November 29, 2016

Anemia as We Age – Part 3

The following information on anemia is excerpted from “Anemia in the Older Adult: 10 Common Causes & What to Ask,” originally written and published by Leslie Kernisan, MD, on Better Health While I am reposting this with her permission and am sharing it to educate readers about anemia.

How doctors evaluate anemia

Once anemia is detected, it’s important for health professionals to do some additional evaluation and follow-up, to figure out what might be causing the anemia.

Understanding the timeline of the anemia — did it come on quickly or slowly? Is the red blood count stable or still trending down with time? — helps doctors figure out what’s going on, and how urgent the situation is.

Common follow-up tests include:
  • Checking the stool for signs of microscopic blood loss
  • Checking a ferritin level (which reflects iron stores in the body)
  • Checking vitamin B12 and folate levels
  • Checking kidney function, which is initially done by reviewing the estimated glomerular filtration rate (included in most basic blood work results)
  • Checking the reticulocyte count, which reflects whether the bone marrow trying to produce extra red blood cells to compensate for anemia
  • Checking levels of an “inflammation marker” in the blood, such as the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
  • Evaluation of the peripheral smear, which means the cells in the blood are examined via microscope
  • Urine tests, to check for proteins associated with certain blood cell disorders

If the anemia is bad enough, or if the person is suffering significant symptoms, doctors might also consider a blood transfusion. However, although even mild anemia has been associated with worse health outcomes, research suggests that transfusing mild to moderate anemia generally isn’t beneficial. (This issue especially comes up when people are hospitalized or acutely ill.)

What to ask the doctor about anemia

If you are told that you or your older relative has anemia, be sure you understand how severe it seems to be, and what the doctors think might be causing it. This will help you understand the plan for follow-up and treatment.

Some specific questions that can be handy include:
  • How bad is this anemia? Does it seem to be mild, moderate, or severe?
  • What do you think is causing it? Could there be multiple causes or factors involved?
  • How long do you think I’ve had this anemia? Does it seem to be stable or is it getting worse?
  • Is this the cause of my symptoms or do you think something else is causing my symptoms?
  • Could any of my medications be involved?
  • What is our plan for further evaluation?
  • What is our plan for treating this anemia?
  • When do you recommend we check the CBC again? What is our plan for monitoring the anemia?

Be sure to request and keep copies of your lab results. It will help you and your doctors in the future to be able to review your past labs related to anemia and any related testing.

Avoiding common pitfalls related to anemia and iron

A very common diagnosis in older adults is iron-deficiency anemia. If you are diagnosed with this type of anemia, be sure the doctors have checked a ferritin level or otherwise confirmed you are low on iron.

I have actually reviewed medical charts in which a patient was prescribed iron for anemia, but no actual low iron level was documented. This suggests that the clinician may have presumed the anemia was due to low iron.

However, although iron deficiency is common, it’s important that clinicians and patients confirm this is the cause, before moving on to treatment with iron supplements. Doctors should also assess for other causes of anemia, since it’s very common for older adults to simultaneously experience multiple causes of anemia (e.g. iron deficiency and vitamin B12 deficiency).

If an iron deficiency is confirmed, be sure the doctors have tried to check for any causes of slow blood loss.

It is common for older adults to develop microscopic bleeds in their stomach or colon, especially if they take a daily aspirin or a non-steroidal anti-inflammatory drug (NSAIDs) such as ibuprofen. (For this reason — and others — NSAIDs are on the list of medications that older adults should use with caution.)

Bear in mind that iron supplements are often quite constipating for older adults. So you only want to take them if an iron-deficiency anemia has been confirmed, and you want to make sure any causes of ongoing blood loss (which causes iron loss) have been addressed.

The most important take home points on anemia in older adults

Here’s what I hope you’ll take away from this article:
#1. Anemia is a very common condition for older adults, and often has multiple underlying causes.
#2. Anemia is often mild-to-moderate and chronic; don’t let the follow-up fall through the cracks.
#3. If you are diagnosed with anemia or if you notice a lower than normal hemoglobin on your lab report, be sure to ask questions to understand your anemia. You’ll want to know:
  • Is the anemia chronic or new?
  • Is it mild, moderate, or severe?
  • What is thought to be the cause? Have you been checked for common problems such as low iron or low vitamin B12?
#4. If you are diagnosed with low iron levels: could it be from a small internal bleed and could that be associated with aspirin, a non-steroidal, or another medication?
#5. Keep copies of your lab reports.
#6. Make sure you know what the plan is, for following your blood count and for evaluating the cause of your anemia.

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