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| LETTER TO EDITOR |
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| Year : 2023 | Volume
: 19
| Issue : 1 | Page : 79-80 |
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Approach to geriatric anemia
Muhammed Jasim Abdul Jalal1, Riyas Basheer2
1 Consultant, Department of Family Medicine, Internal Medicine and Rheumatology, Olive Healthcare, Thrissur, Kerala, India
2 Assistant Surgeon, PHC Perumatty, Palakkad, Kerala, India
| Date of Submission | 26-Dec-2022 |
| Date of Decision | 10-Jan-2023 |
| Date of Acceptance | 15-Jan-2023 |
| Date of Web Publication | 17-Mar-2023 |
Correspondence Address:
Muhammed Jasim Abdul Jalal
Olive Healthcare, Thrissur, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jiag.jiag_68_22
How to cite this article:
Jalal MJ, Basheer R. Approach to geriatric anemia. J Indian Acad Geriatr 2023;19:79-80 |
Sir,
A 70-year-old Indian woman presented with complaints of shortness of breath and palpitations of 1-week duration. She reported feeling “giddy” on and off for the past year; the giddiness was associated with weakness worsening for the past month. She had been feeling “too tired, weak, and often experienced fatigue.” She had breathing difficulty on walking up the stairs. She did not have any other significant medical history.
On examination, her vitals were stable. Significant findings on examination were pallor (conjunctival), epigastric tenderness on deep palpation with normal bowel sounds, and no organomegaly.
The most likely diagnosis in this case can be anemia secondary to gastrointestinal (GI) bleeding. The differentials should also include new-onset angina and congestive heart failure.
A 70-year-old woman who has developed dyspnea and palpitations over 1-week period of time needs to be evaluated for cardiac and respiratory problems. The patient's weakness and conjunctival pallor warranted testing for anemia. She needed further evaluation with cardiac enzymes and electrocardiogram. A complete hemogram with peripheral smear, reticulocyte count, iron studies, Vitamin B12, and folic acid levels would provide clues to the type of anemia.
The possibility of intestinal parasites has to be ruled out. If the prothrombin time and activated partial thromboplastin time are abnormal, GI bleeding from a coagulopathy or liver disease could be the possibility. Weight loss, lymphadenopathy, and coagulopathy may warrant evaluation for non-GI malignancies, such as leukemia or lymphomas.
Initial workup of anemia in old age should include a complete hemogram with measurement of red blood cell indices, a peripheral blood smear, and a reticulocyte count.
The most common cause of anemia with a low mean corpuscular volume (MCV) and microcytic anemia is iron deficiency, confirmed by subsequent testing that shows a low serum iron, low ferritin, and high total iron-binding capacity. In the elderly, iron deficiency is frequently caused by chronic GI blood loss, poor nutritional intake, or a bleeding disorder.[1] Iron-deficiency anemia may be the initial presentation of a GI malignancy.
Anemia with an elevated MCV and macrocytic anemia is most often a manifestation of folate or Vitamin B12 deficiency; other causes include drug effects, liver disease, and hypothyroidism.[2]
In the elderly, anemia of chronic inflammation (formerly known as anemia of chronic disease) is the most common cause of a normocytic anemia.[3] In anemia of chronic inflammation, the body's iron stores (measured by serum ferritin) are normal, but the capability of using the stored iron in the reticuloendothelial system becomes decreased. 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 1]. | Table 1: Laboratory values differentiating iron-deficiency anemia from anemia of chronic inflammation
Click here to view |
Iron-deficiency anemia is treated first by identification and correction of any source of blood loss. Most iron deficiency can be corrected by oral iron replacement. Oral iron is given as ferrous sulfate 325 mg (contains 65 mg of elemental iron) three times a day. In uncomplicated anemia, it is considered first-line therapy given its low cost and easy accessibility.[3] Adherence to oral iron may be poor due to GI side effects (dark stools, nausea, vomiting, and constipation) and the required 6–8 weeks of treatment needed to correct the anemia. Oral iron replacement may not be a solution in malabsorption diseases, malignancies, chronic kidney disease, heart failure, or significant blood loss and therefore require parenteral iron preparations. It is recommended that patients requiring parenteral administration be given iron intravenously and not intramuscularly.
Vitamin B12 deficiency can be corrected by intramuscular B12 administration using 1000 μg daily for 7 days followed by weekly for 4 weeks and then monthly for the rest of the patient's life. Newer research shows that many patients can be successfully treated with oral B12 administration using 1000–2000 μg PO in a similar regimen.[4]
Folate deficiency can be treated with oral therapy of 1 mg daily until the deficiency is corrected.[5]
Anemia of chronic inflammation is managed primarily by treatment of the underlying condition in order to decrease inflammation and bone marrow suppression.[3] When anemia of chronic inflammation is severe (hemoglobin <10 g/dL), the risks and benefits of two modalities of treatment, blood transfusion, and erythropoiesis-stimulating agents may be considered.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Stauder R, Valent P, Theurl I. Anemia at older age: Etiologies, clinical implications, and management. Blood 2018;131:505-14.  |
| 2. | Migone De Amicis M, Poggiali E, Motta I, Minonzio F, Fabio G, Hu C, et al. Anemia in elderly hospitalized patients: Prevalence and clinical impact. Intern Emerg Med 2015;10:581-6. |
| 3. | Price EA, Mehra R, Holmes TH, Schrier SL. Anemia in older persons: Etiology and evaluation. Blood Cells Mol Dis 2011;46:159-65. |
| 4. | Layden AJ, Täse K, Finkelstein JL. Neglected tropical diseases and vitamin B12: A review of the current evidence. Trans R Soc Trop Med Hyg 2018;112:423-35. |
| 5. | Green R, Datta Mitra A. Megaloblastic anemias: Nutritional and other causes. Med Clin North Am 2017;101:297-317. |
[Table 1]
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