Anemia in Older Adults

 

Am Fam Physician. 2018 Oct 1;98(7):437-442.

Author disclosure: No relevant financial affiliations.

The opinions and assertions in this article are those of the authors and do not represent official policy of the Army Medical Department, Department of the Army, or the Department of the Defense.

Anemia is associated with increased morbidity and mortality in older adults. Diagnostic cutoff values for defining anemia vary with age, sex, and possibly race. Anemia is often asymptomatic and discovered incidentally on laboratory testing. Patients may present with symptoms related to associated conditions, such as blood loss, or related to decreased oxygen-carrying capacity, such as weakness, fatigue, and shortness of breath. Causes of anemia in older adults include nutritional deficiency, chronic kidney disease, chronic inflammation, and occult blood loss from gastrointestinal malignancy, although in many patients the etiology is unknown. The evaluation includes a detailed history and physical examination, assessment of risk factors for underlying conditions, and assessment of mean corpuscular volume. A serum ferritin level should be obtained for patients with normocytic or microcytic anemia. A low serum ferritin level in a patient with normocytic or microcytic anemia is associated with iron deficiency anemia. In older patients with suspected iron deficiency anemia, endoscopy is warranted to evaluate for gastrointestinal malignancy. Patients with an elevated serum ferritin level or macrocytic anemia should be evaluated for underlying conditions, including vitamin B12 or folate deficiency, myelodysplastic syndrome, and malignancy. Treatment is directed at the underlying cause. Symptomatic patients with serum hemoglobin levels of 8 g per dL or less may require blood transfusion. Patients with suspected iron deficiency anemia should be given a trial of oral iron replacement. Lower-dose formulations may be as effective and have a lower risk of adverse effects. Normalization of hemoglobin typically occurs by eight weeks after treatment in most patients. Parenteral iron infusion is reserved for patients who have not responded to or cannot tolerate oral iron therapy.

Anemia is a common condition in adults 60 years and older. Given the demographic growth of this population and the morbidity and mortality associated with anemia, primary care physicians should be familiar with the evaluation and management of anemia in older persons.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A low serum ferritin level is associated with a diagnosis of iron deficiency anemia.

C

17

Older patients with suspected iron deficiency anemia should undergo endoscopy to evaluate for occult gastrointestinal malignancy.

C

15, 16

Low-dose formulations of iron (15 mg of elemental iron) can be effective for treatment of suspected iron deficiency anemia and have a lower risk of adverse effects than standard preparations.

C

27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

A low serum ferritin level is associated with a diagnosis of iron deficiency anemia.

C

17

Older patients with suspected iron deficiency anemia should undergo endoscopy to evaluate for occult gastrointestinal malignancy.

C

15, 16

Low-dose formulations of iron (15 mg of elemental iron) can be effective for treatment of suspected iron deficiency anemia and have a lower risk of adverse effects than standard preparations.

C

27


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Anemia has historically been defined as a hemoglobin level of less than 12 g per dL (120 g per L) in women and less than 13 g per dL (130 g per L) in men.1  These values and reference ranges remained static until recently, when cohort studies such as the third National Health and Nutrition Examination Survey suggested that this definition needs to be adjusted because of the variability in normal hemoglobin levels with age, sex, and black race (values for different ethnicities are not available). A revised definition that may better reflect these differences has been proposed (Table 1).2

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TABLE 1.

Proposed Lower Limits for Hemoglobin Levels

SexRaceAge (years)Hemoglobin, g per dL (g per L)

Men

White

20 to 59

13.7 (137)

≥ 60

13.2 (132)

Black

20 to 59

12.9 (129)

≥ 60

12.7 (127)

Women

White

≥ 20

12.2 (122)

Black

≥ 20

11.5 (115)


Adapted with permission from Beutler E, Waalen J. The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration? Blood. 2006;107(5):1749.

TABLE 1.

Proposed Lower Limits

The Authors

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J. BRIAN LANIER, MD, FAAFP, is commander of the U.S. Army Health Clinic, Presidio of Monterey, Calif....

JAMES J. PARK, MD, is an assistant clinical professor in the Department of Family and Community Medicine at the University of California, San Francisco School of Medicine.

ROBERT C. CALLAHAN, DO, is a staff physician and medical director at Irwin Army Community Hospital, Fort Riley, Kan.

Address correspondence to J. Brian Lanier, MD, U.S. Army Health Clinic, 473 Cabrillo St., Building 422, Monterey, CA 93944-5006 (e-mail: jeffrey.lanier@us.army.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

The opinions and assertions in this article are those of the authors and do not represent official policy of the Army Medical Department, Department of the Army, or the Department of the Defense.

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