What workup is recommended for a 75-year-old male with chronic anemia (low hemoglobin)?

Workup for a 75-Year-Old Male with Chronic Low Hemoglobin (11-12 g/dL)

A comprehensive anemia workup should be initiated for a 75-year-old male with chronic hemoglobin of 11-12 g/dL, including complete blood count with indices, iron studies, vitamin levels, renal function tests, and evaluation for occult blood loss. 1

Initial Laboratory Evaluation

The following tests should be ordered as part of the initial workup:

1. Complete Blood Count (CBC) with differential

   • Evaluates red blood cell indices including MCV
   • Provides information about white blood cells and platelets

2. Iron Studies

   • Serum ferritin
   • Transferrin saturation (TSAT)
   • Total iron binding capacity (TIBC)
   • Serum iron

3. Reticulocyte Count

   • Critical for distinguishing between different causes of anemia
   • Helps assess bone marrow response 2

4. Peripheral Blood Smear

   • Examines red blood cell morphology for abnormalities

5. Additional Tests

   • Serum vitamin B12 and folate levels
   • Kidney function tests (BUN, creatinine, eGFR)
   • Liver function tests
   • C-reactive protein (CRP) or other inflammatory markers 2

Specific Considerations for Elderly Males

For a 75-year-old male with hemoglobin of 11-12 g/dL:

1. Anemia Definition and Significance

   • Hemoglobin <13.5 g/dL is considered anemia in adult males 1
   • Even mild anemia in older adults is associated with increased morbidity and mortality 3, 4

2. Common Etiologies in Elderly

   • Approximately one-third have nutritional deficiency
   • One-third have anemia of chronic inflammation or chronic kidney disease
   • One-third have unexplained anemia 4

3. Gastrointestinal Evaluation

   • Endoscopic evaluation (colonoscopy and upper endoscopy) is warranted to rule out gastrointestinal malignancy, especially with evidence of iron deficiency 3
   • Fecal occult blood testing should be performed

Specialized Testing Based on Initial Results

If Microcytic or Normocytic with Low Ferritin:

• Proceed with gastrointestinal evaluation for occult blood loss
• Consider hemoglobinopathy screening if appropriate

If Normocytic with Normal/High Ferritin:

• Evaluate for chronic kidney disease (if eGFR <30 ml/min per 1.73 m²)
• Consider anemia of chronic inflammation
• Evaluate for myelodysplastic syndrome if other causes excluded 5

If Macrocytic:

• Evaluate for vitamin B12 and folate deficiency
• Consider medication effects
• Evaluate for liver disease, alcoholism, or myelodysplastic syndrome

Renal Considerations

If GFR <30 ml/min per 1.73 m²:

• Monitor hemoglobin at least every three months 1
• Check serum bicarbonate, calcium, phosphorus, and iPTH levels
• Consider erythropoietin therapy if anemia persists despite iron repletion 1

Follow-up Recommendations

1. Repeat CBC in 4-8 weeks after initiating treatment to assess response 2
2. Continue iron therapy for at least 3 months after hemoglobin normalization to fully replenish iron stores 2
3. Regular monitoring of hemoglobin levels at least annually, more frequently if unstable 1

Common Pitfalls to Avoid

1. Attributing anemia to age alone - Anemia in elderly always warrants evaluation 4
2. Missing occult gastrointestinal malignancy - Thorough GI evaluation is essential with iron deficiency 3
3. Overlooking mixed anemias - Multiple causes may coexist in elderly patients 6
4. Inadequate follow-up - Ensure appropriate monitoring of treatment response and long-term surveillance 2

Remember that anemia in older adults is often multifactorial and requires thorough evaluation to identify all contributing causes. Even mild anemia should not be dismissed as it significantly impacts quality of life and mortality.