Clinical Presentation

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Fatigue, weakness, and dyspnea are symptoms that are commonly reported by elderly persons with anemia. These vague and nonspecific symptoms are often ignored by both patients and physicians as symptoms of "old age." Anemia may result in worsening of symptoms of other underlying conditions. For example, the reduced oxygen-carrying capacity of the blood as a consequence of anemia may exacerbate dyspnea associated with congestive heart failure.

Certain signs found on examination may prompt a work-up for anemia. Conjunctival pallor is recommended as a reliable sign of anemia in the elderly. Other signs may suggest a specific cause of anemia. Glossitis, decreased vibratory and positional senses, ataxia, paresthesia, confusion, dementia, and pearly gray hair at an early age are signs suggestive of vitamin Bp-deficiency anemia. Folate deficiency can cause similar signs, except for the neurologic deficits. Profound iron deficiency may produce koilonychias.

Initial work-up of anemia should include a CBC with measurement of red blood cell (RBC) indices, a peripheral blood smear, and a reticulocyte count. Further laboratory studies would be indicated based on the results of the initial tests and the presence of symptoms or signs suggestive of other diseases.

The most common cause of anemia with a low mean corpuscular volume (MCV). microcytic anemia, is iron deficiency. Iron deficiency could be confirmed by subsequent testing that shows a low serum iron. low ferritin and high total iron-binding capacity (TIBC). Other causes of microcytic anemia include thalassemias and anemia of chronic disease. In the elderly, iron deficiency is frequently caused by chronic gastrointestinal blood loss, poor nutritional intake, or a bleeding disorder. A thorough evaluation of the gastrointestinal tract for a source of blood loss, usually requiring a gastroenterology consultation for upper and lower GI endoscopy, should be undertaken, as iron-deficiency anemia may be the initial presentation of a GI malignancy.

Anemia with an elevated MCV. macrocytic anemia, is most often a manifestation of folate or vitamin B,, deficiency. The presence of macrocytic anemia. with or without the symptoms previously mentioned, should lead to further testing to determine Bp and folate levels. An elevated methylmalonic acid (MMA) level can be used to confirm a vitamin B,2 deficiency. Folate deficiency anemia is usually seen in alcoholics, whereas B|2-deficiency anemia mostly occurs in people with pernicious anemia, a history of gastrectomy, diseases associated with malabsorption (e.g.. bacterial infection, Crohn disease, celiac disease), and strict vegans (rare).

In the elderly, anemia of chronic disease is the most common cause of a normocytic anemia. Anemia of chronic disease is anemia that is secondary to some other underlying condition. Along with causing a normocytic anemia, anemia of chronic disease can also present as a microcytic anemia. This type of anemia can easily be confused with iron-deficiency anemia because of its similar initial laboratory picture. In anemia of chronic disease, the body's iron stores are normal, but the capability of using the stored iron in the reticuloendothelial system becomes decreased. A lack of improvement in symptoms and hemoglobin level with iron supplementation are important clues indicating that the cause is chronic disease and not iron depletion, regardless of the laboratory picture. Although bone marrow iron store remains the gold standard to differentiate between iron-deficiency anemia and anemia of chronic disease, simple serum testing is still used to diagnose and differentiate these two types of anemia (Table 9-1).


The treatment of anemia is determined based 011 the type and cause of the anemia. Any cause of anemia that creates a hemodynamic instability can be treated with a red blood cell transfusion. Iron-deficiency anemia is treated first by

Table 9-1


Table 9-1





Serum iron


Low or normal




Transferrin saturation


Low or normal

Serum ferritin


Normal or high

identification and correction of any source of blood loss. Most iron deficiency can be corrected by oral iron replacement. Various iron preparations are available; a typical treatment is ferrous sulfate 325 mg three times a day. Parenteral iron preparations are available for those with poor iron absorption and high iron replacement needs. Vitamin B], deficiency traditionally has been treated by intramuscular B|: therapy with a regimen of l(XX) |ig IM daily for 7 days, then weekly for 4 weeks, then monthly for the rest of the patient's life. Newer research shows that many patients can be successfully treated with oral B12 therapy using 1(XX)-2000 |ig PO in a similar regimen. Folate deficiency can be treated with oral therapy of 1 mg daily until the deficiency is corrected. Anemia of chronic disease is managed primarily by treatment of the underlying condition.

Comprehension Questions

Match the following lab pictures of patients with anemia with the cases described below:

A. Normal MMA: decreased serum folate level

B. Elevated MMA; decreased serum B,, level

C. Elevated ferritin; normal MCV; decreased serum iron level

D. Decreased ferritin; decreased MCV; decreased serum iron level

[9.1 ] A 66-year-old male with anemia and "stocking-and-glove" distribution of a burning sensation.

[9.2] A 68-year-old male with an incidental finding of anemia while in the hospital for alcohol abuse.

[9.3] A 65-year-old female with anemia who has chronic renal failure.

[9.4] A 67-year-old male with dizziness and a positive stool guaiac test.

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