aged
65.4 9.0 years),9 but differed from those from a
Japanese analysis that showed no significant association between Hb levels and depressed mood in
elderly men at a high risk of requiring care.2 This
discrepancy may be caused by sample differences,
ethnic differences, or different depression ratings. The
underlining mechanism of the link between lower
Hb levels and depressive mood still requires full elucidation. Anemia could worsen symptoms of fatigue,
irritability, and poor concentration, which are significant components of depression. Furthermore,
anemia reduces brain oxygenation,10 which may
affect brain function for stress coping. In a large longitudinal prospective study of English communitydwelling older adults, anemia did not predict risk of
depression over 2 years of follow up.9 Therefore, the
causal correlation may be in the reverse direction
(depression causes anemia). For example, lower Hb
may be a consequence of poor dietary iron intake
among subjects with more depressed moods.

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Psychiatry and Clinical Neurosciences 2012 Japanese Society of Psychiatry and Neurology

Psychiatry and Clinical Neurosciences 2012; 66: 367369

Hemoglobin and depression 369

Although certain studies demonstrated that lower

Hb levels were associated with poorer cognitive function in old age,4,5 the data of the present study did not
reveal any significant association between Hb levels
and cognition in its elderly healthy male subjects.
This result may be caused by differences in sample
populations between the studies and varying cognitive ratings used.
This study has several limitations. First, the sample
comprised a population of Chinese elderly men
living in a veterans home; therefore, any association
between Hb levels and depression in women or other
populations requires further confirmation. Second,
patient assessments did not include the causes of
anemia. Third, this cross-sectional study could not
identify the causal correlation between anemia and
depression.

3. Onder G, Penninx BW, Cesari M et al. Anemia is associated

with depression in older adults: Results from the InCHIANTI study. J. Gerontol. A Biol. Sci. Med. Sci. 2005; 60:
11681172.
4. Lucca U, Tettamanti M, Mosconi P et al. Association of
mild anemia with cognitive, functional, mood and quality
of life outcomes in the elderly: The Health and Anemia
study. PLoS ONE 2008; 3: e1920.
5. Terekeci HM, Kucukardali Y, Onem Y et al. Relationship
between anaemia and cognitive functions in elderly
people. Eur. J. Intern. Med. 2010; 21: 8790.
6. Sheehan DV, Lecrubier Y, Sheehan KH et al. The MiniInternational Neuropsychiatric Interview (M.I.N.I.): The
development and validation of a structured diagnostic
psychiatric interview for DSM-IV and ICD-10. J. Clin. Psychiatry 1998; 59 (Suppl 20): 2233.
7. Teng EL, Hasegawa K, Homma A et al. The Cognitive
Abilities Screening Instrument (CASI): A practical test
for cross-cultural epidemiological studies of dementia. Int.
Psychogeriatr. 1994; 6: 4558.
8. Liu HC, Chou P, Lin KN et al. Assessing cognitive abilities
and dementia in a predominantly illiterate population of
older individuals in Kinmen. Psychol. Med. 1994; 24: 763
770.
9. Hamer M, Molloy GJ. Cross-sectional and longitudinal
associations between anemia and depressive symptoms in
the English Longitudinal Study of Ageing. J. Am. Geriatr.
Soc. 2009; 57: 948949.
10. Weiskopf RB, Feiner J, Hopf H et al. Fresh blood and aged
stored blood are equally efficacious in immediately reversing anemia-induced brain oxygenation deficits in humans.
Anesthesiology 2006; 104: 911920.

ACKNOWLEDGMENTS
There are no conflicts of interest to disclose.

REFERENCES
1. Woodman R, Ferrucci L, Guralnik J. Anemia in older
adults. Curr. Opin. Hematol. 2005; 12: 123128.
2. Umegaki H, Yanagawa M, Endo H. Association of lower
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Psychiatry and Clinical Neurosciences 2012 Japanese Society of Psychiatry and Neurology