![]() Fecal occult blood testing should be performed to assess for gastrointestinal blood loss, and endoscopic evaluation should be strongly considered for patients with iron deficiency anemia or in whom occult blood is identified, taking into consideration factors such as patient comorbidities and the risk of complications. ) An index of more than 1.5 supports the diagnosis of iron deficiency anemia. (An online calculator is available for registered users at. In these patients, the serum transferrin receptor–ferritin index can be used to distinguish between iron deficiency anemia and other types. 17 Iron deficiency anemia is less likely in patients with serum ferritin levels of 46 to 100 ng per mL (103 to 225 pmol per L), although it cannot be ruled out. 15 – 19 A level less than 19 ng per mL (43 pmol per L) is highly suggestive of iron deficiency anemia (positive likelihood ratio = 41), but this condition can be present in patients with higher levels (LR+ = 3.1 in patients with serum ferritin of 45 ng per mL or less). 15, 16 Therefore, obtaining a serum ferritin level is the first step when evaluating these patients ( Figure 1). Iron deficiency anemia occurs in 11% to 57% of patients with colorectal cancer and may be the presenting symptom in 15%. Although microcytic anemia is classically associated with iron deficiency, and normocytic with chronic disease or unknown causes, there is significant overlap between the manifestations of these diseases. Microcytic and normocytic anemias are most common in older adults. 11, 12 Overall, one-third of older patients with anemia have a nutritional deficiency, which includes iron deficiency due to subsidiary causes (e.g., bowel malignancy), one-third have chronic inflammation or chronic kidney disease (CKD), and one-third have an unknown cause. 10 After adjusting for comorbid conditions, anemia in community-dwelling older adults is associated with functional decline and decreased mobility, balance, and ability to rise from a chair. 5 A 2016 British prospective cohort study of 220 patients with a mean age of 83.6 years found that anemia is associated with increased all-cause mortality one year after hospitalization. 5 Common causes of morbidity in these patients are listed in Table 2. 5 – 9 A prospective cohort analysis of 3,758 patients 65 years and older found that new-onset anemia and decreased hemoglobin levels with or without anemia are associated with increased mortality (hazard ratios of 1.39 and 1.11, respectively, per 1 g per dL decrease in hemoglobin). 3, 4 Most of these patients have mild anemia (hemoglobin level of 11 g per dL or greater), but even mild anemia is independently associated with increased morbidity and mortality. The overall prevalence of anemia is 17% in older adults (7% to 11% of community-dwelling older adults, 47% of those in nursing homes, and 40% in hospitalized patients). Parenteral iron infusion is reserved for patients who have not responded to or cannot tolerate oral iron therapy. Normalization of hemoglobin typically occurs by eight weeks after treatment in most patients. Lower-dose formulations may be as effective and have a lower risk of adverse effects. Patients with suspected iron deficiency anemia should be given a trial of oral iron replacement. Symptomatic patients with serum hemoglobin levels of 8 g per dL or less may require blood transfusion. Treatment is directed at the underlying cause. ![]() Patients with an elevated serum ferritin level or macrocytic anemia should be evaluated for underlying conditions, including vitamin B 12 or folate deficiency, myelodysplastic syndrome, and malignancy. In older patients with suspected iron deficiency anemia, endoscopy is warranted to evaluate for gastrointestinal malignancy. A low serum ferritin level in a patient with normocytic or microcytic anemia is associated with iron deficiency anemia. A serum ferritin level should be obtained for patients with normocytic or microcytic anemia. The evaluation includes a detailed history and physical examination, assessment of risk factors for underlying conditions, and assessment of mean corpuscular volume. ![]() 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. 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. Anemia is often asymptomatic and discovered incidentally on laboratory testing. Diagnostic cutoff values for defining anemia vary with age, sex, and possibly race. Anemia is associated with increased morbidity and mortality in older adults.
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