From the Guidelines
For chronic macrocytic anemia in an 86-year-old patient with dementia, the basic initial investigations should include a complete blood count with peripheral smear, vitamin B12 and folate levels, thyroid function tests, liver function tests, reticulocyte count, and serum creatinine. These tests help identify the most common causes of macrocytic anemia in elderly patients, particularly vitamin B12 and folate deficiencies which are prevalent in this population 1. The peripheral smear can reveal characteristic findings such as hypersegmented neutrophils in B12 deficiency.
Key Investigations
- Complete blood count with peripheral smear
- Vitamin B12 and folate levels
- Thyroid function tests
- Liver function tests
- Reticulocyte count
- Serum creatinine Thyroid function tests are important as hypothyroidism can cause macrocytosis. Liver function tests help identify liver disease which may contribute to macrocytic anemia. The reticulocyte count helps determine if the anemia is due to decreased production or increased destruction of red blood cells. Renal function assessment is relevant as chronic kidney disease can affect erythropoiesis. When investigating anemia in an elderly patient with dementia, it's essential to consider the clinical context, including medication review (as drugs like methotrexate, phenytoin, and certain chemotherapeutics can cause macrocytosis), alcohol use history, and nutritional status, which may be compromised in patients with dementia due to poor intake or absorption issues 1.
From the Research
Initial Investigations for Chronic Macrocytic Anemia
The initial investigations for chronic macrocytic anemia in an 86-year-old patient with dementia include:
- A detailed history and physical examination to assess for underlying conditions 2
- Assessment of mean corpuscular volume (MCV) to confirm macrocytosis 3, 4, 5
- Blood tests, such as:
- Vitamin B12 level to evaluate for deficiency 3, 4, 5
- Folate level to evaluate for deficiency 3, 4, 5
- Reticulocyte count to differentiate between megaloblastic and non-megaloblastic anemias 3, 4, 5
- Peripheral smear to evaluate for megaloblastic anemia (macro-ovalocytes and hyper-segmented neutrophils) 3, 4
- Thyroid function tests to evaluate for hypothyroidism 4, 5
- Liver function tests to evaluate for liver disease 4, 5
- Additional tests may be required based on the initial evaluation, such as bone marrow aspirate and biopsy with cytogenetic analysis 5
Considerations in Older Adults
In older adults, it is essential to consider the potential for underlying conditions, such as: