Contributing Author

Dr Rashmi M V
Professor of Pathology

Shree Siddhartha Medical College

Tumakuru, Karnataka, India

Define Anemia
Definition: anemia is functionally defined as an insufficient RBC mass to adequately deliver oxygen to peripheral tissues.
According to World Health Organisation, Hb <13g/dl in males and <12g/dl is females (<11g/dl in pregnant females) is considered as anemia.
Studies have found increases prevalence in elderly without an underlying pathology: Reasons: decreased androgen secretion in men or age related decrease in stem cell proliferation.

What are the most common causes of Anemia in Elderly?
Most common causes of anemia in elderly:
1. Nutritional anemias.
2. Chronic renal failure.
3. Anemias due to chronic diseases (including chronic blood loss)
4. Endocrinopathies
5. Myelodysplastic syndromes
6. Malignancies
7. Unexplained

What is the importance of clinical history in the evaluation of anemia in elderly?
A good clinical history is a prerequisite to good approach:
Anemia in elderly is usually insidious. Many elderly patients adjust their activities as their bodies make physiologic adaptations for the conditions.

Some common symptoms of anemia patient may present with – fatigue, weakness, dyspnoea on excretion, tinnitus, palpitation, syncope, headache, poor concentration, pale skin, dementia, dysphagia.
Ask the patient for history of diabetes, hypertension, any other chronic illnesses like arthritis, TB etc., alcohol intake, any drugs, any recent illness, travel, fever, food habits, tarry stools, altered bowel habits, menstrual history in females.

What should one look for , in physical examimation, in avaluation of anemia in elderly?
Physical examination: pallor, icterus, tachycardia, cardiac murmurs, hepatomegaly, splenomegaly, oedema.
Specifically look for lymphadenopathy, splenomegaly, thyroid abnormalities, changes in nails, poor balancing walking abilities and hand grip strength (decrease in physical performance and strength), impairment in cognitive functions.

What are the Basic investigations to be asked for?
Basic investigations to be ordered in elderly anemic patients:
Complete hemogram (includes complete blood counts & peripheral smear).
Fasting/random blood sugar levels.
Blood urea & serum creatinine levels.

How do you interpret the results of complete hemogram, in evaluation of anemia?

Interpretation based on the complete hemogram results:

Type of anemia Microcytic hypochromic anemia Normocytic normochromic anemia Macrocytic anemia
 Common causes nutritional anemia, chronic blood loss, some cases of anemia due to chronic diseases. Chronic renal diseases, malignancies, acute blood loss, hypothyroidism Vitamin B12 or folate deficiency, myelodysplastic syndromes, chronic alcoholics, hepatic diseases, some cases of hypothyroidism
 Investigations to be done Iron profile, stool for occult blood, gastroscopy & colonoscopy(for GI bleeds & malignancies), urinanalysis for blood, ultrasonongram & Pap smears to be considered in females. Blood urea, serum creatinine, peripheral smear examination, ESR, reticulocyte count, ultrasound examination, TSH Vitamin B12 & folic acid assays, Liver function tests, PS & BM.

Iron profile includes Sr. Ferritin, Sr.Iron, total iron binding capacity, %satuartion.
Reticulocytes count – differentiates between hypoproliferative (chronic diseases, bone marrow failure, renal failure, hypothyroidism) and hyperproliferative (acute blood loss) states to check the response of patients to treatment.
ESR – is raised in chronic diseases like tuberculosis, rheumatoid arthritis etc.
Gastroscopy, colonoscopy – for GI bleeds.
Urine for blood – for genitourinary bleeds.
CBC & Peripheral smear examination – leukemias, myeloproliferative disorders.

Too easy acceptance of mild anemia as a physiological phenomenon in elderly runs risk of ignoring a potentially valuable, early clue to an important underlying disorder. Each case needs workup based on the history and clinical examination.

The above suggested investigations are just a guide to decide what can be done in the most common scenarios.

Do not ask for bulk investigations and prioritize them based on your findings.