Anemia in Older Adults

Aka: Anemia in Older Adults, Anemia in the Elderly

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II. Epidemiology

  1. Anemia Prevalence in older adults
    1. Community: 7-11%
    2. Hospitalized: 40%
    3. Nursing Homes: 47%

III. Risk Factors

  1. Chronic Alcohol Abuse
  2. Nutritional Deficiency (including Iron Deficiency Anemia, Vitamin B12 Deficiency, Folate Deficiency)
  3. Chronic Inflammatory Conditions (Diabetes Mellitus, Arthritis)
  4. Chronic Kidney Disease
  5. Chronic Liver Disease
  6. Myelodysplastic Disorder
  7. Gastrointestinal Bleeding
  8. Cancer
  9. Impaired Bone Marrow Function
  10. Hypogonadism (androgen deficiency)

IV. History

  1. See Anemia History
  2. Ask about risk factors as above
  3. Sources of blood loss
    1. Hematochezia (bright red) or Melanotic stool
    2. Hematuria
  4. Systemic symptoms suggestive of malignancy (e.g. myeldysplastic disorder)
    1. Weight loss
    2. Recurrent Infections

V. Findings

  1. See Anemia Clinical Clues
  2. Acute Anemia
    1. Light Headedness
    2. Syncope
    3. Hypotension
    4. Tachycardia
  3. Chronic Anemia (often asymptomatic)
    1. Weakness
    2. Fatigue
    3. Shortness of Breath
    4. Comorbidity exacerbation (e.g. COPD Exacerbation, CHF Exacerbation)

VI. Labs

  1. See Anemia Labs
  2. Complete Blood Count with differential Platelet Count
  3. Basic Chemistry Panel
  4. Iron Studies including Serum Iron, TIBC, Serum Ferritin (in Microcytic Anemia or Normocytic Anemia)
  5. Serum Vitamin B12 Level (in Macrocytic Anemia or Normocytic Anemia)
  6. Consider Peripheral Smear
  7. Consider Reticulocyte Count (in Microcytic Anemia)
  8. Hemoglobin cutoffs in age >60 years old (proposed)
    1. White
      1. Men: <13.2 mg/dl
      2. Women <12.2 mg/dl
    2. Black
      1. Men: <12.7 mg/dl
      2. Women <11.5 mg/dl
    3. References
      1. Beutler (2006) Blood 107(5): 1747-50 [PubMed]

VII. Causes

  1. By MCV
    1. Macrocytic Anemia
    2. Normocytic Anemia
    3. Microcytic Anemia
      1. Iron Deficiency Anemia (consider gastrointestinal malignancy)
      2. Anemia of Chronic Disease (esp. Chronic Kidney Disease)
  2. By Category
    1. See Anemia with Reticulocytosis
    2. See Hemolytic Anemia
    3. See Anemia of Chronic Disease
    4. See Aplastic Anemia
    5. See Fanconi Anemia

VIII. Evaluation: Microcytic or Normocytic Anemia

  1. Serum Ferritin Low (<46 ng/ml or <103 pmol/L)
    1. Treat as Iron Deficiency Anemia
    2. Evaluate for causes including gastrointestinal Anemia (e.g. endoscopy)
  2. Serum Ferritin Intermediate (46 to 100 ng/ml or 103 to 225 pmol/L)
    1. Serum Transferrin receptor (sTfR) to Ferritin index <1.5
      1. Glomerular Filtration Rate (GFR) <60
        1. Chronic Kidney Disease
      2. Glomerular Filtration Rate (GFR) >60
        1. Consider other causes of Microcytic Anemia, Normocytic Anemia
    2. Serum Transferrin receptor (sTfR) to Ferritin index >1.5
      1. Treat as Iron Deficiency Anemia
      2. Evaluate for causes including gastrointestinal Anemia (e.g. endoscopy)
  3. Serum Ferritin High (>100 ng/ml or >225 pmol/L)
    1. Consider congenital Hemoglobinopathy
    2. Consider other causes of Serum Ferritin elevation (as an acute phase reactant)
    3. Consider Macrocytic Anemia workup as below

IX. Evaluation: Macrocytic Anemia

  1. Peripheral Blood Smear Abnormal
    1. Consider Myelodysplastic Syndrome or other malignancy
    2. Consider hematology Consultation and Bone Marrow Biopsy
  2. Peripheral Blood Smear Normal
    1. Reticulocyte Index >2% (normal)
      1. Increased LDH or Indirect Bilirubin or decreased Haptoglobin <25 mg/dl or positive Direct Coombs
        1. Hemolysis
      2. Normal LDH, Indirect Bilirubin, Haptoglobin, Direct Coombs
        1. Recent blood loss
        2. Hypersplenism
    2. Reticulocyte Index<=2% (low)
      1. Vitamin B12 Level <100 pg/ml or Serum Folate <5 ng/ml
        1. Vitamin B12 Deficiency OR
        2. Serum Folate Deficiency
      2. Vitamin B12 Level or Serum Folate borderline low
        1. Methylmalonic Acid level low
          1. Vitamin B12 Deficiency
        2. Homocysteine level high
          1. Folate Deficiency
      3. Vitamin B12 Level or Serum Folate borderline normal
        1. Medication causes of increased MCV
        2. Alcoholism
        3. Liver Disease
        4. Hypothyroidism

X. Complications

  1. Even mild Anemia (Hemoglobin 11 mg/dl) is associated with functional decline, decreased cognition, mortality
    1. However, causation is not clear
    2. Chaves (2002) J Am Geriatr Soc 50(7): 1257-64 [PubMed]
    3. Penninx (2003) Am J Med 115(2): 104-10 [PubMed]
    4. Zakai (2005) Arch Intern Med 165(19): 2214-20 [PubMed]
    5. Zakai (2013) Am J Hematol 88(1): 5-9 [PubMed]

XI. Management

  1. Acute symptomatic Anemia with Hemoglobin <7-8 mg/dl
    1. See Hemorrhagic Shock
    2. See Acute Gastrointestinal Hemorrhage
    3. Consider Blood Transfusion and hospitalization
  2. Iron Deficiency Anemia
    1. See Iron Deficiency Anemia
    2. See Iron Supplementation
    3. Consider 15 mg elemental iron liquid dissolved in orange juice
    4. Continue Iron Supplementation for at least 3-6 months after iron levels stabilize (at 6-8 weeks)
    5. Consider Parenteral Iron infusion (e.g. Iron Dextran) for refractory cases, or decreased GI absorption
  3. Vitamin B12 Deficiency or Folate Deficiency
    1. Vitamin B12 1000 mcg (1 mg) orally daily (or may use parenteral Vitamin B12 instead)
    2. Folic Acid 1000 mcg (1 mg) orally daily
  4. Other management
    1. Erythropoesis-stimulating agents (e.g. Erythropoietin) may be considered in patients with ESRD, Chemotherapy

XII. References

  1. Lanier (2018) Am Fam Physician 98(7): 437-42 [PubMed]

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