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14 – 16 Iron deficiency anemia and anemia of chronic disease are accompanied by a low serum iron level. Iron deficiency anemia is the main hematologic disorder to consider in the differential diagnosis of anemia of chronic disease ( Table 4 9, 13). 8, 12 DIFFERENTIATING ANEMIA OF CHRONIC DISEASE FROM IRON DEFICIENCY ANEMIA In anemia of chronic disease, the erythrocytes are usually normochromic and normocytic, but about one third of patients with anemia of chronic disease have microcytosis. Patients with anemia of chronic disease have mild to moderate anemia that tends to correlate in severity with the underlying disease, although the anemia rarely progresses to a hemoglobin below 10 g per dL (100 g per L). The difference, however, is that the iron stores are normal or increased in anemia of chronic disease. Nor is the iron available for erythropoiesis, which is the similarity between anemia of chronic disease and iron deficiency anemia. 11 Iron that is held in the reticuloendothelial system is not available for bacterial growth. The reason the reticuloendothelial cells do not release iron is not known, but experts speculate that, similar to fever, this response aids the body's defense mechanisms. The hematologic abnormality in anemia of chronic disease is an impaired ability to use the iron stored in the reticuloendothelial system. Reprinted with permission from Lipschitz DA. In 15 to 25 percent of elderly patients with anemia, no cause is found even when no cause is found the prognosis is good. Unless clinicians consider anemia as a possibility in the elderly, it can be easily overlooked.Ĭohort studies 2, 5 of the elderly have found that the two most common causes of anemia in the elderly are chronic disease and iron deficiency ( Table 1 5). Frequently, patients have signs of a disorder that is made worse by the anemia, such as worsening congestive heart failure, cognitive impairment, dizziness and apathy. 6Īside from conjunctival pallor, few other signs are attributable specifically to anemia. Conjunctival pallor is a reliable sign, and its presence should prompt the clinician to order blood tests for anemia. Pallor can be a helpful diagnostic clue, but pallor can be hard to detect in the elderly. Typical symptoms of anemia, such as fatigue, weakness and dyspnea, are not specific and in elderly patients tend to be attributed to advancing age.
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The onset of symptoms and signs is usually insidious, and many elderly patients adjust their activities as their bodies make physiologic adaptations for the condition. 5Įven though the high prevalence of anemia in the elderly makes it a condition that clinicians might expect to find frequently, several features of anemia make it easy to overlook. Second, in most elderly patients an underlying cause of anemia is found for hemoglobin levels of less than 12 g per dL. First, most older people maintain a normal red cell count, hemoglobin and hematocrit. However, there are at least two reasons for considering anemia in the elderly as a sign of disease. The increased incidence of anemia with aging has led to speculation that lower hemoglobin levels may be a normal consequence of aging. 1 – 4 Using World Health Organization criteria for anemia (hemoglobin of less than 12 g per dL in women and less than 13 g per dL in men), the prevalence of anemia in the elderly has been found to range from 8 to 44 percent, with the highest prevalence in men 85 years and older. Folate deficiency is treated with 1 mg of folic acid daily.Īnemia is common in the elderly and its prevalence increases with age. Vitamin B 12 deficiency is effectively treated with oral vitamin B 12 supplementation. The serum methylmalonic acid level may be useful for diagnosis of vitamin B 12 deficiency. Not all cases of vitamin B 12 deficiency can be identified by low serum levels. Serum ferritin is the most useful test to differentiate iron deficiency anemia from anemia of chronic disease. Vitamin B 12 deficiency, folate deficiency, gastrointestinal bleeding and myelodysplastic syndrome are among other causes of anemia in the elderly. The most common causes of anemia in the elderly are chronic disease and iron deficiency. A cause is found in approximately 80 percent of elderly patients. Anemia should not be accepted as an inevitable consequence of aging.