Workup of Older Adult Presenting with Anemia

Workup of Older Adult Presenting with Anemia - Flowchart Anemia Anemia

«Flowchart»

Hb below expected and/or falling over time

Female: Black Hb <11.5g/dl, white <12.2 g/dl
Males: Black Hb <12.7g/dl, white <13.2g/dl

Hb below expected and/or falling over time

Female: Black Hb <11.5g/dl, white <12.2 g/dl
Males: Black Hb <12.7g/dl, white <13.2g/dl

Hb below expected and/or falling over time

Female: Black Hb <11.5g/dl, white <12.2 g/dl
Males: Black Hb <12.7g/dl, white <13.2g/dl

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Review patient history

Signs and symptoms and risk factors, attention to iron deficiency (blood thinners or bleeding)

Review prior hematologic laboratories

Assess available past hemoglobin values

Review patient history

Signs and symptoms and risk factors, attention to iron deficiency (blood thinners or bleeding)

Review prior hematologic laboratories

Assess available past hemoglobin values

Review patient history

Signs and symptoms and risk factors, attention to iron deficiency (blood thinners or bleeding)

Review prior hematologic laboratories

Assess available past hemoglobin values

Routine laboratory tests

Complete blood count, white blood cell differential, RBC indices
Iron studies: Serum ferritin, serum iron, total iron binding capacity, transferrin saturation
Vitamin B12
Serum creatinine for est. GFR
C-reactive protein
Reticulocyte count
Thyroid stimulating hormone
RBC or serum folate (only when specific risk factors)

Routine laboratory tests

Treatment considerations

Treat underlying inflammatory condition
Consider iron therapy if functional iron deficiency (e.g., ferritin <100 ng/ml and/or iron saturation <20%)

Treatment considerations

Treat underlying inflammatory condition
Consider iron therapy if functional iron deficiency (e.g., ferritin <100 ng/ml and/or iron saturation <20%)

Treatment considerations

Treat underlying inflammatory condition
Consider iron therapy if functional iron deficiency (e.g., ferritin <100 ng/ml and/or iron saturation <20%)

Treatment considerations

Assess for other causes of anemia and treat
Refer to nephrologist if Hb <10 g/dl
Consider iron therapy +/– ESA

Treatment considerations

Assess for other causes of anemia and treat
Refer to nephrologist if Hb <10 g/dl
Consider iron therapy +/– ESA

Treatment considerations

Assess for other causes of anemia and treat
Refer to nephrologist if Hb <10 g/dl
Consider iron therapy +/– ESA

Treatment considerations

IDA: Once daily oral and treat any cause or risk factor for bleeding
B12: 1000 mcg daily po

Treatment considerations

IDA: Once daily oral and treat any cause or risk factor for bleeding
B12: 1000 mcg daily po

Treatment considerations

IDA: Once daily oral and treat any cause or risk factor for bleeding
B12: 1000 mcg daily po

Treatment considerations

Refer to hematologist for bone marrow examination

Treatment considerations

Refer to hematologist for bone marrow examination

Treatment considerations

Refer to hematologist for bone marrow examination

Treatment considerations

CBC every 6 mo when the Hb level is 2 g/dl below age and race adjusted normal values but the Hb trajectory is stable

Treatment considerations

CBC every 6 mo when the Hb level is 2 g/dl below age and race adjusted normal values but the Hb trajectory is stable

Treatment considerations

CBC every 6 mo when the Hb level is 2 g/dl below age and race adjusted normal values but the Hb trajectory is stable

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Diagnostic considerations of common anemias in older adults

Micronutrient deficiency

Iron deficiency: Serum ferritin <30–50 ng/ml
Vitamin B12 deficiency: B12 level <200 pg/ml with a methylmalonic acid level >0.4 µmol/L
Folate deficiency: Serum folate <4.0 ng/ml or RBC folate <316 ng/ml

Micronutrient deficiency

Iron deficiency: Serum ferritin <30–50 ng/ml Iron deficiency
Vitamin B12 deficiency: B12 level <200 pg/ml with a methylmalonic acid level >0.4 µmol/L Vitamin B12 deficiency
Folate deficiency: Serum folate <4.0 ng/ml or RBC folate <316 ng/ml Folate deficiency Micronutrient deficiency

Chronic kidney disease

Estimated GFR <60 ml/min/1.73m² body surface area

Chronic kidney disease

Estimated GFR <60 ml/min/1.73m² body surface area

Estimated GFR <60 ml/min/1.73m² body surface area ² Chronic kidney disease

Anemia of inflammation

Presence of a subacute or chronic inflammatory condition without evidence of kidney disease and/or vitamin deficiency
Elevated CRP, low iron saturation and normal/low total iron binding capacity

Anemia of inflammation

Presence of a subacute or chronic inflammatory condition without evidence of kidney disease and/or vitamin deficiency
Elevated CRP, low iron saturation and normal/low total iron binding capacity

Presence of a subacute or chronic inflammatory condition without evidence of kidney disease and/or vitamin deficiency
Elevated CRP, low iron saturation and normal/low total iron binding capacity Anemia of inflammation

Hematologic malignancy or other
Abnormal peripheral smear, thrombocytopenia below 120 × 10⁹/L, neutropenia below 1000 10⁹/L, unexplained MCV >100 fL or red cell transfusions

Hematologic malignancy or other Hematologic malignancy or other
Abnormal peripheral smear, thrombocytopenia below 120 × 10⁹/L, neutropenia below 1000 10⁹/L, unexplained MCV >100 fL or red cell transfusions ⁹ ⁹ Hematologic malignancy or other

Unexplained anemia

Typically mild anemia (Hb 10–12 g/dl), normal MCV, without evidence of above etiologies of anemia

Unexplained anemia

Typically mild anemia (Hb 10–12 g/dl), normal MCV, without evidence of above etiologies of anemia

Typically mild anemia (Hb 10–12 g/dl), normal MCV, without evidence of above etiologies of anemia Unexplained anemia